Healthcare: The Way It Should Be The New Era of Opportunity

Healthcare: The Way It Should BeThe New Era of Opportunity John L. Haughom, MD February 2014

Healthcare: The Way It Should Be Section One– Forces Driving Transformation • Chapter One – Forces Defining and Shaping the Current State of U.S. Healthcare • Chapter Two – Present and Future Challenges Facing U.S. Healthcare Section Two– Laying the Foundation for Improvement and Sustainable Change • What will it take to successfully ride the transformational wave? Section Three– Looking into the Future • What will it take to successfully ride the transformational wave?

Poll Questions… How are you involved in healthcare? • Integrated delivery system • Hospital • Physician Group • Other • What is your role? • Clinician • Management • Quality improvement • IT • Consultant

Some Pertinent History • For much of history, if you were ill or injured and saw a physician, your chances of survival actually went down. • Hospitals were where people went to die. “If a physician make a large incision with the operating knife and cure it,… he shall receive ten shekels in money. If a physician make a large incision with the operating knife, and kill him,…his hands shall be cut off.” Code of Hammurabi, 1780 BC, Law 215 (of 280)

Leadership is a Verb or Process, Not a Noun… Between ~1860 and 1915, a few visionary clinical leaders changed all that... • New high standards for clinical education • Strict requirements for professional licensing • Clinical practice founded on scientific research • New internal organization for hospitals • Creation of new, more modern nurse practices • Implementation of more modern hygiene techniques • New public health policies and treatments Sir William Osler Florence Nightingale

1912: The ‘Great Divide’ “…for the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than 50/50 chance of benefiting from the encounter.” – Harvard Professor Lawrence Henderson, MD Harris, Richard. A Sacred Trust. New York, NY, New American Library. 1966

Current Health Care… …is the best the world has ever seen... Some examples: • From 1900 to 2010,average life expectancyat birth increased from only49 years to almost 80 years • Since 1960,age-adjusted mortality from heart disease (the #1 cause of death) hasdecreased by 56 percent • Since 1950,age-adjusted mortality from stroke has decreased by 70 percent

Advancing Life Expectancy

Some Important Points • Most American hospitals and caregivers providesafeandeffectivecare for the vast majority of patients, the vast majority of the time • The vast majority of caregivers arewell trained and conscientious • Western medicine’s ability to save and extend life, and to improve the quality of life for the ill and injured is nothing short ofmiraculous

Does This History Matter? • All of this history is important, because it changes how we think about the present and the future. • As health care increasingly contributes to the national debate, let’s debate in the context of thephenomenal progress we’ve made and theprogress we’re capable of making. • The day we engage the hearts and minds of clinicians will be the day that the issues facing healthcare are solved.

The Great Equation Health= medical care …and medical care = “access to care” “But the Great Equation iswrong…” Wildavsky A. Doing Better and Feeling Worse: The Political Pathology of Health Policy. Daedelus 106(1); 105-123

Determinants of How Well We Live Behavior: Tobacco Ethanol Diet/Exercise pattern Etc. ~40% ~30% Genetics ~20% Environment/public health ~10% Health care delivery (hospitals & clinics) • McGinnis J, Williams-Russo P, Knickman JR. The Case for More Active Policy Attention to Health Promotion. Health Affairs, 2002; 21(2):78-93.

How This Impacts the Policy Debate • It is widely accepted that clinicians help patients • Yet, clinicians have little or no controlover 90 percent of factors that determine health • Thus, it is unlikely more money for clinical care will advance health • Policymakers believe we are spending enough on healthcare delivery

U.S. Healthcare Spending

Healthcare an Expected Benefit? • Since World War II, healthcare coverage has been an expected benefit for the employed… • …and since the late 1960s, an expected benefit for the elderly… • …but will it remain so?

Health Insurance as an Employee Benefit… …Will It Continue? • Probably not… • …data from December 2013 shows that less than 51% of employers now offer health insurance as a benefit… • …and the trend is down…

U.S. Healthcare Spending

U.S. Healthcare Spending US Spends two-and-a-half times the OECD average

The Reality… • We are spending more than we can afford on clinical care… • …we have promised more than we can deliver… • …we are not spending as much as we need on major determinants of health… …something has to change…

A Twofold Solution • The solution to this national dilemma is twofold: • First, we need to slow the rate of growthin spending on health care; and • Second, we have to spend what we devote to health care more effectively(i.e., generate more value) …clinician-driven, data-driven quality improvement is the answer…

High Touch: Caring, not just curing “A man stricken with disease today is assaulted by the same fears and finds himself searching for the same helping hand as his ancestors did five or ten thousand years ago. He has been told about the clever tools of modern medicine and somewhat vaguely, he expects that by-and-by he will profit from them, but in his hour of trial his desperate want is for someone who is personally committed to him, who has taken up his cause, and who is willing to go to the trouble for him.” Szilagyl DE. In defense of the art of medicine. Archives of Surgery 1965; 91:925-30

What do we get for all that money? • High touch– patients value their relationship with a trusted clinical advisor more than any other element in healthcare delivery(the clinician-patient relationship) • Choice– Americans have grown used to maximal choice, to being insulated from the costs of care. • It is unlikely this will continue for everyone; at a minimum, American society will need to define the limits. • Rapid response– the Rule of Rescue

The Rule of Rescue “The imperative people feel to rescue identifiable individualsfacing suffering or death” – A.R. Jonsen • Subconscious personal identificationat an emotional level • A person instead of just a number; a name and a face • The child down the well • The miners trapped in the mine • The whales trapped in ice • The dog on the abandoned boat Jonsen AR. Bentham in a box: Technology assessment and health care allocation. Law Med Health Care. 1986;14(3-4):172–174

System Performance, by nation United States Germany Sweden United Kingdom 20 20 17.1 16.5 15 14.3 15 Mortality Rate (%) 10 9.4 10 9.2 8.2 8.1 6.5 5 5 0 0 Major trauma Heart attack • Organization for Economic Cooperation and Development (OECD) data available at: http://www.oecd-ilibrary.org/sites/health_glance-2011-en/04/08/index.html?itemId=/content/chapter/health_glance-2011-36-en

System Performance, by nation United States United States Germany Germany Sweden Sweden United Kingdom United Kingdom 24.5 25 25 22.4 21.1 20 20 16.4 Mortality Rate (%) 15 15 12.2 10 10 5 5 0 0 Neonates < 1500 grams • Organization for Economic Cooperation and Development (OECD) data available at: http://www.oecd-ilibrary.org/sites/health_glance-2011-en/04/08/index.html?itemId=/content/chapter/health_glance-2011-36-en

System Performance, by nation • Organization for Economic Cooperation and Development (OECD) data available at: http://www.oecd-ilibrary.org/sites/health_glance-2011-en/04/08/index.html?itemId=/content/chapter/health_glance-2011-36-en

System Performance, by nation U.S. Men and Women Under Age 65 Have Higher Rates of Potentially Preventable Deaths Slowest Rate of Improvement, 1999-2007 Amenable mortality men ages 0-64 Amenable mortality women ages 0-64 100 100 1999 2007 1999 2007 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 GER* GER* FRA UK US FRA UK US *Data from Germany are 1999 and 2006 Source: Nolte E and McKee CM. In Amenable Mortality—Deaths Avoidable Through Health Care—Progress in the US Lags That of Three European Countries. Health Affairs, published online August 29, 2012.

In Summary… • Over the past century, remarkable progresswas made • We need more focus on otherdeterminants of health • Cultural norms—high touch, the desire for choice, and the Rule of Rescue—will likely continue to play a significant role in patient decisions • The pressure to achieve more valuefrom the resources applied to clinical care will grow • Solving healthcare’s issues will be similar to other industries—engaging front line worker in data-driven quality improvementand new, more efficient care delivery models

Healthcare: The Way It Should Be Section One– Forces Driving Transformation • Chapter One – Forces Defining and Shaping the Current State of U.S. Healthcare • Chapter Two – Present and Future Challenges Facing U.S. Healthcare Section Two– Laying the Foundation for Improvement and Sustainable Change • What will it take to successfully ride the transformational wave? Section Three– Looking into the Future • What will it take to successfully ride the transformational wave?

Poll Questions… How difficult will it be for Americans to balance high touch, the need for choice, and the Rule of Rescue to control healthcare costs? • Very difficult • Difficult • Easy Does your organization have an effective strategy to engage clinicians in data-driven improvement? • Yes • No • Don’t know • Is your organization considering new care models like the NCQA Medical Home • Yes • No • Don’t know

Questions and Answers Additional Information • See us at HIMSS 2014booth #6076 • Call 801.708.6800 to request a meeting • Listen to two clients speak: • “Improving Outcomes with an Innovative Approach to Population Health Analytics” • Stanford Hospital & Clinics • Yohan Vetteth, PraveneNath, MD • Date/Time: Thursday, 2/27, 12 PM • Location: Room 304A, Session #229 • “Blending Clinical and Financial Data to Drive the Value Equation” • Texas Children’s Hospital • Charles Macias, MD • Date/Time: Wednesday, 2/26, 1 PM • Location: Room 304A, Session #191

Healthcare: The Way It Should Be The New Era of Opportunity