iht² health it summit in new york 2012 - opening keynote "the changing health environment in...
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The Changing Environment in Health Reform - Dr. John Lumpkin, SVP & Director, Healthcare Group, Robert Wood Johnson FoundationTRANSCRIPT
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The Changing Environment in Health Reform
John R Lumpkin MD MPHSVP & Health Care DirectorRobert Wood Johnson Foundation
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Victory awaits him who has everything in order – luck people call it. Defeat is certain for him who has neglected to take necessary precautions in time; this is
called bad luck
Roald Amundsen, Norwegian polar explorer
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Why was health reform on the National agenda in 2009?
The same reason why health reform is on today’s agenda:
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• 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
Insurance Matters
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The system was/is broken:Click icon to add picture
Insurance market concerns
• Pre-existing conditions
• Denial of coverage
• Retroactive denial of coverage
• Excessive rating gradients
• Annual and lifetime limits
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Basics of Health Reform
Insurance Market reforms
Insurance works best if the risk pool is large
Allowances for the working poor
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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
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Coverage Expansion Categories
0 100 200 300 400 500
Medicaid
Subsidy
$88,000 Family of
Four
$29,326 Family Of Four
Medicaid Expansion
138%
Premium Subsidy
400%
Federal Poverty Level
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Supreme Court Decision
• Individual mandate constitutional
• Medicaid expansion constitutional, but now a state option
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Supreme Court decision
Exchange 15M
Medicaid17M
Total Expansion = 32 Million
Supreme Court Decision
Sources: Urban Institute analysis, HIPSM 2011.
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William Gibson - 1993
The Future is already here, it is not very evenly distributed.
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Average Annual Contributions to Premiums for Family Coverage, 1999-2011
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011.
$5,791
$6,438*$7,061*
$8,003*
$9,068*
$9,950*
$10,880*
$11,480*
$12,106*$12,680*
$13,375*$13,770*
$15,073*
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Cumulative Percent Change in National Health Expenditures, by Selected Sources of Funds, 2000-2010
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).
Medicare
Medicaid
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Healthy Life Expectancy at Age 60, 2007
2221 21 21 21 20 20 20 20 20 20 20 20 20 19 19 19 19 19 19 19 18 1818 18 18 17 18 18
1618 17 18 17 16 17 17 17 18 17 17 17 16 16 16
15
0
10
20
30
Japa
n
Switzerla
nd
France
Spain
Italy
Australia
Finlan
d
Icel
and
Canada
Sweden
Austria
Belgiu
m
Norway
Germ
any
Nether
lands
New Zeala
nd
Irela
nd
Greece
United
Kingdom
United
State
s
Portugal
Denmar
k
Czech
Repub
lic
Women Men
Years
Data: Provided by C. Mathers. Unpublished data set consistent with HALE estimates published in World Health Statistics 2009 (Geneva: World Health Organization).
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
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
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Deaths Avoidable Through Health Care:Nolte & McKee – Health Affairs August 29, 2012
Mortality Amenable to Health Care
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Medical, Medication, and Lab Errors
1618 19
22 23
2628
32
0
10
20
30
40
NETH FRA GER UK NZ CAN AUS US
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2008 Commonwealth Fund International Health Policy Survey.
EXHIBIT 16
Percent of adults reported medical mistake, medication error, or lab error in past two years
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
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Test Results or Records Not Available at Time of Appointment
9
1315 15 15
18 18
23
0
10
20
30
NETH GER AUS FRA UK CAN NZ US
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2008 Commonwealth Fund International Health Policy Survey.
Percent of adults reported test results or records were not available at time of appointment in past two years
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
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We have run out of money, it is time to start thinking.
Ernest Rutherford (1871-1937)
Nobel Laureate
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Six Drivers of Excess Cost
Driver Examples Excess cost
Unnecessary services Defensive medicine, overuse $210 B
Inefficient services Mistakes, duplication $130 B
Excess administrative costs
Administrative inefficiencies by payers and providers $190 B
Prices that are too high Prices higher than competitive benchmarks $105 B
Missed prevention opportunities
Missed screenings and condition monitoring $55 B
Fraud Payer, provider, patient fraud $75 B
Source: Institute of Medicine
Better Care at Lower Cost
September, 2012
Six Drivers of Excess Cost
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Transparency
Payment reform
Clinical re-engineering
Informatics
Key Trends in Response
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Transparency
Payment reform
Clinical re-engineering
Informatics
Key Trends in Response
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Consumer Reports
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Community Highlight: Minnesota
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Transparency
Payment reform
Clinical re-engineering
Informatics
Key Trends in Response
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Payment Reform
Shared Savings
Bundled Payment
Capitation
Accountable Care Organizations (ACO)
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Payment Reform
Shared Savings
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Payment Reform
Shared Savings
Bundled Payment
• Episode of acute care or procedure
• Treatment of chronic condition over time
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Payment Reform
Shared Savings
Bundled Payment
Capitation
• Upside benefit
• Downside risk
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Payment Reform
Shared Savings
Bundled Payment
Capitation
Accountable Care Organizations (ACO)
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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
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Transparency
Payment reform
Clinical re-engineering
Informatics
Key Trends in Response
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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
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Transparency
Payment reform
Clinical re-engineering
Informatics
Key Trends in Response
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ComplexityIncreasing amounts of information
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Current practice depends upon the clinical decision-making capacity and reliability of
autonomous individual practitioners, for classes of problems that routinely exceeds the bounds of
unaided human cognition
Daniel R. Masys, M.D.
2001 IOM Annual Meeting
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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
Clinical Complexity
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The Vision
• Computing Power
• Connectivity
• Improvements in organizational capabilities
• Collaboration between teams of clinicians and with patients
New Tools
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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
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Archimedes
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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
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50
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Pills with chips embedded track medication use
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Change is the law of life. And those who look only to the past or present are certain to miss the future.
- John F. Kennedy
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55April 13, 2023
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Slide 56 of 23
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
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Slide 57 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
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Slide 58 of 23
Recommendations: Summary
Current market forces are not adequately addressing the potential risks associated with use of health IT.
All stakeholders must coordinate efforts to identify and understand 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
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Disease X
Severe case mortality 50%
Treatment Y 50% to 25%
Fatality rate 10%
New test
10% are severe
With Treatment
Deadly Overuse
100 cases – 50 die
100 cases – 25 die
100 cases – 35 die
100 cases – 5 die
100 cases – 12 die
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Disease X
Severe case mortality 50%
Treatment y 50% to 25%
Fatality rate 10%
New test
10% are severe
With Treatment
Deadly Overuse
100 cases – 50 die
100 cases – 25 die
100 cases – 35 die
100 cases – 5 die
100 cases – 12 die
Standard diagnosis with treatment 30% reductionEnhanced diagnosis with treatment 140% increase