Along for the Bumpy Ride?Market Responses in the New

Health Care Marketplace

Eric D. Kupferberg, PhDAssociate Director

Trust Initiative, HSPH

28 October 2010

“. . . if you’re not part of the steamroller, you’re part of the road.”

-- Stewart Brand

Source: Brand, The Media Lab: Inventing the Future at MIT (New York: Penguin 1988)

Mapping I-FM Syndrome

• Virtual epidemic in all regions of the country

• Mostly affects successful males and females

• Spread by air travel and hand-to-hand contact

• Carriers rarely recognize affliction

• Secondary victims suffer greatly

Carrier ProfilesNormally Healthy Adults

Communicated Via AirplanesBut NOT Corporate Jets

First ClueWhy are Pilots and Attendants Not Affected?

Second ClueWhy 1st Class and Business Class Only?

Third ClueWhy are Sleepers and Typers Immune?

Decisive ClueAll Carriers Handled an In-Flight Magazine

Causal Link

• Magazines featuring interviews with successful CEOs

• Pithy conclusions

• Strong appeal to join the next organizational revolution

• Recommendations require radical restructuring and substantial money

Carrier StateExecutive Returns to Office

• Delivers torn-out article to executive assistant

Secondary Victims

• Senior executive requests that management team read the article and implement recommendations ASAP

Great Suffering Ensues

Harm Magnifier

• Senior executive demands to know why revolution has not already begun to reap noticeable benefits

Harm MultiplierExecutive Takes Another Flight (ughh!)

Taking Tropes SeriouslyUbiquity of the “Great Leap Forward”

“A Great Leap Forward ?”

Is IT the Right Leap Forward?

Health Care IT Growing

Technological “Cures”

The Importance of Networking

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Source: Marie Reed and Joy Grossman, Center for Studying Health System Change, Issue Brief 89, September, 2004

Chaotic IT Adoption

The wide variation in physician technology adoption inhibits efforts to improve patient care

56%

39%

37%

26%

21%

16%

28%

40%

44%

46%

38%

49%

47%

15%

14%

16%

15%

35%

29%

36%

44%

Start-up costs

Lack of uniform standards

Lack of time

Maintenance costs

Lack of evidence of effec tiveness

Privacy concerns

Lack training/know ledge

Major Barrier Minor Barrier Not a Barrier

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Barriers to HIT Adoption

The Unbearable Hype of IT

The Promise of Standardization

Publication

Bibliographic databases

Submission

Reviews, guidelines, textbook

Negative results

variable

0.3 year

6. 0 - 13.0 years50%

46%

18%

35%

0.6 year

0.5 year

5.8 years

Dickersin , 1987

Koren , 1989

Balas, 1995

Poynard , 1985

Kumar, 1992

Kumar, 1992

Poyer , 1982

Antman , 1992

Negative results

Lack of numbers

Expertopinion

Inconsistentindexing

17:14

Original research

Acceptance

Implementation

Medical Innovations Move Slowly

“A Change is Gonna Come?”

• A majority of physicians fail to recommend at least one major drug up to ten years after it’s been shown to be efficacious.

• A majority of physicians continue to recommend therapy up to ten years after it’s been shown to be useless.

Source; Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC: A comparison of results of meta-analyses of randomised control trials and recommendations of clinical experts. JAMA 1992;268:240-8.

Facts are simple and facts are straightFacts are simple and facts are straightFacts are lazy and facts are lateFacts are lazy and facts are late

Facts all come with points of viewFacts all come with points of viewFacts don't do what I want them toFacts don't do what I want them to

Facts just twist the truth aroundFacts just twist the truth aroundFacts are living turned inside outFacts are living turned inside outFacts are getting the best of themFacts are getting the best of them

Facts are nothing on the face of thingsFacts are nothing on the face of things

-- David Byrne, -- David Byrne, Cross-eyed and Cross-eyed and PainlessPainless

Standardization Via Clinical Guidelines

Standardization Via Clinical Guidelines

Guidelines & Contentious Ambiguities

No Guarantee of Implementation

Legal Considerations Drive Guidelines

History of EBM:Archibald L. Cochrane (1909-1988)

• Concerned with the over use of medical techniques

• Published landmark Effectiveness and Efficiency (1972)

John Wennberg and theCenter for Evaluative Clinical Services

• The Center for the Evaluative Clinical Sciences . . . conducts cutting edge research on critical medical and health issues with the goal of measuring, organizing, and improving the health care system.

• . . . at the micro level, they hold the promise of reforming the doctor-patient relationships through shared-decision making and of improving the quality and value of clinical care.

David L. Sackett:Ascendance of Evidence-Based Medicine

• EBM is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

What is Evidence-Based Practice?Sackett’s Short Definition

• “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

• BMJ 1996; 312: 71-2.

The Big Promise

Is EBM Really New?

• Often labeled as a “radical overhaul” or a “paradigm shift” in medicine

• Yet, some advocates trace its roots to post-revolutionary France and the work of Bichat, Louis, and Magendie

• Why does this “newness” or “oldness” matter?

Source: Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. “Evidence based medicine: what it is and what it isn’t”. BMJ 1996;312:71-2.

Locus of Expert Knowledge in EBM

• Pre-EBM: Source of knowledge is the expert opinion of individual or institution

• Clinical skills beyond outside purview

• Patients are objects of treatment

• Post-EBM: Source of knowledge is the collective systematic review of evidence

• Clinical skills subject to audit

• Patients are part of “studies”

Criticisms of Evidence-Based Medicine

• It is basically what we’ve been doing for ages• It is possible only under “ideal” conditions• It encourages “cookbook” medicine• It increases the authority of managers and

insurers• Evidence from randomized trials and systematic

reviews rarely works in clinical settings• It is antipathetic to patient-centered medicine

But EBM IS Part of Cost-Cutting

Can Providers Evaluate Evidence?

• Doctors have little time to pose specific questions and search for targeted evidence

• The number of journals and studies is astronomical

• Providers often lack the technical skills to conduct exhaustive searchers

• Studies lack standardized formats• Providers have difficulty resolving conflicting

clinical evidence• Even the best evidence requires “interpretation”

EBM as a “Way of Being”

Compensation as the Cure

Incentive Goals for P4P

How P4P Works - The Power of Incentives

The Business Case for P4P

Stakeholder P4P “Investment” Return on Investment

Consumers •Self-care management•Switch to “excellent” providers

•Improved health & productivity•Financial incentives (employer and plan option)

Employers •P4P program operations•P4P physician rewards•Employee incentives for self-care and switch to excellent providers

•Employee health & productivity•Healthcare cost savings•Employee retention

Health Plans •P4P program operations (costs not paid by self-insured customers)•P4P physician rewards (costs not paid by self-insured customers)•Member incentives for self-care and switch to excellent providers

•Reduced healthcare costs•Increased profitability•Competitive positioning / marketing

Providers •Data collection & submission•Practice re-engineering

•Performance rewards•Reputation for excellence•Increased patient volume

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Source: Jonathan Conklin and Audrey Weiss. Pay-for-Performance: Assembling the Building Blocks of a Sustainable Program, 2004 published by Thomson Medstat.

update: 7/6/06

"We are seeing that pay for performance works. We are seeing increased quality care for patients, which will mean fewer costly complications – exactly what we should be paying for in Medicare."

- Mark McClellan, M.D., Ph.D.,Former Administrator of Centers for Medicare and Medicaid Services

Pay for Performance as the Promised Cure

P4P: Physician Skepticism

© 2006 Physician’s Weekly, LLC

March 13, 2006 Vol. XXIII, No. 11

P4P: Physician Skepticism

P4P: Complexity Kills

The Glow of Consumer-Driven Health Care

Are Current Market Responses Sufficient?