Dr. Robert Riehle Jr. Wofford College 2/24/10

Dr. Robert Riehle Jr. Wofford College 2/24/10

Wofford Healthcare Symposium Our current system and its need to change Financing of the delivery system Components of an ideal delivery system What change is possible

Healthcare Reform- Is now the time? 80% 60% 62% 61% 62% 59% 61% 56% 53% 57% 55% 58% 54% 54% 40% 20% 37% 34% 34% 37% 35% 39% 42% 39% 41% 36% 41% 39% It is more important than ever to take on health care reform now We cannot afford to take on health care reform right now 0% Oct08 Dec08 Feb09 Apr09 Jun09 Jul09 Aug09 Sep09 Oct09 Nov09 Dec09 Jan10

Healthcare Comments Healthcare system is broken. We don t want a government run healthcare system. I want to choose my doctor! We don t put enough resources into prevention Insurance companies are villains. They get between me and my doctor. 80% of Medicare costs are in the last 6 months of life. I m satisfied with the quality of care. It just costs too much. We have a sickness, not a wellness system.

Issues and Challenges 2010 Wants: 1. Excellent care (acute and chronic) 2. Availability access (convenient, timely) 3. Insurance coverage 4. Affordable Complaints: 1. Cost of care and coverage 2. Uninsured and underinsured 3. Inefficiencies of process care delivery

Distribution of National Health Expenditures, by Type of Service, 2008 Other Personal Health Care 12.9% Other Health Spending 16.5% Hospital Care 30.7% Home Health Care, 2.8% Nursing Home Care, 5.9% Prescription Drugs 10.0% Physician/ Clinical Services 21.2% Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc. 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 1960-2008; file nhe2008.zip).

Healthcare Arena Delivery Systems Healthcare provider, facility, vendor = delivery system Hospitals and Medical Centers FP, NFP Faith based Municipal Governmental Integrated Healthcare Systems Hospitals Physicians (office based) Rehab, ASC, Primary Care Centers, Diagnostic Centers, Home Health, Hospice Levels of care (continuum)

Healthcare Arena: Reform Plan- insurance coverage Insurance-employer, group, individual Finance Delivery system- IDS, providers Information Regulation Certification, Accreditation Government role: financed, managed, regulated, sponsored, coordinated, run, owned Comprehensive Reform- Change all components

Health Versus Healthcare Health: shaped by genetics, lifestyle, diet, social factors, chance, and sometimes healthcare Healthcare: Episodic vs. longitudinal Restores health vs. promotes health Basic vs. specialty Preventive vs. reactive

Ideal Delivery System Concepts High quality; effective care and service Standardized, measurable, improving Accessible (acute and chronic) Efficient- cost controlled, technology, innovative Universal for all; basic, prevention Managed across continuum (levels of care) Accountable, monitored

Ideal Delivery System Components Integrated Delivery Systems (IDS) Engaged physicians Evidence based medicine Information sharing via EMR, telemedicine, RHIN Consolidation versus competition Transparency of operations (cost, quality, continuum) Primary care focus Chronic disease focus End of life: planned Tort Reform

Integrated Delivery System Organized, managed, owned across the continuum Employed staff, new role for extenders Accountable care organizations Efficient Measurable by metrics Incentives Vendor bidding Pay for performance Prevention pays Clinical effectiveness research rules evidence based medicine Hub and spoke- rural + tertiary

Engaged Physicians Employed and managed Accountable by metrics Use of extenders-patient centered team Incentive based on productivity, process and outcomes performance based pay Evolution of manpower: training, financing, continued learning, certification, patient/physician relationship

Are doctors following the guidelines? Retrospective review, cancer care delivered 1300 oncologists Non-compliance with NCCN guidelines: 17%,61%, 31%, 24%, 31% Optimal compliance (NCCN) 85%! Clinical variation? United Healthcare 2010

Non-Federal Physicians per 100,000 Civilian Population, 1970-2008 350 312 316 319 322 300 262 266 268 273 277 280 250 200 150 146 165 193 220 234 100 50 0 1970 1975 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008

Evidence Based Medicine National guidelines Algorithms Risk predicting software CER (Clinical Effectiveness Research) Patient education= interactive

Information Sharing-Informatics EMR (EHR, multimedia, patient health records, interactive) Telemedicine Teleradiology, pathology Teleconsultation Telesurgery Telerounding Tele-ICU (e-icu) RHIN (regional health info network) Important for rural, community and public health

Consolidation versus Competition Mergers at regional/national levels Devolution of For Profit Hospitals Certification of Centers of Excellence More IDS, hub and spoke, geographic mergers Physician multi-specialty groups, employed networks More regional/ national networks

Medical Liability: Tort Reform Relocate from tort system to alternative, administrative Civil court replaced by health court Less adversarial, more efficient form of justice No fault concepts Administrative medical injury compensation Poor result versus malpractice (negligence) Current examples: no-fault, government administered National Vaccine Injury Compensation Program NLRB, Tax, worker s compensation board State initiatives: birth injury funds Risk management Consent to independent structured arbitration process www.commongood.org

Transparency of Operations Performance metrics (clinical and services) Pricing/changes how much will it cost me? Report card: value, quality of care Regulation- certification, accreditation Conflict of interests- ownership, research, industry expert

Primary Care Focus Patient centered: new model Group visits Medical home, PCP coordination Electronic visits Alternative Hours, case managers Multidisciplinary, coordinated visits Prevention via EMR Patient education; responsibility Specialist advice without visit video and audio

Chronic Disease Focus Increasing prevalence (emphysema, heart failure, arthritis, cancer, multiple sclerosis) Standardized around guidelines Drugs to slow progression Extenders as providers; medical home Acute on chronic: efficient management back to baseline Transition to symptom management (palliative)

End of Life- Planned Advanced directives: What I want done if I can t decide myself Family involvement Quality of life metrics Individualized decision/autonomy/patient rights PCP/ geriatrics What can we do vs. what you want done

Ideal Delivery System Components Integrated Delivery Systems (IDS) Engaged physicians Evidence based medicine Information sharing via EMR, telemedicine, +RHIN Consolidation versus competition Transparency of operations (cost, quality, continuum) Primary care focus Chronic disease focus End of life: planned Tort Reform

Healthcare System Reform: Summary Less segmented, more integrated Less independent, more monitored More standardized, effective, efficient More electronic, interactive, coordinated More transparent More socially responsive More personal responsibility Less liability for poor outcomes

Websites Hospital www. Hospitalcompare.org www.myschospital.org www.ncqualitycenter.org www.abouthealthquality.org Physician www.healthgrades.com ($12.95) www.ncqa.org recognition program Patient Info www.jama.com Patient page www.myhealthcareoptions.org Facility www.medicare.gov/dialysisco mpare/snf compare

Healthcare Reform : tenets Reduce # of uninsured Reduce cost of care, premiums Reduce clinical care variance re practice Reduce encounter based payments Reduce administrative costs Reduce role of government

White House : Healthcare Reform Proposal 2/22/10 Medicaid Expansion fully funded by Washington -eligibility 133% of FPL Tax high cost healthplans (2018) Medicaire payroll tax increase.9% on earnings Medical Device tax (2013)

WH HC Reform 2/22/10 Individual Mandate (2014) Employer mandate (??) Insurance companies: assessments Insurers no exclusions (2014) Insurers premium increases Fed Rate Auth Review Pharma - assessment

WH HC Reform 2/22/2019 Assume Close to universal coverage Commission to manage Medicaire (not congress) CER clinical effectiveness research More community health centers (CHC) Decreased funding to hospitals Technology Assessment (clinical) Different payment methodology Incentive to use EMR