THE SECOND REVOLUTION IN HEALTH CARE

SUTTER HEALTH RESEARCH, DEVELOPMENT & DISSEMINATION

Buzz Stewart

DID YOU MISS THE FIRST

REVOLUTION?

NO ONE WOULD HAVE PREDICTED THE RESULT OF THE FIRST REVOLUTION

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For-Profit Buyers

NonProfit Buyers

U.S. Hospital Mergers and

Acquisitions

HISTORY OF MODERN HEALTHCARE

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Health Expenditures as Share of GDP

AMA

1847 1910

Flexner

Report

1930 1940’s

Rise of

Employer

1965

Social Security

Amendments

HMO’s Act

1973 1990s

Accountable

care

(PPACA)

Research specializes and separates from

bedside

Market growth and fragmentation

Rise of systems of care

Digital era of care begins

Accelerating consolidation Formal

organization of physicians established

Revolutionized medical

education

17.9 %

By 2012, 72% of physicians use

EMR/EHR systems

OVERVIEW

• A revolution has consequences

• The benefits and challenges

• Things we should and should not be doing in the second revolution

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THE

pe

r ca

pit

a [l

og]

GDP per capita [log]

R2 = 0.95

Source: Jacques van der Gaag; WHO/IMF 2005

Income elasticity > 1.0

N = 174

U.S. NATIONAL DEBT PROBLEM

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US TOTAL HEALTH CARE SPEND PER YEAR

Strong link between countries' wealth and total health spending

This relationship is largely unaffected by:

• Relative share of public / private

spending

• External donor assistance (which may inadvertently crowd out spending elsewhere)

EXTRAORDINARY HEALTH CARE SPENDING 2007

$2,200 billion

U.S. health care

$1,020 billion

U.S. food* China: personal consumption

$1,390 billion

Source: US Congressional Budget Office, Nov 2007

% GDP

PROJECTED U.S. HEALTH SPENDING

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ildh

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<5)

mo

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(per

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R2 = 0.58

GDP PPP per capita

Rwanda

Kenya

Poorer countries' health is worse off, in general...

...but poor countries vary widely in health

outcomes

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Similar health outcomes at different levels of wealth: what matters is not total spending, but how it is used

Source: WHO Source: WHO/IMF 2005

And good health exists across a range of GDP

...BUT COUNTRIES WITH SIMILAR SPENDING HAVE A RANGE OF HEALTH OUTCOMES

WHAT ARE AMERICANS BUYING?

OUR HEALTH SYSTEM’S STRENGTHS

Source: OECD, Commonwealth Fund, ‘International Comparison: Access and Timeliness”, Dec 2006, Boehm, T, ‘How can we explain the American dominance in biomedical research and development?’, Journal of Medical Marketing, Vol 5, 2005 NY Times, RAND, MGI

Clinical trials by country Number of trials

Top 5 US Hospitals

Canada

Germany

France

UK

Australia

Switzerland

Japan

South Korea

Singapore

ONE VIEW OF EXCESS COSTS (2009)

• Unnecessary services ($210B)

• Inefficiently delivered services ($130B)

• Excess administrative costs ($190B)

• Prices that are too high ($105B)

• Fraud ($75B)

• Missed prevention opportunities ($55B)

WHY WE BUY SO MUCH

• Wealth • The more we have, the more we spend on health.

• Insurance • Greater coverage makes us indiscriminating consumers.

• Aging population • Aging equals more health problems and more demand.

• Heroics • Make every effort possible, even if there is no chance of a good outcome.

WHY WE SELL SO MUCH

• Business model

• Volume based model promotes unnecessary services.

• Technology

• The more we have to sell, the more we sell.

• Guideline-based care paradigm

• Evidence based guidelines for only 30% of clinical decisions. The rest is opinion.

• High prices

• No price competition.

IMPROVING CARE AND CONTROLLING COSTS

Using unproven and costly forms of radiation treatments for many early prostate cancer patients:

• 3-D conformal radiation $11,000 • Brachytherapy: $15,000 • IMRT: $42,500 • Proton Beam: $80,000

• No head-to-head comparative studies

• No survival difference -- at best a 10% decline in side effects

from 14% to 4%

Adoption of costly and unproven technology

SCREENING VERSUS USUAL CARE: PLCO

Prostate-Cancer Deaths

Screening PSA and digital rectal exam (N=76,693)

Andriole GL, et al. N Engl J Med 2009;360:1310-9

SURGERY VERSUS SURGERY: STICH LV reconstruction versus CABG only (N=1000)

Jones RH, et al. N Engl J Med. 2009;360 (on line) Eisen HJ, N Engl J Med. 2009; 360 (on line)

Death from Any Cause

Approximately 40 Million of 100 million dollars of emergency department care at Alta Bates

Summit Medical Center is attributed to the top 10% of patients

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Number of Encounters Per Distinct Patient

Top 10 Percent of Most "Costly" ED Patients Visiting from 2011-2012 ( Cutoff 50 encounters)

Encounters for Patients in the Top 10 % of Cost

Encounters for Patients in the Top 10 % of Cost

LIFESTYLE VERSUS MEDICAL: DPP Lifestyle or metformin to prevent DM (N=3234)

Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393-403

Joe may only be able to get so far in managing his diabetes even with the help of four specialists,

a dietician and trainer.

ENVIRONMENT AND HEALTH

• Patients are on their own 99%+ of the time

• Local factors influence diet, activity, & stress levels

• The best health care may have little impact on patient outcomes

Local Physical Activity Opportunity Environment (LPAOE). Municipal boundaries, GHS’s 31 counties, 4287 LPAOE points.

Local Food Environment: Food Sources & Retailers in GHS’s 31 Counties

STUFF THAT WILL NOT MATTER MUCH

• More knowledge • New knowledge is a commodity

• Stuff that yields the same advice

• We already know about eating, exercising, addictions, moderation

• Stuff that requires a lot more data

• Do customers really want this

• Does it really matter?

• Providers clearly are not interested

STUFF THAT WILL NOT MATTER MUCH

• More procedures & other stuff to sell

• This is what we do now and it does not help that much

• Personalized and more expensive

• This is what we do now and it does not help that much

• Solving problems in isolation

ENHANCE CAPABILITIES THAT MATTER

Data Abstraction & Standardization

Liquifying and then purifying for clinical use

Knowledge Access

Exact searching of knowledge by data with intuitive grading

Communication Process

What are you talking about and do you understand me

Extending Reach

Exact, precise, and portable guides

Patient Tools

Knowing where to go, how to choose, and what to avoid

Using tools that work in improving health