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

• 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%)

Rewarding Efficiency, Reducing Waste: The Physician's Role

Went to ER for Condition That Could Have Been Treated by Regular Doctor (2005)

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

6

9

12

15

21

26

0

10

20

30

GER NZ UK AUS CAN US

Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available

Physicians’ Use of Electronic Medical Records, U.S. Compared to Other Countries, 2000/2001

90 88

6258 56 55 52

4842

3730 29 28

25

17 1714

9 6 5

0

50

100

Sweden

Netherl

ands

Denmark

United K

ingdom

Finland

Austria

New Zealand*

Germany

Belgium

Italy

Luxembourg

EU Average

Ireland

Australia

*

Greec

e

United States*

Canada*

Spain

France

Portugal

Percent of physicians

*2000SOURCE: 2001 European Union EuroBarometer and 2000 Commonwealth Fund International Health Policy Survey of Physicians (Harris Interactive 2002)

Percent reporting test results/records not available at time of appointment in past 2 years

11 12

16 1619

23

0

10

20

30

40

50

GER AUS NZ UK CAN US

Test Results or Medical Record Not Available at Time of Appointment, Sicker Adults in Six Countries, 2005

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

Ways to Improve Care AND Reduce Costs

• Primary Care/Prevention

• Patient Engagement

• Redesign of Practice with Emphasis on Care Coordination

COMPARECOMPARE

• 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)

Primary Care - A Vanishing Species?GENERALIST SHORTAGEGENERALIST SHORTAGE

• Physicians pursue specialties more than primary care

• Clinical demands

• Inadequate reimbursement

• No support for teams and systems

How can the best medical care in the world cost twice as much as the best medical care in the world?

Uwe Reinhardt

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

• 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

Medicare Medical Home Demonstration Project

H.R. 611Tax Relief and Health Care Act of 2006 (Sec. 204)

H.R. 611Tax Relief and Health Care Act of 2006 (Sec. 204)

1. Accountability─ Standards for professionals and how they

organize care─ Reform financing to reduce perverse

incentives

2. Rewards for reducing costs can be reinvested ─ More time with patients─ Information systems─ Interdisciplinary team

Innovation, Reward and Reinvestment