Transcript Leading Edge Opportunities in Health Care and Medicine

Leading Edge Opportunities in
Health Care and Medicine:
Using Data to Increase Value
Bob Gluckman, MD, FACP
CMO- Providence Health Plan
January 25, 2013
Exhibit 1. International Comparison of Spending on Health, 1980–2010
Average spending on health
per capita ($US PPP)
2
Total health expenditures as
percent of GDP
18
$8,000
US
$7,000
16
SWIZ
NETH
$6,000
14
CAN
12
GER
FR
10
AUS
UK
8
JPN
US
NETH
FR
GER
CAN
SWIZ
UK
JPN
AUS
Notes: PPP = purchasing power parity; GDP = gross domestic product.
Source: Commonwealth Fund, based on OECD Health Data 2012.
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
0
1988
$0
1986
2
1984
$1,000
1982
4
1980
$2,000
1980
6
2010
$3,000
2008
$4,000
2006
$5,000
Exhibit 3. Premiums Rising Faster Than Inflation and Wages
Cumulative changes in insurance
premiums and workers’ earnings,
1999–2012
Projected average family premium as a
percentage of median family income,
2013–2021
Percent
Percent
200
Health insurance premiums
175
180%
Workers' contribution to premiums
150
Workers' earnings
125
Overall inflation
35
30
172%
25
22 23
20
100
15
75
50
25
47%
10
38%
5
12
13
15
17
18 18 18 18
19
24
26
25 26
27
28 29
30
31
20
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
0
0
Projected
Sources: (left) Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits Annual Surveys, 1999–
2012; (right) authors’ estimates based on CPS ASEC 2001–12, Kaiser/HRET 2001–12, CMS OACT 2012–21.
Member Cost Sharing
20.0%
Member Portion of Allowed Amount
Member Cost Sharing
18.0%
Deductible
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
Incurred Month
PHP All Commercial Insured
Per Member Per Month Expenses
(Portland Service Area Only)
PMPM
$140.00
$120.00
$100.00
$80.00
$60.00
$40.00
$20.00
$0.00
2006
2007
PCP
2008
Spec
Hosp
2009
RX
2010
Admin
Jan-Dec 11
Case and Disease Management
Health Care Cost Continuum - Why We Focus on Specific members
1% of People
30% Total
Cost
10% Total Cost
0% Total Cost
20% of People
Source: Milliman USA Health Cost Guidelines—2001 Claim Probability Distributions.
70% of People
% of
People

6
JAMA 2012;307:1513-1516
Exhibit 7. Synergistic Strategy: Cumulative Savings, 2013–2023
Payment reforms to accelerate delivery system innovation ($1,333 billion)
• Pay for value: replace the SGR with provider payment incentives to improve care
• Strengthen patient-centered primary care and support care teams
• Bundle hospital payments to focus on total cost and outcomes
• Align payment incentives across public and private payers
Policies to expand and encourage high-value choices ($189 billion)
• Offer new Medicare Essential plan with integrated benefits through Medicare, offering positive
incentives for use of high-value care and care systems
• Provide positive incentives to seek care from patient-centered medical homes, care teams, and
accountable care networks (Medicare, Medicaid, private plans)
• Enhance clinical information to inform choice
Systemwide actions to improve how health care markets function ($481 billion)
• Simplify and unify administrative policies and procedures
• Reform malpractice policy and link to payment*
• Target total public and private payment (combined) to grow at rate no greater than GDP
per capita**
Notes: SGR = sustainable growth rate formula; GDP = gross domestic product.
* Malpractice policy savings included with provider payment policies.
** Target policy was not scored.
Seven Megatrends That Will Influence
the Healthcare Industry
• Demanding demographics
– Aging, obesity, income inequality
• Strategic globalization
– Competitive global economy, medical tourism
• Unconstrained connectivity
– Personal health records, smartphone apps
• Accelerated consolidation
– ? Impact on cost
www.medcitynews.com/?s=keckley
Seven Megatrends That Will Influence
the Healthcare Industry
• Constrained resources
– Limited public budget, inability to shift costs
• Consumer discontent
– Cost sharing, mistrust of government, payers,
providers
• Big data
– Ability to aggregate data to demonstrate quality
and cost variation
Integrating Claims and Clinical Data
to Improve Quality and Lower Cost
Cardiology
Appropriateness of
Diagnostic Angiography
Retrospective analysis of 565,504 patients without previous
MI or revascularization from 2005-2008 undergoing elective
coronary angiography
JACC 2011;58:801-809
Cardiology- Practice Variation
Cardiac Procedure Rates
by Top 6 Regions (Jan 2010-Sep 2011)
Data from Large Employer
CAD Presentation in Patients Receiving
Diagnostic Coronary Angiography
100%
90%
80%
42.0%
31.4%
24.3%
29.8%
70%
31.3%
20%
10%
40.1%
45.7%
27.2%
40%
30%
26.7%
31.2%
60%
50%
18.9%
11.5%
3.4%
22.4%
25.9%
32.3%
A
B
C
8.4%
22.2%
5.6%
19.0%
27.8%
0%
Non-STEMI and STEMI
Unstable Angina
Stable Angina
56.8%
D
E
10.8%
5.7%
F
No Symptoms and Symptoms Unlikely to be Angina
CAD Presentation in Patients Receiving PCI
100%
90%
31.4%
80%
70%
48.6%
50.6%
27.4%
50.6%
63.5%
60%
34.3%
50%
56.3%
40%
36.8%
30%
20%
10%
0%
36.8%
44.1%
30.4%
3.1%
3.1%
A
10.1%
5.1%
B
1.6%
11.0%
C
No Symptoms and Symptoms Unlikely to be Angina
21.6%
2.4%
2.9%
12.7%
D
E
Stable Angina
Unstable Angina
10.4%
5.9%
F
Non-STEMI and STEMI
Two or More Anti-Anginal Meds in PCI Patients
without ACS
40.0%
38.5%
36.2%
35.0%
31.8%
30.0%
23.4%
25.0%
19.8%
20.0%
15.0%
11.4%
10.0%
5.0%
0.0%
A
B
C
D
E
F
Cardiology
I = Inappropriate
U = Uncertain
A = Appropriate
Note: 100% Agreement on Class I and Class III Guidelines
Large Statewide Employer
Caths/1,000 in a High Use Community
Large Statewide Employer
Stents/10,000 in a High Use Community
Large Statewide Employer
CABGs/10,000 in a High Use Community
PEBB Cardiac Procedure
Rates by Top 6 Regions (Jan 2010 - Dec 2011)
15
13.4
12
10.7
9
8.5
7.5
6
7.1
6.1
5.6
4.7
4.4
3
2.7
3.1
3.3
2.0
2.6
2.4
2.3
2.7
1.7
0
Cardiac Caths/1,000
Cardiac Stents/10,000
CABG/10,000
Large Statewide Employer Cardiac
Procedure Rates by Top 6 Regions (Jan 2012 – Sep 2012)
15
12
10.0
9
7.6
6
9.8
7.3
6.8
6.0
4.9
4.8
4.1
3
2.2
2.4
1.7
2.5
3.6
3.0
2.3
3.7
1.9
0
Cardiac Caths/1,000
Cardiac Stents/10,000
CABG/10,000
CAD Presentation in Patients Receiving PCI
Distribution of Stress Testing w/ High Tech Imaging
100%
% of total count of Stress Tests
90%
11%
0%
6%
8%
8%
80%
21%
3%
5%
17%
8%
24%
12%
12%
6%
5%
15%
14%
17%
36%
39%
13%
14%
8%
19%
68%
53%
31%
43%
29%
30%
20%
18%
13%
9%
8%
17%
15%
18%
6%
3%
9%
11%
7%
27%
70%
60%
10%
23%
8%
28%
4%
17%
23%
13%
3%
13%
3%
25%
13%
50%
8%
40%
70%
70%
18--46
19--394
9--321
64%
17--36
8--127
63%
16--24
7--824
55%
62%
15--143
6--254
52%
59%
14--69
47%
59%
13--184
47%
58%
12--329
47%
11--44
46%
5--247
3--101
45%
4--36
34%
2--53
10%
32%
44%
10--46
30%
20%
2%
6%
75%
22%
0%
20--48
1--37
Provider Group-count of total Stress tests
(% below represent averages across all groups)
Stress w/ SPECT only, 52.5%
Stress w/ ECHO only, 19.5%
Stress w/ SPECT and ECHO, 19.2%
Stress only, 8.8%
Test performed by cardiologist within 30 days of cardiologist office visit
25
Integrating Patient Outcome
Data to Improve Care
Orthopedics and Neurosurgery
Total Joint Replacement and Spine
Surgery
• Add pre-operative and 6 month post-op
standardized assessment of pain and
functional status
– WOMAC- TJR
– OSWESTRY- LS Surgery
– NDI- cervical spine surgery
Using Data to Target Care to the
Right Patients
GI-Colonoscopy
Cumulative Mortality from Colorectal Cancer in the General Population, as Compared with the
Adenoma and Nonadenoma Cohorts.
Zauber AG et al. N Engl J Med 2012;366:687-696
Colonoscopy vs. Fecal Immunochemical Testing in
Colorectal Cancer Screening
Colonoscopy
FIT
Cancer
0.5%
0.3%
Advanced adenoma
9.7%
2.4%
Non-advanced adenoma
22.1%
1.1%
Rate of high grade dysplasia or cancer
with 5 year surveillance colonoscopy
Baseline colonoscopy
findings
No neoplasia
Rate per 1000 patient years
Adenoma < 10 mm
1.5
Large tubular or any villous
adenoma
High grade dysplasia
6.4
Cancer
74.8
0.7
26.0
Complication rate requiring surgery approximately 1 per thousand procedures
Gastroenterology 2007; 133; 1077-85
PHP Diagnosis Associated with Colonoscopy:
2011-12
Colonoscopy Dx.(Age 75-79)
Surveillance
20%
Screening
29%
Other
33%
Polyp
18%
Colonoscopy Dx. (Age 80+)
Surveillance
14%
Other
52%
Screening
19%
Polyp
15%
Is this a shared decision making
opportunity?
• A collaborative process between patients and
physicians
• Uses best scientific evidence
• Considers patient values and preferences
Final Thoughts
• Data can inform physicians on current practice
and opportunities to improve value
• Transparency needed to better inform
patients and physicians on how practice
variation impacts the value of care
• Payment reform required to create better
value
• Improving value essential to pay for new
treatment