We Can Do Better Richard G. Roberts, MD, JD Wonca President 2010-2013 Professor of Family Medicine, University of Wisconsin TEL: +1 608 263 3598 Email:

We Can Do BetterWe Can Do Better

Richard G. Roberts, MD, JD Richard G. Roberts, MD, JD Wonca President 2010-2013Wonca President 2010-2013Professor of Family Medicine, University of Wisconsin Professor of Family Medicine, University of Wisconsin TEL: +1 608 263 3598 Email: [email protected]: +1 608 263 3598 Email: [email protected]

U.S. Healthcare SystemU.S. Healthcare System1,300 payers1,300 payers11

4,919 hospitals4,919 hospitals22

764,000 physicians764,000 physicians33

3,119,000 nurses3,119,000 nurses44

302,000,000 people302,000,000 people55

11http://www.ahip.org/http://www.ahip.org/

22http://www.aha.org/aha/research-and-trends/health-and-hospital-trends/2006.htmlhttp://www.aha.org/aha/research-and-trends/health-and-hospital-trends/2006.html

33http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/2.htm http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/2.htm

44Dionne M, Moore J, Armstrong D, and Martiniano R. Dionne M, Moore J, Armstrong D, and Martiniano R. The United States Health Workforce ProfileThe United States Health Workforce Profile . . Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany. October Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany. October 2006. http://chws.albany.edu.2006. http://chws.albany.edu.

55http://www.census.gov/http://www.census.gov/

U.S. Healthcare SystemU.S. Healthcare System• 2009 National Health Expenditures (NHE)2009 National Health Expenditures (NHE)11

17.6% of GDP (Switzerland 11%); largest sector17.6% of GDP (Switzerland 11%); largest sector $2,500 billion$2,500 billion $8086 NHE per capita$8086 NHE per capita

• 1 in 4 without any or enough insurance1 in 4 without any or enough insurance22

• 2000 World Health Report2000 World Health Report33: : ranked 37ranked 37thth for system performance for system performance ranked 72ranked 72ndnd for health outcomes for health outcomes

11https://www.cms.gov/NationalHealthExpendData/02_NationalHealthAccohttps://www.cms.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPageuntsHistorical.asp#TopOfPage22http://www.census.gov/prod/2006pubs/p60-231.pdfhttp://www.census.gov/prod/2006pubs/p60-231.pdf33http://www.who.int/whr/2000/en/whr00_en.pdfhttp://www.who.int/whr/2000/en/whr00_en.pdf

Healthcare servicesHealthcare services

U.S., 2005 U.S., 2005

Physician office visitsPhysician office visits 963,617,000963,617,000

Emergency dept visitsEmergency dept visits 115,223,000115,223,000

Hospital outpatient dept visitsHospital outpatient dept visits 90,393,000 90,393,000

Hospital dischargesHospital discharges 34,667,000 34,667,000

Source: National Ambulatory Medical Care Survey, 2005 Source: National Ambulatory Medical Care Survey, 2005 http://www.cdc.gov/nchs/data/ad/ad387.pdfhttp://www.cdc.gov/nchs/data/ad/ad387.pdf

U.S. Physician Office Visits 2005U.S. Physician Office Visits 200511U.S. Physician Office Visits 2005U.S. Physician Office Visits 200511

11Excludes anesthesiology, pathology & radiology. Excludes anesthesiology, pathology & radiology. Source: http://www.cdc.gov/nchs/data/ad/ad387.pdfSource: http://www.cdc.gov/nchs/data/ad/ad387.pdf

0

100

200

300

400

500

600

Fam Med-GP Internal Medicine Pediatrics All Primary Care Other Specialists

216 216 MilliMillionon

22% 17%

168 168 MilliMillionon 129 129

MilliMillionon

13%

512 512 MilliMillionon

53%

451 451 MilliMillionon

47%

Visit rates by setting type: Visit rates by setting type: United States, 1995 and 2005United States, 1995 and 2005

020406080

100120140160180200

Primary CareOffice

SurgicalSpecialist

Office

MedicalSpecialist

Office

HospitalOutpatient

Department

EmergencyDepartment

1995

2005

162162

197197

5656

6969

4848

6565

26263131 3737 4040

Sources: National Ambulatory Medical Care Survey and National Hospital Sources: National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey. http://www.cdc.gov/nchs/data/ad/ad388.pdfAmbulatory Care Survey. http://www.cdc.gov/nchs/data/ad/ad388.pdf

Vis

its

per

100

per

son

sV

isit

s p

er 1

00 p

erso

ns

% change% change+22%+22%

+23%+23% +35%+35%

+19%+19%+8%+8%

““Primary health care also offers the best way of Primary health care also offers the best way of coping with the ills of life in the 21st century: the coping with the ills of life in the 21st century: the globalization of unhealthy lifestyles, rapid unplanned globalization of unhealthy lifestyles, rapid unplanned urbanization, and the ageing of populations.” urbanization, and the ageing of populations.”

Dr Margaret Chan, Director General, WHO - 2008Dr Margaret Chan, Director General, WHO - 2008

““A world that is greatly out of A world that is greatly out of balance in matters of health is balance in matters of health is neither stable nor secure. . . “neither stable nor secure. . . “

““Primary health care brings Primary health care brings balance back to health care, balance back to health care, and puts families and and puts families and communities at the hub of communities at the hub of the health system. “the health system. “

Primary Health Care, including Primary Health Care, including health systems strengthening.health systems strengthening.

World Health Assembly adopted a resolution urging World Health Assembly adopted a resolution urging member states to “accelerate action towards member states to “accelerate action towards universal access to primary health care” and “to universal access to primary health care” and “to train and retain adequate numbers of health train and retain adequate numbers of health workers . . . including . . . workers . . . including . . . family physiciansfamily physicians. . .”. . .”

World Health Assembly Resolution WHA62.12World Health Assembly Resolution WHA62.12Geneva, World Health Organization, May 2009.Geneva, World Health Organization, May 2009.

Rosenthal TG. The medical home: growing evidence to Rosenthal TG. The medical home: growing evidence to support a new approach to primary care. JABFM 2008; support a new approach to primary care. JABFM 2008; 21:427-440. 21:427-440.

Starfield B, Shi L, Macinko J. Contribution of primary care Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quar 2005;83:457-to health systems and health. Milbank Quar 2005;83:457-502.502.

Family PhysiciansFamily Physicians

• Doctors of first & last resort – e.g., cancerDoctors of first & last resort – e.g., cancer

• Continuous & comprehensive careContinuous & comprehensive care

• Responsible for total health needsResponsible for total health needs

• 75% of complaints are self-limited75% of complaints are self-limited

– 80% < 65 years; 40% > 65 years80% < 65 years; 40% > 65 years

• Time and relationship as diagnostic and Time and relationship as diagnostic and therapeutic toolstherapeutic tools

0

0.5

1

1.5

2

1000 1500 2000 2500 3000 3500 4000

Per Capita Health Care Expenditures

Pri

ma

ry C

are

Sco

re

Primary Care Score vs. Health Care Expenditures, 1997

US

NTH

CANAUS

SWEJAP

BEL FRGER

SP

DK

FIN

UK

Relationship between Strength of Primary Care and Combined Outcomes

0

2

4

6

8

10

12

0 1 2 3 4 5 6 7 8 9

Pri

mar

y C

are

Ran

k*

Outcomes Indicators (Rank)

USA

GER

BEL

AUS

SWE

SP

CAN

FIN

UK

NTHDK

*1=best11=worst

Primary Care Strength and Premature Mortality in 18 OECD Countries

*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77.

Source: Macinko et al, Health Serv Res 2003; 38:831-65.

Year

High PC Countries*

Low PC Countries*

10000

PYLL

1970 1980 1990 2000

0

5000

CommunityCommunityHealthHealth

Personal Personal Health Health

Mortality OutcomesMortality Outcomes• Primary care physiciansPrimary care physicians: 1 per 10,000 (20%) more : 1 per 10,000 (20%) more

primary care physicians primary care physicians decreasesdecreases mortality by 40 mortality by 40 per 100,000 (per 100,000 (5% fewer deaths5% fewer deaths).).

Family PhysiciansFamily Physicians: 1 per 10,000 (33%) more family : 1 per 10,000 (33%) more family physicians results physicians results decreasesdecreases mortality by 70 per mortality by 70 per 100,000 (100,000 (9% fewer deaths9% fewer deaths).).

• SpecialistsSpecialists: 1 per 10,000 (8%) more specialists : 1 per 10,000 (8%) more specialists increasesincreases mortality by 16 per 100,000 ( mortality by 16 per 100,000 (2% more 2% more deathsdeaths).).

Shi. J Am Board Fam Pract 2003;16:412-22.Shi. J Am Board Fam Pract 2003;16:412-22.

Indonesia Infant MortalityIndonesia Infant Mortality

1996-19971996-1997 1997-19981997-1998 1998-19991998-1999 1999-20001999-2000

Primary Primary care*care*

Hospital*Hospital*

Infant Infant MortalityMortality

10.310.3 9.69.6 8.58.5 8.28.2

4.14.1 4.14.1 4.64.6 5.35.3

70% improvement in70% improvement in 14% worsening in 14% worsening inall provinces 1990-1996all provinces 1990-1996 22 of 28 provinces 22 of 28 provinces

**constant Indonesian rupiah per capita, in billionsconstant Indonesian rupiah per capita, in billions

Simms et al. Lancet 2003;361:1382-5.Simms et al. Lancet 2003;361:1382-5.

Personal physician: Personal physician: primary care vs specialistprimary care vs specialist

• 33% lower cost of care33% lower cost of care

• 19% less likely to die19% less likely to die

Frank et al. J Fam Pract 1998;47:105-9Frank et al. J Fam Pract 1998;47:105-9

Increasing physicians Increasing physicians 1 per 10,000 population1 per 10,000 population

• SpecialistsSpecialists Decrease 9 states in qualityDecrease 9 states in quality Increase costs $526/beneficiaryIncrease costs $526/beneficiary

• Primary carePrimary care Increase 10 states in qualityIncrease 10 states in quality Decrease costs $684/beneficiaryDecrease costs $684/beneficiary

Baicker et al. Health Affairs 2004;W4:184-197Baicker et al. Health Affairs 2004;W4:184-197

Equity effects of primary careEquity effects of primary care

• Improves self-rated healthImproves self-rated health

• Reduces disparitiesReduces disparities

• Reduces effects of income inequalityReduces effects of income inequality

Starfield B et al. Milbank Quar 2005;83:457-502Starfield B et al. Milbank Quar 2005;83:457-502

People do better People do better with primary care.with primary care.

Starfield B, Shi L, Grover A, Macinko J.Starfield B, Shi L, Grover A, Macinko J.The Effects of Specialist Supply on Populations’The Effects of Specialist Supply on Populations’Health: Assessing the Evidence.Health: Assessing the Evidence.http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.97/DC1http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.97/DC1

Why do people worse with specialists?Why do people worse with specialists?

• Outside area of expertise: Outside area of expertise:

CAP, AMI, CHF, UGI bleedCAP, AMI, CHF, UGI bleed11

• Late stage diagnosis of breastLate stage diagnosis of breast2 2

or colorectalor colorectal33 cancer cancer

• Excessive utilizationExcessive utilization44

• Handoff or communication errorsHandoff or communication errors55

1.1. Weingarten et al. Arch Int Med 2002;162:527-532.Weingarten et al. Arch Int Med 2002;162:527-532.2.2. Ferrante et a. J Am Board Fam Pract 2000;13:408-414.Ferrante et a. J Am Board Fam Pract 2000;13:408-414.3.3. Rotezheim et al. J Fam Pract 1999;48:850-858.Rotezheim et al. J Fam Pract 1999;48:850-858.4.4. Greenfield et al. JAMA 1992;367:1024-1030.Greenfield et al. JAMA 1992;367:1024-1030.5.5. Skinner et al. Health Affairs 2006;25:w34-w37.Skinner et al. Health Affairs 2006;25:w34-w37.

Pyramid of CarePyramid of Care

<1<1

55

99

250250

750750

10001000

Taken from Taken from White KL, et al. N Engl J Med 1961;265:885-92 andWhite KL, et al. N Engl J Med 1961;265:885-92 and Green LR, et al. N Engl J Med 2001;344:2021-25. Green LR, et al. N Engl J Med 2001;344:2021-25.

How good is the evidence?How good is the evidence?DesignDesign: Review of all original clinical research in 3 : Review of all original clinical research in 3

major general clinical journal or high-impact major general clinical journal or high-impact specialty journals from 1990-2003 that were cited specialty journals from 1990-2003 that were cited more than 1000 times.more than 1000 times.

ResultsResults: Of 49 highly cited studies, 45 claimed that : Of 49 highly cited studies, 45 claimed that the intervention was effective.the intervention was effective.

7 (16%) contradicted by subsequent studies7 (16%) contradicted by subsequent studies 7 (16%) found effects stronger than those of 7 (16%) found effects stronger than those of

subsequent studiessubsequent studies 20 (44%) were replicated20 (44%) were replicated 11 (24%) remained largely unchallenged11 (24%) remained largely unchallenged

Source: Ioannidis JPA. JAMA 2005;294:218-228.Source: Ioannidis JPA. JAMA 2005;294:218-228.

Case of Hemoglobin A1cCase of Hemoglobin A1c

• ACCORD (N=10,251) ACCORD (N=10,251) NEJM 2008;358:2545-59.NEJM 2008;358:2545-59.

• ADVANCE (N=11,140) ADVANCE (N=11,140) NEJM 2008;358:2560-72.NEJM 2008;358:2560-72.

• VA Trial (N=1791) VA Trial (N=1791) NEJM 2009;360:129-39.NEJM 2009;360:129-39.

The Truth Wears Off. Is there something wrong with the scientific method?

Lehrer J. The New Yorker. December 13, 2010, p. 52 ff.

http://www.newyorker.com/reporting/2010/12/13/101213fa_fact_lehrer

EpistemologyEpistemology

• LawLaw Beyond a reasonable doubtBeyond a reasonable doubt Clear and convincingClear and convincing To a reasonable degreeTo a reasonable degree

• MedicineMedicine 2 standard deviations (p<.05)2 standard deviations (p<.05)

• EngineeringEngineering 6 SD (p<.00000002; 2 per billion) 6 SD (p<.00000002; 2 per billion) Six Sigma: <3.4 defects per million opportunitiesSix Sigma: <3.4 defects per million opportunities

Time RequirementsTime Requirements

• 10.6 hrs/day – chronic conditions10.6 hrs/day – chronic conditions1, 21, 2

• 7.4 hrs/day – preventive services7.4 hrs/day – preventive services33

• Patient agenda?Patient agenda?• Acute care?Acute care?• Administrative issues?Administrative issues?

1.1. ØØstbye T. Ann Famed Med 2005; 3:209-214.stbye T. Ann Famed Med 2005; 3:209-214.

2.2. Tsai et al. Am J Man Care 2005;11:478-88.Tsai et al. Am J Man Care 2005;11:478-88.

3.3. Yarnall KHS. AJPH 2003;43:635-641.Yarnall KHS. AJPH 2003;43:635-641.

4.4. Bodenheimer T. NEJM 2006:355:861-864.Bodenheimer T. NEJM 2006:355:861-864.

ComplexityComplexity

• Average visit: 1.4 – 8 problemsAverage visit: 1.4 – 8 problems• Diagnoses: Diagnoses:

“ “ologist”: top 5 = 90%ologist”: top 5 = 90% family doctor: top 25 = 60% total family doctor: top 25 = 60% total

Stange KC, et al. J Fam Pract 1998;46(5):363-8.Stange KC, et al. J Fam Pract 1998;46(5):363-8.

PersonalPersonal ProfessionalProfessional

PopulationPopulationPublicPublic

Primary Health CarePrimary Health Care

PersonalPersonal ProfessionalProfessional

PopulationPopulationPublicPublic

Primary Health CarePrimary Health Care

Tar Wars Counseling, medication

Registry, immunization

Tobacco control

Tobacco-related disease

Predictors for successPredictors for success

• Provide ready accessProvide ready access

• Prevent & manage chronic conditionsPrevent & manage chronic conditions

• Prove & improve performanceProve & improve performance

Aims & Assets Aims & Assets of Primary Health Careof Primary Health Care

• ContinuityContinuity

• ComprehensiveComprehensive

More important More important

than knowing the disease than knowing the disease

is knowing the person is knowing the person

with the dis-ease.with the dis-ease.

It’s theIt’s the

RELATIONSHIP!RELATIONSHIP!