Components of a Learning Health Care System

1. Componentsof a Learning Health Care System Denis A. Cortese, MD BPC Health Care Reform EventApril 24, 2008

2. Learning organizations Value* Individ-ualizedMedicine Scienceof HealthCare Delivery Integration and coordination Pay for value *Value = Quality/Cost = Outcomes, Safety, Service/Cost Over Time

3. Quality Value = Cost over a span of care Pay for Value • Pay for results, outcomes, value,not process compliance • Purpose for process is to achievebetter value (outcomes, safety, service)

4. Innovation (New Idea, Old Idea,New Way) NewClinicalPractice BasicResearch TranslationalResearch ClinicalPractice Value Translational Education Increasing Value in Health Care Time, people and capital 4

5. Value Individualized Medicine Science of Health Care Delivery Integration Increasing Value in Health Care Innovation (New Idea, Old Idea,New Way) NewClinicalPractice BasicResearch TranslationalResearch ClinicalPractice Enterprise Learning System Enterprise Learning System Time, people and capital Translational Education 5

6. Learning organizations Value* Individ-ualizedMedicine Scienceof HealthCare Delivery Integration and coordination Insurance for all Pay for value *Value = Quality/Cost = Outcomes, Safety, Service/Cost Over Time

7. Mayo Clinic Health Policy Center Goal Influence stakeholders to implementsubstantive health care reform before 2011that will enhance quality and availabilityof health care for all patients Role Convening body

8. Mayo Clinic Health Policy Center • 10 sectors • 800 people • 400 patient comments – 9-city tour • 1000 patients surveyed

9. MCHPC Cornerstones Coordinated care Value Payment reform Insurancefor all: FEHBP model

10. Health Policy Center Action Steps:Public Sector • Insurance for all • Ensure/mandate insurance coverage for all • Interoperable EMR • Require all providers to have interoperable EMRs withina certain time (5 years) with patient accessibility • Federal Health Board/Reserve • Implement an independent board to set rules/standardsto promote value in health care • Care coordination • Reward care coordination • Pay for value • Direct Medicare to pay for value/outcomes/preventionusing innovative payment models

11. Insurance for All • FEHBP – Model • All people own insurance; All participate • Employers can purchase all or some • Government help finance in sliding scale • All insurers take All patients • No pre-existing condition exclusions • Adjust for initial conditions • Sunset Medicare and Medicaid

12. If Medicare Continues…Mayo Clinic Calls for Major Changes: • Congress must be out as BOD • Stop price controls in exchange for provider pricing transparency on a set of common visits/procedures/tests and quality • Pay for value • Focus on results ▫ O,S,S, and Cost over span of care • UHC ▫ Dartmouth Atlas ▫ NQF ▫ Leapfrog ▫ AHRQ • Let patients pay more if they chose • Coverage with evidence development • Allow comparative effectiveness considerationsin benefit design and coverage decisions

13. Pay For Value: Concepts • FFS with reward for good outcomes • FFS with shared savings • Shared decision making • Episode based payments • Chronic disease coordinator payment

14. Role for President • Learning Organization • Value: O,S,S, / Cost over Time • Insurance for all • Pay for value

16. WI ME MN UT SD ND NE NH CO HI CT IA VT MA MD NJ ID VA TX FL OK MS AR LA Medicare Spending** and Quality of Care* Best quality – Lowest cost Quality score Lowest quality – Highest cost Medicare personal health care spending per enrollee *Quality from “National Health Quality Report, 2006” by AHRQ **Cost from Medicare Health Expenditures by State 2004, CMS website (www.cms.hhs.gov)

17. 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0 10 20 30 40 50 60 Teaching Hospital Variability in Value B A GoodEffectiveness GoodEfficiency GoodEffectiveness PoorEfficiency Reward Case mixadjustedmortality(>1 is better) PoorEffectiveness GoodEfficiency PoorEffectiveness PoorEfficiency Incentto moveto upper left C D Cost in last 6 months of life ($000s)