The architects of ACO describe them as needing to have three characteristicsThe ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care;The capability of prospectively planning budgets and resource needs; andSufficient size to support comprehensive, valid, and reliable performance measurement. ? The new law authorizes Medicare to contract with Accountable Care Organizations—or ACOs—in order to find ways to deliver high-quality care while, according to the Congressional Budget Office, saving an estimated $5 billion in spending in the first eight years. ACOs don’t exist yet but they are envisioned to be a network of physicians and providers who are incented work together to deliver high quality, high value care. By providing financial incentives to coordinate care and measure performance against scientifically based outcomes, there is every reason to believe that the cost curve could be bent. 8 Health Affairs, Accountable Care Organizations, July 27, 2010.Devers, K., Berenson, R. “Can Accountable Care Organizations Improve the Value of Health Care by Solving the Cost and Quality Quandry?” http://www.rwjf.org/files/research/acobrieffinal.pdf p. 2
iHT² Health IT Summit in New York 2012 - Opening Keynote "The Changing Health Environment in Health Reform"
The Changing Environmentin Health Reform John R Lumpkin MD MPH SVP & Health Care Director Robert Wood Johnson Foundation
Victory awaits him who has everything in order – luck people call it. Defeat iscertain for him who has neglected to take necessary precautions in time; this is called bad luck Roald Amundsen, Norwegian polar explorer
Why was health reform on the National agenda in 2009? The same reason why health reform is on today’s agenda:
Insurance Matters • Medicaid expansion • 90,000 applied • 10,000 enrolled via lottery • Outcomes • Higher use of preventive services • Better physical and mental health • Less medical related debt
The system was/is broken: Insurance market concerns • Pre-existing conditions • Denial of coverage • Retroactive denial of coverage • Excessive rating gradients • Annual and lifetime limits
Basics of Health Reform Insurance Market reforms Insurance works best if the risk pool is large Allowances for the working poor
2014 Coverage Expansion • Protects consumers in the insurance market • Requires individuals to purchase insurance • Requires employers to purchase insurance • Creates health insurance exchanges • Provides subsidies • Expands Medicaid
Coverage Expansion Categories Medicaid Premium Expansion Subsidy 138% 400% Medicaid Subsidy $29,326 $88,000 Family Family of Of Four Four 0 100 200 300 400 500 Federal Poverty Level
Supreme Court Decision• Individual mandate constitutional• Medicaid expansion constitutional, but now a state option
Supreme Court Decision Supreme Court decision Total Expansion = 32 Million Exchange Medicaid 15M 17MSources: Urban Institute analysis, HIPSM 2011.
The Future is already here, it is not very evenly distributed. William Gibson - 1993
Average Annual Contributions to Premiums for Family Coverage, 1999-2011 $15,073* $13,770* $13,375* $12,680* $12,106* $11,480* $10,880* $9,950* $9,068* $8,003* $7,061* $6,438* $5,791* Estimate is statistically different from estimate for the previous year shown (p<.05).Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011.
Cumulative Percent Change in National Health Expenditures, by Selected Sources of Funds, 2000-2010 Medicare MedicaidSource: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National HealthStatistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and sourceof funds, CY 1960-2010; file nhe2010.zip).
Healthy Life Expectancy at Age 60, 2007 Developed by the World Health Organization, healthy life expectancy is based on life expectancy adjusted for time spent in poor health because of disease and/or injury Years 30 Women Men 22 21 21 21 21 20 20 20 20 20 20 20 20 20 19 19 19 20 18 18 18 19 19 19 19 18 18 18 18 18 17 16 17 18 17 16 17 17 17 18 17 17 17 16 16 16 15 10 0 ria es ly n m ay l s lia k m ce n d y ic d da nd e en d nd ga nd ar an ai ec an an pa an Ita iu do bl st at ra an rw na la ed Sp rtu nm la la pu lg m re nl el Ja St Au al st Ire ng er Fr No Sw Ca er Ic er Be Fi G Po Ze Au De Re d it z Ki th G ite w Sw Ne d h Un Ne ec ite Cz UnData: Provided by C. Mathers. Unpublished data set consistent with HALE estimates published inWorld Health Statistics 2009 (Geneva: World Health Organization).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
Mortality Amenable to Health CareDeaths Avoidable Through Health Care:Nolte & McKee – Health Affairs August 29, 2012
EXHIBIT 16 Medical, Medication, and Lab Errors Percent of adults reported medical mistake, medication error, or lab error in past two years 40 32 30 28 26 22 23 20 18 19 16 10 0 NETH FRA GER UK NZ CAN AUS USSicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized orhad major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=NewZealand; UK=United Kingdom; US=United States.Data: 2008 Commonwealth Fund International Health Policy Survey.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
Test Results or Records Not Available at Time of Appointment Percent of adults reported test results or records were not available at time of appointment in past two years 30 23 20 18 18 15 15 15 13 10 9 0 NETH GER AUS FRA UK CAN NZ USSicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized orhad major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=NewZealand; UK=United Kingdom; US=United States.Data: 2008 Commonwealth Fund International Health Policy Survey.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
We have run out of money, it is time to start thinking. Ernest Rutherford (1871-1937) Nobel Laureate
Six Drivers of Excess Cost Six Drivers of Excess Cost Driver Examples Excess cost Unnecessary services Defensive medicine, overuse $210 B Inefficient services Mistakes, duplication $130 B Excess administrative Administrative inefficiencies $190 B costs by payers and providers Prices higher than Prices that are too high $105 B competitive benchmarks Missed prevention Missed screenings and $55 B opportunities condition monitoring Fraud Payer, provider, patient fraud $75 BSource: Institute of MedicineBetter Care at Lower CostSeptember, 2012
Accountable Care Organizations Ability to provide care and manage patients across the continuum of care Capability to prospectively plan budgets and resource needs Sufficient size to support comprehensive, valid, and reliable performance measurement• 33 measures • Patient experience • Care coordination/safety • Preventive health • At-risk populations
Clinical Re-Engineering• Improved care coordination and communication• Improved access – physician extenders – email – phone call etc.• Prevention and early diagnosis• ED and Immediate Care Center visits• Increase generic medication utilization• Hospital re-admissions and multiple ED visits• Improved management of complex patients • Care Coordination • High Resource Utilizers
Current practice depends upon the clinical decision-making capacity and reliability ofautonomous individual practitioners, for classesof problems that routinely exceeds the bounds of unaided human cognition Daniel R. Masys, M.D. 2001 IOM Annual Meeting
Complexity Clinical Complexity• Physicians in private practice interact with as many as 229 other physicians in 117 different practices just for their Medicare patient population• ICU clinicians have 180 activities per patient per day• Chronic disease: a 79 year old patient with osteoporosis, osteoarthritis, type 2 diabetes, hypertension, and chronic obstructive pulmonary disease: 19 medications per day
The Vision New Tools• Computing Power• Connectivity• Improvements in organizational capabilities• Collaboration between teams of clinicians and with patients
The Future Big data • Predictive Modeling • Next infectious disease hot spot in hospital? • How will utilization change with Medicaid expansion in ACA? • How to predict patient demand to minimize use of contract nurses? Liberated data Patient generated data Advanced sensors
The Future Big data • Predictive Modeling • Next infectious disease hot spot in hospital? • How will utilization change with Medicaid expansion in ACA? • How to predict patient demand to minimize use of contract nurses? • Hot spotting Liberated data Patient generated data Advanced sensors
Key findings Health IT can improve patient safety in some areas such as medication safety; however, there are significant gaps in the literature regarding how health IT impacts patient safety overall Safer implementation and use begins with viewing health IT as part of a larger sociotechnical system All stakeholders need to work together to improve patient safety Slide 55 of 23
Current state of health IT Literature has shown that health IT may lead to safer care and/or introduce new safety risks Magnitude of harm and impact of health IT on patient safety is not well known because: – Heterogeneous nature of health IT products – Diverse impact on different clinical environments and workflow – Legal barriers and vendor contracts – Inadequate and limited evidence in the literature Slide 56 of 23
Recommendations: SummaryCurrent market forces are not adequately addressing thepotential risks associated with use of health IT.All stakeholders must coordinate efforts to identify andunderstand patient safety risks associated with health IT by: Facilitating the free flow of information Creating a reporting and investigating system for health IT– related deaths, serious injuries, or unsafe conditions Researching and developing standards and criteria for safe design, implementation, and use of health IT Slide 57 of 23
Deadly OveruseDisease XSevere case mortality 50% 100 cases – 50 dieTreatment Y 50% to 25% 100 cases – 25 die Fatality rate 10% 100 cases – 35 dieNew test10% are severe 100 cases – 5 dieWith Treatment 100 cases – 12 die
Deadly OveruseDisease XSevere case mortality 50% 100 cases – 50 dieTreatment y 50% to 25% 100 cases – 25 dieFatality rate 10% 100 cases – 35 dieNew test10% are severe 100 cases – 5 dieWith Treatment 100 cases – 12 die Standard diagnosis with treatment 30% reduction Enhanced diagnosis with treatment 140% increase