Looking Ahead: The Future of American Health Care Ezekiel J. Emanuel, M.D., Ph.D.
Looking Ahead:
The Future of American
Health Care
Ezekiel J. Emanuel, M.D., Ph.D.
US Health Care Spending (2016)
$3.4 Trillion
Rx for Cost Cutting
GDP (nominal) in 2016 Rank
USA $18.57 trillion #1
CHINA $11.22 trillion #2
JAPAN $4.94 trillion #3
GERMANY $3.47 trillion #4
UK $2.63 trillion #5
FRANCE $2.46 trillion #6
INDIA $2.26 trillion #7
Two TrendsMeasure USA FRANCE GERMANY
Health Care Cost
per person (2015, PPP)
$9,451 $4,407 $5,267
Average Life Expectancy 79.3 (31st) 82.4 (9th) 81.0 (24th)
Infant Mortality
(per 1,000 births)
5.80 3.30 3.20
Cancer 5 year survival
Breast
Colon
Childhood Leukemia
88.6%
64.7%
87.7%
86.9%
59.8%
89.2%
85.3%
64.6%
91.8%
Years of life lost (per 100,000
inhabitants aged 0-69)
4,600 3,100 3,000
WHO Health System
Ranking*
37 1 25
* Based on a composite score of health, health inequality, responsiveness-level,
responsiveness distribution, and fair financing.
Affordability Index
14.2%
15.3%
16.7%
18.9%
20.9%
22.4%
23.5% 23.8% 24.1%
25.2%
26.9%
27.9%
30.1%30.9%
31.5% 31.4% 31.0%
10%
15%
20%
25%
30%
35%
Perc
enta
ge
Family Health Insurance Premiums as Percentage of Median Income (2001-2015)
Unnecessary Services
Source: Scott Ramsey. How Should We Define Value in Cancer Care.
IOM Affordable Cancer Care Workshop. 8 Oct, 2012.
Inefficient Care
3 Weeks 7 Weeks
5-year local
recurrence-free
survival
97.2% 96.8%
Excellent/good global
cosmetic outcome at
3 years
76.8% 77.0%
Excellent/good global
cosmetic outcomes at
5 years
76.8% 77.4%
% Women receiving 34.5% 65.5%
Breast Cancer Irradiation Outcomes by Treatment Duration
*No difference in overall survival rates was detected between study arms.
Whelan T, MacKenzie R, Julian J et al. Randomized trial of
breast cancer irradiation schedules after lumpectomy for
women with lymph node-negative breast cancer. J Natl Cancer
Inst. 2002; 94(15):1143-50.
Inefficient Care
• Robotic-assisted
radical
nephrectomies had
longer operating
times, higher
hospital costs, and
no better outcomes
than laparoscopic
surgeries.
JAMA. 2017;318(16):1561-68.
doi:10:1001/jama.2017.14586
Pricing Failures
• Medicare pays
$2,062 for cardiac
imaging done in-
hospital, compared
to $626 done in-
office.
• $105 billion per
year.
Enactment of Health Care Reform
Patient Protection and Affordable Care Act
March 23, 2010
Access
Cost
Cost
Health care price growth dropped to 2-year
low of 1.2% in August 2017
Source: Altarum Institute
Quality
AHRQ : 21%
reduction HACs
from 2010 to 2015
• 125,000 fewer deaths
• 3.1 million fewer
incidents of harm
• Approximately $28
billion in savings
The Iron TriangleCost
AccessQuality
The Cost-Quality “Tradeoff”Q
ualit
y
Cost Effectiveness
Lower costHigher cost
High quality
Low quality
Job Growth
5
-816
1451
366
226 204 227
110
204
-1000
-800
-600
-400
-200
0
200
400
600
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
1-M
onth
Ne C
hange
Year
Monthly Change in Total Private Employment (in thousands), 2008-2017
Adapted from Bureau of Labor Statistics
VC Investments
2006 – 2010 $47.0 bn
2011 – 2015 $61.9 bn
32% growth
Source: Pitchbook
What will the future of
American health care look
like?
The Way Forward
“I’ve always been independent. Always
been the one helping everyone else. Now
I can’t do nothing for myself…I’m ready,
I’ve been ready ever since I had my heart
attack. Ready whenever the Good Lord is
ready to do His work.”
~ Ms. Harris
The 12 PracticesScheduling
Registration & rooming
Shared decision-making
Performance measurement
Standardi-zation
Care management
Site of service
De-institutionaliz
ation
Behavioral health
management
Hospice & Palliative Care
Community interventions
Lifestyle interventions
2 Key Practices
We will focus on:
1. Chronic care coordination
2. Behavioral health
Chronic Care Coordination
• 36% of Americans (117 million) have 1+
chronic conditions.
• 86% of all health expenditures are for
people with chronic conditions.
• High-need, chronically ill U.S. adults spend
$21,000 per year, 4x more than average
adults.
Chronic Care Coordination
Chronic Care Coordination
Identify high-risk patients
Embed care managers in primary care
teams
Empower care managers to close
care gaps
Use active outreach to
contact patients and improve
compliance/access in case of
complications
Educate patients about their illness,
adherence, and how to use the health system
Chronic Care Coordination
“Our number one
complaint is that they
[patients] hear from us too
much. We are trying to
streamline the calls and
the appointment, so that
you know that you’re
getting these [high-risk]
patients in early and
often.”
Dr. Sachin H. Jain, CareMore CEO
Behavioral Health
“This woman had post-
partum depression
and was suicidal.
She insisted she
would not see a
psychiatrist.”
Behavioral Health
$20
$840 $860
$130
$1,290
$1,420
Mental health expenditures Medical expenditures Total expenditures
Monthly Health Care Expenditures for Chronic Conditions, With and Without Comorbid Depression, 2005
Without depression With depression
Adapted from Melek S & Norris D (2008). Chronic conditions and comorbid psychological
disorders. Cited in: Druss BG & Walker ER (2011). Mental Disorders and Comorbidity.
Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.
Behavioral Health
The 3 Approaches to Behavioral Health:
1. Co-locating behavioral health specialists in PCP and
specialist offices
2. Connecting PCPs with behavioral health providers
who have unused appointments
3. Utilizing virtual medicine to do remote consults
Behavioral Health
Mike Nagoshi, MD
“This woman had post-
partum depression and was
suicidal. She insisted she
would not see a psychiatrist.
At the end of our
appointment, I asked her to
accompany me down the
hall. I then introduced her to
the health psychologist who
works in our office space.
Right then, he began seeing
her.”
Behavioral Health
David Wennberg, MD
What about Virtual Medicine?
Virtual Medicine
“Over the past decade, smartphones have radically
changed many aspects of our everyday lives, from
banking to shopping to entertainment. Medicine is
next…Just as the printing press democratized
information, the medicalized smartphone will
democratize health care. Anywhere you can get a
mobile signal, you’ll have new ways to practice
data-driven medicine. Patients won’t just be
empowered; they’ll be emancipated.”
~ Eric J. Topol, MD
Role of Virtual Medicine
• A 2016 JAMA-IM study looked at effects of
wearable tech.
1437 Patients
hospitalized with CHF
Usual care
Health coaching phone calls with wireless blood pressure, heart
rate, weight, and symptom,
monitoring. Nurse initiated protocolized
interventions.
Role of Virtual Medicine
• There were no significant differences
between the two groups in:
30-day readmission
180-day mortality
JAMA IM, 2016
Role of Virtual Medicine
• Virtual medicine cannot replace
physician-patient relationships.
• It is best designed to work in the
background.
Applications of Virtual Medicine
Rural health
Tele-ICU
Behavioral health
MD-MD consultation
Follow-up care for chronic conditions
Minor care resolution
Text message communication
Phasing in the 12 Practices
• No single practice or health system has
implemented all 12 practices.
• Instead, it is important to prioritize starting with
a few key practices.
Scheduling
Chronic care management
Performance management
Site of service
Timeline of Transformation
Timeline of Transformation –
ACOs
Source: David Muhlestein, Robert Saunders, and Mark McClellan. Medicare Accountable Care Organization
Results For 2015: The Journey To Better Quality And Lower Costs Continues. Health Affairs Blog. September 9,
2016
Timeline of Transformation
“In the beginning, a big share of the
savings was associated with changing
site of service…By year four, it was 50%
price, 50% utilization in terms of how we
were saving.”
~ Dana G. Safran,
Chief Performance Measurement &
Improvement Officer, BCBS MA
Timeline of Transformation
“We found surprisingly strong sentiment that the
industry will be transformed over the next five
to ten years by the development of new pricing
models broadly known as value-based
care…the responses indicated that value-based
care may have even more of an impact on the
industry than scientific breakthroughs.”
~ Lazard 2017 Global Healthcare Leaders
Study
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