educating for high value care: a national perspective€¦ · atul grover, m.d., ph.d. chief public...

Atul Grover, M.D., Ph.D.Chief Public Policy Officer, AAMCMarch 6, 2014

Educating for

High Value Care:

A National Perspective

Case Western Reserve University

School of Medicine Education Retreat

© 2014 AAMC. May not be reproduced without permission.

Our health care reality

2


Analysis

• Although the deficit has decreased since FY 2009 and is projected by the CBO to continue to drop through

FY 2015, it remains at historically high levels

• The CBO projects the deficit will increase steadily from FY 2015 to FY 2023 due to rising health care costs

and entitlement spending, interest payments on federal debt, and reduced GDP projections

CBO Adds $1T to Deficit Forecast for Next Decade

U.S. Deficit and Surplus

$400B

$0B

-$400B

-$800B

-$1,200B

-$1,600B

Source: Congressional Budget Office, February 2014, NationalJournal Membership3


Federal Health Care Spending Projections Decline

Projected Spending for Major Health Care Programs*

(Net of Offsetting Receipts, in Billions)

Analysis

•CBO’s latest health care spending projections for 2013-2023 is $11,929B, $240B below its Feb. 2013 estimate of $12,169B

•The latest CBO figures continue the trend of declining health care spending projections; each report since at least 2012 has shown

expected costs coming in lower than those of the previous report

•Experts remain unsure why the rate of health care spending’s growth has slowed down; the slowing pace may be due to the recession or

to longer-lasting structural changes in health care delivery and health reform legislation

*Includes Medicare (net of receipts from premiums), Medicaid, CHIP, and subsidies offered through new health insurance exchanges and related spending.

Source: Congressional Budget Office, NationalJournal Membership.4


Health Care Costs Are Projected to Outpace

Economic Growth

—NPR, Sept. 19, 2013

5


2013 Milliman Medical Index$22,030 total annual spending on health care per family

6


Deficits in Outcomes

Source: OECD Health Data 2013, July 2013

U.S. Comparison to OECD Nations

Bottom Quarter78.7 yrs compared to Italy

and Japan at 82.7 yrs

4th Highest Highest 6.1 deaths/1,000 births

compared to average 4.1

deaths per 1,000 births

33.8% obese compared

to average 16.9%

Life Expectancy Adult ObesityInfant Mortality

2011 20112011

7


Entities With Major Responsibility to Reduce Cost of Health Care As Reported By 2,556 U.S. Physicians

Source: Tilburt, J. C., M. K. Wynia, et al. (2013). "VIews of us physicians about controlling health care costs." JAMA 310(4): 380-388.8


Change is inevitable,

and it will affect

academic medicine.

10

72%

370%278%

56%148%

425%

1,500%

0%

200%

400%

600%

800%

1,000%

1,200%

1,400%

1,600%

U.S. Population GDP inConstantDollars

# of Physicians # of FullyAccredited

Medical Schools

# of Graduates # of Full-timeBasic Science

Faculty

# of Full-timeClinical Faculty

Growth in U.S. Population, GDP, and Medicine

1960-61 to 2010-11

Five Decades of Medical School Growth

Source: Bureau of Economic Analysis, http://www.bea.gov/national/#gdp; US Census Bureau 1960-2011.11

http://www.bea.gov/national/

Flow of Funds in AMCs…

$144,087,882

$99,993,043

$117,373,490

12


Clinical Care Is A Major Source of

Revenue for Medical Schools

Source: Medical School Revenue by Source, Fully Accredited Medical Schools, LCME Part I-A Annual Financial Questionnaire, FY2012

Total Revenue: $96B

Median Revenue: $547M

55% of

Total

Revenue

13


ACA Implementation Timeline

2011 2014

Doctors

paid

according

to quality of

care

Medicare Reforms

Covers preventive services,

add’l primary care payments,

drug discounts

Insurance Reforms

Individual mandate,

guaranteed issue,

no annual limits

Medicaid Expansion

in 25 states and DC

Health Exchanges Open

Enrollment and tax credits begin

Oct. 1 to help Americans pay

premiums in individual market

Medicaid and Medicare

Payment Reforms Continue

2010

Insurance Reforms

Dependents covered to

age 26, no lifetime limits,

preventive care coverage

2012 2013

More Medicare Reforms

Reduced payments for

readmissions, value based

purchasing, Accountable Care

Organizations

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ACA Hospital Issues on Horizon

• Medicare/Medicaid cuts to hospitals = $155 B/10 yrs

o Includes $40B in Medicare/Medicaid DSH cuts

• Hospital price transparency

• Community benefit reporting requirements/IRS

• Readmissions policies FY 2013

• Value based purchasing FY 2013

• Medicaid voluntary expansion CY 2014

• Exchange establishment (fed/state) CY 2014

• Hosp Acquired Conditions reductions FY 2015

Will coverage levels cover cuts?

15


Estimated Medicare Losses for

All Major Teaching Hospitals

Source: AAMC Analysis of IPPS Impact File, FY2014 Final Rule Data (August 1, 2013 Release)

0%

2%

4%

6%

8%

10%

12%

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

2014 2015 2016 2017 2018 2019 2020 2021 2022

Fiscal Year

Sequestration DSH/UCP Cut Readmission VPB ACA Multi-FactorProductivity

% of Total Payments

Es

tim

ate

d L

os

se

s a

s %

of

To

tal E

sti

ma

ted

Re

ve

nu

es

Baseline Reductions in Medicare Revenue

Es

tim

ate

d L

os

se

s (

Millio

ns

)


Do Our Clinical Models Meet the Needs of the Health Care System of the Future?

17


Strive for the “Triple Aim” in Health Care

Source: Berwick, DM, Nolan, TW, Whittington, J. Health Aff May 2008 vol. 27(3), 759-769.18


—Pittsburgh Post-Gazette, Oct. 18, 2013

Kicking the Can: The Shutdown Ends at

the Expense of the Future

—Huffington Post, Aug. 23, 2013

NIH Director on Sequestration: ‘God Help

Us if We Get a Worldwide Pandemic’

—CNN, Oct. 2, 2013

Doctor Shortage, Increased Demand Could

Crash Health Care System

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NIH Funding in Billions – FY 2000-2014 Labor-HHS Budget Authority only

$0

$2

$4

$6

$8

$10

$12

$14

$16

$18

$20

$22

$24

$26

$28

$30

$32

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

$17.8

$28.9$29.93

$19.0

Billio

ns

Current Constant (BRDPI)

Sources: NIH Budget Office; House and Senate Appropriations Committees


NIH Funding

FY 2012 $30.6 billion

FY 2013 (pre-sequestration) $30.6 billion

FY 2013 (post-sequester) $28.9 billion

FY 2014 House committee no bill

FY 2014 Senate committee $30.9 billion

FY 2014 Omnibus (final) $29.9 billion

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Right-Sizing the Research Enterprise

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Is Our Fundamental Research Actually Linked to Improvements in Care?


Pressing Questions

Are we going to lose a whole

generation of scientists?

When will residency

slots increase?

Is our business model

sustainable?

We talk about teams, but how

do we put them together?

Is our commitment to diversity

fading?

Given our new partnerships, is

our core academic mission

changing?

What does it mean to be a

faculty member in the future?

24


Despite these challenges, you

can be part of the change in

health care.

25


Academia as a Major Provider of Health Care

AAMC-member teaching hospitals represent 6% of all acute general hospitals

Their work represents: • 20% of all Medicare inpatient days• 26% of all Medicaid inpatient days• 37% of all hospital charity care

They provide:• 70% of all burn center beds• 37% of neonatal intensive care beds• 80% of all ACS-verified Level 1 regional trauma centers

Overall, AAMC-member teaching hospitals provide 23%of all hospital care

Source: AAMC Analysis of American Hospital Association Survey Data, FY2010Source: AAMC Analysis of American Source: AAMC analysis of AHA 2011 annual survey data 26


AP Photo/Elise Amendola


“Is Our Children Learning?”

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Different Leadership Competencies

Self oriented

White male

Individualistic

Basic or clinical science

Tactical

Knowledge centered

Tenure track

Incremental

Status/titles/income

Aligned with organization

Diverse

Teamwork/collaboration

Translational

Strategic

Competence centered

Non-tenure track

Breakthrough

Ethical fulfillment

Traditional Future-Oriented

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The Choices We Make

Am I just hoping the

status quo holds

until I retire?

Am I living the values of

interprofessional respect

and collaboration in front

of my learners?

Am I obsessing about grades

and USMLE scores, or am I

focusing on developing

empathetic and patient-centered

communication skills?

Are the number of graduate

students and postdocs I recruit

based on the needs of my lab,

or future career opportunities

for these trainees?

Is reducing health care costs

someone else’s problem or

my chance to lead?

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A Tale of Two Affiliated Hospitals:

Prostatectomy Rates

# Patients w/

Localized

Prostate Cancer

# of Patients

Undergoing

Surgery

% of Patients

Undergoing

Surgery

University

Hospital103 61 59.2

Veterans Affairs

(VA) Hospital119 33 27.7

• HUP and the Philadelphia VA are about 4 walking

minutes apart.

• Both hospitals share the same staff urologists.

• Both hospitals share the same urology residents.

Source: (adapted from) Asch DA and Armstrong K. Aggregating and partitioning populations in

health care disparities research: differences in perspective. J Clin Oncol. 2007; 25:2117-2121.31


What’s Already Happening?

32


The Complete Physician

Physician

Patient Care

Knowledge for Practice

Inter-professional Collaboration

Personal and Professional Development

Systems-based Practices

Practice-based Learning and Improvement

Professionalism

Interpersonal and

Communication Skills

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Learning Health System Challenge Awards

Challenge Award Winners University of Chicago, Department of Medicine

Massachusetts General Hospital

Emory University, Healthcare Innovation Program

Meharry-Vanderbilt Alliance, Vanderbilt University

University of Missouri-Columbia School of Medicine

Planning Award Winners Duke University School of Medicine

Henry Ford Health System

Medical College of Wisconsin

Saint Francis Hospital and Medical Center, University of

Connecticut School of Medicine

University of Alabama at Birmingham (UAB)

University of Wisconsin School of Medicine and Public Health

Yale-New Haven Hospital

Special Innovation Award Loyola University Chicago Stritch School of Medicine

www.aamc.org/initiatives/rocc/363080/challengeawardwinners.html

Te4Q can help members develop a critical mass of faculty

ready, able, and willing to engage in, role model, and teach

about patient safety and the improvement of health care.

Teaching for Quality (Te4Q) A Unique Faculty Development Program

Professional Development Community Building Scholarship

www.aamc.org/initiatives/cei/te4q/

Distribution of Services Targeted by “Choosing Wisely” Lists, According to Specialty Society

Source: Morden NE et al. Choosing Wisely — The Politics and Economics of Labeling Low-Value Services. N Engl J Med 2014;370: 589-592.


1. ADVOCATE

Create a culture where caregivers are responsible for the cost and value of their decisions, take action to avoid waste, and help build the will for change

2. EDUCATE

Give caregivers the knowledge and skills to make cost-conscious, high-value decisions with their patients

3. SUPPORT

Help caregivers deflate costs with IT and decision-support tools that make cost and quality information available when medical decisions are made

DOCTORS, NURSES, AND OTHER CAREGIVERS

SHOULD PROTECT PATIENTS FROM FINANCIAL HARM


Teaching Value & Choosing Wisely Competition (2013)

• Collaboration between Costs of Care & ABIM Foundation

• Received 74 submissions from 14 specialties.

• Innovations targeting medical students, residents, faculty, and interprofessional learners.

• Judging panel reviewed abstracts to determine practices that could be scaled up to other institutions.

• Trade-off between feasibility and novelty?

• Most promising submissions employed methods beyond traditional training.

• Several of the winners were medical students and trainees.

• Submissions available at: http://www.teachingvalue.org/study.aspx?which=lg (free registration req’d)

• Next competition: Fall 2014

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http://www.teachingvalue.org/study.aspx?which=lg


Christiana Care Value Institute Academy

• Offers formalized approach to staff education and training to create innovative, effective, affordable systems of care.

• Maximizes individual and team abilities to innovate and lead change and drive scientifically-based improvements in health care delivery.

• Set a goal to become a regional center for education and training of individuals or groups outside of Christiana Health System in health care value.

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Christiana Care Value Institute Academy (cont’d)

Advanced Quality and Safety Improvement Science Program:

• Train-the-trainer program that focuses on faculty (professionals who already possess the requisite teaching skills).

• Provides faculty with advanced knowledge and skills in improvement and safety that transforms them into teachers of quality improvement and safety.

• 9-month curriculum that combines self-directed, didactic and experimental learning with coaching and mentoring among learners, faculty, and course directors.

• Important to the overall learning experience is the application of skills through performance improvement projects.

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© 2014 AAMC. May not be reproduced without permission.42

Subject Area Level

Improvement Science Advanced

Audience Delivery

Faculty/teaching staff (faculty physicians, nurse leaders,

pharmacists, and physician leaders) actively involved in leading

departmental, service or system-wide quality and safety

improvement initiatives and have responsibility for mentoring

residents in systems based practice.

Mixed didactic, e-learning, self-directed and experiential

learning.

Requirements Pre-Requisites

Demonstrate application by leading and/or facilitating the

improvement effort in their current position and by mentoring

other faculty or residents in their quality and safety improvement

science skills development.

Pre-requisite Education. Completion of one of the

following: Medicine Value Program, Achieving

Competency Today course, ACT Course Facilitator

program, or Other equivalent knowledge or approved

Improvement Science training. Learners must come with

an improvement project relevant to their current role.

Project must be pre-approved by their immediate

supervisor, program director, and/or department head.A

Credits/Certification Length

Participants may be eligible to sit for the American College of

Medical Quality’s Certification in Medical Quality (CMQ)

Examination. Certificate of completion will be awarded by the

Value Institute program directors.

40 hours (16 sessions) over the course of nine months.

Date(s) Fee(s)

August 27, 2013 - May 27, 2014. No charge for Christiana Care employees, Medical-Dental

staff and credentialed providers.

Christiana Care Value Institute Academy (cont’d)

Advanced Quality and Safety Improvement Science Program


UCSF Resident & Fellow QI Incentive Program

Engaged residents & fellows in setting QI project goals, with financial incentives for meeting them.

• All-Program Goals: Achieved 61% of goals (11 of 18 projects) in three domains:

• Patient satisfaction;

• Quality/safety; and

• Operation/utilization.

• Program-Specific Goals: Achieved 76% of goals(28 of 37 projects) in four categories:

• Patient-level interventions;

• Enhanced communication;

• Workflow improvements; and

• Effective documentation.

Source: Vidyarthi AR, et al. Engaging residents and fellows to improve institution-wide quality:

the first six years of a novel financial incentive program. Academic Medicine. 2014 Jan 20

[ePub ahead of print].43


UCSF Resident & Fellow QI Incentive Program (cont’d)

Factors contributing to projects’ success:

• Perceived importance to residents & fellows;

• Availability of mentors;

• Department buy-in; and

• Measurement assistance.

Potential returns:

• Positive impacts on cost avoidance (e.g., regulatory citations);

• Cost savings (e.g., on-time surgical starts);

• Revenue generation (e.g., patient referral from enhanced satisfaction).

Source: Vidyarthi AR, et al. Engaging residents and fellows to improve institution-wide quality:

the first six years of a novel financial incentive program. Academic Medicine. 2014 Jan 20

[ePub ahead of print].44


University of Colorado School of Medicine:

• Peer-reviewed resource published Aug. 26, 2010 on MedEdPORTAL: www.mededportal.org/publication/7787

• Educational Objectives:• To be able to understand the present cost of a hospital

stay.

• To be able to break down how physician decisions affect hospital costs.

• To be able to discuss appropriate resource utilization in light of stated costs.

• Case-based, interactive session with a small group of students during Internal Medicine clerkship

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Teaching the Cost of Hospital Care to Medical Students

http://www.mededportal.org/publication/7787



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Teaching the Cost of Hospital Care to Medical Students (cont’d)

Outcomes (based on pre- and post-test surveys):

• Students believed that costs associated with diagnostic testing are infrequently considered in medical decision-making.

• 31.2% agreed/strongly agreed that their medicine team considered the cost in the medical decision-making process when ordering a test.

• Students felt only a minority of residents/attending physicians routinely discussed the cost of care as a component of patient management.

• Knowledge of health economics was poor at baseline and improved with the curriculum.

• Answered correctly pre-test: 42.6%

• Answered correctly post-test: 78.6%

• Student beliefs & attitudes also changed.• More students reported that patient’s ability to pay should be

considered and that cost of test should be discussed with patient.

• Students did not change opinion that diagnostic accuracy is more important than cost.



47

Teaching the Cost of Hospital Care to Medical Students (cont’d)

Outcomes (based on pre- and post-test surveys):

• Student beliefs and attitudes that changed:• More students reported that patient’s ability to pay should be

considered and discussed with the patient.

• More students reported that cost of the test should be discussed with the patient.

• More students felt they could effectively weigh cost against benefit when considering a diagnostic test.

• Student beliefs & attitudes that did not change:• Students did not change opinion that diagnostic accuracy is more

important than cost.

• No significant change in the number of people who thought patient’s insurance status should be discussed.

• Majority of students reported they will change their future practice (64.5%); planned to incorporate cost into decision-making based on this experience (83.9%); and planned to discuss the topic with their residents (70.1%).


Do you know how much a blood test costs?Posted by Sehj Kashyap, “Almost” MD on Jan. 28, 2014The Almost Doctor’s Channel

“Whether we (future physicians) like it or not, conversations on cost will likely become a fixture as we step into the hospital ... Until the time when Siri can tell me how much my blood test costs, or until hospitals start displaying their prices, the onus falls on us to educate ourselves. Lets not wait for medical schools or residency programs to teach us ...

“As students, we can take steps now to better position ourselves later. Here’s what I propose: if you are an almost-MD or an aspiring-MD, whenever you hear about a medical test or procedure, look the cost up. I’ve started doing it and logging into in this fancy spreadsheet ... join me!”

Source: http://almost.thedoctorschannel.com/do-you-know-how-much-a-blood-test-costs/


From Facts to How It All Fits Together

Source: http://gapingvoid.com/49


AAMCAction @AAMCToday

@AtulGroverMD

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educating for high value care: a national perspective€¦ · atul grover, m.d., ph.d. chief public...

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