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Game Changers in Health Care for
2014
Steven M. Berkowitz, MD
SMB Health Consulting,
Austin, TX
512-415-6095
[email protected]
2012- 2013 Clients- Two Lessons Learned
Every System is unique.
But… Every System is dealing with the same issues.
So What’s New in Health Care Reform?
Same old wine in a brand new bottle?
So What’s New in Health Care Reform?
You can always count on Americans to do the right thing…
…after they’ve exhausted all the other possibilities !!”
Winston Churchill
People do not change until the pain of staying the same…
… exceeds the pain of changing.
Anonymous
The Health Care Team
Medicine is a Team effort….
…..Why do we insist on playing Solo !
The Evolution of Health Care Reform
1990’s--
Market Correction
2013--
Market Reconfiguration
Remember, It’s Not Nice to Fool Mother Nature
Health care must follow the same market
rules as all other industries
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The event is surprise
It has an extreme impact
After the event occurs, it is rationalized by hindsight
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The event is surprise
It has an extreme impact
After the event occurs, it is rationalized by hindsight
Examples:
The Internet
Personal computer going to the phone
911
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The event is surprise
It has an extreme impact
After the event occurs, it is rationalized by hindsight
Examples:
The Internet
Personal computer going to the phone
911
Maybe some day……. The Chicago Cubs
Management Goals:
 Cannot predict event
 Build robustness against negative events
 Acknowledge and exploit positive ones
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The “Viral” Influence of Transparency
The Increasing Trend of Higher Deductible Insurance
The information technology system- EMR, ICD-10
New Technology- Personalized Medicine-Genomics
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The “Viral” Influence of Transparency
The Increasing Trend of Higher Deductible Insurance
The information technology system- EMR, ICD-10
New Technology- Personalized Medicine-Genomics
Value Based Purchasing
The increasingly informed consumer will make
health care decisions on the basis of VALUE
Value Based Purchasing
The increasingly informed consumer will make
health care decisions on the basis of VALUE
VALUE =
Outcomes + Satisfaction
Cost
The CONSUMER ultimately determines which
of the above elements constitute VALUE
Read all about it !!
April 2005
This is Your Life !!
Data Transparency in Action
Data Transparency
Data Transparency
That which is measured, tends to improve.
That which is measured publicly, tends to improve faster.
“What we concluded was that even when hospitals know their
performance is not good, that's not sufficient motivation for them to do
something. Making it public made a big difference in motivating them to
improve.”
Judith Hibbard, Health Affairs 2003
Core Measures:
Heart Attack
Heart Failure
Pneumonia
Surgical Care Improvement
HCAHPS
CMS Core Measures– the Top Decile
Core Measures:
Heart Attack
Heart Failure
Pneumonia
Surgical Care Improvement
HCAHPS
Data Transparency and Accountability
Transparency is the best thing that’s happened to
quality since antibiotics...
…by decreasing variance and improving results
Exposure to and Use of Quality Information
Kaiser Family Foundation, October 2008
If the other guy’s getting better, then you’d better be getting
better faster than that other guy’s getting better…
…Or you’re getting worse.
Tom Peters
Data Transparency and Accountability
Transparency is the best thing that’s happened to
quality since antibiotics...
…by decreasing variance and improving results
As transparency matures, it will rewrite the book on:
Who is your competitor?
The Role of Transparency
Price
Transparency
Quality
Transparency
The Role of Transparency
Price
Transparency
Quality
Transparency
System Strategic Planning
Who is Your Competitor…. The role of Transparency
Stage IV
Medical tourism
Stage III
The entire nation ?
Stage II
All hospitals in Oklahoma
Stage I
The “other guy”
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The Continued Influence of Transparency
The Increasing Trend of Higher Deductible Insurance
The information technology system- EMR, ICD-10
New Technology- Personalized Medicine-Genomics
Total Health Care Spending
OECD, 2012
Distribution of Health Care Spending
Kaiser HRET, 2013
Distribution of Health Care Spending
Kaiser HRET, 2013
Distribution of Health Care Spending
Kaiser HRET, 2013
Total Premium and Percentage paid by Worker
Kaiser HRET, 2013
Total Premium and Percentage paid by Worker
Kaiser HRET, 2013
Percentage of Plans with $1,000 or $2,000 Deductible
Kaiser HRET, 2013
Average Single Premium Deductible
Kaiser HRET, 2013
The Role of Transparency
Price Transparency:
???
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Price
Transparency
Quality
Transparency
Steve has a URI symptoms and feels bad!
Steve has great insurance but a $3,000 deductible
What does he do?
Treatment Options:
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Emergency Department
Urgent Care
PCP visit
Local Pharmacy
Self Treat.. rest, OTC meds...
Approximate*:
Out of Pocket
Wait
$ 300
2-3 hrs
150
1 hr
120
1 hr (if available)
80
30 min
10
? none
* The actual cost may not be known until the
evaluation is completed
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The physician’s reimbursement for the visit
The nurses reimbursement for the visit
The cost of his treatment to the institution
Any other contractual relationships
◦ Physicians
◦ Vendors
◦ Any other arrangements with the insurance company
Just tell me: How Much Do I Need to Pay !!
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The Continued Influence of Transparency
The Increasing Trend of Higher Deductible Insurance
The information technology system- EMR, ICD-10
New Technology- Personalized Medicine-Genomics
The Role of Information Systems
Health Care Information Systems-- We are so far behind !!!
1 Zettabyte =
1,000,000,000,000,000,000,000 bytes
= 10007 bytes = 1021 bytes
The Role of Information Systems
Health Care of the Future…..
…. We can’t get there from here
…. Without Information Systems !!
The Role of Information Systems
EMR and Evidence Based Order Sets are not just another
IT initiative….
…. it is a Clinical Transformation to how we will be
practicing better medicine in the future.
The Role of Information Systems
The EMR will do for health care
What the assembly line did for manufacturing
The Role of Information Systems
Health Care of the Future…..
…. We can’t get there from here
…. Without Information Systems !!
The Role of Information Systems
EMR and Evidence Based Order Sets are not just another
IT initiative….
…. it is a Clinical Transformation to how we will be
practicing better medicine in the future.
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The Continued Influence of Transparency
The Increasing Trend of Higher Deductible Insurance
The information technology system- EMR, ICD-10
New Technology- Personalized Medicine-Genomics
For a Given Condition or Disease:
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Identify the individual risk for the patient
Identify patients most likely to respond beneficially
Identify patients most likely to respond adversely– Minimize
adverse complications!
Identify the optimal dosage
Monitor the progress of the treatment
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Carrier Status
◦ Cystic Fibrosis
◦ Huntington’s Disease
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Risk of Disease
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Cardiovascular disease
Diabetes
Alzheimers
Breast/ ovarian cancer
Colon cancer
Response to Therapy/ Optimal Drug Treatment
◦ Cancer
◦ Heart Disease
◦ Pain Management
Original gene mapping-James Watson 2007: $ 1,000,000
Currently: $ 1,000 – 4,000
23 and Me…. 248 health conditions and traits: $99
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Human genes that produce tumor suppressor proteins
BRCA 1and 2 account for about 5-10 percent of all
breast cancers and 15% of ovarian cancers
Mutation can be inherited from mother or father
Each child has 50% chance if parent has defect
BRCA1
Breast CA
Ovarian CA
Pancreatic CA
Prostate CA
55-65%
39%
BRCA2
45%
15%
increased risk
increased risk
Normal
12%
1.4%
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The major enzyme systems involved in drug metabolism-- about 75% of
total metabolism
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The cytochrome P450 system can either:
◦ Metabolize a drug to make it inactive
◦ Make a drug active by degrading its precursor
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57 human genes code for this process
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There are many differences in genetic makeup within the population that
for a given drug may lead to:
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High metabolizer
Normal metabolizer
Low metabolizer
Examples of Drugs Metabolized by P450 System
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Common medication widely used to thin blood
◦ Treatment of blood clots
◦ Stroke prevention in atrial fibrillation
◦ Treatment of other hypercoagulable states
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The most serious complication is bleeding
◦ Runs the spectrum from bruising ( usually benign) to
intracranial bleeds (life-threatening)
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Identify the genetic status of the individual patient
◦ High metabolizer
◦ Intermediate metabolizer
◦ Poor metabolizer
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Adjust the medication and dosage accordingly
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A drug that inhibits platelets…. Decreasing the clotting mechanism
Indications:
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Acute coronary syndrome
Stroke
Myocardial infarction
PCI
Peripheral artery disease
Post CABG
Not all patients taking plavix achieve the same level of platelet
inhibition
20-50% of patients are poor metabolizers
Variability in individual response is due to genetic factors, drug
interaction
Heterogeneity of response could be due to non compliance
Traditional Model
Personalized Model
Patient develops symptoms and
accesses health care system
Testing is done upfront on patient’s
DNA
Lifetime Risk of Specific Disease
History
Physical Exam
Testing
Unique Response to Medications
Diagnosis of Established
Disease
Treatment based upon
statistical evidence
Likely Diseases Predicted
Treatment based upon the
individual needs
Putting Together IT and Genomics
A Perfectly Perfect Storm
Increasing medical
knowledge- research
Increasing individual
knowledge- cell phone
Increasing penetration of
the Internet
Increasing speed and
power of computers
Enhanced data capture ICD 10
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The Continued Influence of Transparency
The Increasing Trend of Higher Deductible Insurance
The information technology system- EMR, ICD-10
New Technology- Personalized Medicine-Genomics
To the world you may be just one person,
But to one person you may just be the world.
Unknown