THE SECOND REVOLUTION IN HEALTH CARE SUTTER HEALTH RESEARCH, DEVELOPMENT & DISSEMINATION Buzz Stewart
DID YOU MISS THE FIRST REVOLUTION?
NO ONE WOULD HAVE PREDICTED THE RESULT OF THE FIRST REVOLUTION
HISTORY OF MODERN HEALTHCARE 17.9 % Market growth and fragmentation Rise of systems of care Accelerating consolidation Research Formal specializes and Revolutionized organization Digital era of care begins separates from medical of physicians bedside education established 1940’s 1965 1990s 1847 1910 1930 1973 By 2012, 72% of Social Security AMA Accountable physicians use Amendments EMR/EHR systems care (PPACA) U.S. Hospital Mergers and 120 Flexner Acquisitions 100 Report Rise of For-Profit Buyers HMO’s Act 80 Employer NonProfit Buyers 60 40 20 0 Health Expenditures as Share of GDP 4
OVERVIEW • A revolution has consequences • The benefits and challenges • Things we should and should not be doing in the second revolution 5
U.S. NATIONAL DEBT PROBLEM US TOTAL HEALTH CARE SPEND PER YEAR 3 Strong link between countries' wealth Trillions ($) and total health spending 2.5 10000 Income elasticity > R 2 = 0.95 This relationship is largely 1.0 2 unaffected by: THE per capita [log] 1.5 1000 • Relative share of public / private spending 1 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 • External donor assistance (which Year 100 may inadvertently crowd out N = 174 spending elsewhere) 10 100 1000 10000 100000 GDP per capita [log ] Source: Jacques van der Gaag; WHO/IMF 2005
EXTRAORDINARY HEALTH CARE SPENDING 2007 $2,200 billion $1,390 billion $1,020 billion China: personal U.S. food* U.S. consumption health care
PROJECTED U.S. HEALTH SPENDING % GDP Source: US Congressional Budget Office, Nov 2007
...BUT COUNTRIES WITH SIMILAR SPENDING HAVE A RANGE OF HEALTH OUTCOMES 1 2 300 Childhood (<5) mortality (per 1,000) Poorer countries' ...but poor countries health is worse 250 vary widely in health Rwanda off, in general... outcomes 200 3 R 2 = 0.58 150 And good health exists across a 100 Kenya range of GDP 50 0 100 1,000 10,000 100,000 GDP PPP per capita Similar health outcomes at different levels of wealth: what matters is not total spending, but how it is used Source: WHO/IMF 2005 Source: WHO
WHAT ARE AMERICANS BUYING?
OUR HEALTH SYSTEM’ S STRENGTHS Clinical trials by country Number of trials Top 5 US Hospitals Canada Germany France UK Australia Switzerland Japan South Korea Singapore Source: OECD, Commonwealth Fund, ‘ International Comparison: Access and Timeliness ” , Dec 2006, Boehm, T, ‘ How can we explain the American dominance in biomedical research and development? ’ , Journal of Medical Marketing, Vol 5, 2005 NY Times, RAND, MGI
ONE VIEW OF EXCESS COSTS (2009) • Unnecessary services ($210B) • Inefficiently delivered services ($130B) • Excess administrative costs ($190B) • Prices that are too high ($105B) • Fraud ($75B) • Missed prevention opportunities ($55B)
WHY WE BUY SO MUCH • Wealth • The more we have, the more we spend on health. • Insurance • Greater coverage makes us indiscriminating consumers. • Aging population • Aging equals more health problems and more demand. • Heroics • Make every effort possible, even if there is no chance of a good outcome.
WHY WE SELL SO MUCH • Business model • Volume based model promotes unnecessary services. • Technology • The more we have to sell, the more we sell. • Guideline-based • Evidence based guidelines for only 30% of clinical decisions. care paradigm The rest is opinion. • High prices • No price competition.
IMPROVING CARE AND CONTROLLING COSTS Adoption of costly and unproven technology Using unproven and costly forms of radiation treatments for many early prostate cancer patients: • 3-D conformal radiation $11,000 • Brachytherapy: $15,000 • IMRT: $42,500 • Proton Beam: $80,000 • No head-to-head comparative studies • No survival difference -- at best a 10% decline in side effects from 14% to 4%
SCREENING VERSUS USUAL CARE: PLCO Screening PSA and digital rectal exam (N=76,693) Prostate-Cancer Deaths Andriole GL, et al. N Engl J Med 2009;360:1310-9
SURGERY VERSUS SURGERY: STICH LV reconstruction versus CABG only (N=1000) Death from Any Cause Jones RH, et al. N Engl J Med. 2009;360 (on line) Eisen HJ , N Engl J Med. 2009; 360 (on line)
Approximately 40 Million of 100 million dollars of emergency department care at Alta Bates Summit Medical Center is attributed to the top 10% of patients
Top 10 Percent of Most "Costly" ED Patients Visiting from 2011-2012 ( Cutoff 50 encounters) 60000 50000 Total Cost (includes Direct and Indirect) 40000 30000 20000 10000 0 0 10 20 30 40 50 60 Number of Encounters Per Distinct Patient
Encounters for Patients in the Top 10 % of Cost
Encounters for Patients in the Top 10 % of Cost
LIFESTYLE VERSUS MEDICAL: DPP Lifestyle or metformin to prevent DM (N=3234) Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393-403
ENVIRONMENT AND HEALTH Local Physical Activity Opportunity Environment (LPAOE). • Patients are on their Municipal boundaries, GHS ’ s 31 counties, 4287 LPAOE points. own 99%+ of the time • Local factors influence Local Food Environment: Food Sources & Retailers in GHS ’ s 31 Counties diet, activity, & stress levels • The best health care may have little impact Joe may only be able to get so far in managing on patient outcomes his diabetes even with the help of four specialists, a dietician and trainer.
STUFF THAT WILL NOT MATTER MUCH • More knowledge • New knowledge is a commodity • Stuff that yields the • We already know about eating, exercising, addictions, same advice moderation • Stuff that requires a • Do customers really want this lot more data • Does it really matter? • Providers clearly are not interested
STUFF THAT WILL NOT MATTER MUCH • More procedures & • This is what we do now and it does not help that much other stuff to sell • This is what we do now and • Personalized and more it does not help that much expensive • Solving problems in isolation
ENHANCE CAPABILITIES THAT MATTER Data Abstraction & Knowledge Standardization Access Liquifying and then purifying for Exact searching of knowledge by clinical use data with intuitive grading Communication Extending Process Reach What are you talking about and do Exact, precise, and portable guides you understand me Patient Tools Knowing where to go, how to choose, and what to avoid Using tools that work in improving health
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