Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
1
By: Tom Bartol, NP
Twitter: @tombartol
Truth Or Consequences
Where is our health care system going
and how NPs can make a difference
Objectives
Following your presentation, participants will be able to:
• Identify where health care is going and some reasons why
• Describe some consequences of the attempts to improve health care in the US
• Name some creative, innovative ways that individual clinicians can make health care different
Disclosures
• The presenter has no financial affiliations with pharmaceutical companies or the health care industry
• Most of the solutions I share with you have been taught to me by my patients
• Some of the ideas shared may make you feel uncomfortable. Be open
Stay curious
2
Truth or UNINTENDED Consequences
Truth or Consequences: We spend more per capita on
healthcare in the US than any other nation in the world?
Per Capita Health Care Spending
$4,445
$4,349
$4,016
$3,717
$3,422
$3,213
$3,019
$8,247U.S.
Canada
Germany
France
Sweden
U.K.
Japan
Italy
$ Per Capita (2010)
http://www.oecd-ilibrary.org/social-issues-migration-health/total-expenditure-on-health-per-capita_20758480-table2, accessed 10/28/13
3
National Health Expenditures 2014
• $3 Trillion (3,000,000,000,000)
• 17.5% of GDP spent on healthcare
• $9523 per person
• 5.3% increase from 2013
• Prescription drugs increased 12.2% to $297.7 billion
https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-
and-reports/nationalhealthexpenddata/downloads/highlights.pdf, National
Health Expenditures 2014 CMS, accessed 3/21/16
Life Expectancy
US ranks 42nd for life expectancy in the World http://www.oecd-ilibrary.org/social-issues-migration-health/life-expectancy-at-birth-total-population_20758480-table8, accessed 10/28/13
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html, The World Factbook, accessed 5/7/15
http://www.cdc.gov/nchs/fastats/life-expectancy.htm, CDC faststats, accessed 5/7/15
International Health Care Ranking
4
Truth or Consequences: For most people in the United States, healthcare is paid for by insurance?
$24,671/year!
http://www.forbes.com/sites/danmunro/2015/05/19/annual-healthcare-cost-for-family-of-four-now-at-
24671/#7d340564dfb7, Forbes/Pharma & Healthcare, May 19th 2015, Accessed 3/21/16
Millman Medical Index Average Cost for Family of 4 with PPO Coverage
Health Care Costs: 23 y/o female $35,000 annual salary
• $2,100 Annual employee premium
• $500.00 Annual deductible
• $6,190 Employer premium contribution
• $1,500 Payment to Federal and State for Medicare/Medicaid
Total: $10,290 Per Year! Estimated $1.8 Million over Lifetime
David Goldhill,Catasrtophic Care: How American Healthcare
Killed My Father—and How We Can Fix It, 2013
5
Consequences of Health Insurance: Many can afford health care, but it is not
sustainable
Would you service your car this way?
• Mechanic tells you what repairs are going to be done to your car having no idea what they will cost nor do you
• Mechanic is paid for whatever they do, after it is done the “usual and customary” fees.
• You don’t shop around for parts, the mechanic just gets them and installs them
• The service done may not even make a difference in how the car runs.
If Auto Insurance were like Health Care Insurance
• Preventive maintenance with no co-pay, no deductible (oil changes, tires, routine maintenance)
• Service and repairs, in network covered with minimal co-pay
• Oil, additives, fluids, etc. covered with co-pay
• Catastrophic care (accidents, injuries) covered with deductible and co-pay
6
If Auto Insurance were like Health Care Insurance…what would happen?
• We’d do more routine maintenance on our cars
• Mechanics would do more service
• New businesses would emerge to service cars in various different ways
• Would we take care of our cars as well if all service/repairs were covered by insurance?
• Premiums would go up!
Consequence: The “Health Profit” System
Reimbursement System
• Pays for doing more
• Pays for being quick
• Pays for “doing” prevention not preventing
• Looks at low hanging fruit
7
Incentives for Providers
• Currently based on procedures and numbers of patients seen
• Transitioning to number of boxes checked
– PCMH and ACO’s are becoming a game to get the money
– Check the boxes, you get paid
– We are given lists of things we must check at each visit
– Patients’ Agenda is often neglected
Per Capita National Health Spending
Reached $4,637 in 2000
$82 $105 $141 $202$341
$582
$1052
$1733
$2690
$3637
$4637
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
SOURCE: Centers for Medicare and Medicaid Services
•Up to $9523 in 2014
The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults;
2009 International Health Policy Survey of Primary Care Physicians; OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
http://stats.oecd.org/Index.aspx?DataSetCode=SHA, accessed 9/25/12
https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-
reports/nationalhealthexpenddata/downloads/highlights.pdf, National Health Expenditures 2014 CMS, accessed 3/21/16
•In 1950 the US health status
rank was 7th, Now it’s 37th!
American Health Insurance Plans: Solutions to Cost
https://www.jasondavies.com/wordcloud/, accessed 3/23/16
8
Truth or Consequence: Providing high quality care will improve
health?
A Tale of Two Patients: Who is Heathier?
55 y/o Patient A with diabetes
• A1c 6.8% on 3 oral agents and basal insulin, up from 6.4%
• B/P 118/80 on 3 B/P medications
• LDL-C 98 on simvastatin 40mg
• Asked about smoking and gave Rx for Chantix
• Weight measured: BMI 43, up from 39 six months ago
55 y/o Patient B with diabetes
• A1c 7.4, no meds, down from 8.1%
• B/P 142/88, no meds, down from 160/100
• LDL 108 on no meds, down from 157
• Quit smoking 2 weeks ago cold turkey
• Weight measured BMI 33, down from 40 a year ago
It’s not just getting to the goals but HOW they get there
that makes a difference!
“Quality” Reports
9
Consequences
• Treating numbers
• More treatments/testing
• Incentives for doing things that may distract from what matters
• Quality measures that do not have improved outcomes
Clinical Guidelines • Quick , easy, costly and maybe ineffective
• Process, not outcome oriented (short term, not long term)
• “Cookbook” care treats everyone the same based on numbers or age but not necessarily on individual risk.
• “One size fits all” Not stratified by risk or patient desires
• Many guidelines don’t demonstrate significantly improved outcomes
• PCMH, Meaningful Use of EHR, ACO’s are using many guidelines to evaluate care leading to payment for box checking not necessarily good care.
• Businesses are springing up to take advantage of ACO, PCMH money
Problem: Clinical “guidelines” become “mandates”
Without clear outcomes or risks shared.
10
“We need to measure true health outcomes rather than relying solely on process measures, such as compliance with practice guidelines, which are incomplete and slow to change.”
Porter, ME. N Engl J Med. 2009. 361:109-112
The Essential Guide to Quality Care NCQA’s 53 page guide to Quality Care
https://www.ncqa.org/Portals/0/Publications/Resource%20Library/NCQA_Primer_web.pdf,
accessed 3/24/16
Truth or Consequence: Health care is always helpful?
11
All diagnostic tests are helpful
• Harms of the study such as radiation exposure from a CT scan
• Pre-test probability – Low leads to false positive tests
– High leads to false negative tests
• Overdiagnosis: discovering a disease that will never bother you in your lifetime
• Unnecessary care and testing may crowd out necessary care
The medical system had done what it so often does:
performed tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk.
Atul Gawande, “Overkill”
Causes of Death in the United States
http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm,accessed 3/22/16
http://www.hospitalsafetyscore.org/newsroom/display/hospitalerrors-thirdleading-
causeofdeathinus-improvementstooslow, accessed 3/22/16
Medical Errors Estimated to cause
440,000 Deaths per year in the US!
12
Truth or Consequences: Evidence-based care will improve health
care?
Risk Reduction
• Reduction from Baseline Risk
• 50% off coupon
– Save $0.50 on a $1.00 item
– Saves $500.00 on a $1000.00 item
• Relative Risk Reduction is 50%
• Absolute Risk Reduction depends on the cost
• Higher baseline risk, higher the absolute reduction
• Baseline risk is important in using Relative Risk Reduction
AFCAPS/TexCAPS: Results
3304 Lovastatin 3301 Placebo
Number with
Primary Endpoint 116/3304 (3.5%) 183/3301 (5.5%)
Relative Risk Ratio 3.5÷5.5= 0.63
Relative Risk
Reduction 5.5-3.5/5.5 = .37 or 37%
Absolute Risk
Reduction (ARR) 5.5-3.5= 2%
JAMA 1998;279:1615-1622
13
Early Detection Saves Lives
http://www.mammographysaveslives.org/facts, accessed 3/24/16
Breast Cancer Deaths
http://seer.cancer.gov/statfacts/html/breast.html, breast cancer statfacts, accessed 5/7/15
31 deaths/100,000 in 1975 to
21/100,00 in 2012
(from 0.03% to 0.02%)
Consequences of Evidence Based Medicine:
• More Studies
• More Treatment
• More Guidelines
• Changing Evidence
• More Cost
• Better Care…?
Is there good evidence for all we do?
14
Daylight Saving Time Switch May Boost
Stroke Risk – 10 year study
– compared the incidence of ischemic stroke (IS) among 3033 patients hospitalized during the week after the daylight saving transition
– with the stroke rate among a control group of 11,801 patients hospitalized 2 weeks before and 2 weeks after transition
– 8% increased risk of ischemic stroke during 1st 2 days of transition (p=0.02)
American Academy of Neurology (AAN) 2016 Annual Meeting. Abstract 2952
http://www.medscape.com/viewarticle/860109, accessed 3/13/16
Evidenced Based Medicine or
Reimbursement Based Medicine?
Truth or Consequences: Patient experience makes a difference?
15
VALUE =
Outcomes that Matter to the Patient
Cost Per Patient
“Compression of Morbidity”
• Extending healthy life expectancy more than life expectancy
• Chronic disease and disability are compressed into a smaller portion of a person’s life
• Lifelong health care costs are lower and quality of life is improved
• The goal is not the longest number of years but the best number of years alive.
Fries, JF. http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2005.00401.x/pdf, accessed 10/28/12
Solutions! Most can’t be legislated
16
Threat or Opportunity
Threat
• Rigid Response
• Response with established patterns
• Convergent thinking
Opportunity
• Flexible
• Creative response
• New ideas
• Divergent thinking
Creative Thinking
• Be innovative
• Try new things
• Think outside of the box
• Erase past ways of thinking
• Be open to new perspectives and ideas
• Ask more questions to try to understand
• Remember even expert opinions and “evidence” change
Think Outside the Box
Think beyond
– the way everybody is doing things
– the way we have been paid to do things
A culture (way of thinking, behaving, or working) change
– not on minimizing cost of each intervention
– maximizing the value over the entire care cycle
Rather than treat the symptoms (rash, blood pressure, blood sugar, anxiety) engage patients to treat the cause (stress, low self-esteem, fear)
17
Keys to Transforming Health Care
1. Building Relationships
2. Sharing Information
Building RELATIONSHIPS
• Build a relationship of HOPE
• Believe in the patient and help them to believe in themselves
• Affirmations for what they are doing positive
• What does the patient need, what is going on in their lives?
Engaging Patients
• Ask, “What matters to you?” as well as “What is the matter?”
• Ascertaining the patients needs, values and goals at that point in time.
• From telling the patient what is wrong and telling what to do, to listening for the patient to tell us what is wrong and exploring with the patient what to do
• Helping people find connection, purpose and hope in life.
18
Creating “Magical Moments”
• Make each visit unique and special for the patient
• Really listen…to the why beyond the what
• Treat the person, not the numbers
• Use the patient’s name
• Smile
• Believe in the patients and help them to believe in themselves
• Make a follow-up call back
Networking the Healthcare System
• Build relationships in the healthcare system
• Talk to consultants don’t just send patients
• Create a 2-way dialogue with consultants
• Talk to radiologists and pathologists more about what tests to order and what results mean
• Track imaging done on your patients to manage radiation exposure
Shared Decision Making
• Stratify Risk
• Share information – Risks of problem/condition being checked or treated
– Risks of intervention
– Benefits of intervention
– Costs
• Let patients make choices
19
How do we do Shared Decision Making outside of Health Care?
• Buying a car
• Auto repairs
• Choosing a college
• Financial investments
These are based on relationships, information, making rational decisions
…Are health care choices made like any of these?
https://www.harding-center.mpg.de/en/health-information/facts-boxes/mammography, accessed 12/5/14
http://www.cancer.gov/cancertopics/factsheet/prevention/physicalactivity
Additional ways to reduce risk:
“Physically active women have a lower
risk of developing breast cancer than
inactive women…risk reduction varies
(between 20-80%).
20
http://www.thennt.com/nnt/strength-and-balance-programs-for-elderly-falls/, accessed 2/22/15
Strength and Balance Training Programs for Preventing Falls in the Elderly
Thennt.com
My Practice All Providers (n=44) % Change
Rx per User 3.47 5.57 -48%
Diagnostic Tests
User 0.13 0.50 -74%
Consult Referrals
per User 0.26 0.62 -58%
Rx per Encounter 1.15 1.60 -28%
Diagnostic Tests per
Encounter 0.04 0.14 -61%
Referrals per
Encounter 0.08 0.18 -66%
Results of Shared Decision Making
Data on file with speaker
Framing: The Way the Data is Presented
37% reduction in 1st major coronary events
3304 patients treated with lovastatin for 5 years:
– prevent 67 1st major coronary events
– Has no preventive effect on 3118 patients
Taking lovastatin for ~5 years can reduce risk of 1st major coronary event from 5.5 in 100 to 3.5 in 100
Risk of NOT having 1st major coronary event
– 94.5 out of 100 without taking simvastatin
– 96.5 out of 100 with taking simvastatin
JAMA 1998;279:1615-1622
21
Focus on the 95%!
$97,956
$28,468
$43,058
Think Healthy!
• Think Positive
• Delete the negative thoughts
• Help patients focus thoughts on health, not illness or disease
• We become what we think
• “I want to run again.”
• “I decided to be happy.”
22
Keep your eyes first on the goal
• Good patient care with improved outcomes
– Then, in light of this work on PCMH, ACO,NCQA, etc
• The goal should not be to meet the criteria for meaningful use, PCMH, and ACO…these should be pathways to better patient care, better outcomes.
Building a Relationship of Hope
Institute for Healthcare Improvement Vision and Mission
http://www.ihi.org/about/pages/ihivisionandvalues.aspx
23
Changing Health Care Requires: Vision: – Seeing the need, keeping focused on the goal
– See something better…not just doing things the same
– Creating solutions
Creativity: – Thinking outside of the box/curiosity
– Things people never thought of may work
Risk – Listen to your gut.
– What we do is an art, not a science
Passion: Passion is the energy that comes from bringing more of YOU into what you do
Teamwork: We need to collaborate not dominate