Making Care More Efficient: Promising Innovations and Options for Reinvesting Savings

1. Making Care More Efficient: Promising Innovations and Options for Reinvesting Savings Christine K. Cassel, M.D., MACP The Commonwealth Fund Bipartisan Congressional Health Care Conference January 13, 2007

2. Rewarding Efficiency, Reducing Waste: The Physician's Role • Physician Services • Physician-Generated Services: • Referrals/technology • Hospital use • Generating Patient Demand • Who rewards the physician to reduce costs? • Organization of Care Delivery • Solo practice (20%) • Multispecialty groups (20%)

3. Went to ER for Condition That Could Have Been Treated by Regular Doctor (2005) Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available SOURCE: Schoen et al., “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” Health Affairs Web Exclusive November 3, 2005 W5-509–W5-525; Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

4. Physicians’ Use of Electronic Medical Records, U.S. Compared to Other Countries, 2000/2001 Percent of physicians *2000 SOURCE: 2001 European Union EuroBarometer and 2000 Commonwealth Fund International Health Policy Survey of Physicians (Harris Interactive 2002)

5. Test Results or Medical Record Not Available at Time of Appointment, Sicker Adults in Six Countries, 2005 Percent reporting test results/records not available at time of appointment in past 2 years SOURCE: Schoen et al., “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” Health Affairs Web Exclusive November 3, 2005; DATA: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

6. Ways to Improve Care AND Reduce Costs • Primary Care/Prevention • Patient Engagement • Redesign of Practice with Emphasis on Care Coordination

8. Primary Care - A Vanishing Species? COMPARE GENERALIST SHORTAGE • Physicians pursue specialties more than primary care • Clinical demands • Inadequate reimbursement • No support for teams and systems • Interventional Cardiologist • hospital pays staff, technology • pay for procedure • 4-8 x annual incomes • General Internist • pay for visits • no source of revenue for nurses, office staff, information systems • no reward for avoiding visits and hospital use(email, phone, presentation)

9. How can the best medical care in the world cost twice as much as the best medical care in the world? Uwe Reinhardt

10. Physician Training, Knowledge and Clinical Judgment ABIM Exam: "Conservative Management Score" High-intensity training areas correlated with worse performance on these questions EXCEPT for the top tier (20%) who did well on all questions

12. Medicare Medical Home Demonstration Project H.R. 611Tax Relief and Health Care Act of 2006 (Sec. 204) • Care Management / Incentive Fees • High-Need Population: multiple, complex chronic illnesses • 8 states / 3 years • Board certified physicians • Interdisciplinary teams • Patient empowerment • Health Information Technology • Demonstration inspired by ACP: http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplesforpatientcenteredmedicalhome.Par.0001.File.tmp/patient-centered-medical-home.pdf

13. Innovation, Reward and Reinvestment • Accountability • Standards for professionals and how they organize care • Reform financing to reduce perverse incentives • Rewards for reducing costs can be reinvested • More time with patients • Information systems • Interdisciplinary team