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Keynote Address: Jack Wennberg

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Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
May 24, 2013

John E. Wennberg, The Dartmouth Institute

Published in: Health & Medicine
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Keynote Address: Jack Wennberg

  1. 1. Ke y n o t e A d d r e s s Aligning Incentives for Patient Engagement May 24, 2013
  2. 2. Unwarranted Variation in Health Care Delivery and the Struggle for Reform Aligning Incentives for Patient Engagement Washington D.C. May 24, 2013 John Wennberg
  3. 3. The Research in a nutshell In Health Care, Geography is Destiny Medical practice occurs within a local context: Per capita expenditures, resource use and utilization vary extensively among regions, communities and health care organizations.
  4. 4. The Research in a nutshell In Health Care, Geography is Destiny Medical practice occurs within a local context: Per capita expenditures, resource use and utilization vary extensively among regions, communities and health care organizations. Much of this variation is unwarranted: It isn’t explained by illness, evidence-based medicine or patient preferences. The causes and remedies of unwarranted variation differ according to the category of care.
  5. 5. Preference-Sensitive Care • Involves tradeoffs -- more than one treatment exists and the outcomes are different • Decisions should be based on the patient’s own preferences – On the ethic of informed patient choice • But provider opinion often determines which treatment is used
  6. 6. Boston New Haven
  7. 7. 1.00 0.0 0.5 1.0 1.5 2.0 2.5 RatioBoston/NewHaven Same Boston vs. New Haven for selected common procedures 1.48 1.75 2.33 Boston higher 0.49 0.65 0.70 Boston lower
  8. 8. The Dartmouth Atlas Project: 306 Hospital Referral Regions Ongoing Study of Traditional Medicare Population USA
  9. 9. Knee replacement per 1,000 Medicare enrollees 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 1992 2000 2007 Red dot = US average: 4.0 5.4 8.6
  10. 10. Relationship between rates of knee replacement per 1,000 Medicare enrollees in 1992 and 2007 0.0 4.0 8.0 12.0 16.0 0.0 4.0 8.0 12.0 16.0 Knee replacement (1992) Kneereplacement(2007) R2 = 0.62
  11. 11. Determining the Need for Hip and Knee Arthroplasty: The Role of Clinical Severity and Patients’ Preferences • . . . Among those with severe arthritis, no more than 15% were definitely willing to undergo (joint replacement), emphasizing the importance of considering both patients’ preference and surgical indications in evaluating need and appropriateness of rates of surgery
  12. 12. Which Rate is Right? Medical Necessity = clinically appropriate + informed patient choice
  13. 13. Which Rate is Right? Medical Necessity = clinically appropriate + informed patient choice Informed patient choice is an ethical imperative for uncovering “true” demand for surgery & learning which rate is right.
  14. 14. Which Rate is Right? Medical Necessity = clinically appropriate + informed patient choice Informed patient choice is an ethical imperative for uncovering “true” demand for surgery & learning which rate is right. In the absence of informed patient choice, surgeons are at risk for operating on the wrong patient: on patients who preferred another treatment.
  15. 15. Which Rate is Right? Medical Necessity = clinically appropriate + informed patient choice Informed patient choice is an ethical imperative for uncovering “true” demand for surgery & learning which rate is right. In the absence of informed patient choice, surgeons are at risk for operating on the wrong patient: on patients who preferred another treatment. Effective tools are available to improve decision quality and avoid wrong patient surgery.
  16. 16. Supply-Sensitive Care Everyday services provided mainly to patients with medical (non-surgical) conditions: physician visits, referrals to specialists, MRIs, laboratory tests, screening exams and hospitalizations, and stays in ICUs
  17. 17. Supply-Sensitive Care Everyday services provided mainly to patients with medical (non surgical) conditions: physician visits, referrals to specialists, MRIs, laboratory tests, screening exams and hospitalizations, and stays in ICUs At issue is the frequency of use of such care, particularly in managing chronic illness over time: “Which rate is Right?”
  18. 18. Supply-Sensitive Care Everyday services provided mainly to patients with medical (non surgical) conditions: physician visits, referrals to specialists, MRIs, laboratory tests, screening exams and hospitalizations, and stays in ICUs At issue is the frequency of use of such care, particularly in managing chronic illness over time: “Which rate is Right?” Supply-sensitive care accounts for most of the more two-fold variation in Medicare spending among regions.
  19. 19. Boston New Haven
  20. 20. Hospital resources invested in health care of Bostonians compared to New Havenites Resources Ratio: Boston to New Haven Beds per 1,000 1.55 Employees per 1,000 1.89 Per capita Spending 1.87
  21. 21. Standardized hospital discharge rates for medical conditions: Boston and New Haven region (1994-95) (Discharge ratio: Boston/New Haven in black) Figure 8.2 1.64 1.14 1.66 1.58 1.72 2.17 1.52 1.89 3.06 1.50 0.0 0.5 1.0 1.5 2.0 2.5 AllMedical Discharges Uncomplicated Pneumonia Heart Failure Gastro- enteritis Cellulitis COPD Diabetes Kidney&Urinary TractInfections Bronchitis &Asthma Angina Pectoris RatiotoU.S.average(1994-95) Boston New Haven :
  22. 22. Hip Fracture R2 = 0.06 All Medical Conditions R2 = 0.54 0 50 100 150 200 250 300 350 400 1.0 2.0 3.0 4.0 5.0 6.0 Acute Care Beds DischargeRate Association between hospital beds per 1,000 and discharges per 1,000 among Medicare Enrollees: 306 Hospital Regions
  23. 23. R2 = 0.49 NumberofVisitstoCardiologists 0.0 0.5 1.0 1.5 2.0 2.5 0.0 2.5 5.0 7.5 10.0 12.5 15.0 Number of Cardiologists per 100,000 Association between cardiologists and visits per person to cardiologists among Medicare Enrollees: 306 Regions
  24. 24. A behavioral interpretation of variation in frequency of use of supply-sensitive care • The frequency of use is governed by the assumption that resources should be fully utilized, i.e. that more is better. • Specific medical theories and medical evidence play little role in governing frequency of use.
  25. 25. Supply-Sensitive Care Physician Visits per Decedent During Last Six Months of Life Among Patients Assigned to Academic Medical Centers (2010 deaths) 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 Cedars-Sinai Medical Center 72.6 NY-Presbyterian Hospital 39.1 Mass. General Hospital 34.7 Brigham & Women's Hospital 31.5 Beth Israel Deaconess 30.3 Boston Medical Center 29.2 UCSF Medical Center 28.3 Mayo Clinic-St. Mary's 21.3 Scott & White Memorial Hosp 19.8 NYU Langone Medical Center 58.5 Ronald Reagan UCLA Med Ctr 49.7 Mount Sinai Hospital 49.1
  26. 26. A behavioral interpretation of variation in frequency of use of supply-sensitive care • The frequency of use is governed by the assumption that resources should be fully utilized, i.e. that more is better. • Specific medical theories and medical evidence play little role in governing frequency of use. • In the absence of evidence and under the assumption that more is better, available supply governs frequency of use.
  27. 27. Which Rate is “Right”? More frequent use of supply-sensitive care isn’t resulting in better outcomes:
  28. 28. Which Rate is “Right”? More frequent use of supply-sensitive care isn’t resulting in better outcomes: • More than two-fold variation in frequency of use is uncorrelated with prevalence of severe chronic illness and with outcome measured by mortality.
  29. 29. Which Rate is “Right”? More frequent use of supply-sensitive care isn’t resulting in better outcomes: • More than two-fold variation in frequency of use is uncorrelated with prevalence of severe chronic illness and with outcome measured by mortality. • Technical quality of care tends to be better in low use regions.
  30. 30. Which Rate is “Right”? More frequent use of supply-sensitive care isn’t resulting in better outcomes: • More than two-fold variation in frequency of use is uncorrelated with prevalence of severe chronic illness and with outcome measured by mortality. • Technical quality of care tends to be better in low use regions. • Patients rank their hospital experiences higher in low use regions.
  31. 31. Which Rate is “Right”? More frequent use of supply-sensitive care isn’t resulting in better outcomes: • More than two-fold variation in frequency of use is uncorrelated with prevalence of severe chronic illness and with outcome measured by mortality. • Technical quality of care tends to be better in low use regions. • Patients rank their hospital experiences higher in low use regions. • Care coordination is better in low use regions.
  32. 32. Which Rate is “Right”? More frequent use of supply-sensitive care isn’t resulting in better outcomes: • More than two-fold variation in frequency of use is uncorrelated with prevalence of severe chronic illness and with outcome measured by mortality. • Technical quality of care tends to be better in low use regions. • Patients rank their hospital experiences higher in low use regions. • Care coordination is better in low use regions. • End of life care is less aggressive in low use regions.
  33. 33. Supply-Sensitive Care Percent of Deaths Associated with ICU Admission Among Patients Assigned to Academic Medical Centers (2010 deaths) 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 Boston Medical Center 27.8 NYU Langone Medical Center 23.8 UCSF Medical Center 22.7 Beth Israel Deaconess 22.2 Brigham & Women's Hospital 19.4 Mass. General Hospital 17.9 Mount Sinai Hospital 17.0 Mayo Clinic-St. Mary's 16.8 NY-Presbyterian Hospital 16.2 Scott & White Memorial Hosp 15.7 Ronald Reagan UCLA Med Ctr 40.6 Cedars-Sinai Medical Center 38.2
  34. 34. Conclusion: Song et al. The use of clinical or claims-based diagnoses in risk adjustment may introduce important biases in comparative effectiveness studies, public reporting and payment reforms. Conclusion: Welch et al. There is an inverse relationship between regional frequency of diagnosis and the case fatality rate for chronic conditions. Conclusion: Wennberg et al. Adjusting for illness using HCCs, Iezzoni chronic illness and Charlson co- morbidity index make regions with high visit rates seem to have lower mortality and lower costs and visa versa.
  35. 35. Visits per person L6M ASR Mortality/ 1000 HCC Mortality/ 1000 Percent change Mortality Miami 58 52 33 -37% Minneapolis 20 43 55 +28% Illness adjusted regional mortality rate using HCC scores in regions with high and low visit rates among 306 HRRs
  36. 36. Dartmouthatlas.org Thank You!!!!!

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