Transcript Document
The Case for Health System Change
Dan Rahn, M.D.
Chancellor, University of Arkansas for Medical
Sciences
What is Driving Health System
Change?
How Does the United States Compare
Health Expenditure Per Capita
Health Expenditures by Country
Health spending % of GDP in 2011:
• United States 17.7%
• Netherlands 11.9%
• France 11.6%
• OECD Average 9.3%
Health Expenditures by Country
• The United States together with Mexico and Chile are the only
OECD countries where less than 50% of health spending is
publicly financed.
• The overall level of health spending in the United States is so
high that public (i.e. government) spending on health per capita is
still greater than in all other OECD countries, except Norway and
the Netherlands.
Health Expenditures by Country
• In the United States, life expectancy at birth increased by almost
9 years between 1960 and 2011, but this is less than the increase
of over 15 years in Japan and over 11 years on average in OECD
countries. As a result, while life expectancy in the United States
used to be 1 ½ years above the OECD average in 1960, it is now,
at 78.7 years in 2011, almost 1 ½ years below the average of 80.1
years.
What is driving health system change?
What is driving health system change?
• National Research Council/IOM report
– US males and females in all age groups up to 75
years of age have shorter life expectancies and
higher prevalence and mortality from multiple
diseases, risk factors and injuries than 16 other
developed nations
• For 45 of 48 years, health care cost growth has
outstripped growth in public funds and GDP
Comparison of International Infant
Infant Mortality
Mortality Rate: 2000
Singapore
Hong Kong
Japan
Sweden
Norway
Finland
Spain
Chech Republic
Germany
Italy
France
Austria
Belgium
Switzerland
Netherlands
Northern Ireland
Australia
Denmark
Canada
Israel
2.5
3.0
3.2
3.4
3.8
3.8
3.9
4.1
4.4
4.5
4.5
4.8
4.8
4.9
5.1
5.1
5.2
5.3
5.3
5.4
5.5
5.6
Portugal
England & Wales
Scotland
5.7
Greece
6.1
6.2
6.3
Ireland
New Zealand
United States
6.9
Cuba
7.2
Deaths per 1,000 Live Births
WHY?
Multifunctional
• Health System Design and Performance
• Social Determinants of Health
Social Determinants Side
Institute of Medicine Report: Best Care at Lower Cost: The
Path to Continuously Learning Health Care in America
“Health Care in America has experienced an explosion
in knowledge, innovation, and capacity to manage
previously fatal conditions. Yet, paradoxically, it falls
short on such fundamentals as quality, outcomes, cost,
and equity. Each action that could improve qualitydeveloping knowledge, translating new information into
medical evidence, applying the new evidence to patient
care-is marred by significant shortcomings and
inefficiencies that result in missed opportunities, waste,
and harm to patients.”
If…
• If banking were like health care, automated teller machine (ATM)
transactions would take not seconds but perhaps days or longer as a
result of unavailable or misplaced records
• If home building were like health care, carpenters, electricians, and
plumbers each would work with different blueprints, with very little
coordination.
• If shopping were like health care, product prices would not be
posted, and the price charged would vary widely within the same
store, depending on the source of payment.
• If automobile manufacturing were like health care, warranties for
cars that require manufacturers to pay for defects would not exist.
As a result, few factories would seek to monitor and improve
production line performance and product quality.
• If airline travel were like health care, each pilot would be free to
design his or her own preflight safety check, or not perform one at
all.
Waste estimates
• Unnecessary Services
• Inefficiently delivered services
• Excess administrative costs
• Prices that are too high
• Missed prevention opportunities
• Fraud
Total
$210 billion
$130 billion
$190 billion
$105 billion
$55 billion
$75 billion
$765 billion
The Vision
Categories of the Committee’s Recommendations
Foundational Elements
Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery
process,
and financial data for better care, system improvement, and the generation of new knowledge.
Recommendation 2: The data utility. Streamline and revise research regulations to improve care,
promote the
capture of clinical data, and generate knowledge.
Care Improvement Targets
Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge
into care
decisions.
Recommendation 4: Patient-centered care. Involve patients and families in decisions regarding
health and health
care, tailored to fit their preferences.
Recommendation 5: Community links. Promote community-clinical partnerships and services aimed
at
managing and improving health at the community level.
Recommendation 6: Care continuity. Improve coordination and communication within and across
organizations.
Recommendation 7: Optimized operations. Continuously improve health care operations to reduce
waste,
streamline care delivery, and focus on activities that improve patient health.
Supportive Policy Environment
Recommendation 8: Financial incentives. Structure payment to reward continuous learning and
improvement in
the provision of best care at lower cost.
Recommendation 9: Performance transparency. Increase transparency on health care system
performance.
Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning
health care system.
What About Arkansas?
Arkansas’ Healthcare Population
45th in Stroke
50th in Immunization Coverage
46th in Occupational Fatalities
49th in per Capita Health Spending
43rd in Infant Mortality
42nd in Lack of Health Insurance
43rd in Obesity
45th in Children in Poverty
45th in Premature Death
45th in Physical Activity
th
48
in Overall Health
45th in Cardiovascular Deaths
41st in Adequacy of Prenatal Care
44th in Poor Physical Health Days
45th in Cancer Deaths
Source: Americas Health Rankings.org 2010
What about Arkansas?
Life Expectancy at Birth
82.0
80.0
78.0
76.0
74.0
72.0
70.0
68.0
66.0
64.0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of Death
US Males
US Females
AR Males
AR Females
Infant Mortality by Race in Arkansas
What about Arkansas?
18
2000-2010 Arkansas Resident Infant Death Rates by Race
Infant Mortality Rate
16
Total
White
Black
14
12
10
8
6
4
2
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Comparison of International Infant
What about Arkansas?
Mortality Rate: 2000
Singapore
Hong Kong
Japan
Sweden
Norway
Finland
Spain
Chech Republic
Germany
Italy
France
Austria
Belgium
Switzerland
Netherlands
Northern Ireland
Australia
Denmark
Canada
Israel
2.5
3.0
3.2
3.4
3.8
3.8
3.9
4.1
4.4
4.5
4.5
4.8
4.8
4.9
5.1
5.1
5.2
5.3
5.3
5.4
5.5
5.6
Portugal
England & Wales
Scotland
5.7
Greece
6.1
6.2
6.3
Ireland
New Zealand
United States
6.9
Cuba
7.2
Deaths per 1,000 Live Births
What about Arkansas?
Age-Specific Death Rates from Coronary Heart Disease, Arkansas & U.S.,
Aged 45-64 years, 1968 - 2010
450
400
350
45-64 age group
2005-2010, 62%
Rate per 100,000
300
250
200
150
100
50
0
CHD AR 45-64
CHD US 45-64
What about Arkansas?
Age-Specific Death Rates from Cancer, Arkansas & U.S.,
Aged 45-64 years, 1968 - 2010
350
45-64 age group
300
2005-2010, 26%
Rate per 100,000
250
200
150
100
50
0
Cancer AR 45-64
Cancer US 45-64
What about Arkansas?
Age-Specific Death Rates from Stroke, Arkansas & U.S.,
Aged 45-64 years, 1968 - 2010
120
Rate per 100,000
100
80
60
45-64 age
group
2005-2010,
54%
40
20
0
Stroke AR 45-64
Stroke US 45-64
Uninsurance
Health Outcomes
Mortality
Morbidity
Socio-Economic Factors
Educational Factors
African American Population
What are Social Determinants of Health?
Within countries, cities and communities
there are dramatic variations in health
among certain groups of people that are
closely linked to those groups
socioeconomic status
These conditions are the social
determinants of health and are defined by
the World Health Organization – diet,
exercise, tobacco, obesity
Social Determinants
Access to Health Care
Poverty
Education
Work
Leisure – diet/exercise
Tobacco
Obesity
Living
conditions/environments
Environmental toxins
Role of Poverty
Study from England and Wales (Curran,
2009)
Between 1972 – 1996 (UK had universal
health insurance)
Life expectancy of men in the highest “social
class” increased from 72 yrs in the period of
1972-1976 to 79 yrs in the period 1992-1996,
an increase of 7 years and 8%.
For this same period, life expectancy of men
in the lowest social class increased from 66
yrs to 68 yrs an increase of only 3%. The gap
widened.
Role of Education
Study conducted by Steven Woolf at VCU
(published in 2009 in JAMA). Mortality for
adults aged 25-64 varied by education
level
Some education beyond high school:
206/100,000
High school education: 478/100,000
Less than high school education:
650/100,000
Role of Education
Impact of college education on population
health - Giving Everyone the Health of the
Educated: An examination of whether
social change would save more lives than
medical advances (Woolf, et. Al., AJPH,
2007)
Using US vital statistics data from 1996-2002
Results: Medical advances averted 178,193
deaths during the study period. Correcting
disparities in education – associated mortality
rates would have saved 1,369,335 lives, a
ratio of 8:1
Impact of Health Literacy
Health Literacy and Outcomes Among
Patients with Heart Failure (Peterson, et.
al. JAMA 2011)
Retrospective review of 2156 patients with
discharge diagnosis of heart failure identified
between 2001-2008
Surveyed by mail with median follow up of 1.2
years
Health literacy assessed with a 3 question
screen tool: on a scale of 1-5
Screening Tool
How often do you have
someone help you read
hospital material?
How often do you have
problems learning about
your medical condition
because of difficulty
reading hospital
materials?
How confident are you
filling out forms by
yourself?
Screening Tool Outcomes
Score less than 10 was called low health
literacy.
Of 1494 included responders, 262 had low
health literacy. Those with LHL had a 17.6%
mortality rate during the study period
compared with 6.3% for all others, adjusted
for other illnesses, age, economic status, etc.
Overall Impact of Health Literacy of Health
Outcomes
Low Health Literacy and Health Outcomes: An
Updated Systematic Review (Berkman, et. al.,
AIM 2011)
Low Health Literacy was consistently associated
with:
More hospitalizations
Greater use of emergency care
Lower receipt of mammography screening and influenza
vaccine
Poorer ability to demonstrate taking medication
appropriately
Poorer ability to interpret labels and health messages
In elderly patients: poorer overall health status, higher
mortality rates
Race / Ethnicity
Race: inextricably
intertwined with economic
status and education but
infant mortality of black
newborns in the US is
twice as high as that of
white newborns (Woolf,
2009)
If we could eliminate racebased inequalities, five
lives would be saved for
every life saved by
medical advances
Economic Impact
“If medicine is to fulfill her great test, then she must
enter the political and social life. Since disease so
often results from poverty, physicians are the natural
attorneys of the poor and social problems should
largely be solved by them.” Rudolf Virchow, 19th
century pathologist
Our system is oriented toward assuring that those with
illness receive all available treatment rather than on
health promotion and addressing the conditions that
produce disease.
Fundamental Change
is Required
Strategies for Health System Change
• Accelerate the use of health information technology
o Health information exchange
o Telehealth
o Electronic medical records systems
• Restructure the health care payment system to improve the
quality of medical care and curb rising costs
o Arkansas Payment Improvement Initiative
o Patient centered medical homes
o Episode-based payments
Strategies for Health System Change
• Reduce the number of uninsured Arkansans
o Private health insurance exchanges (ACA)
o Arkansas Private Option for Medicaid Population
• Plan for a health care work force that provides appropriate
access to medical services particularly in underserved areas
o Health Work Force Strategic Plan
o Forty separate recommendations
A time of disruptive change but it’s not the first…
• Hill Burton Act: 1946
• Medicare/Medicaid: 1965
“We are against forcing all citizens, regardless of need, into a
compulsory government program. It is socialized medicine. If it
stands, one of these days you and I are going to spend our sunset
years telling our children and our children's children, what it once
was like in America when men were free.” Ronald Reagan
• SCHIP (State Children’s Health Insurance Program) 1997
• Medicare Modernization Act: 2003 (Prescription drug coverage and
Medicare Advantage Plans)
• PPACA: 2011
• Arkansas Private Option Insurance Expansion
• Arkansas Payment Improvement Initiative
6500
5500
4500
3500
Death rate per 100,000 population
7500
All-Cause Mortality for Individuals aged 65+
United States, 1950 - 2010
2000 2005 2010
Triple Aim
• Better population and individual health
• Better patient experience
• Lower cost
Patient Protection and Affordable Care Act
Goal: Extend access to insurance for the vast
majority of currently uninsured citizens while
improving quality and controlling cost growth
Patient Protection and Affordable Care Act
– Key strategies:
• Private Insurance exchanges for individuals and families
with income above 138% of federal poverty level
• Medicaid Expansion for individuals and families with
incomes up to 138% of federal poverty level
• Medicaid expansion is funded federally for first three years
after which states begin sharing cost up to 10% state share
by 2020
• Many other provisions for funding the insurance expansion
including reductions in:
–
–
–
–
DSH payments,
Payment for avoidable hospital readmissions
Failure to meet quality targets
Other
Patient Protection and Affordable Care Act
– Arkansas Plan: Private Option
• Rather than expand traditional Medicaid, use federal
Medicaid dollars to purchase insurance on the health
insurance exchange
• Advantages:
– Provider networks and Payment rates for providers are the same for
individuals above and below 138% of federal poverty level
– No churn between coverage at 138% of federal poverty
– Expands risk pool
– Federal waiver
• Cost control and care coordination promoted through
linkage with Arkansas Payment Improvement Initiative
for Payment Improvement
Medical Home: Arkansas multi-payer emerging vision
• All Arkansans have access to an advanced PCMH
within 2-4 years
• PCMHs proactively manage patients on a 24/7 basis
• Primary care providers should be rewarded for
continuous improvements in quality and efficiency
• Primary care providers are stewards of overall system
resources and have accountability for total cost of
care
• PCMHs support and expect patients to actively
engage and manage their own health.
The model rewards a Principal Accountable Provider (PAP) for
leading and coordinating services and ensuring quality of care
across providers
PAP role
Core
provider for
episode
Episode
‘Quarterbac
k’
Performanc
e
managemen
t
What it means…
• Physician, practice, hospital, or
other provider in the best position to
influence overall quality, cost of care
for episode
• Leads and coordinates the team of
care providers
• Helps drive improvement across
system (e.g., through care
coordination, early intervention,
patient education, etc.)
• Rewarded for leading high-quality,
cost-effective care
• Receives performance reports and
data to support decision-making
PAP selection:
•
•
Payers review
claims to see which
providers patients
chose for episode
related care
Payers select PAP
based main
responsibility for
the patient’s care
Organizational and practice level requirements to
successfully transform to meet triple aim and be successful
in the new payment environment
• Patient engagement and patient centeredness
• Avoid waste: “non-value added” services
• Transform from volume based to outcome based
focus with accountability for patient and population
health outcomes
• Patient registries: patient activation and disease
management focus to achieve targets for major adult
diseases, vaccination rates, etc.
• Denominator focus
Organizational and practice level requirements to
successfully transform to meet triple aim and be successful
in the new payment environment
• EMR infrastructure: information moving with patient
through the system
• Guideline focus: practice in accord with what is
known to be best practice: real time decision support
• Organization must be accountable for care outcomes,
patient experience and total costs
• Structured relationship for collaboration in care
across continuum.
What we cannot do is keep doing
what we have been doing
and expect different results.