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The Future of Academic Medicine

Peter L. Slavin, MDPresident, Massachusetts General Hospital

Professor, Health Care Policy, Harvard Medical School

August 6, 2015

Agenda

Health Care in the United States

Benefits of Academic Medical Centers

MGH at a Glance

How We are Bending the Cost Curve

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THE US HEALTH CARE ENVIRONMENT

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Health Care Costs are High – and Rising

1960 – $30 billion

1980 – $200 billion

2000 – $1.3 trillion – or 15% of GDP

2013 - $2.9 trillion – or 17.4% of GDP

2020 – estimated $4.6 trillion – 19.8% of GDP

Source: Centers for Medicare and Medicaid Services, 2013

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U.S. Health Care Costs In 2013, the United States spent $2.9 trillion, or 17.4

percent of gross domestic product (GDP), on health care – translates to $8,915 per person annually

Projections for health care costs in 2020 are $4.64 trillion, or 19.8 percent of GDP, which would be $13,708 per person

U.S. spends more on health care than any other developed country, but unlike countries that provide universal coverage, 13.4 percent of Americans are uninsured

Vital for hospitals to do what they can to take costs out of the system

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Rising Health Care Costs have Squeezed Employers and Employees for Years

Cumulative Increases in National Health Care Premiums, Workers’ Contributions to Premiums, Inflation, and Workers’ Earnings, 1999-2014

SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2014.

High Costs – Difficult Choices

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Politicians must address tough questions about limited resources. How many teachers are you willing to fire in order to have 78-year olds have a procedure which will be invented five years from now that adds four months to their life? That sounds terrible, but infinitely choosing those things will shift you away from education for the young, and towards infinite invention of such [medical] procedures.

Bill GatesFinancial TimesFebruary 22, 2011

ACADEMIC MEDICAL CENTERS

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AMCs have Higher Average Costs

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3,974 3,984 3,993

2,214 1,389 985

2,360

674 260

8,548

6,047

5,238

0

2,000

4,000

6,000

8,000

10,000

AHC Other Teaching Hospital Type Other Urban Community

Cost Per Case, 1998

Multiple Mission

Wages & Case Mix

Base

Source: Analysis of American Hospital Association data by the Lewin Group, 1998.

What Makes Up Those Higher Costs?

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Standby capacity refers to capacity to provide high-technology or intensive services when needed.Source: Analysis of American Hospital Association data by Lewin Group, 1998.

Standby Capac-ity*45%

Research13%

Indirect Medical Education Costs

42%

Distribution of Mission-Related Costs for AHCs, 1998

Teaching Hospitals, an Economic Engine

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Source: Conference of Boston Teaching Hospitals

Academic Medical Centers…

Have higher mission and personnel-related costs

Are research powerhouses

Garner support from a multitude of benefactors

Train future health care leaders

Provide thousands of jobs and drive the economy

Have the potential to transform the health care environment

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MASSACHUSETTS GENERAL HOSPITAL

Our Mission

Guided by the needs of our patients and their families, we aim to deliver the very best health care in a safe, compassionate environment; to advance that care through innovative research and education; and to improve the health and well-being of the diverse communities we serve.

Two Key Affiliations

1811 –

1994 –

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Clinical Services

MGH offers care in primary care and virtually every medical and surgical specialty and subspecialty

Multiple specialized intensive care units to care for sickest patients

1 in 6 patients transferred from other hospitals Level-1 trauma center and advanced emergency

preparedness system

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Facts and Figures (2014)999 available beds49,334 inpatient admissionsMore than 41,000 surgical cases3,950 births a yearMore than 1.6 million outpatient and emergency

visits At least 300,000 of these visits take place at a

community health center

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MGH Research Revenue by Sponsor MGH conducts the largest hospital-based

research program in the United States

Note: Research Activity, excluding Other Science and P&L deductions for capital and reserves. Net P&L revenue is $750M.

Sundry19%

DHHS46%

ARRA0%

Other Federal4%

Foundations7%

Non-Profit16%

Industry8%

State/Local0%

FY2014 Direct + Indirect Research Revenue by Sponsor =$739M

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Education at MGH More than 2,200 MGH doctors teach the next generation

of physicians as residents and fellows

The MGH provides Harvard Medical School students with approximately 500 “core clerkship” experiences

The MGH sponsors GME in 17 core specialties and offers 90 subspecialty GME training programs

MGH Institute of Health Professions offers graduate training to more than 900 students in nursing, communication science, physical therapy and imaging

Knight Nursing Center offers wide range of continuing education programs for staff in Patient Care Services

BENDING THE COST CURVE

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Preparing for the Future: MGH/MGPO Strategic Framework

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MGH/Partners HealthCare Aggressively Pursuing Ways to Reduce Costs

Leadership opportunity to bend cost curve Efforts to reduce health care spending not going

away – government and private sector being proactive

Our readiness to care for populations of patients

Our Approach: Varied technological interventions Population Health Initiatives

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Managing Health Care Costs by Managing Populations

Inpatient and Outpatient Encounters

Episodes of Illness

Population Management

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New models to manage patients and deliver care

Targeted interventions address known issues

Success evaluated over years of work—we strategize and experiment to address issues that face our population and our communities

CMS Demonstration Project Starting in 2006, targeted sickest 10% of Medicare

beneficiaries, responsible for 70% of Medicare spending Patients had multiple chronic conditions, benefit from ongoing

management Improved care coordination and communication between

patients and care team through care managers Effective deployment of advanced practitioners Outcomes:

Higher satisfaction for patients and providers Lower hospitalization rates Lower ED visit rates Lower mortality rates Lower cost of care

Expanded across Partners and to all Medicare patients covered by Pioneer ACO, and to some commercial patients

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Population Health Management

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Care of High-Risk Medicare Patients – iCMP

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Navigating the Patient Journey

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*Patient reported outcome measures

Demonstrating Value for Patient, Caregiver

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Navigating the Patient Journey: Progress

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eConsults Example: Cardiac CurbsideOnline Consult from PCP to Specialist

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Technology can Help Reduce Costs

Implementation of Epic for health records and revenue cycle—evolving beyond Meaningful Use.

Decision support tools to drive appropriate use of diagnostic tools and procedures.

Initiatives to reduce administrative burden to keep practitioners working at the top of their licenses.

Patients involved in their care through online portal—develops active, engaged consumers of health care.

Increasing use of Telehealth (virtual visits)—began in Psychiatry and extending into other areas.

Exploring opportunities to leverage big data with EDWs and data visualization tools.

Community Health Initiative: Substance Use Disorders

Prevalent issue in Massachusetts Complex, downstream effects Typically treated as episodes present in our ED More than 2,000 SUD patients admitted to MGH annually Longer length of stay, higher readmission rate

MGH has developed a multipronged, continuous care solution to address these issues: Multidisciplinary inpatient addiction consult team Community health center support, recovery coaches Connection to other community resources Tailored wellness plans

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Addiction

“The question is frequently asked: Why does a man become a drug addict? The answer is that he usually does not intend to. [The drug] wins by default. I tried it as a matter of curiosity… I ended up hooked. You don’t decide to be an addict. One morning you wake up sick and you’re an addict. ”

William S. Burroughs, Junky (1953)

Natural History of Opioid Use DisorderW

ithdr

awal

Nor

mal

Eup

horia

Chronic useAcute use

Tolerance & Physical Dependence

Slide courtesy of Dan Alford, 2012

Substance Use Disorder: A national and a local problem

Illicit drug use: 24.6 million users 681,000 heroin users OD quadrupled since 1999

SUD: 21.6 million with SUD 2.5 mil (11%) treated

Boston Metro area: Highest ED visits for drugs Heroin 4 times higher

SAMHSA (2013) NSDUH Series H-48, HHS publication No. (SMA) 14-4863.SAMHSA (2011) NSDUH Series H-41, HHS publications No. (SMA) 11-4658.

What is Addiction?Primary, chronic brain disease characterized by

compulsive drug use despite harmful consequences

American Society of Addiction Medicine. April 12, 2011. www.asam.orgNIDA. August, 2010. http://www.drugabuse.gov/publications/science-addiction

Diseased Heart

Decreased Heart Metabolism in Coronary Artery Disease

High

Low

Decreased Brain Metabolism in Addiction

Visualizing Recovery

Volkow et al. J. Neurosci., December 1, 2001, 21(23):9414–9418

Normal

Reduced function

Return to normal

A Chronic & Treatable Disease

NIDA. Principles of Drug Addiction Treatment. 2012. McLellan et al., JAMA, 284:1689-1695, 2000 .

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Comprehensive Approach: From Prevention to Chronic Disease Management

Inpatient(ACT)

OutpatientCommunit

y

Recovery Coaches

Bridge Clinic

Prevention, Education & Evaluation

Maintaining and Building Referrals Network

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Expanding Regional and Global Outreach

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MGH Cancer Center: Toward Integrated Cancer Research and Clinical Care

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Targeted Therapies: Changing Standard of Care for Common Malignancies

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Selecting Targeted Therapies Based on Genetic Abnormalities Within Each Tumor

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Termeer Center at MGH

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Termeer Center Efforts

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The Future of Academic Medicine

Pursue four pronged mission: Care, Research, Education, Community Health

Deliver clinical excellence Advance our knowledge of human biology to improve

prevention, diagnosis, and treatment of human disease Innovate in care delivery to improve care and make it

more affordable

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