Transcript Slide 1

The Foreseeable Technological
Advancements, Clinical Expectations and
Financial Challenges in Diagnostic Imaging
Tibor Duliskovich, M.D.
Enterprise Imaging Informatics, Philips Healthcare
March 26th, 2010 - Association of University Radiologists
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Agenda
Philips Academic Faculty Development Program
• Introduction of the speaker
• Let’s ignore the economic realities and consider what is theoretically possible:
– Medical Device Development Cycle
– Technology of radiology in 2030
– Major evolutionary and revolutionary trends
– Clinical expectations of medical field from imaging in 2030
– Practicing radiology in 2030
• Let’s adjust for possible consequences of global economic crisis and recent
reimbursement changes in USA.
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do
not necessarily reflect the official policy or position of his employer or of the little green men that have
been following him yesterday. The presentation contains forward-looking statements that are based on
limited publicly available information and current expectations and certain assumptions of presenter,
and are, therefore, subject to certain risks and uncertainties. Should one or more of these risks or
uncertainties materialize, or should underlying assumptions prove incorrect, actual results may vary
from those described in the presentation. The author does not intend or assume any obligation to
update or revise these forward-looking statements in light of developments which differ from those
anticipated.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Introduction of the speaker
• Dr. Tibor Duliskovich
• Radiologist, member of Philips
Healthcare Medical Leadership Team
• Sr. Product Manager, Enterprise
Imaging Informatics, Philips Healthcare
• 4100 E. Third Avenue, Suite 101, Foster
City, California 94404
• Direct line: +1 (650) 293-2371
• Cell: +1 (650) 740-9459
• E-mail: [email protected]
• Website: www.duliskovich.com
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Tapping into collective wisdom of Diagnostic
Imaging Group on LinkedIn
Click to see RAW
data from the survey
• http://www.linkedin.com/e/gis/80424/5905C51D2283
• 4800 medical imaging professionals, radiologists, imaging vendors
employees, healthcare research and clinical IT specialists across the
globe.
• Focused on radiology, modalities, medical devices, image processing,
image-guided intervention and treatment, CAD, PACS, 3D, DICOM,
HL7, IHE.
• 70 responders who fully completed the survey in time to count in
• A dozen follow up calls performed
• If you are reading this presentation – you are welcome to join!
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Fundamental Principles of a Physician Behavior
• Principle of Primacy of Patients' Welfare
This principle is based on a dedication to serving the interest of the
patient. Altruism contributes to the trust that is central to the physicianpatient relationship.
• Principle of Patients' Autonomy
Physicians must have respect for patients' autonomy. Physicians must
be honest with their patients and empower them to make informed
decisions about the course of their treatment.
• Principle of Social Justice
The medical profession must promote justice
in the healthcare system, including the fair
distribution of finite healthcare resources.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Product Creation Process
Process Zero
Strategy Deployment
Project Realization Process
New Product Introduction
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Process Zero
Exploring
Creative
Idea
Generation
Technology
scouting.
Selection
Know-how
generation
Conception
Tibor Duliskovich dr., Philips Healthcare, EII.
Clinical
Opportunities
Feasibility
Comparative
Effectiveness
Insights
validation
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Product Creation Process
Process Zero
Strategy Deployment
Project Realization Process
New Product Introduction
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Strategy Deployment
Alignment
with
Business
Strategy
Roadmapping
Resource
Planning
Project
Portfolio
Opportunity
Creation
Tibor Duliskovich dr., Philips Healthcare, EII.
Enhancements
via Mergers
and
Acquisitions
Requesting CPT Codes,
Affecting Policies,
working with payers
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Product Creation Process
Process Zero
Strategy Deployment
Project Realization Process
New Product Introduction
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Product Realization Process
Product
Proposal
Transfer to
Manufacturing
Verification
Design,
Prototyping
Validation
Tibor Duliskovich dr., Philips Healthcare, EII.
Product
Life-cycle
Management
Regulatory
Approvals
March 26th, 2010 at Annual Meeting of Association of University Radiologists
Intellectual
Property,
Trademarks
11
Product Creation Process
Process Zero
Strategy Deployment
Project Realization Process
New Product Introduction
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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New Product Introduction
Marketing
Activities
Knowledgebase
transfer within
Company, etc.
Documentation
Professional Organization
Engagement
Tibor Duliskovich dr., Philips Healthcare, EII.
Training
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Clinical Trends Roadmap:
Clinical Adoption Curve
Innovators
(1)
14
Early Adopters
(2)
Tibor Duliskovich dr., Philips Healthcare, EII.
Consensus
Adopters (3)
Cautious
Adopters (4)
March 26th, 2010 at Annual Meeting of Association of University Radiologists
Late
Adopters (5)
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Medical Devices Industry Specifics
• Highly regulated, mainly to ensure safety
and effectiveness of the devices.
• FDA wants to further „strengthen” 510(K)
process (see next slide).
• Lengthy development cycle, years before
you see results of your work out in the
field.
• Very expensive to introduce a novelty,
disruptive technology to market.
• Needs clinical proof points to be
successful, marketing alone is not enough.
• Different realities in different countries,
can’t expect to be relevant globally.
• Short-term political horizon in conflict with
long-term disease life cycle.
• Increasing cost of research but decreasing
budgets.
Tibor Duliskovich dr., Philips Healthcare, EII.
Diagnostic Imaging Group
on LinkedIn
35
30
25
20
15
10
5
0
1Y
2Ys
3Ys
5Ys
7Ys
10Ys
Develop idea into commercial product
Perform a clinical trial
Wide-spread adoption of new tech in the market
Entire cycle from idea to widespread adoption
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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„Strengthening” of 510(K) process by FDA
• FDA stated: “The basis for the 510(k) process is a determination regarding substantial
equivalence to a predicate device. How can the program effectively and efficiently evolve
if devices from 1976 set the bar for comparison? How can the agency deal with predicate
devices with sub-par performance compared to the other devices in the class? Sponsors
often pursue and get clearance for a “narrow” claim when it is obvious they’re interested in
something else.” - among other challenges.
• New technologies - when do they raise a different type of safety and effectiveness
question? Evidence needed?
– Bench studies
– Animal studies
– Human clinical trials- most often needed when:
•
•
•
We can’t predict the outcome
Changes might alter clinical effectiveness
Might lead to a new clinical practice
• Examples of situations when clinical studies may be needed:
– Nanotechnology - may impact safety and effectiveness, or the impact of the change
may be unknown
– Algorithms - statistical modeling where calculations are used to provide clinical
diagnosis, screening, etc.
• Approximately 80% of US medical device companies have fewer than 50 employees and
98% have fewer than 500 employees. Additional regulatory requirements currently being
proposed by FDA will translate into additional expenses.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Evolutionary changes expected
• Higher resolution images (NM, PET, MRI, US), however rad images account for
less than 30-40% of total image volume generated in a large hospital.
• Better signal/noise in images (across the board, maybe except PET)
• Larger dynamic range (bit depth) of images (NM, US, MRI)
• Lower dose to patient and personnel (CT, X-rays, NM, dual-energy)
• More cines versus still images (MRI, US)
• More functional and physiological data vs morphological (MRI, CT, NM)
• Combining multiple modalities into one (PET/CT/US)
• Enterprise Informatics and interfaced systems (DICOM API, HL7, etc.)
• Point-of-care imaging (US)
• Cheaper HW/SW product (across the board)
• Sophisticated CAD (across the board)
• Volumetric acquisitions (US, thomosynthesis)
• Informatics driving workflow changes
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Evolutionary changes expected
X-rays
50
Higher resolution
images
Visual light
40
Mammo
30
Better
signal/noise in
Dual-energy
images
20
CT
10
Larger dynamic
range (bit depth)
of images
0
Lower dose D.
to Pathology
patient and
personnel
More cines
versus still
images
MRI
PET
Tibor Duliskovich dr., Philips Healthcare, EII.
US
March 26th, 2010 at Annual Meeting of Association of University Radiologists
NM
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Evolutionary changes expected
X-rays
More functional
and
Visual light
physiological
data vs
morphological
Combining
multiple
modalities into
Dual-energy
one
50
40
Mammo
30
20
CT
10
Point-of-care
imaging
0
Cheaper HW/SW
D. Pathology
product
Sophisticated
CAD
MRI
PET
Tibor Duliskovich dr., Philips Healthcare, EII.
US
March 26th, 2010 at Annual Meeting of Association of University Radiologists
NM
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30
Technological advancements
Human-machine interaction
25
20
15
• Presentation of images/volumetric datasets 10
5
in holographic way on 3D screens.
0
• Volumetric reading with tactile feedback
1, Agree 2
3,
4 5, Disagree
of navigation devices.
Undecided
• Eye movement driven human-machine interaction.
• Speech-driven GUI. Thought recognition?
• For digital pathology – a navigation tool resembling microscope
controls.
• Merging multiple screens in OR into one big with intelligent behavior.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Technological Advancements
Safety
• Radiation management of patient.
• Radiation management of personnel.
• Safety - easier to design/implement safety guards into product (need to
convince a few dozen manufacturers) rather than mitigate safety issues
via training of thousands of end-users at sites.
• ALARA, just enough image quality to answer the clinical question.
• Detectors with higher DQE.
• Ionizing radiation slowly loosing grounds in diagnostics.
• 3-7 Tesla magnets to improve signal to noise ratio and allow for
functional neuroimaging and susceptibility-weighted MR imaging.
• Whole body imaging.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Right Viewer at the Right Time
30
Technological Advancements
IT improvements
25
20
15
10
• „Right viewer at the right time” – launch the software
that provides optimal viewing experience and tools
for a specific type of exam.
• „Enterprise application” concept.
• Language barrier going extinct by improved
structured reporting.
• UI harmonization (today industry prescribes the UI
for portable media, tomorrow it will across vendors)
• Thin vs thick client (OS independence, centralized
management, security, privacy)
• Time zone mismatch when modality, PACS,
radiologist, printers, RIS are in different time zones.
• CDS as mandatory “second opinion”
• CAD will not only analyze the current exam, but also
provide retrospective analysis from country-wide
databases. CAD will ask "Are you certain it is ...?
Look at this almost identical case it has been
histologically proven to be XYZ”.
Tibor Duliskovich dr., Philips Healthcare, EII.
5
0
1, Agree
2
3,
4 5, Disagree
Undecided
Structured reporting
25
20
15
10
5
0
1, Agree
2
3,
4 5, Disagree
Undecided
CDS as second opinion
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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CAD replacing rad in screening
Technological Advancements
IT improvements
• CAD replacing radiologist in screening
• Privacy regulations (HIPAA) allow for retrieval of
information from non-associated institution.
• Unique patient ID (master index) a must
• Implantable chip with entire electronic patient record
on it
• Web-based medical history (my own experience)
• Open source applications gain market share
• Clinical Decision Support - aggregating data from
multiple sources to provide care givers with a
personalized view of clinical patient information
(Dashboard) and enable them to make better
informed decisions.
• Cloud radiology (outsourced storage, managed
applications)
Tibor Duliskovich dr., Philips Healthcare, EII.
Master Patient Index
Implantable chip with EHR
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Web-based electronic medical record
My own experience
•
http://www.healthvault.com/
•
http://www.google.com/intl/en/health/whatsnew.html
•
•
Only one of my various providers was listed (Quest Diagnostics – thank you!)
Step 1. – create account. Problem – zero records. Step 2. – Contact Quest „I am a physician and have
paper copies of my lab results, but wanted to populate my EHR record automatically. Currently live in
California”.
„... unfortunately Florida Laboratory Regulations prohibit laboratories from releasing results to patients
without written authorization from the ordering physician. I understand your frustration but ...”
No way to import XML EHR.
Expect massive data breaches as more systems become interconnected.
•
•
•
•
•
http://en.wikipedia.org/wiki/List_of_open_source_healthcare_software
27 open source electronic health record SW
http://www.idoimaging.com/index.shtml
256 free imaging applications
Trademarks referenced herein are the property of their respective owners.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Workflow enhancements
• Facility changes - There is a convergence of
surgical and medical imaging with less invasive
procedures that rely more on image guidance.
The physical environment must anticipate this and future collaboration.
Hybrid OR Suite is the best example.
• Numerous studies on increased volume of interpretations by rads, this
requires radical changes to ergonomics of reading space.
• In the past, radiologists took breaks in the day as they searched/waited
for films or consultations. With PACS, images are read as they come in
and there is little opportunity for breaks.
• If a CT scanner is 300 feet from an elevator, it takes longer for the
patient to get to and from the scanner and on and off the table than it
does to take to perform the exam.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Current Challenges
... and Many More...
• Reimbursements are down.
• Most countries have „sickcare", not
healthcare, where reimbursement is
for amount of work not patient outcomes.
• Population getting older and expecting not just live, but live actively.
• Geographical mismatch of where radiologists are and where exams are
performed.
• The supply of radiologists to provide interpretations has remained
relatively constant while imaging volumes increased.
• Radiologists lack formal business and leadership training, which may be
contributing to increased move from private practices into paying jobs.
• Commoditization of radiology interpreting (bidding wars).
• Turf battles, erosion of trust. Congress is budget neutral – other
„ologies” benefit from cuts in radiology and cardiology domain.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Revolutionary disruptive trends
•
•
•
•
•
•
•
•
•
•
•
•
•
Transform serial events into parallel to shorten the care cycle (remember co-morbidities).
Event anticipation through live, imaging-based monitoring (by implantable devices?) and preventive
intervention to avoid the worst case scenarios.
Patient becoming member of medical team – improving outcomes and quality of life. Personal
responsibility for health record.
Patient needs to learn about one disease only, not thousand, so they are more knowledgeable than
their doctors about their conditions. Already majority of patients are researching their disease on web.
Decentralization of imaging – think blood pressure monitors in retail health clinics (currently around
1100 in US and growing). Imaging performed by radiologist extenders (rad assistants).
Improving continuity of care, communicating the information into patient health record, actually affecting
the actions of physicians.
Point-Of-Care-Diagnostics will be considered part of main radiology, so mistakes will cost license or
result fines to hospital (just like the POCT today)
General imaging and radiology services becoming commodity.
Radiologist’s hands will be even more bound by enforcement of
standardized clinical pathways and procedures
Disclosure of errors and performance statistics publicly available
CPT code for e-mail or IM exchange between patient and rad
Personalized codes for patients to access their own exams in
PACS systems. It would become a norm to expect a copy of
images and results.
mHealth = mobile health apps
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Radiology as profession
Radiologists
• Radiologists will be divided into
– Multi-disciplinary, specific disease or
clinical area focused imaging specialists
– Generic radiologists
– Narrowly sub-specialized imagers
– Preventive screening imagers employed
by companies and communities
• Hospitals depending on size:
– Small ones will be outsourcing
Rad communicating results to patient
– Medium will have in house expertise
– Large institutions, military, countries
will be insourcing on temp basis
– Imaging departments will become a
dispatcher of incoming patients
• Patient’s expectations:
– Making decisions about their health
– Direct communication of results by radiologist
– Radiologists admitting diagnostic mistakes, warranty of services
– Consumer-oriented marketing of radiology services. Educating consumers.
28
– Public-ranked performance. Expertise locator. Crowd wisdom.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Clinical Expectations
Clinicians vs. Patients
• Clinicians:
– Closed loop imaging (optimal exam protocols selected for clinical question) to avoid
repeat exams and maximize cost/health benefit.
– Rads co-responsible for collecting anamnesis, selecting course of therapy, verifying
response to therapy, image-guided targetted drug delivery.
– Rads exercising self-control and limiting or extending services.
– Integrate quantitative analysis into the image interpretation process (no more
„probable”, „possible” - 11.5% this and 45.1% that).
– Physiological, not just morphological information (tumor angiogenesis rates, oxygen
utilization, metabolic rates with hyperpolarized C13, chemotherapy response,, etc.)
– Turning clinical data into information and information into knowledge and actionable
insights.
– Augmenting imaging with POC testing for biomarkers as part of imaging procedure
– Analogy with photographer - everybody is a photographer these days.
• Patients:
– Patients know more about their diseases, they will pressure family docs to order
newest exams - importance of educating the patients.
– Patient become member of care team via POCT.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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CDS loops throughout radiology
Slide content removed per request from the Company.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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What can we do to maximize benefit to society?
•
•
•
•
•
Advocate fairness in the distribution of acceptable and legitimate
care that confirms to patient and social preferences regarding
accessibility, the patient-practitioner relation, the amenities, the effects
of care, and the cost of care.
Apply evidence-based medicine principles to figure out the most
advantageous balance of costs and health benefits to ensure
sustainable medical coverage.
Provide evidence-based guidelines to ordering physicians about
appropriateness of any requested imaging procedure based on the
clinical indications, and enforce those guidelines. This should consider
co-morbidities and risks/benefits.
Empower patients, reduce the perceived examination stress, provide
prompt access to relevant information about their health, assist in their
health choices via communication and education.
Coverage with Evidence Development (CED) - an evolving method
of providing provisional access to novel medical interventions while
generating the evidence needed to determine whether unconditional
coverage is warranted.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Potential future trends
• The right viewer at the right time = the right radiologist - find the best
expertise available - teleradiology, outsourcing, insourcing.
• Specialty expensive diagnostics may concentrate in places where the
care is provided as a result of medical tourism, driving rads to relocate.
• Business model innovation will be vital, not just product innovation!
• Expansion into new markets
• Expansion of roles - the Radiology Practitioner will become an essential
role due to expanded utilization of services and a reduction in
reimbursement. Radiology Practitioner and Physician Assistant are
"physician extenders." The Radiology Practitioner will be performing and
interpreting exams. Radiologist will be providing value-add interpretation
or intervention/therapy planning services.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Potential future trends
• Trend toward sophisticated zero-wait personalized best-of-class
radiology services for self-paying patients or people with special
insurance coverage.
• „Baseline” level services, portioned and capitated in line with availability
of resources for average insurance. CAD playing more significant role in
diagnostics and screening for this group. Used equipment, generic
contrast agents, rule-based imaging protocols.
• Direct marketing to patients who are able to pay for services out-ofpocket.
• Paying attention to basics: quality, usability, ease of use, reliability,
uptime through the entire lifecycle of the systems to reduce TCO.
• 85% of global population leave in emerging markets. Cannot copy and
paste western medicine into emerging markets - cultural anthropology.
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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US Economic Environment (March 21st, 2010)
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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The Value Environment in Healthcare Most countries have “sickcare”
Unsustainable Economics
Single payer system is better
than multiple payer system
25
20
15
10
5
0
1, Agree 2
3,
45, Disagree
Undecided
Roughly 50% of health care is publicly financed in the US, driving demand for a
systematic approach to value analysis financed by the federal government
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
National Health Expenditures per Capita
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
36
Medicare Spending on Imaging 2000-2007
Expenditures per beneficiary in dollars
450
$419
$392
400
$353
350
$303
300
250
$375
$255
$268
$220
200
150
100
50
0
2000
2001
2002
2003
2004
2005
2006
2007
Year
Total imaging expenditures
Other imaging expenditures
Advanced imaging expenditures
Source: http://www.gao.gov/new.items/d081102r.pdf
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Key themes in US Healthcare reform
• Contribution from industry will pay for half of the bill (500 billion over next 10
years, 20 billion from medical devices industry, incl. imaging companies).
• Increase coverage from 85% to 95% (app. 30-40 million additional individuals
covered, including pre-existing conditions and kids up to age 26).
• Bending the cost curve, slow the growth rate. CMS and federal agencies will
have authority to experiment with payment and system delivery models and also
to extend the successful models without additional legislation approval.
Rationing of care.
• Cut unnecessary spending due to inefficiencies and financial incentives
misplaced in the system (self-referral, defensive medicine, demand by patients,
transparency of conflict of interests)
• Comparative effectiveness research
• Focus on value
• Missed opportunities - lack of scrutiny of malpractice
reform
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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Drivers of Increased Demand for Evidence and
Value-based Purchasing
Unsustainable
Growth in
Health Care
Expenditures
Increased
Demand for
Evidence
and Value
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
39
Recent policy changes align with the major drivers
for evidence generation and value-based initiatives
CONTAINING COST
IMPROVING QUALITY
DRG to MS-DRG transition
Comparative Effectiveness
Technology Assessments
Incentive Payments
Transition to Cost-Based Weights from
Physician Quality Reporting Initiative
Charge-Based
Reporting Hospital Quality Data
Prospective Payments/Bundling
Non-payment for Hospital Acquired
Conditions (HACs)/Never Events
Cost-Effectiveness
Demand for
E-Prescribing
Evidence and
Value
INCREASING TRANSPARENCY
EXPANDING ACCESS
Health Information Technology
Health Insurance Exchange
Electronic Medical Records
New Public Plan Options
E-prescribing
Subsidy Expansion in Public Programs
Health Care Claims Data
Expanding Preventative Care Services
Physician Ownership Disclosure
Expanding Telehealth Services
Tibor Duliskovich dr., Philips Healthcare, EII.
March 26th, 2010 at Annual Meeting of Association of University Radiologists
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