US Health Care is in deep trouble The US Health Care System - PDF document

VS. What We’ll Talk About Quality, Costs, & Special Interests: 1. Problems with US Health Care Can We Change Our Behavior in time to Save US Health Care? 2. How new information technologies can address some of the problems Thomas M. Vogt, MD, MPH, FAHA Kaiser Permanente 3. Changes in system and personal behaviors Center for Health Research, Hawaii and expectations needed to address the problems US Health Care is in deep trouble The US Health Care System Regulatory, legal, and cultural incentives prevent us from: Lost in the Forest • Setting priorities • Managing costs to optimize outcomes • Stopping what doesn’t work � excessive care for the insured • Insuring those who most need care Health Care Costs as Percent of GDP Annual Per Capita Health Care Costs in the US, USA, 1960-2003 Japan, United Kingdom and Canada, 1960-2005 7000 % GDP 6000 18 16 5000 USA 14 4000 12 Japan 10 United K. 3000 8 Canada 6 2000 4 2 1000 0 0 1960 1985 2003 1960 1990 1998 2001 2005 ������������������������������������������������������������ �������������������������������������������������� ����������������������������������������������������������������� �������������������������������������������� 1

Children’s Well Being: Overall and Health Ranks in 21 Developed Nations WHY ARE HEALTH COSTS SOARING? The Economist, Feb. 17, 2007 from UNICEF 2005 data We probably put too many people 25 in the hospital. 20 15 Overall Rank Health Rank 10 5 0 Netherlands France Italy USA No. developed nations lacking nearly universal health care coverage = 1 (48 million US uninsured & rising fast) WHY ARE HEALTH COSTS SOARING? Hospital Discharges Per 100,000 Persons Australia Discharges Per 100,000 30 Canada 25 Finland 20 France 15 Drugs cost a fortune. We must spend more Japan 10 Norway on drugs than other countries. 5 Spain 0 Sweden 1980 1985 1990 1995 2000 2005 United Kingdom Year USA OOPS. GUESS THAT’S NOT IT WHY ARE HEALTH COSTS SOARING? Pharmaceutical Spending (% of Total Health $) Australia % of Spending on Drugs 25 Canada 20 Finland Hospitals are expensive. Maybe we 15 France have too many hospital beds? Japan 10 Norway 5 Spain 0 Sweden 1980 1985 1990 1995 2000 2005 United Kingdom Year USA NOT THAT EITHER . 2

WHY ARE HEALTH COSTS SOARING? Hospital Beds per 1000 Persons Australia 7 Canada 6 Beds per 1000 Maybe we have too many too many 5 Finland 4 doctors? France 3 Norway 2 1 Spain 0 Sweden 1980 1985 1990 1995 2000 United Kingdom Year USA HMM. NOT THAT EITHER. WHY ARE HEALTH COSTS SOARING? Doctors per 1000 People Australia 3.5 Canada Doctors per 1000 3 Maybe it’s because we live so much Finland 2.5 France 2 longer than other countries? 1.5 Japan 1 Norway 0.5 Spain 0 Sweden 1980 1985 1990 1995 2000 United Kingdom Year USA WELL, WHAT THEN? • USA 2006: $ 6697 /person! – 36% increase in 3 yrs [= $ 26788 for a family of 4] Countries & Areas that Spend Less Than Half of the US per capita on Health Care and Have 2003 Health Care Costs & Life Expectancy in 19 Developed Nations Higher Life Expectancies (in order from highest) Andorra, Macau, Singapore, San Marino, Hong 6000 Kong, Japan, Switzerland, Sweden, Australia, 5000 USA Ann Expend Iceland, Canada, Cayman Islands, Italy, France, 4000 Norw ay Canada Denmark Monaco, Lichtenstein, Spain, Norway, Israel, 3000 Japan Aruba, Greece, Austria, Virgin Islands, 2000 Italy Netherlands, Malta, Luxembourg, Germany, New 1000 Greece Spain Zealand, Belgium, United Kingdom, Finland, 0 Jordan, Bermuda, Saint Helena, Puerto Rico, 76 77 78 79 80 81 Cyprus, Denmark Life Expectancy Source: http://www.geographyiq.com/ranking/ranking_life_expectancy_at_birth_ Why do we look so bad when we spend so much? aall.htm [based on US Dept. of State data and CIA World Fact Book] 3

WHY ARE HEALTH COSTS SOARING? WHY ARE HEALTH COSTS SOARING? “…I look at the U.S. health care system and “At least 90% of the care we give is unnecessary.” see an administrative monstrosity, a truly Archie Cochrane, 1978 bizarre mélange…” Personal communication Henry Aaron “Our focus…should be on eliminating the gross NEJM 2003, 349:801 inefficiencies …in the US health care system. If we do that, we will be able to cover the uninsured “An epidemic of waste blights the US Health while spending less than we do now. ” Care delivery system … [the system] is not Uwe Reinhardt, quoted in Krugman, Wells safe…is not effective…is not efficient...is not NY Rev of Books, 53; 3-23-2006 patient-centered…is not timely…[and] is not “The US health care system becomes a more equitable.” embarrassing disaster each year…” Roger W. Bush, 2007 Donald Kennedy JAMA 2007, 297:871 Science 2003;301:895 WHY ARE HEALTH COSTS SOARING? “President Bush is committed to assuring that the United States continues to have the finest health care system in the world.” <whitehouse.gov> (2003) (since removed) Well…it’s pretty serious. We’ll know a lot more after the autopsy. Why Do We Spend So Much Why Do We Spend So Much More Than Other Nations? More Than Other Nations? • We can’t stop doing what doesn’t work • We don’t relate costs of care • We do too much of what does work – to outcomes duplicative facilities drive vast excess • We don’t set priorities that • Bureaucracy of plans & insurers adds maximize benefit from available >$65 billion in annual costs. resources • We don’t systematically learn • We don’t rationally translate science into from our experiences medical practice 4

Why Do We Spend So Much US Health Care: More Than Other Nations? Summary • Malpractice laws & “community • US per capita health care costs are more practice” standards keep us from than twice those of any other nation applying what we know • Monopolistic drug & device • US outcomes are, overall, among the patent laws worst of all developed nations • Congress won’t consider real reform • Superb care is available, but not --they won’t get re-elected if they do consistently, and not for the uninsured US Health Care: US Health Care: Summary Summary • The US is the only developed nation lacking nearly universal health care The greatest threat to the quality of • US health costs threaten the entire American health is the strange notion economy that health care should be unrestrained • The current system is an unsustainable by cost or by lack of evidence of disaster benefit. We ration people instead of care. Three Steps toward What Can We Do About the Fixing the System Situation? • Collect the right information I. Better information – Electronic medical • Pay attention to it records (EMRs) offer many opportunities • Do what is proven instead to improve care and efficiency of what is fashionable II. Change individual behaviors to improve lifestyles behaviors that enhance health. • Change institutional & system behaviors & expectations III. Change system behaviors to support optimal health care from available resources 5

How Can EMR Systems Help the Situation? Electronic medical records allow us to examine the relation of past patterns of care I. Better Information from Electronic Records to outcomes of care at low cost and in defined populations. Person-Time Coverage (PTC) “…electronic health record (EHR) databases from millions of people could rapidly advance the U.S. evidence base for clinical care.” Lynn Etheredge Health Affairs. 2007; 26 (2):w107-w118 How Can EMR Systems There is a downside Help the Situation? Electronic medical records can: • Identify care variations across systems & practitioners “.. a wealth of information creates a poverty • Relate practice variations to outcomes & cost of attention , and a need to allocate that attention efficiently..." • Pinpoint and facilitate repair of failures and implementation of successes. Herbert Simon, 1971 • Help determine how to stop doing what doesn’t work Too Much Information Isn’t Always a Good Thing Much information is of poor quality or is inadequate to address key questions: - surveys with low response rates - biased samples and questions - insufficient numbers to address questions asked - invalid statistical analyses (or none at all), etc. “I have my own method for choosing the Remember GIGO – Garbage in, garbage out best treatment. It’s quicker than reading all those journals.” 6