Bringing Health Care to the World –What Does the Future Hold?

Ogden Surgical-Medical Society

74th Annual CME Conference –Bringing Healthcare to the World 2019

Shepherd Union Building, 3rd Floor, 3848 Harrison Boulevard, Ogden, UtahWednesday, 15 May 2019 – 11:00a - 12:n

Brent C. James, M.D., M.Stat.Quality Science

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Disclosures

I receive a monthly retainer as a part time

(3 days / month) senior advisor for Health Catalyst.

Other than that, neither I nor any family

members have any relevant financial

relationships to be directly or indirectly

discussed, referred to or illustrated within the

presentation, with or without recognition.

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The basis for variation research:

Apply rigorous

clinical research measurement methods(think “statistics”)

to

routine care delivery performance(that is, to quality of care)

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The opportunity (care falls short of its theoretic potential)

1. Massive variation in clinical practices (beyond

even the remote possibility that all patients receive good care)

2. High rates of inappropriate care (where the risk of

harm inherent in the treatment outweighs any potential benefit)

3. Unacceptable rates of preventable care-

associated patient injury and death

4. Striking inability to "do what we know works"

5. Huge amounts of waste, leading to spiraling

prices that limit access to care

James, B.C. Testimony to the U.S. Senate Finance Committee, February 2009

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The waste opportunity is HUGE

30-50+% of all health care resource

expenditures are

quality-associated waste:

• recovering from preventable foul-ups

• building unusable products

• providing unnecessary treatments

• simple inefficiency

Institute of Medicine Roundtable on Value and Science-Driven Healthcare. The Healthcare Imperative:

Lowering Costs and Improving Outcomes. Yong, Pierre L., Saunders, Robert S., and

Olsen, LeighAnne, editors. Washington, DC: National Academy Press, 2010.

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We know why this happens

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Why? The collision of 2 forces:

(1) Continued reliance on the "craft of medicine" (clinicians as stand-alone experts; “best care” = “personal excellence”)

encounters

(2) Complexity; a.k.a. clinical uncertainty(the fruits of 100 years of clinical discovery, that changed the

nature of clinical practice – the ground shifted under our feet)

in the context of

(3) Low clinical transparency at a process level

(relatively poor data makes it difficult to causally link

treatment to outcome in routine care delivery)

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The craft of medicine

placing her patient's health care needs before any other end or goal,

Drawing on extensive clinical knowledge gained through formal education and experience

An individual physician

can craft a unique diagnostic and treatment regimen

customized for that particular patient.

This approach guarantees the best result possible for each patient.

Medicine's promise:

Used with permission from Intermountain Healthcare. ©~1995 Intermountain Healthcare. All rights reserved.

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Until now, we have believed that

the best way to transmit knowledge from its

source to its use in patient care

is to first load the knowledge into human minds

… and then expect those minds, at great

expense, to apply the knowledge

to those who need it.

Lawrence Weed

(Weed LL. New connections between medical knowledge and patient care. BMJ 1997; 315(7102):231-5 .

A culture of personal excellence

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The craft of medicine

gets it right

54.9%of the time.

(for adults; only 46% “right” for pediatrics)

McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the

United States. N Engl J Med 2003; 348(26):2635-45 (June 26).

Relying on expert memory …

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“The complexity of modern medicine

exceeds the capacity of the unaided

expert mind.”David M. Eddy, MD, PhD

In today’s increasingly complex practice environment,

reliance on the craft alone

is scientifically untenable

➢ Eddy is the “father” of evidence-based medicine- first used the term in the published literature in 1990

- developed most of the formal methods still used today for evidence review and summation

➢ He was based out of Stanford University at the time

➢ Evidence-based medicine was popularized by Dr. David Sackett, et al.- first used the term in the published literature in 1995

- Which is more important? Inventing it, or spreading it broadly?

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Case-rate utilization(# cases per population)

Within-case utilization(# and type of units per case)

Efficiency(cost per unit of care)

1.

2.

3.

% of all

waste

45%

40%

15%

Examples of removing waste

Waste class

a) Inappropriate cases (risk outweighs benefit)

(e.g., many cath lab procedures; CTPA)

b) Preference-sensitive cases(when given a fair choice, many patients opt out)

(e.g., elective hips, knees; end-of-life care)

c) Avoidable cases(hot spotting; move upstream)

(e.g., team-based care)

Waste subclasses

a) Supply chain

b) Administrative inefficiencies- regulatory burden - billing thrash

- TPS Lean observation - current EMR function

a) Clinical variation(e.g., QUE studies; surgical equipment)

b) Avoidable patient injuries(e.g., serious safety event systems; CLABSI)

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• Nuclear Stress Testing

• Angioplasty and Stents (PCI)

• Implantation of Permanent Pacemakers

• Implantation of Defibrillators

Evidence-based use of cardiac interventions

Used with permission from Intermountain Healthcare. ©2016 Intermountain Healthcare. All rights reserved.

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Angioplasty & Stents

Used with permission from Intermountain Healthcare. ©2016 Intermountain Healthcare. All rights reserved.

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0

100

200

300

400

500

600

700

8002

01

0 -

1 2 3 4 5 6 7 8 9

10

11

12

20

11

- 1 2 3 4 5 6 7 8 9

10

11

12

20

12

- 1 2 3 4 5 6 7 8 9

10

11

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20

13

- 1 2 3 4 5 6 7 8 9

Pro

ced

ure

s p

er

Mo

nth

MonthCathLab procedures per month Baseline LCL UCL

All Cath Lab procedures (system-wide)

620.8

482.0(-22.4%)

Used with permission from Intermountain Healthcare. ©2016 Intermountain Healthcare. All rights reserved.

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Results in cardiac procedures

Clinical Outcomes: • Remained Excellent (a slight uptick, actually)

2014 Costs to Community:

Decrease in Variable

Cost

Echo $161,634

Nuclear Medicine $1,644,344

Cath Lab $17,112,541

Total $18,918,519

Used with permission from Intermountain Healthcare. ©2016 Intermountain Healthcare. All rights reserved.

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Nearly always with proper clinical management

better care is cheaper carethrough waste elimination

The path to financial success leads

through clinical excellence

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Quality is not free (Phil Crosby was waxing poetic)

It always requires investment- change leadership (time and thought),

- study and investigation,

- data systems,

- physical plant, equipment …

it’s just that it has a

massive return on investment (ROI)

➢ Key questions:

- Who makes the investment?

- Who gets the savings?

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Financial incentive alignment underdifferent payment mechanisms

Note: For green arrows, savings from waste elimination accrue to the care

delivery organization; for red arrows, savings go to payer organizations.

Case-rate utilization(# cases per population)

Within-case utilization(# and type of units per case)

Efficiency(cost per unit of care)

FFS Per

case

Provider

at risk

WASTE REMOVAL

LEVEL

PAYMENT METHOD

1.

2.

3.

% of all

waste

45%

40%

15%

James Brent C and Poulsen Gregory P. The case for capitation: It’s the only way to cut wastewhile improving quality. Harv Bus Rev 2016; 94(7-8):102-11, 134 (Jul-Aug).

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What does the future hold?

Walter Gretzky (Wayne Gretzky’s father):

Skate to where the puck is going to be, not where it has been.

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“Pay for value” continues to grow

Forward looking indicators:

➢Kaiser Permanente (continued rapid growth within

existing geographic markets, mostly)

➢Medicare Advantage (continued rapid growth)

➢ACOs (Leavitt Group; mostly commercial)

➢ERISA direct to provider contracting(11% of large employers, according to Modern Healthcare)

➢Provider-payer consolidation (vertical alignment)

by ownership or partnership (e.g., United Healthcare; UPMC)

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Medicare trends over time

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012 2013 2014 2015 2016 2017 2018

Me

dic

are

mar

ket

shar

e

Year

Traditional FFS Med Advantage ACO

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HCCI - 12Feb19 - 2017 Health Care Cost and Utilization Report – employer-sponsored insurance (ESI) patients

Employer-sponsored insurance

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Implications – we will see:

➢ Increasing focus on waste elimination: primary care-based population health; clinical variation control using clinical decision support tools (a.k.a. clinical knowledge management = “learning healthcare systems”)

➢ Care delivery organizations will increasingly seek capitated risk through

ownership or partnership (a.k.a. “pay for value); watch for payer/care provider consolidation

➢ Stand-alone specialty care practices and hospitals become “price takers” –intense competition mainly around payment rates

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Better has no limit ...

an old Yiddish proverb