Leading Edge Opportunities in Health Care and Medicine:
Using Data to Increase Value
Bob Gluckman, MD, FACPCMO- Providence Health Plan
January 25, 2013
Exhibit 1. International Comparison of Spending on Health, 1980–2010
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
USSWIZNETHCANGERFRAUSUKJPN
Average spending on healthper capita ($US PPP)
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
0
2
4
6
8
10
12
14
16
18
USNETHFRGERCANSWIZUKJPNAUS
Total health expenditures aspercent of GDP
Notes: PPP = purchasing power parity; GDP = gross domestic product.Source: Commonwealth Fund, based on OECD Health Data 2012.
2
20012003
20052007
20092011
20132015
20172019
20210
5
10
15
20
25
30
35
1213
1517
18 18 18 18 1920
22 23 24 25 26 26 27 28 29 30 31
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
0
25
50
75
100
125
150
175
200 Health insurance premiumsWorkers' contribution to premiumsWorkers' earningsOverall inflation
Exhibit 3. Premiums Rising Faster Than Inflation and Wages
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.
Projected average family premium as a percentage of median family income,
2013–2021
Cumulative changes in insurance premiums and workers’ earnings,
1999–2012
Percent Percent
180%
47%
38%
Projected
172%
200101
200106
200111
200204
200209
200302
200307
200312
200405
200410
200503
200508
200601
200606
200611
200704
200709
200802
200807
200812
200905
200910
201003
201008
201101
2011060.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
Member Cost Sharing
Member Cost Sharing
Deductible
Incurred Month
Mem
ber
Port
ion
of A
llow
ed A
mou
nt
2006 2007 2008 2009 2010 Jan-Dec 11$0.00
$20.00
$40.00
$60.00
$80.00
$100.00
$120.00
$140.00
PHP All Commercial InsuredPer Member Per Month Expenses
(Portland Service Area Only)
PCP Spec Hosp RX Admin
PMPM
Case and Disease ManagementHealth Care Cost Continuum - Why We Focus on Specific members
Source: Milliman USA Health Cost Guidelines—2001 Claim Probability Distributions.
% of People
1% of People
30% Total Cost
10% Total Cost
70% of People
0% Total Cost
20% 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
A B C D E F0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
22.4% 25.9%32.3%
19.0%27.8%
5.7%
8.4%11.5% 3.4%
5.6%
22.2%
10.8%
27.2%
31.3% 40.1%
45.7%
31.2%
56.8%
42.0%31.4%
24.3% 29.8%18.9%
26.7%
No Symptoms and Symptoms Unlikely to be Angina Stable Angina Unstable Angina Non-STEMI and STEMI
CAD Presentation in Patients Receiving PCI
A B C D E F0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3.1% 5.1%11.0%
2.9%12.7%
5.9%3.1%
10.1% 1.6%2.4%
21.6%
10.4%
30.4%
36.8% 36.8%44.1%
34.3%
56.3%
63.5%
48.6% 50.6% 50.6%
31.4% 27.4%
No Symptoms and Symptoms Unlikely to be Angina Stable Angina Unstable Angina Non-STEMI and STEMI
Two or More Anti-Anginal Meds in PCI Patients without ACS
A B C D E F0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%38.5%
19.8%
36.2%
11.4%
23.4%
31.8%
Note: 100% Agreement on Class I and Class III Guidelines
CardiologyI = Inappropriate U = Uncertain A = Appropriate
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)
Cardiac Caths/1,000 Cardiac Stents/10,000 CABG/10,0000
3
6
9
12
15
2.0
4.4
2.62.7
7.5
2.3
5.6
13.4
6.1
3.1
10.7
1.7
3.3
8.5
4.7
2.4
7.1
2.7
Large Statewide Employer Cardiac Procedure Rates by Top 6 Regions (Jan 2012 – Sep 2012)
Cardiac Caths/1,000 Cardiac Stents/10,000 CABG/10,0000
3
6
9
12
15
2.2
7.6
1.91.7
7.3
3.64.1
10.0
4.8
2.43.0
6.0
2.5
4.9
3.7
2.3
9.8
6.8
CAD Presentation in Patients Receiving PCI
1--37
2--53
3--101
4--36
5--247
6--254
7--824
8--127
9--321
10--46
11--44
12--329
13--184
14--69
15--143
16--24
17--36
18--46
19--394
20--48
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
22%32% 34%
44% 45% 46% 47% 47% 47% 52% 55% 58% 59% 59% 62% 63% 64%70% 70% 75%
68%53%
43%31% 25%
13%
29% 30%
8%
20% 18% 15%18%
23%
3%13%
28% 13%3%
6%
0% 8%
3% 8%24%
36%12%
17%
39%13% 14%
19% 13%9%
27% 8%
3%
7% 23% 2%
11% 8%
21% 17%6% 5%
12%6% 5%
15% 14%8% 10% 9% 8%
17%6%
11%4%
17%
Distribution of Stress Testing w/ High Tech Imaging
Stress w/ SPECT only, 52.5% Stress w/ ECHO only, 19.5%Stress w/ SPECT and ECHO, 19.2% Stress only, 8.8%
Provider Group-count of total Stress tests(% below represent averages across all groups)
% o
f tot
al co
unt o
f Str
ess T
ests
Test performed by cardiologist within 30 days of cardiologist office visit25
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 Rate per 1000 patient years
No neoplasia 0.7
Adenoma < 10 mm 1.5
Large tubular or any villous adenoma
6.4
High grade dysplasia 26.0
Cancer 74.8
Complication rate requiring surgery approximately 1 per thousand proceduresGastroenterology 2007; 133; 1077-85
PHP Diagnosis Associated with Colonoscopy: 2011-12
Other33%
Polyp18%Scree
ning30%
Sur-veil-lance20%
Colonoscopy Dx.(Age 75-79)
Other52%
Polyp15%
Screen-ing19%
Surveil-lance14%
Colonoscopy Dx. (Age 80+)
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