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Along for the Bumpy Ride?Market Responses in the New
Health Care Marketplace
Eric D. Kupferberg, PhDAssociate Director
Trust Initiative, HSPH
28 October 2010
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“. . . if you’re not part of the steamroller, you’re part of the road.”
-- Stewart Brand
Source: Brand, The Media Lab: Inventing the Future at MIT (New York: Penguin 1988)
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Mapping I-FM Syndrome
• Virtual epidemic in all regions of the country
• Mostly affects successful males and females
• Spread by air travel and hand-to-hand contact
• Carriers rarely recognize affliction
• Secondary victims suffer greatly
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Carrier ProfilesNormally Healthy Adults
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Communicated Via AirplanesBut NOT Corporate Jets
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First ClueWhy are Pilots and Attendants Not Affected?
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Second ClueWhy 1st Class and Business Class Only?
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Third ClueWhy are Sleepers and Typers Immune?
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Decisive ClueAll Carriers Handled an In-Flight Magazine
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Causal Link
• Magazines featuring interviews with successful CEOs
• Pithy conclusions
• Strong appeal to join the next organizational revolution
• Recommendations require radical restructuring and substantial money
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Carrier StateExecutive Returns to Office
• Delivers torn-out article to executive assistant
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Secondary Victims
• Senior executive requests that management team read the article and implement recommendations ASAP
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Great Suffering Ensues
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Harm Magnifier
• Senior executive demands to know why revolution has not already begun to reap noticeable benefits
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Harm MultiplierExecutive Takes Another Flight (ughh!)
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Taking Tropes SeriouslyUbiquity of the “Great Leap Forward”
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“A Great Leap Forward ?”
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Is IT the Right Leap Forward?
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Health Care IT Growing
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Technological “Cures”
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The Importance of Networking
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Dav
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Source: Marie Reed and Joy Grossman, Center for Studying Health System Change, Issue Brief 89, September, 2004
Chaotic IT Adoption
The wide variation in physician technology adoption inhibits efforts to improve patient care
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56%
39%
37%
26%
21%
16%
28%
40%
44%
46%
38%
49%
47%
15%
14%
16%
15%
35%
29%
36%
44%
Start-up costs
Lack of uniform standards
Lack of time
Maintenance costs
Lack of evidence of effec tiveness
Privacy concerns
Lack training/know ledge
Major Barrier Minor Barrier Not a Barrier
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
Barriers to HIT Adoption
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The Unbearable Hype of IT
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The Promise of Standardization
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Publication
Bibliographic databases
Submission
Reviews, guidelines, textbook
Negative results
variable
0.3 year
6. 0 - 13.0 years50%
46%
18%
35%
0.6 year
0.5 year
5.8 years
Dickersin , 1987
Koren , 1989
Balas, 1995
Poynard , 1985
Kumar, 1992
Kumar, 1992
Poyer , 1982
Antman , 1992
Negative results
Lack of numbers
Expertopinion
Inconsistentindexing
17:14
Original research
Acceptance
Implementation
Medical Innovations Move Slowly
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“A Change is Gonna Come?”
• A majority of physicians fail to recommend at least one major drug up to ten years after it’s been shown to be efficacious.
• A majority of physicians continue to recommend therapy up to ten years after it’s been shown to be useless.
Source; Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC: A comparison of results of meta-analyses of randomised control trials and recommendations of clinical experts. JAMA 1992;268:240-8.
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Facts are simple and facts are straightFacts are simple and facts are straightFacts are lazy and facts are lateFacts are lazy and facts are late
Facts all come with points of viewFacts all come with points of viewFacts don't do what I want them toFacts don't do what I want them to
Facts just twist the truth aroundFacts just twist the truth aroundFacts are living turned inside outFacts are living turned inside outFacts are getting the best of themFacts are getting the best of them
Facts are nothing on the face of thingsFacts are nothing on the face of things
-- David Byrne, -- David Byrne, Cross-eyed and Cross-eyed and PainlessPainless
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Standardization Via Clinical Guidelines
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Standardization Via Clinical Guidelines
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Guidelines & Contentious Ambiguities
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No Guarantee of Implementation
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Legal Considerations Drive Guidelines
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History of EBM:Archibald L. Cochrane (1909-1988)
• Concerned with the over use of medical techniques
• Published landmark Effectiveness and Efficiency (1972)
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John Wennberg and theCenter for Evaluative Clinical Services
• The Center for the Evaluative Clinical Sciences . . . conducts cutting edge research on critical medical and health issues with the goal of measuring, organizing, and improving the health care system.
• . . . at the micro level, they hold the promise of reforming the doctor-patient relationships through shared-decision making and of improving the quality and value of clinical care.
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David L. Sackett:Ascendance of Evidence-Based Medicine
• EBM is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research."
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What is Evidence-Based Practice?Sackett’s Short Definition
• “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”
• BMJ 1996; 312: 71-2.
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The Big Promise
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Is EBM Really New?
• Often labeled as a “radical overhaul” or a “paradigm shift” in medicine
• Yet, some advocates trace its roots to post-revolutionary France and the work of Bichat, Louis, and Magendie
• Why does this “newness” or “oldness” matter?
Source: Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. “Evidence based medicine: what it is and what it isn’t”. BMJ 1996;312:71-2.
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Locus of Expert Knowledge in EBM
• Pre-EBM: Source of knowledge is the expert opinion of individual or institution
• Clinical skills beyond outside purview
• Patients are objects of treatment
• Post-EBM: Source of knowledge is the collective systematic review of evidence
• Clinical skills subject to audit
• Patients are part of “studies”
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Criticisms of Evidence-Based Medicine
• It is basically what we’ve been doing for ages• It is possible only under “ideal” conditions• It encourages “cookbook” medicine• It increases the authority of managers and
insurers• Evidence from randomized trials and systematic
reviews rarely works in clinical settings• It is antipathetic to patient-centered medicine
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But EBM IS Part of Cost-Cutting
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Can Providers Evaluate Evidence?
• Doctors have little time to pose specific questions and search for targeted evidence
• The number of journals and studies is astronomical
• Providers often lack the technical skills to conduct exhaustive searchers
• Studies lack standardized formats• Providers have difficulty resolving conflicting
clinical evidence• Even the best evidence requires “interpretation”
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EBM as a “Way of Being”
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Compensation as the Cure
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Incentive Goals for P4P
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How P4P Works - The Power of Incentives
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The Business Case for P4P
Stakeholder P4P “Investment” Return on Investment
Consumers •Self-care management•Switch to “excellent” providers
•Improved health & productivity•Financial incentives (employer and plan option)
Employers •P4P program operations•P4P physician rewards•Employee incentives for self-care and switch to excellent providers
•Employee health & productivity•Healthcare cost savings•Employee retention
Health Plans •P4P program operations (costs not paid by self-insured customers)•P4P physician rewards (costs not paid by self-insured customers)•Member incentives for self-care and switch to excellent providers
•Reduced healthcare costs•Increased profitability•Competitive positioning / marketing
Providers •Data collection & submission•Practice re-engineering
•Performance rewards•Reputation for excellence•Increased patient volume
Dav
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Source: Jonathan Conklin and Audrey Weiss. Pay-for-Performance: Assembling the Building Blocks of a Sustainable Program, 2004 published by Thomson Medstat.
update: 7/6/06
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"We are seeing that pay for performance works. We are seeing increased quality care for patients, which will mean fewer costly complications – exactly what we should be paying for in Medicare."
- Mark McClellan, M.D., Ph.D.,Former Administrator of Centers for Medicare and Medicaid Services
Pay for Performance as the Promised Cure
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P4P: Physician Skepticism
© 2006 Physician’s Weekly, LLC
March 13, 2006 Vol. XXIII, No. 11
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P4P: Physician Skepticism
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P4P: Complexity Kills
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The Glow of Consumer-Driven Health Care
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Are Current Market Responses Sufficient?