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Looking Ahead:

The Future of American

Health Care

Ezekiel J. Emanuel, M.D., Ph.D.

US Health Care Spending (2016)

$3.4 Trillion

Rx for Cost Cutting

GDP (nominal) in 2016 Rank

USA $18.57 trillion #1

CHINA $11.22 trillion #2

JAPAN $4.94 trillion #3

GERMANY $3.47 trillion #4

UK $2.63 trillion #5

FRANCE $2.46 trillion #6

INDIA $2.26 trillion #7

Two TrendsMeasure USA FRANCE GERMANY

Health Care Cost

per person (2015, PPP)

$9,451 $4,407 $5,267

Average Life Expectancy 79.3 (31st) 82.4 (9th) 81.0 (24th)

Infant Mortality

(per 1,000 births)

5.80 3.30 3.20

Cancer 5 year survival

Breast

Colon

Childhood Leukemia

88.6%

64.7%

87.7%

86.9%

59.8%

89.2%

85.3%

64.6%

91.8%

Years of life lost (per 100,000

inhabitants aged 0-69)

4,600 3,100 3,000

WHO Health System

Ranking*

37 1 25

* Based on a composite score of health, health inequality, responsiveness-level,

responsiveness distribution, and fair financing.

Affordability Index

14.2%

15.3%

16.7%

18.9%

20.9%

22.4%

23.5% 23.8% 24.1%

25.2%

26.9%

27.9%

30.1%30.9%

31.5% 31.4% 31.0%

10%

15%

20%

25%

30%

35%

Perc

enta

ge

Family Health Insurance Premiums as Percentage of Median Income (2001-2015)

Unnecessary Services

Source: Scott Ramsey. How Should We Define Value in Cancer Care.

IOM Affordable Cancer Care Workshop. 8 Oct, 2012.

Inefficient Care

3 Weeks 7 Weeks

5-year local

recurrence-free

survival

97.2% 96.8%

Excellent/good global

cosmetic outcome at

3 years

76.8% 77.0%

Excellent/good global

cosmetic outcomes at

5 years

76.8% 77.4%

% Women receiving 34.5% 65.5%

Breast Cancer Irradiation Outcomes by Treatment Duration

*No difference in overall survival rates was detected between study arms.

Whelan T, MacKenzie R, Julian J et al. Randomized trial of

breast cancer irradiation schedules after lumpectomy for

women with lymph node-negative breast cancer. J Natl Cancer

Inst. 2002; 94(15):1143-50.

Inefficient Care

• Robotic-assisted

radical

nephrectomies had

longer operating

times, higher

hospital costs, and

no better outcomes

than laparoscopic

surgeries.

JAMA. 2017;318(16):1561-68.

doi:10:1001/jama.2017.14586

Pricing Failures

• Medicare pays

$2,062 for cardiac

imaging done in-

hospital, compared

to $626 done in-

office.

• $105 billion per

year.

Enactment of Health Care Reform

Patient Protection and Affordable Care Act

March 23, 2010

Access

Cost

Cost

Health care price growth dropped to 2-year

low of 1.2% in August 2017

Source: Altarum Institute

Quality

AHRQ : 21%

reduction HACs

from 2010 to 2015

• 125,000 fewer deaths

• 3.1 million fewer

incidents of harm

• Approximately $28

billion in savings

The Iron TriangleCost

AccessQuality

The Cost-Quality “Tradeoff”Q

ualit

y

Cost Effectiveness

Lower costHigher cost

High quality

Low quality

Job Growth

5

-816

1451

366

226 204 227

110

204

-1000

-800

-600

-400

-200

0

200

400

600

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

1-M

onth

Ne C

hange

Year

Monthly Change in Total Private Employment (in thousands), 2008-2017

Adapted from Bureau of Labor Statistics

VC Investments

2006 – 2010 $47.0 bn

2011 – 2015 $61.9 bn

32% growth

Source: Pitchbook

What will the future of

American health care look

like?

The Way Forward

“I’ve always been independent. Always

been the one helping everyone else. Now

I can’t do nothing for myself…I’m ready,

I’ve been ready ever since I had my heart

attack. Ready whenever the Good Lord is

ready to do His work.”

~ Ms. Harris

The 12 PracticesScheduling

Registration & rooming

Shared decision-making

Performance measurement

Standardi-zation

Care management

Site of service

De-institutionaliz

ation

Behavioral health

management

Hospice & Palliative Care

Community interventions

Lifestyle interventions

2 Key Practices

We will focus on:

1. Chronic care coordination

2. Behavioral health

Chronic Care Coordination

• 36% of Americans (117 million) have 1+

chronic conditions.

• 86% of all health expenditures are for

people with chronic conditions.

• High-need, chronically ill U.S. adults spend

$21,000 per year, 4x more than average

adults.

Chronic Care Coordination

Chronic Care Coordination

Identify high-risk patients

Embed care managers in primary care

teams

Empower care managers to close

care gaps

Use active outreach to

contact patients and improve

compliance/access in case of

complications

Educate patients about their illness,

adherence, and how to use the health system

Chronic Care Coordination

“Our number one

complaint is that they

[patients] hear from us too

much. We are trying to

streamline the calls and

the appointment, so that

you know that you’re

getting these [high-risk]

patients in early and

often.”

Dr. Sachin H. Jain, CareMore CEO

Behavioral Health

“This woman had post-

partum depression

and was suicidal.

She insisted she

would not see a

psychiatrist.”

Behavioral Health

$20

$840 $860

$130

$1,290

$1,420

Mental health expenditures Medical expenditures Total expenditures

Monthly Health Care Expenditures for Chronic Conditions, With and Without Comorbid Depression, 2005

Without depression With depression

Adapted from Melek S & Norris D (2008). Chronic conditions and comorbid psychological

disorders. Cited in: Druss BG & Walker ER (2011). Mental Disorders and Comorbidity.

Research Synthesis Report No. 21. Princeton, NJ: The Robert Wood Johnson Foundation.

Behavioral Health

The 3 Approaches to Behavioral Health:

1. Co-locating behavioral health specialists in PCP and

specialist offices

2. Connecting PCPs with behavioral health providers

who have unused appointments

3. Utilizing virtual medicine to do remote consults

Behavioral Health

Mike Nagoshi, MD

“This woman had post-

partum depression and was

suicidal. She insisted she

would not see a psychiatrist.

At the end of our

appointment, I asked her to

accompany me down the

hall. I then introduced her to

the health psychologist who

works in our office space.

Right then, he began seeing

her.”

Behavioral Health

David Wennberg, MD

What about Virtual Medicine?

Virtual Medicine

“Over the past decade, smartphones have radically

changed many aspects of our everyday lives, from

banking to shopping to entertainment. Medicine is

next…Just as the printing press democratized

information, the medicalized smartphone will

democratize health care. Anywhere you can get a

mobile signal, you’ll have new ways to practice

data-driven medicine. Patients won’t just be

empowered; they’ll be emancipated.”

~ Eric J. Topol, MD

Role of Virtual Medicine

• A 2016 JAMA-IM study looked at effects of

wearable tech.

1437 Patients

hospitalized with CHF

Usual care

Health coaching phone calls with wireless blood pressure, heart

rate, weight, and symptom,

monitoring. Nurse initiated protocolized

interventions.

Role of Virtual Medicine

• There were no significant differences

between the two groups in:

30-day readmission

180-day mortality

JAMA IM, 2016

Role of Virtual Medicine

• Virtual medicine cannot replace

physician-patient relationships.

• It is best designed to work in the

background.

Applications of Virtual Medicine

Rural health

Tele-ICU

Behavioral health

MD-MD consultation

Follow-up care for chronic conditions

Minor care resolution

Text message communication

Phasing in the 12 Practices

• No single practice or health system has

implemented all 12 practices.

• Instead, it is important to prioritize starting with

a few key practices.

Scheduling

Chronic care management

Performance management

Site of service

Timeline of Transformation

Timeline of Transformation –

ACOs

Source: David Muhlestein, Robert Saunders, and Mark McClellan. Medicare Accountable Care Organization

Results For 2015: The Journey To Better Quality And Lower Costs Continues. Health Affairs Blog. September 9,

2016

Timeline of Transformation

“In the beginning, a big share of the

savings was associated with changing

site of service…By year four, it was 50%

price, 50% utilization in terms of how we

were saving.”

~ Dana G. Safran,

Chief Performance Measurement &

Improvement Officer, BCBS MA

Timeline of Transformation

“We found surprisingly strong sentiment that the

industry will be transformed over the next five

to ten years by the development of new pricing

models broadly known as value-based

care…the responses indicated that value-based

care may have even more of an impact on the

industry than scientific breakthroughs.”

~ Lazard 2017 Global Healthcare Leaders

Study

www.improvinghealthcare.net