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The Persisting Challenges

Improving Value in Health Care: Challenges and Potential Strategies Arnold M Epstein October 24, 2008 Congressional Health Care Reform Education Project. The Persisting Challenges. Quality. Cost. Access. National Health Expenditures and Their Share of Gross Domestic Product, 1960-2006.

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The Persisting Challenges

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  1. Improving Value in Health Care: Challenges and Potential StrategiesArnold M EpsteinOctober 24, 2008Congressional Health Care Reform Education Project

  2. The Persisting Challenges Quality Cost Access

  3. National Health Expenditures and Their Share of Gross Domestic Product, 1960-2006 Dollars in Billions 5.2% 9.1% 13.7% 13.6% 13.8% 15.3% 15.9% 16.0% Source: Centers for Medicare and Medicaid Services, Kaiser Family Foundation

  4. On Main Street Affordability is the Issue • Premiums increased 8.5% annually in the last 4 years • Individual coverage costs $4,700; family coverage costs $12,680 • Increasing costs show no signs of abating • Polls show that affordability is the number one health care issue for likely voters

  5. The Persisting Challenges Quality Cost Access

  6. “There is abundant evidence that serious and extensive quality problems exist throughout American medicine.” Institute of Medicine

  7. Opportunities to Improve Quality are Ubiquitous • Only 28-36% of elderly receive pneumococcal vaccines when they should. • Only 41-54% of hypertensives have their blood pressure controlled. • Failure to provide proven therapies for AMI results in 18,000 preventable deaths annually.

  8. Medical Error is the 8th Leading Cause of Death 44,000 43,458 42,497 16,516 Motor Vehicle Accidents Medical Errors Breast Cancer AIDS Source: To Err is Human: Building a Safer Health System, Institute of Medicine, November 1999.

  9. Disparities in Care by Race, Ethnicity and Social Class Abound

  10. Per Capita Medicare Expenditures Vary Nearly Two-fold Across States Source: Dartmouth Atlas

  11. Per Capita Medicare Spending and Overall Quality of Care (24 Indicators) Source: Baicker and Chandra, Health Affairs, 2004

  12. Options to Achieve Higher Value-Reducing Costs and Raising Quality Primary Prevention Disease Management Public Reporting Managed Care Payment Reform (eg P4P) Consumerism Information Technology Comparative Effectiveness

  13. Options to Lower Cost or Raise Quality • Primary Prevention • Delays illness, unlikely to save costs • Disease Management • CBO report: increased quality, no impact on cost • Public Reporting • Modest impact on quality, not much on cost

  14. Strategies to Lower Cost or Raise Quality • Managed Care • Some potential, enrollment is a concern • Payment Reform (eg P4P, medical home) • P4P has modest impact on quality, growing focus on “efficiency”; medical home broadly piloted • Consumerism • Some impact • threats to access, and 10% of patients account for 70% of the costs

  15. What is Health Information Technology? • Health IT includes a diverse set of technologies for transmitting and managing health information. • Electronic health records are the lynchpin of HIT • Core functions • Health information and data ( e.g. problem and med lists), • Results management (lab and imaging results) • Order entry and support • Decision support • Other Functions • Patient support, reporting and population management, electronic communication

  16. The Promise of HIT • Chadhry et al reviewed 257 studies (2006) • Multi- function EHRs increased adherence to guidelines, reduce medication errors, and decreased use of care • Key studies were from 4 institutions that pioneered IT and developed their own EHRs • Data on cost of care were limited • RAND corporation estimated that a 90% rate of adoption of EHRs in hospitals and physician offices would save net $531B over 15 years

  17. The Challenges to HIT Source: DeRoches et al N Engl J Med , 2008

  18. What is Comparative Effectiveness? • Comparative effectiveness analysis evaluates the clinical effectiveness of drugs, surgical procedures, devices, and dxic tests versus the alternatives. • Comparative Effectiveness will address shortfalls in the current system • Comparisons among competing alternatives • Evaluation of long term efficacy and adverse effects • Review of diagnostic and surgical procedures,

  19. The Promise of Comparative Effectiveness • Comparative effectiveness information has the potential to rationalize our use of services and promote care of higher value and quality • MedPAC has proposed that Congress create a comparative-effectiveness entity • Independent with public and private funding • Examine comparative-effectiveness over time • Disseminate information to its constituents • No role in recommending coverage

  20. The Challenges to Comparative Effectiveness Prodigious undertaking Many unanswered questions:- design of the board, placement, level of funding, primary versus secondary data collection Will costs be considered, and if so what levels of cost effectiveness will be unacceptable How will judgments be translated into clinical policy and utilization review? Will CMS change current policy to cover any “reasonable and necessary” treatment

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