The Road Ahead for America’s Physicians

HIP SYMPOSIUM

April 11, 2012

James L. Madara, MD Executive Vice President/CEO American Medical Association

The AMA Mission

To promote the art and science of medicine and the betterment of

public health

A critical success factor is to have attractive, thriving physician practices

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In the Next 20 Years Physicians Will… •  Need more % effort for patients •  Practice in a collaborative environment

with other health professionals •  Heavily utilize technology (EMR,

telemedicine, online consultation…) •  Practice in “continuity” systems •  Focus on outcomes (and value) rather

than process 3

More Physicians Joining Systems - June, 2010 •  65% of established

physicians who changed jobs

•  49% of physicians completing residency

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What Caused the Shift? •  Seeking stability •  Work-life balance •  Advancement opportunity •  Pay back student loans •  Costs (expenses outpace reimbursement,

2:1) •  Administrative burden (i.e. dealing with

payers) •  Access to improved infrastructure

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Technology Future

•  Office EHR •  Online coaches for chronically ill patients •  Online physician/patient portals

AT&T/AMA collaboration Benefits

•  Powerful decision support tools •  Personalized based on large data sets •  Continuity •  Access

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Technology: Improvement with Health IT

The Learning Health System Expanded capacity for new knowledge

Driving improvement with health IT

Redesigning the Clinical E!ectiveness Research Paradigm, 2010. Evidence development in the learning health system.

Kaushal, et al., 2009. E!ect of electronic medical record (EMR) systems on medication safety in community-based o"ce practices. Practices that adopted EMR systems experienced a seven-fold decrease in prescription errors compared to non-adopters.

EMR Adopters

Pres

crip

tion

Err

ors

(per

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0)

Non-Adopters

Dat

a Pr

oduc

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er Y

ear

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Systematic ReviewsRandomized Trials

(E"cacy) Randomized Trials (E!ectiveness)

Market Entry

Timeline of Medical Product Research

Surveillance and Observational Studies

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Initial

1 Year Follow-up

Patient engagement for better outcomes

Joseph Kvedar, IOM Meeting 1 April 2010. E!ect of enrollment in Partners HealthCare’s Connected Cardiac Care Program (CCCP) program on heart failure hospitalization. Enrollment in the CCCP program, with health IT-facilitated self-monitoring and patient-clinician communication, reduced the rate of hospital-ization for heart failure.

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Before Program After Engagement Program

Engineering systems for continuous improvement

David Pryor, IOM Meeting 29 April 2008. E!ect of Ascension Health’s Call to Action—a systems engineering approach to quality improvement— on medical errors in Ascension Health hospitals.

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40

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Birth Trauma NeonatalMortality

Pressure Ulcer Blood Stream Infections

% R

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The Opportunity

The Learning Health System and its Innovation Collaboratives Update Report 1514

Kaushal, et al, 2009 7

Prescription Errors In Community Based Practices

Technology Future: Decision Support

The Learning Health System Medical decisions becoming more complex

William Stead, IOM Meeting, 8 October 2007. Growth in facts a!ecting provider decisions versus human cognitive capacity.

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Fact

s pe

r D

ecis

ion

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1990 2000 2010 2020

Human Cognitive Capacity

Decisions by Clinical Phenotype

Structural Genetics: e.g. SNPs, haplotypes

Functional Genetics: Gene expression profiles

Proteomics and other e!ector molecules

10

100

1000

Robert Cali!, IOM Meeting, 12 December 2007. Less than 20% of AHA/ACC heart disease management guidelines are based on a high level of evi-dence and over 40% are based on the lowest level of evidence. Furthemore, the proportion of guidelines with high evidence levels has not increased over time (green vs. blue).

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KOR LUX

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High Med Low High Med Low High Med Low

Strength of Evidence

Perc

ent

of G

uide

lines

Inadequate evidence to guide care

10

20

30

40

50

60

70

Atrial Fibrillation(2001–06)

Heart Failure (2001–06)

Pacemaker (1998–2002)

Systemic waste across the board

The Healthcare Imperative, 2010. Lower bound totals of various estimates of excess healthcare expenditures, adjusted to 2009 total expenditure levels.

Excess Cost EstimatesUnnecessary Services $210 B

Ine"ciently Delivered Services $130 B

Excess Administrative Costs $190 B

Prices That Are Too High $105 B

Missed Prevention Opportunities $55 B

Fraud $75 B

Total Excess Costs: $765 B

Poor health despite high spending

OECD Health Data, 2009. Life expectancy at birth in di!erent countries versus per capita expenditures on health care in dollar terms, adjusted for purchasing power. The United States is a clear outlier on the curve, spending far more than any other country yet achieving less.

AUS

AUT BEL

CAN

CZE

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FIN

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DEU

GRC

HUN

ISL

IRL

ITA

JPN

KOR LUX

MEX

NLDNZLNOR

POL

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SVK

ESP SUE

CHE

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GBR USA

72

74

76

78

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84

Life

exp

ecta

ncy

in y

ears

600050004000300020001000

Health spending per capita (USD)

The Case

The Learning Health System and its Innovation Collaboratives Update Report12 1312

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Technology Future Our Future Incorporates Large Data Sets: The Learning Health System Medical decisions becoming more complex

William Stead, IOM Meeting, 8 October 2007. Growth in facts a!ecting provider decisions versus human cognitive capacity.

AUS

AUT BEL

CAN

CZE

DNK

FIN

FRA

DEU

GRC

HUN

ISL

IRL

ITA

JPN

KOR LUX

MEX

NLDNZLNOR

POL

PRT

SVK

ESP SUE

CHE

TUR

GBR USA

Fact

s pe

r D

ecis

ion

5

1990 2000 2010 2020

Human Cognitive Capacity

Decisions by Clinical Phenotype

Structural Genetics: e.g. SNPs, haplotypes

Functional Genetics: Gene expression profiles

Proteomics and other e!ector molecules

10

100

1000

Robert Cali!, IOM Meeting, 12 December 2007. Less than 20% of AHA/ACC heart disease management guidelines are based on a high level of evi-dence and over 40% are based on the lowest level of evidence. Furthemore, the proportion of guidelines with high evidence levels has not increased over time (green vs. blue).

AUS

AUT BEL

CAN

CZE

DNK

FIN

FRA

DEU

GRC

HUN

ISL

IRL

ITA

JPN

KOR LUX

MEX

NLDNZLNOR

POL

PRT

SVK

ESP SUE

CHE

TUR

GBR USA

High Med Low High Med Low High Med Low

Strength of Evidence

Perc

ent

of G

uide

lines

Inadequate evidence to guide care

10

20

30

40

50

60

70

Atrial Fibrillation(2001–06)

Heart Failure (2001–06)

Pacemaker (1998–2002)

Systemic waste across the board

The Healthcare Imperative, 2010. Lower bound totals of various estimates of excess healthcare expenditures, adjusted to 2009 total expenditure levels.

Excess Cost EstimatesUnnecessary Services $210 B

Ine"ciently Delivered Services $130 B

Excess Administrative Costs $190 B

Prices That Are Too High $105 B

Missed Prevention Opportunities $55 B

Fraud $75 B

Total Excess Costs: $765 B

Poor health despite high spending

OECD Health Data, 2009. Life expectancy at birth in di!erent countries versus per capita expenditures on health care in dollar terms, adjusted for purchasing power. The United States is a clear outlier on the curve, spending far more than any other country yet achieving less.

AUS

AUT BEL

CAN

CZE

DNK

FIN

FRA

DEU

GRC

HUN

ISL

IRL

ITA

JPN

KOR LUX

MEX

NLDNZLNOR

POL

PRT

SVK

ESP SUE

CHE

TUR

GBR USA

72

74

76

78

80

82

84

Life

exp

ecta

ncy

in y

ears

600050004000300020001000

Health spending per capita (USD)

The Case

The Learning Health System and its Innovation Collaboratives Update Report12 1312

9

Telemedicine

Patients •  42% positive about virtual visits •  48% would do check-ups at home •  78% willing to try virtual visits

2010 internet survey by Euro RSCG Tonic, consumer health and wellness arm of marketing firm Euro RSCG

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Telemedicine Uses

•  See patients outside office hours •  Communicate with chronic disease

patients •  Coordinate with patients’ other physicians •  Consulting with other physicians •  Communicating with caregivers

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Focus on Outcomes and Value: What We Really Want “Knowing is not enough; we must apply. Willing is not enough; we must do.”

-Goethe

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