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WealthTrust-Arizona - Five Fallacies for Improving Healthcare

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Educational workshop presented by WealthTrust-Arizona and world-renowned guest Robert K. Smoldt, Chief Administrative Officer Emeritus at Mayo Clinic and Associate Director of Healthcare Delivery & …

Educational workshop presented by WealthTrust-Arizona and world-renowned guest Robert K. Smoldt, Chief Administrative Officer Emeritus at Mayo Clinic and Associate Director of Healthcare Delivery & Policy Programs at Arizona State University. Mr. Smoldt has been involved in health care administration for more than 30 years and is currently pursuing U.S. health reform in close partnership with Mayo Clinic’s Emeritus President and CEO.

At this workshop Robert examines a number of general statements that are, in his view, fallacious.

Published in: Health & Medicine, Business

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  • 1. General Fallacies About Improving U.S. Healthcare
  • 2. Robert K. Smoldt Associate Director, ASU Healthcare Delivery and Policy Program Emeritus CAO, Mayo Clinic Wealth Trust Scottsdale, Arizona October 12-13, 2011
  • 3. Three general aims for all health systems Some of the claims for meeting these three aims don’t meet the Smoldt common sense test
  • 4. Fallacy 1: If physicians didn’t make so much money, the health cost problem would be gone
  • 5. Source: nytimes.com; Laugesen and Glied, “Higher Fees Paid…….”, Health Affairs 30. No 9 (2011) 1647 -1656.
  • 6. Average orthopedic surgeon pre-tax earnings (2008) Source:  Laugesen and Glied, “Higher Fees Paid…….”, Health Affairs 30. No 9 (2011) 1647 -1656.
  • 7. Are U.S. primary care doctors underpaid? Source:  Laugesen and Glied, “Higher Fees Paid…….”, Health Affairs 30. No 9 (2011) 1647 -1656.
  • 8. Average primary care pre-tax earnings (2008) Source:  Laugesen and Glied, “Higher Fees Paid…….”, Health Affairs 30. No 9 (2011) 1647 -1656.
  • 9. Specialist compensation vs. GDP per capita (2004) US$ ’000s Source: U.S. Health Care Spending: Comparison with Other OECD Countries, CRS report for Congress, 2007 GDP per capita Specialist compensation 20%
  • 10.
    • U.S. physicians make 20% more than would be expected for a developed country with our level of GDP
    Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx?referrer=search
    • So if U.S. doc’s made 20% less, what would happen to US healthcare?
  • 11. Components of U.S. health spending (2008) Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx?referrer=search Physician services
  • 12. Physician spending
    • Physicians = 21%
    • Physician overhead approximately 50% - So MD income approximately 10% of total healthcare cost
    • Thus a 20% reduction in physician income = 2% reduction in cost
    • One time – then the factors that are driving costs up would just continue on
    • Or have doc’s work for nothing
  • 13. Fallacy 2: If we just put in price controls and lowered the price we paid providers, the U.S. healthcare cost problem would be solved
  • 14. “ It’s the price, stupid” by Gerald F. Andersen, et. al. Source: http://content.healthaffairs.org/content/22/3/89.full.pdf
  • 15. Total Cost = Price Per Unit of Service X Use Rate of Services
  • 16. Let’s examine each component individually Total Cost = Price x Use Rate
  • 17.
    • Line item price controls
    • Overwhelming complexity
    How has Medicare attempted to control its rate of spending?
  • 18. *Payment ij = Payment for service “i” (e.g., chest X-ray) in geographic area “j” (e.g., Danville, PA) Source: “Part B News: A Plain English Guide” The formulas to determine what Medicare pays for physician services are complex Payment ij = RVUi 1  [(GPCIw j x w i %) + (GPCIoh j  oh i %) + (GPCIm j  m i %)]  CF Payment ij = Payment for service “i” (e.g., chest X-ray) in geographic area “j” (e.g., Danville, PA) CF = conversion factor CF 08 = -10.1% CF 08 = CY 08  MEI 08  UAF 08  0.33 UAF 08 = Target 07 – Actual 07 Actual 07  0.75 + Target 4/96-12/07 – Actual 4/96-12/07 Actual 07  (1 + SGR 08 )
  • 19. Total prices set* What was one reason we started this formula approach in the mid-1980s? Primary care underpaid 1,418,656 *21,026 line items and 1-449 geographic areas Medicare Part B prices
  • 20. The complexity of price controls “ No matter how simply you begin, your controls will get more complex and voluminous. We started with…3 ½ pages of regulations and ended with 1,534. In an effort to correct one inequity, you create another.” C. Jackson Grayson Jr. Chair, U.S. Price Commission (1971-1973 ) Source: Wall Street Journal, 29 Mar 1993 Hospital cost reports for Mayo Clinic, Rochester hospitals for a single year
  • 21. Keeping track of communications regarding CMS annual provider pricing updates is nearing the 20,000 page mark Hospital 1,032 Publication Number of Federal Register pages
    • Proposed 2012 PPS rule
    • Hospital Value- Based Purchasing Final Rule
    • Hospital Outpatient 2011 Final Rule
    194 1,852 Physician 1,562
    • Physician Fee Schedule 2011 Final
    Subtotal 4,643 3,599
    • Contractor bulletins
    • CMS communications
    11,177 Other estimated pages from CMS and contractors Total 19,419
  • 22. So Medicare price controls have added complexity. But has it also led to a lower rate of cost growth than rest of healthcare?
  • 23. Total healthcare spending for Medicare beneficiaries has grown at a faster rate than that of private plans *The proportion of Medicare enrollees with employer-sponsored primary insurance more than doubled **Medicare beneficiaries who also received funding under Medicaid Source: Robert Book, Heritage Foundation No. 2301, July 24, 2009 PLUS private insurance in 2005 was also absorbing a 10-15% cost shift from government run plans
    • Private insurance, non-Medicare
    • (including out of pocket, other sources)
    • Medicare
    • (cost paid by Medicare only)
    Average annual growth in spend per beneficiary (1997-2005) Percent 5.8% 7.7%
    • Medicare beneficiaries total
    • (including other sources)
    10.6%
      • Out of pocket 15.0%
      • Private insurance* 18.7%
      • Medicaid** 26.3%
  • 24. Despite the complex price-setting efforts, Medicare excess cost growth has outpaced that of the non-Medicare population Excess cost growth* (percentage points) *Excess cost growth refers to the number of percentage points by which the growth of spending on Medicare, Medicaid, or health care generally (per beneficiary or per capita) exceeded the growth of nominal gross domestic product (per capita) Source: Peter Orszag, “New Ideas About Human Behavior in Economics and Medicine”, Eighth Annual Marshall J. Seidman Lecture, Harvard Medical School, 2008
  • 25. There is some evidence that private insurers are better at controlling costs than public payors
  • 26. GDP per capita (nominal) Healthcare expenditures per capita (PPP$) Change in growth Growth in healthcare expenditures vs. GDP in the United States (1990-2009) Source: OECD, 2011 Everyone wants healthcare costs to grow in line with GDP; this has already happened during the HMO era Managed Care
  • 27. Commercial payors have shown more success at managing healthcare spend and utilization Total spend per enrollee Medicare ratio McAllen to El Paso Commercial ratio* McAllen to El Paso 0.93 0.84 1.86 1.31 Indicator *Blue Cross and Blue Shield of Texas **Per 1,000 enrollees; Medicare ratio calculated based on hospital discharges in the last 2 yrs of life Source: Franzini et al.: “McAllen And El Paso Revisited: Medicare Variations Not Always Reflected In The Under-Sixty-Five Population”, Health Affairs , 2010; Dartmouth Atlas of Healthcare, 2007 Inpatient utilization** Outpatient spend per enrollee 0.69 1.32 Inpatient spend per enrollee 1.10 1.63
  • 28. Why don’t price controls work in healthcare? The same reason they don’t work elsewhere in the economy
  • 29. Price controls: Grayson’s maxim “ Add (price) controls and you will see ‘new’ services appear. Expect ‘unbundling’ of services with the price of individual units, when added together, totaling more than the original services.” C. Jackson Grayson Jr. Chair, U.S. Price Commission (1971-1973) Source: Wall Street Journal, 29 Mar 1993
  • 30. The Medicare price control cycle
  • 31. Price controls do not lead to lower total spending Source: Letter to Medicare Payment Advisory Commission from Herb B. Kuhn, Director, Center for Medicare Management, CMS 4/7/06 as referenced by Dr. Stuart Guterman, The Commonwealth Fund Annual % change SGR-related expenditures/ fee-for-service beneficiary Physician fees 7.4 3.4 7.4 -0.7 -2 -1 0 1 2 3 4 5 6 7 8 1997-2001 2001-2005
  • 32. *2007 data Source: The Commonwealth Fund, Multinational Comparisons of Health Systems Data, 2010 MRI scan and imaging fees (2009) Dollars Medicare already pays 40% less for imaging than Canada and additional rate cuts have been proposed
  • 33. Healthcare reform reliance on across the board reductions in Medicare payments has severe implications for providers and patients "... the prices paid by Medicare for health services are very likely to fall increasingly short of the costs of providing these services. By the end of the long-range projection period, Medicare prices for hospital, skilled nursing facility, home health, hospice, ambulatory surgical center, diagnostic laboratory, and many other services would be LESS THAN HALF of their level under the prior law. Medicare prices would be considerably below the current levels paid by private health insurance. Well before that point, Congress would have to intervene to prevent the withdrawal of providers from the Medicare market and the severe problems with beneficiary access to care that would result." Source: Annual report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2011
  • 34. Problem with present Medicare line item price control approach “ The secret is not, however, to re-jigger 10,000 prices in 3,000 counties so that we get them ‘right’ once and for all (until medical knowledge or technology or input prices change again).” Dr. Len M. Nichols (New America Foundation) testimony to U.S. Committee of the Budget, June 26, 2007 “ The secret is to pay for what we want – health – … while bundling ever-larger sets of services into one payment, which frees clinicians and providers to find the most efficient way to deliver health, given our particular circumstances.”
  • 35. Medicare is committing significant effort to price paid per unit of service, when use rate is actually the more important variable The use rate is the direct function of the medical practice style in the delivery system
  • 36. Let’s examine each component individually Total Cost = Price x Use Rate
  • 37. Use rate is the key
    • "… utilization - not local price differences - drives Medicare regional payment variation…” 1
    • “ Most of this variation (Medicare spending) was not due to differences in the price of care in different parts of the country, but rather to differences in the volume….” 2
    • There is a two fold difference between the MSA with greatest service use (Miami, FL) and the MSA with the least service use (La Crosse, WI).” (After adjusting for regional prices, added payments for GME, IME, etc., demographics and beneficiary health statues) 3
    • Gottlieb et al.: "Prices Don't Drive Regional Medicare Spending Variations”, Health Affairs , March 2010
    • Wennberg et al.: "Tracking the Care of Patients with Severe Chronic Illnesses”, The Dartmouth Atlas of Health Care 2008
    • MedPac Report to Congress, January 2011, “Regional variation in Medicare services use.”
  • 38. What additional services are provided in high cost areas? Those services determined by physician practice style
    • Discrete: Effective care
    • Reperfusion in 12 hours (heart attack)
    • Aspirin at admission (heart attack)
    • Mammogram, Women 65-69
    • Pneumococcal immunization (Ever)
    • Discrete: Preference-sensitive care
    • Total hip replacement
    • Total knee replacement
    • Back surgery
    • CABG following a heart attack
    • Care delivery: Who/ How often/ Where
    • Total inpatient days
    • Inpatient days in ICU or CCU
    • Evaluation and management (Visits)
    • Imaging
    • Diagnostic tests
    Source: Peter Orszag, “New Ideas About Human Behavior in Economics and Medicine”, Eighth Annual Marshall J. Seidman Lecture, Harvard Medical School, 2008 Ratio of use rates (risk-adjusted) Higher in high-spending regions Lower in high-spending regions 0.5 1.0 1.5 2.0 2.5
  • 39. Dr. Elliott Fisher et al., Conclusion on quality and cost: “ Efforts to improve the quality and cost of U.S. health care have focused largely on fostering adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. … Clinical judgment, not clinical guidelines, should be the focus of policy efforts to improve the quality of care and address disparities in spending.” Source: Health Affairs, May/June 2008
  • 40. Case study: Elyria, Ohio Percutaneous Coronary Interventions, HRR (2007) Rate per 1000 enrollees Source: Dartmouth Atlas of Health Care Baltimore, MD 12.4 Cleveland, OH 11.2 Houston, TX 10.1 Rochester, MN 8.0 Boston, MA 7.0 Elyria 26.8 Locations of top 5 U.S. News Best Hospitals: Heart & Heart Surgery 1 11 21 31
  • 41. Which strategy is most likely to curb costs in Elyria, while not adversely affecting areas where rates might be “just right”?
    • Cut prices for cardiology procedures everywhere
    • Conduct OIG investigations
    • Pay for value
  • 42. When attempting health cost containment, remember why robbers rob banks
  • 43. The high concentration of healthcare costs Source: “Health Care Costs: A Primer”, Kaiser Family Foundation, 2009 100% 100% 20% 80% 10% 64% % Total population % Total healthcare spending 1% 20% 80%
  • 44. To address healthcare costs begin with a focused approach
    • Focus on the sickest and most costly patients by defining value for the top five costly medical conditions
    • Work to improve efficiency and effectiveness for these limited conditions based on outcomes, safety, services and costs over time
    • Once completed work on these limited conditions move on to the next most expensive set
    • How to do the above? Come November 9-10
  • 45. Fallacy 3: The U.S. needs more physicians to improve access to care
  • 46. U.S. has a similar supply of physicians Physicians per 1,000 population (2009)* *For US and UK data refer to practicing physicians, defined as those providing care directly to patients; For Canada data refer to professionally active physicians, including practicing physicians plus other physicians working in the health sector as managers, educators, researchers, etc. (adding another 5-10% of doctors) Source: OECD Health Data, 2011
  • 47. Canada and UK have more generalists and fewer specialists than U.S. Density per 1,000 population (2009)* *Primary care includes: General practice, general pediatrics, obstetrics and gynecology; Specialist care includes: Psychiatry, medical group of specialties, surgical group of specialties, other Source: OECD Health data, 2011
  • 48. Trade offs – fewer specialists in other countries part of longer waits there Percent of population waiting for specified periods for care (2010) Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries 21 UK 25 Canada 19 UK 41 Canada 7 U.S. 9 U.S. Wait ≥4 months for elective surgery Wait >1 month for specialist appointment 0 10 20 30 40 50 60
  • 49. An increase in physician supply would likely carry significant cost implications
    • Correlation of MD supply and health care cost in U.S. states (2004)
    Health cost/ capita ($) Total MDs/ 1,000 population Source: CMS HHS Health Care Expenditure Data, US Census Bureau; statehealthfacts.org Correlation coefficient: 0.85 0 2,000 4,000 6,000 8,000 10,000 12,000 0 2 4 6 8 10
  • 50. U.S. needs more integrated care rather than more physicians
    • Adjusted primary and specialty care provider supply in prepaid group practices compared with U.S. supply (2001-2002)
    • MDs/DOs per 100,000 population
    Specialty Primary care Specialty care Total U.S. supply* 93 136 229 Integrated practice average** 69 93 162 Integrated average vs. US -26% -32% -29% *US supply numbers differ from OECD estimates likely due to differences in survey years and methodology (e.g., counting practicing vs. total physicians); **Kaiser, Group Health, HealthPartners Source: Weiner: “Prepaid Group Practice Staffing And U.S. Physician Supply: Lessons For Workforce Policy”, Health Affairs , 2004 If the U.S. practiced medicine they way integrated practices do, the U.S. will have more physicians than needed, even primary care
  • 51. Fee for service integrated systems also use fewer physicians
    • “… in several of the low input regions, much of the care is provided by large, multispecialty group practices (for example, the Mayo Clinic) or integrated delivery systems (for example, Intermountain Health Care)…Our study suggests that even in FFS environments, group practices use fewer physicians per capita than is true in small-group or solo practices (the dominant modes in most U.S. regions).”
    • “ Instead of financing further growth in our medical education system, resources might be better directed to reorganizing delivery systems to models of FFS and prepaid group practice that have already demonstrated that they can deliver good care at relatively low costs.”
    Source: Goodman et al.: “End-Of-Life Care At Academic Medical Centers: Implications For Future Workforce Requirements”, Health Affairs , 2006
  • 52.
    • Fallacy 4: U.S. healthcare quality is not as good as other developed countries because our life expectancy at birth is less in the U.S.
  • 53. Life expectancy at birth
    • Japan (2006) 82.4
    • U.S. (2006) 78.1
    • CA Asian-Pacific Islander Americans (2001)* 82.9
    • LA county Asian-Pacific Islander Americans (2006) 84.8
    • California Adventists (1988) 83.5
      • No smoking, diet, exercise, weight
    Life expectancy is a poor measure of the healthcare delivery system quality *Weighted average of life expectancy by gender (1999-2001) using CA population estimates in 2000 Sources: OECD, 2011; Fraser and Sharlik: “Ten Years of Life: Is it a Matter of Choice?” Archives of Internal Medicine , July 9, 2001; RAND California; Clarke et al.: “Racial and social class gradients in life expectancy in contemporary California”, Soc Sci Med, 2010 ; “Life expectancy in Los Angeles county: How long do we live and why?”, A Cities and Communities Health Report, July 2010
  • 54. Healthcare is a minor determinant of the overall health of the population Source: McGinnis et al: “The Case For More Active Policy Attention To Health Promotion”, Health Affairs , Mar-Apr 2002 40% Behavior 10% Health Care 15% Social circumstance 5% Environmental exposures
  • 55. Life expectancy in the U.S. varies widely Source: OECD Factbook 2010: Economic, Environmental and Social Statistics; statehealthfacts.org Life expectancy at birth, OECD countries vs. best and worst US states (2005) Years OECD average U.S. average Top 10 OECD Bottom 10 OECD
  • 56.
    • If life expectancy is not a good measure of quality, does the U.S. do well on other measures?
  • 57. U.S. health system has some of the best and some of worst mortality outcomes in the world Mortality amenable to healthcare: Deaths before age 75 that are potentially preventable with timely and appropriate medical care (International data 2002-2003, State data 2004-2005) Deaths per 100,000 population U.S. Top 5 states Minnesota Bottom 5 states *Top 5 states: MN, UT, VT, CO, NE; Bottom 5 states: LA, MS, AR, TN, AL; excludes District of Columbia data Sources: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2009; Nolte and McKee: “Measuring The Health Of Nations: Updating An Earlier Analysis”, Health Affairs , Jan-Feb 2008
  • 58.
    • Fallacy 5: When all U.S. providers finally get on electronic medical records, our quality and cost problems will be solved
  • 59. Maybe. Maybe not.
    • If all we do is electronify what is on paper and do not change how we deliver care….result will not change.
  • 60.
    • Background question: Why has it taken so long for medicine to go electronic when banks have had ATMs for years?
  • 61. Basic data set used by banks $ and cents
    • Basic data set used by medicine
    • Blood tests: 1,276
    • Imaging procedures: 739
    • Surgical procedures: 6,003
    • Diagnostic codes: ICD-9 = 14,000
    Source: “ICD10 Code Set to Replace ICD 9,” AMA Physician Resource, accessed, October 5, 2011. ‘ICD10”, Wikipedia, accessed, October 5, 2011
  • 62. Talk about CMS creating complexity
    • ICD-9 = 14,000 codes
    Source: “ICD10 Code Set to Replace ICD 9,” AMA Physician Resource, accessed, October 5, 2011. ‘ICD10”, Wikipedia, accessed, October 5, 2011; WSJ, September 13, 2011
    • ICD-10 (WHO) = 68,000 codes
    • ICD-10 (CMS) = 155,000 codes
    • Code V91.07XA
    • Code W22.02XA
    = “Burn due to water-skis on fire” = “Walked into lamppost, initial encounter”
  • 63. But even through those are large numbers, a medical center still just needs one EMR electronic system, right?
    • Number of clinical IT applications at Mayo Clinic
      • 613
        • e.g., Cardiac CathLab Imaging System, Electronic Nurse Assignment Tool, FIN - Financial System
    • And they all have to talk to each other!
  • 64.
    • BUT, once we do get electronic systems in, AND actually use them to change how we deliver care, we can get improvements in effectiveness and efficiency of healthcare.
  • 65. Mayo Clinic ICU Data Mart
    • (>15,000 critically ill patients a year)
    Monitoring Lab Demo Nursing Ventilator Fluid Transfusion Outcome
  • 66. ICU results: Mortality 30 25 20 15 5 0 Jan 02 Feb 03 Mar 04 Apr 05 May 06 Jun 07 Jul 08 10 Hospital Mortality (01-01-02 to 01-31-09) Percent Least squares fit
  • 67. ICU results: Use rate Length of stay (01-01-02 to 01-31-09) Days 6 5 4 3 2 1 Jan 02 Feb 03 Mar 04 Apr 05 May 06 Jun 07 Jul 08 Least squares fit
  • 68. Banner Health pre and post iCare ICU Measure ICU days ICU mortality Risk adjusted result -31% -30%
  • 69.
    • Fallacy 6: When everyone is insured, health reform will be accomplished
  • 70.
    • It would be great if all were insured, but if no change in how we deliver care…cost, quality, and access could all suffer. Plus we have great variability.
  • 71. Huge system variability in healthcare resource utilization *Based on Inpatient days and Inpatient physician visits among chronically ill Medicare beneficiaries; excludes District of Columbia data Source: Commonwealth Fund State scorecard, 2009 Hospital care intensity index, last two years of life (2009)* States All states median Bottom 5 states Top 5 states Rate Ratio to benchmark (Top 5 states average) 0.556 0.949 1.289 Benchmark 1.7 2.3
  • 72. Even teaching hospitals show wide variability in outcomes and utilization *COTH = Council of Teaching Hospitals and Health Systems; n = 269 COTH member facilities; excludes COTH member VA and Children’s hospitals; excludes facilities with <50 actual deaths in 2009 Source: https://www.aamc.org/members/coth/ ; MedPar 2009 Best hospital in category Worst hospital in category Teaching hospital average Mortality ratio >1.0 = better than expected LOS ratio >1.0 = better than expected 1.34 0.63 1.01 2.06 0.65 1.02 COTH hospitals*
  • 73. Integrated systems have more efficient resource utilization – as much as 40-50% less: ICU utilization *Rounded Source: Dartmouth Atlas of Health Care Region (HRR) La Crosse, WI Temple, TX Salt Lake City, UT Danville, PA Integrated average United States Miami, FL Los Angeles, CA Integrated systems Days* Ratio to benchmark (integrated average) 1.2 1.5 1.8 2.5 1.7 3.7 10.1 7.5 Benchmark 2.1 5.8 4.3
  • 74.
    • Fallacy 7: We individual citizens can do nothing ourselves to improve U.S. healthcare
  • 75. Who can do more to improve U.S. healthcare? Members of Congress or you?
  • 76. Healthcare is a minor determinant of the overall health of the population Source: McGinnis et al: “The Case For More Active Policy Attention To Health Promotion”, Health Affairs , Mar-Apr 2002 40% Behavior 10% Health Care 15% Social circumstance 5% Environmental exposures
  • 77. Individual behavior is critical
    • Not Smoking
    • Diet
    • Weight
    • Seat belts
    • Helmets
    • Follow treatments
      • e.g., high blood pressure, high cholesterol, diabetes, etc.
  • 78. If we won’t do these with public education perhaps we should try financial incentives
    • Safeway experience

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