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The Road Ahead for America’s Physicians
HIP SYMPOSIUM
April 11, 2012
James L. Madara, MD Executive Vice President/CEO American Medical Association
The AMA Mission
To promote the art and science of medicine and the betterment of
public health
A critical success factor is to have attractive, thriving physician practices
2
In the Next 20 Years Physicians Will… • Need more % effort for patients • Practice in a collaborative environment
with other health professionals • Heavily utilize technology (EMR,
telemedicine, online consultation…) • Practice in “continuity” systems • Focus on outcomes (and value) rather
than process 3
More Physicians Joining Systems - June, 2010 • 65% of established
physicians who changed jobs
• 49% of physicians completing residency
4
What Caused the Shift? • Seeking stability • Work-life balance • Advancement opportunity • Pay back student loans • Costs (expenses outpace reimbursement,
2:1) • Administrative burden (i.e. dealing with
payers) • Access to improved infrastructure
5
Technology Future
• Office EHR • Online coaches for chronically ill patients • Online physician/patient portals
AT&T/AMA collaboration Benefits
• Powerful decision support tools • Personalized based on large data sets • Continuity • Access
6
Technology: Improvement with Health IT
The Learning Health System Expanded capacity for new knowledge
Driving improvement with health IT
Redesigning the Clinical E!ectiveness Research Paradigm, 2010. Evidence development in the learning health system.
Kaushal, et al., 2009. E!ect of electronic medical record (EMR) systems on medication safety in community-based o"ce practices. Practices that adopted EMR systems experienced a seven-fold decrease in prescription errors compared to non-adopters.
EMR Adopters
Pres
crip
tion
Err
ors
(per
10
0)
Non-Adopters
Dat
a Pr
oduc
ed P
er Y
ear
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
Systematic ReviewsRandomized Trials
(E"cacy) Randomized Trials (E!ectiveness)
Market Entry
Timeline of Medical Product Research
Surveillance and Observational Studies
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
5
10
15
20
25
30
35
40
45
Initial
1 Year Follow-up
Patient engagement for better outcomes
Joseph Kvedar, IOM Meeting 1 April 2010. E!ect of enrollment in Partners HealthCare’s Connected Cardiac Care Program (CCCP) program on heart failure hospitalization. Enrollment in the CCCP program, with health IT-facilitated self-monitoring and patient-clinician communication, reduced the rate of hospital-ization for heart failure.
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
0.4
0.80.92
0.48
1.0
0.6
0.2
Ann
ual
Hos
pita
lizat
ions
(p
er p
atie
nt)
Before Program After Engagement Program
Engineering systems for continuous improvement
David Pryor, IOM Meeting 29 April 2008. E!ect of Ascension Health’s Call to Action—a systems engineering approach to quality improvement— on medical errors in Ascension Health hospitals.
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA60
100
80
40
20
Birth Trauma NeonatalMortality
Pressure Ulcer Blood Stream Infections
% R
educ
tion
s C
omp
ared
to
Nat
iona
l Ave
rag
es
7379
95
35
The Opportunity
The Learning Health System and its Innovation Collaboratives Update Report 1514
Kaushal, et al, 2009 7
Prescription Errors In Community Based Practices
Technology Future: Decision Support
The Learning Health System Medical decisions becoming more complex
William Stead, IOM Meeting, 8 October 2007. Growth in facts a!ecting provider decisions versus human cognitive capacity.
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
Fact
s pe
r D
ecis
ion
5
1990 2000 2010 2020
Human Cognitive Capacity
Decisions by Clinical Phenotype
Structural Genetics: e.g. SNPs, haplotypes
Functional Genetics: Gene expression profiles
Proteomics and other e!ector molecules
10
100
1000
Robert Cali!, IOM Meeting, 12 December 2007. Less than 20% of AHA/ACC heart disease management guidelines are based on a high level of evi-dence and over 40% are based on the lowest level of evidence. Furthemore, the proportion of guidelines with high evidence levels has not increased over time (green vs. blue).
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
High Med Low High Med Low High Med Low
Strength of Evidence
Perc
ent
of G
uide
lines
Inadequate evidence to guide care
10
20
30
40
50
60
70
Atrial Fibrillation(2001–06)
Heart Failure (2001–06)
Pacemaker (1998–2002)
Systemic waste across the board
The Healthcare Imperative, 2010. Lower bound totals of various estimates of excess healthcare expenditures, adjusted to 2009 total expenditure levels.
Excess Cost EstimatesUnnecessary Services $210 B
Ine"ciently Delivered Services $130 B
Excess Administrative Costs $190 B
Prices That Are Too High $105 B
Missed Prevention Opportunities $55 B
Fraud $75 B
Total Excess Costs: $765 B
Poor health despite high spending
OECD Health Data, 2009. Life expectancy at birth in di!erent countries versus per capita expenditures on health care in dollar terms, adjusted for purchasing power. The United States is a clear outlier on the curve, spending far more than any other country yet achieving less.
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
72
74
76
78
80
82
84
Life
exp
ecta
ncy
in y
ears
600050004000300020001000
Health spending per capita (USD)
The Case
The Learning Health System and its Innovation Collaboratives Update Report12 1312
8
Technology Future Our Future Incorporates Large Data Sets: The Learning Health System Medical decisions becoming more complex
William Stead, IOM Meeting, 8 October 2007. Growth in facts a!ecting provider decisions versus human cognitive capacity.
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
Fact
s pe
r D
ecis
ion
5
1990 2000 2010 2020
Human Cognitive Capacity
Decisions by Clinical Phenotype
Structural Genetics: e.g. SNPs, haplotypes
Functional Genetics: Gene expression profiles
Proteomics and other e!ector molecules
10
100
1000
Robert Cali!, IOM Meeting, 12 December 2007. Less than 20% of AHA/ACC heart disease management guidelines are based on a high level of evi-dence and over 40% are based on the lowest level of evidence. Furthemore, the proportion of guidelines with high evidence levels has not increased over time (green vs. blue).
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
High Med Low High Med Low High Med Low
Strength of Evidence
Perc
ent
of G
uide
lines
Inadequate evidence to guide care
10
20
30
40
50
60
70
Atrial Fibrillation(2001–06)
Heart Failure (2001–06)
Pacemaker (1998–2002)
Systemic waste across the board
The Healthcare Imperative, 2010. Lower bound totals of various estimates of excess healthcare expenditures, adjusted to 2009 total expenditure levels.
Excess Cost EstimatesUnnecessary Services $210 B
Ine"ciently Delivered Services $130 B
Excess Administrative Costs $190 B
Prices That Are Too High $105 B
Missed Prevention Opportunities $55 B
Fraud $75 B
Total Excess Costs: $765 B
Poor health despite high spending
OECD Health Data, 2009. Life expectancy at birth in di!erent countries versus per capita expenditures on health care in dollar terms, adjusted for purchasing power. The United States is a clear outlier on the curve, spending far more than any other country yet achieving less.
AUS
AUT BEL
CAN
CZE
DNK
FIN
FRA
DEU
GRC
HUN
ISL
IRL
ITA
JPN
KOR LUX
MEX
NLDNZLNOR
POL
PRT
SVK
ESP SUE
CHE
TUR
GBR USA
72
74
76
78
80
82
84
Life
exp
ecta
ncy
in y
ears
600050004000300020001000
Health spending per capita (USD)
The Case
The Learning Health System and its Innovation Collaboratives Update Report12 1312
9
Telemedicine
Patients • 42% positive about virtual visits • 48% would do check-ups at home • 78% willing to try virtual visits
2010 internet survey by Euro RSCG Tonic, consumer health and wellness arm of marketing firm Euro RSCG
10
Telemedicine Uses
• See patients outside office hours • Communicate with chronic disease
patients • Coordinate with patients’ other physicians • Consulting with other physicians • Communicating with caregivers
11
Focus on Outcomes and Value: What We Really Want “Knowing is not enough; we must apply. Willing is not enough; we must do.”
-Goethe
12