Quality of Health Care in America

1. Quality of Health Care in America Grand Rounds Phillip M. Kibort, M.D., MBA VPMA/CMO March 2010

4. Quality “The journey of a thousand miles begins with a step” Lao Tzu

5. Quality All systems are perfectly designed to achieve the results they do. Batalden

6. Status Quo “The status quo is unacceptable. Without serious commitment to change, health spending as a percentage of the gross domestic product will rise from 16% currently to 20% by 2017; and Americans without adequate insurance and access to essential services will continue to suffer affordable health consequences. American resources and ingenuity are adequate for the challenge. What is required is national leadership and commitment to moving toward a high performance healthcare system.” K. Davis

7. Change “There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage, than the creation of a new system. For the initiator has the enmity of all who would profit by the preservation of the old institutions and merely lukewarm defenders in those who would gain by the new ones.” Machiavelli The Prince, 1518

8. First, do no harm….

9. Quality: A Strategic NecessityBecause • Cost escalation • Variation in practice • Purchaser dominance • Issues of public trust • Integrated systems and managed care • New information systems

10. Quality/Safety “Safety” “Quality” Performance Improvement (Tools) The Science & Theories The outcomes of our product & services

11. Quality A) Patient-Centered B) Systems-Based C) Evidence-Based

12. What is the Problem? • If you don’t think something is broken, you won’t try • to fix it. • There may be a problem but not with my doctor or • hospital.

14. Where did this begin? … all hospitals are accountable to the public for their degree of success… If the initiative is not taken by the medical profession, it will be taken by the lay public. 1918 Am College Surg

15. Our Challenge

16. Reality “Medicine used to be simple, ineffective and relatively safe. “Now it is complex, effective, and potentially dangerous.” Sir Cyril Chantler

17. A failure of execution The science of current western medicine is the best the world has ever seen; (and continues to improve rapidly) while the performance of American care delivery leaves much to be desired. Chassin, MR, Glavin RW, and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. JAMA 1998; 280(11):1000-1005. Chassin, M. Is health care ready for six sigma quality? Milbank Quarterly 1998; 76(4):1-14.

18. We have a broken system Quality Chasm Uninformed Consumers Spiraling Costs “Pimp My Ride”

19. The Battle for Quality: IOM versus “Pimp My Ride” The IOM Vision of Quality: Charles Schwab meets Nordstrom meets the Mayo Clinic The Prevailing Vision of Quality in American Healthcare: “Pimp My Ride”

20. Do we have World’s Best Medical Care? Editorial New York Times, August 12, 2007

21. World’s Best Medical Care? 1.The WHO ranked 191 nations eight years ago regarding the overall quality of their healthcare, France and Italy took the top two spots and the United States was 37th. 2.The Common Wealth Fund compared the United States versus Australia, Canada, Germany, New Zealand, and the United Kingdom. The U.S. was last or next to last compared to these others. 3.All other major industrialized nations provide universal health coverage and most of them have comprehensive benefits with no cost sharing by the patients.

22. World’s Best Medical Care? Top of the Line Care. Despite our poor showing in many international comparisons it is doubtful that many Americans faced with a life threatening illness would rather be treated elsewhere. Is this a realistic assessment or merely a cultural preference for the home team?

23. IOM Add Injury to Insult • 44,000-98,000 plus deaths from • errors during hospitalizations • 7,000 deaths from medication • errors alone • $17-29 billion in added costs • Ambulatory care unknown To Err Is Human 1999

24. Cadillac Prices, Yugo Quality… Condition% Receiving Recommended Care* Breast cancer 76% Heart attack & coronary artery disease 68% Immunizations 66% High blood pressure 65% Osteoarthritis 57% Asthma 53% Diabetes 45% Urinary tract infection 41% Sexually transmitted diseases 37% *McGlynn, et. Al, New England Journal of Medicine, 2003

25. But What About Pediatrics? “Healthcare Quality for America’s Children Even Worse Than for Adults, New Study Finds” NEJM Mangione-Smith, et al 2007

26. Pediatric quality is different • Development • Differential • Demographics

27. What about Quality? How good are we?

28. How hazardous is health care? DANGEROUS REGULATED ULTRA-SAFE  100,000 10,000 1,000 100 10 1 Health Care  Driving  Scheduled Airlines  Chartered Flights  European Railroads  Mountain Climbing  Chemical Manufacturing  Nuclear Power  Bungee Jumping 1 10 100 1,000 10,000 100,000 1,000,000 Number of encounters for each fatality

29. Geography is Destiny!  C-Sections  Coronary Bypasses  Back Surgery

30. Sunday, April 22, 2007 New York Times In turnabout, infant deaths climb in South Race disparity persists Poverty, Obesity and Lack of Prenatal Care Cited – a Visible Toll

31. Equitable Care …the IOM concluded that “(al)though myriad sources contribute to these disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care.”

32. Three main ideas 1. Current American health care is very good, but… there is compelling evidence that health outcomes could be much better. 2. Experience shows that it is possible to close the quality gap. 3. The business case for quality: better patient results can produce significant cost savings.

33. Change Change Three Fundamental Assumptions: • A good physician takes quality personally. • 2. A good physician wants to practice the • best quality possible. • 3. Physicians hate change as much as everyone • else. Change

34. WHY DO THIS? The public has replaced our paternalism with their consumerism

35. WHY DO THIS? Payer fury is becoming stronger

38. Health Care Costs 70% of people 30% of people 80% Cost: $800 Savings opportunity: $400 Cost: $400/person/year Savings opportunity: $0/person/year Costs Cost: $10,000 Savings opportunity: $2,000-$4,000 20% Accident & Catastrophe work injury, car accident Preventive Services Vaccines, healthy lifestyle, blood pressure management Ambulatory Care Physician visits Emergency Room Care Diagnostic imaging, testing, ambulance transportation Chronic Disease diabetes, congestive heart failure, pneumonia

39. Where do those dollars go? $300 billion dollars greater administrative costs than Canada. Enough to support Medicare. U. Reinhardt

40. Drivers of Health Care Costs  Population dynamics: an aging population with chronic diseases  Medical technology and treatment advances; genomics will fuel advances  Healthcare delivery model - failure of evidence-based care, medical errors, reactive interventions, lower threshold for interventions  Coverage mandates  Health professional shortages

41. Drivers of Health Care Costs (continued) •  Consumer education, information, navigating • the complex system • Unnecessary care; duplication of medical services; •  Protecting the medical commons: failure to • “ration” care •  Administrative costs: hospitals, insurers, • medical practices • Physician and hospital compensation incentives • Medical malpractice

42. What have we tried? Historical trends in U.S. healthcare expense P4P Managed Care 15% DRG’s % GDP HMO’s Medicare 4% 1965 1970s 1980s 1990s 2008

43. Reality “For most of its history, Medicare has been paying for services but not for results.” Michael O. Levitt, Secretary of Health & Human Services

44. Is this crazy or what? The best and worst providers receive the same payment

45. Are we like wine? “While practice makes perfect”, in some situations physicians knowledge and performance may decline with the passage of time. N.K. Choudhry, et al Annals of Internal Medicine Feb. 15, 2005

46. Is it possible to keep up? During 2007, the U.S. National Library of Medicine added more than 14,000 new articles per week to its on-line archives. That represented about 40% of all articles published, world-wide, in biomedical and clinical journals. National Library of Medicine: Fact Sheet MEDLINE. 2010. Http://www.nim.nig.gov/pubs/factsheets/medline.html

47. Exploding knowledge base  3 to 4 years after board certification, internists - both generalists and subspecialists - begin to show significant declines in general medical knowledge…  14 to 15 years post-certification, ~68% of internists would not have passed the American Board of Internal Medicine certifying exam...  To maintain current knowledge, a pediatrician would need to read > 20 articles per day, > 365 days of the year an impossible task... Shaneyfelt, TM. Building bridges to quality. JAMA 2001; 286(20):2600-2601 (Nov 28).

48. Quality What is your definition of it?

49. Quality Quality is like pornography – “we know it when we see it” James Todd (AMA) 1986 Potter Stewart (Supreme Court) 1964

50. The Institute of Medicine’s Definition of Quality Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.