Dr. Robert Riehle Jr.

Wofford College 2/24/10

Wofford Healthcare SymposiumOur current system and its need to

change

Financing of the delivery system

Components of an ideal delivery system

What change is possible

Healthcare Reform- Is now the time?

58%54% 54%

39%41%

36%

41%39%

53% 55%57%56%59% 61%62% 62%61%

42%39%

35%37%37%34% 34%

0%

20%

40%

60%

80%

Oct08 Dec08 Feb09 Apr09 Jun09 Jul09 Aug09 Sep09 Oct09 Nov09 Dec09 Jan10

It is more importantthan ever to take onhealth care reform now

We cannot afford totake on health carereform right now

Healthcare Comments Healthcare system is broken.

We don’t want a government run healthcare system.

I want to choose my doctor!

We don’t put enough resources into prevention

Insurance companies are villains. They get between me and my doctor.

80% of Medicare costs are in the last 6 months of life.

I’m satisfied with the quality of care. It just costs too much.

We have a sickness, not a wellness system.

Issues and Challenges 2010Wants:

1. Excellent care (acute and chronic)

2. Availability – access (convenient, timely)

3. Insurance coverage

4. Affordable

Complaints:

1. Cost of care and coverage

2. Uninsured and underinsured

3. Inefficiencies of process – care delivery

Distribution of National Health Expenditures, by Type of Service, 2008

Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc.

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2008; file nhe2008.zip).

Physician/

Clinical

Services

21.2%

Hospital Care

30.7%Other Personal

Health Care

12.9%

Nursing Home

Care, 5.9%

Prescription

Drugs

10.0%

Home Health

Care, 2.8%

Other Health

Spending

16.5%

Healthcare ArenaDelivery SystemsHealthcare provider, facility, vendor = delivery system

Hospitals and Medical Centers FP, NFP

Faith based

Municipal

Governmental

Integrated Healthcare Systems Hospitals

Physicians (office based)

Rehab, ASC, Primary Care Centers, Diagnostic Centers, Home Health, Hospice

Levels of care (continuum)

Healthcare Arena: Reform Plan- insurance coverage

Insurance-employer, group, individual

Finance

Delivery system- IDS, providers

Information

Regulation

Certification, Accreditation

Government role: financed, managed, regulated, sponsored, coordinated, run, owned

Comprehensive Reform- Change all components

Health Versus Healthcare Health: shaped by genetics, lifestyle, diet, social

factors, chance , and sometimes healthcare

Healthcare: Episodic vs. longitudinal

• Restores health vs. promotes health

• Basic vs. specialty

• Preventive vs. reactive

Ideal Delivery System ConceptsHigh quality; effective care and service

Standardized, measurable, improving

Accessible (acute and chronic)

Efficient- cost controlled, technology, innovative

Universal for all; basic, prevention

Managed across continuum (levels of care)

Accountable, monitored

Ideal Delivery System Components Integrated Delivery Systems (IDS)

Engaged physicians

Evidence based medicine

Information sharing via EMR, telemedicine, RHIN

Consolidation versus competition

Transparency of operations (cost, quality, continuum)

Primary care focus

Chronic disease focus

End of life: planned

Tort Reform

Integrated Delivery System Organized, managed, owned across the continuum

Employed staff, new role for extenders

Accountable care organizations

Efficient

Measurable by metrics

Incentives

Vendor bidding

Pay for performance

Prevention pays

Clinical effectiveness research rules –evidence based medicine

Hub and spoke- rural + tertiary

Engaged PhysiciansEmployed and managed

Accountable by metrics

Use of extenders-patient centered team

Incentive based on productivity, process and outcomes… performance based pay

Evolution of manpower: training, financing, continued learning, certification, patient/physician relationship

Are doctors following the guidelines?

Retrospective review, cancer care delivered

1300 oncologists

Non-compliance with NCCN guidelines:17%,61%, 31%, 24%, 31%

Optimal compliance (NCCN) 85%!

Clinical variation?

United Healthcare 2010

Non-Federal Physicians per 100,000 Civilian Population, 1970-2008

146165

193

220234

262 266 268 273 277 280

312 316 319 322

0

50

100

150

200

250

300

350

1970 1975 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008

Evidence Based Medicine

National guidelines

Algorithms

Risk predicting software

CER (Clinical Effectiveness Research)

Patient education= interactive

Information Sharing-Informatics EMR (EHR, multimedia, patient health records,

interactive)

Telemedicine Teleradiology, pathology

Teleconsultation

Telesurgery

Telerounding

Tele-ICU (e-ICU)

RHIN (regional health info network)

Important for rural, community and public health

Consolidation versus CompetitionMergers at regional/national levels

Devolution of For Profit Hospitals

Certification of Centers of Excellence

More IDS, hub and spoke, geographic mergers

Physician multi-specialty groups, employed networks

More regional/ national networks

Medical Liability: Tort Reform Relocate from tort system to alternative, administrative

Civil court replaced by health court

Less adversarial, more efficient form of justice

No fault concepts

Administrative medical injury compensation

Poor result versus malpractice (negligence)

Current examples: no-fault, government administered National Vaccine Injury Compensation Program

NLRB, Tax, worker’s compensation board

State initiatives: birth injury funds

Risk management

Consent to independent structured arbitration process

www.commongood.org

Transparency of OperationsPerformance metrics (clinical and services)

Pricing/changes – how much will it cost me?

Report card: value, quality of care

Regulation- certification, accreditation

Conflict of interests- ownership, research, industry “expert”

Primary Care Focus Patient centered: new model

Group visits

Medical home, PCP coordination

Electronic visits

Alternative Hours, case managers

Multidisciplinary, coordinated visits

Prevention via EMR

Patient education; responsibility

Specialist advice without visit – video and audio

Chronic Disease Focus Increasing prevalence (emphysema, heart failure,

arthritis, cancer, multiple sclerosis)

Standardized around guidelines

Drugs to slow progression

Extenders as providers; medical home

Acute on chronic: efficient management “back to baseline”

Transition to symptom management (palliative)

End of Life- Planned Advanced directives: What I want done if I can’t decide

myself

Family involvement

Quality of life – metrics

Individualized decision/autonomy/patient rights

PCP/ geriatrics

What can we do vs. what you want done…

Ideal Delivery System Components Integrated Delivery Systems (IDS)

Engaged physicians

Evidence based medicine

Information sharing via EMR, telemedicine, +RHIN

Consolidation versus competition

Transparency of operations (cost, quality, continuum)

Primary care focus

Chronic disease focus

End of life: planned

Tort Reform

Healthcare System Reform: Summary

Less segmented, more integrated

Less independent, more monitored

More standardized, effective, efficient

More electronic, interactive , coordinated

More transparent

More socially responsive

More personal responsibility

Less liability for poor outcomes

WebsitesHospital Patient Info

www. Hospitalcompare.org

www.myschospital.org

www.ncqualitycenter.org

www.abouthealthquality.org

Physician

www.healthgrades.com($12.95)

www.NCQA.org

recognition program

www.JAMA.com Patient page

www.myhealthcareoptions.org

Facility

www.medicare.gov/dialysiscompare/SNF compare

Healthcare Reform : tenets Reduce # of uninsured

Reduce cost of care , premiums

Reduce clinical care variance re practice

Reduce encounter based payments

Reduce administrative costs

Reduce role of government

White House : Healthcare Reform Proposal 2/22/10

Medicaid Expansion – fully funded by Washington

-eligibility 133% of FPL

Tax high cost healthplans (2018)

Medicaire payroll tax – increase .9% on earnings

Medical Device tax (2013)

WH HC Reform 2/22/10 Individual Mandate (2014)

Employer mandate ( ??)

Insurance companies: assessments

Insurers – no exclusions (2014)

Insurers – premium increases – Fed Rate Auth Review

Pharma - assessment

WH HC Reform 2/22/2019 Assume Close to universal coverage

Commission to manage Medicaire (not congress)

CER – clinical effectiveness research

More community health centers (CHC)

Decreased funding to hospitals

Technology Assessment (clinical)

Different payment methodology

Incentive to use EMR