in Clinical Care: Too Much of a Good Thing? Wendy Everett, ScD President, NEHI National Quality Forum March 26, 2009
Fostering Innovation Through Collaboration
Strong Reputation as a Trusted Source HIT Innovation Cross Cutting Issues Medical Innovation Waste & Inefficiency Disease Prevention & Wellness Indicators Report II
Fostering Innovation Through Policy Action
Waste: Where & How Much? 50%? 30%?
Demand for Data Is Everywhere
The Call to Action 1. We must find the evidence and understand root causes to solve the problem. 2. We must create a roadmap for progress. 3. We must pull the right policy levers to enable the health care system to reduce waste.
Major Phases of the Policy Process What/Where? Why? How? Definition, Identification, and Quantification Identification of Policy Issues Policy Action Plan What is Waste? Where is it? How much is there? Why does it exist? Who wins and loses? How can we reduce it? How do we reallocate the savings? Phase I Phase II Phase III
Waste Across the System Focus on Clinical Care Development Basic Research Prototype Design/ Discovery Preclinical Development Clinical Development Approval, Scale-up, and Manufacturing Marketing and Evaluation Clinical Care Prevention Screening Diagnosis Acute Care Treatment Chronic Care Treatment End of Life Care Payment & Finance Enrollment Price / Fee Setting Claims Processing Utilization / Disease Management
Piecing Together the Puzzle of Waste 3,000 Studies 1,500 Studies 460 Studies NEHI Goal: Select 3 5 areas for policy action
NEHI s Evidence: Quantifying the Problem Compendium of Evidence Overview of Findings 2008 2008
Waste Evidence in a Few Clicks Searchable by: 1. Type of Waste (overuse, underuse, misuse) 2. Service type 3. Diagnostic category 4. Condition www.nehi.net 5. Region
The $700 Billion Health Care Wasteland = Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving $600 b Potential Opportunities Unexplained Variation Cost Saving $100 b Adverse Events $10 b $1 b $100 m 0 Low Antihypertensive Misuse Back Imaging DM Underuse CABG/PTCA Back Surgery Antidepressant Underuse Non Urgent ED Use Asthma Medication Underuse Antibiotic Beta Blocker Underuse High Strength of Evidence Cost Effective (But Not Cost Saving) Statin Underuse Antihypertensive Underuse Colon & Breast Cancer Screening Underuse Cervical Cancer Screening Underuse
$682 Billion Opportunity Unexplained variation: $500 Billion Adverse events: $ 52 Billion Non-urgent ED use: $ 32 Billion
Top Three Contenders Unexplained variation Adverse events Non-urgent ED use
NEHI and NQF: NPP Intersections NEHI Opportunities NQF Opportunities Adverse Events Asthma Medication Underuse Antihypertensive Misuse Back Imaging Antibiotic Non Urgent ED Use Practice Variation: CABG/PTCA Back Surgery Harmful preventive services with no benefit Maternity care interventions Diagnostic Procedures Inappropriate non-palliative services at end of life Lab tests
The $700 Billion Health Care Wasteland = Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving $600 b Potential Opportunities Unexplained Variation Cost Saving $100 b Adverse Events $10 b $1 b $100 m 0 Low Antihypertensive Misuse Back Imaging DM Underuse CABG/PTCA Back Surgery Antidepressant Underuse Non Urgent ED Use Asthma Medication Underuse Antibiotic Beta Blocker Underuse High Strength of Evidence Cost Effective (But Not Cost Saving) Statin Underuse Antihypertensive Underuse Colon & Breast Cancer Screening Underuse Cervical Cancer Screening Underuse
Practice Variation: Key Driver of Waste The largest source of wasteful spending is unexplained practice variation in patterns of care that are not associated with differences in clinical outcomes. This variation represents a potential cost savings of up to $500 billion annually. of three procedures contribute significantly to overall practice variation: Back surgery Coronary artery bypass grafts (CABG) Percutaneous coronary interventions (PCI)
Root Causes and Strategies for Change
Reducing /Practice Variation What can we do? Reform guideline development process and use Encourage IT innovations to advance clinical decision support Train physicians on guideline use and IT Pay for performance and adherence
Money Matters Likelihood of Compliance with Guidelines by Bonus Level 19% 32% 51% 81% Somewhat or much more likely to comply 49% 36% 13% 15% 4% 2% 9% 20% Bonus Bonus Bonus
The $700 Billion Health Care Wasteland = Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving $600 b Potential Opportunities Unexplained Variation Cost Saving $100 b Adverse Events $10 b $1 b $100 m 0 Low Antihypertensive Misuse Back Imaging DM Underuse CABG/PTCA Back Surgery Antidepressant Underuse Non Urgent ED Use Asthma Medication Underuse Antibiotic Beta Blocker Underuse High Strength of Evidence Cost Effective (But Not Cost Saving) Statin Underuse Antihypertensive Underuse Colon & Breast Cancer Screening Underuse Cervical Cancer Screening Underuse
Combined Preventable Adverse Drug Events: 10.4% of All Admissions Preventable Adverse Drug Events 8.8% of total adult admissions Preventable Renal Dosing Errors 1.6% of all admissions with renal ADE
Adverse Events: Medication Errors With CPOE: 55,000 medication errors eliminated annually $170 million in annual savings to hospitals and payers
Adverse Events: Policy Change SECTION 36 Health Reform Bill, August 2008: February 2008: Massachusetts payers to require hospitals to adopt CPOE by 2012 for participation in quality incentive programs the department of public health shall adopt regulations requiring hospitals and community health centers, as a standard of eligibility for original licensure and renewal of licensure, to implement computerized physician order entry systems.
The $700 Billion Health Care Wasteland = Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving $600 b Potential Opportunities Unexplained Variation Cost Saving $100 b Adverse Events $10 b $1 b $100 m 0 Low Antihypertensive Misuse Back Imaging DM Underuse CABG/PTCA Back Surgery Antidepressant Underuse Non Urgent ED Use Asthma Medication Underuse Antibiotic Beta Blocker Underuse High Strength of Evidence Cost Effective (But Not Cost Saving) Statin Underuse Antihypertensive Underuse Colon & Breast Cancer Screening Underuse Cervical Cancer Screening Underuse
ED : a $32 Billion Problem 16% 14% 13% 13.9% 12% Non-urgent 10% ED Visits as Percent of 8% Overall Visits 6% 9.7% 9% 9% 10.7% 9.1% 10% 12.5% 4% 2% 0% 1997 1998 1999 2000 2001 2002 2003 2004 2005 Source: CDC Year 40% of all ED visits could be treated or avoided with timely primary care.
Who s EDs? A new mother cannot get her baby to stop crying - her doctor s office is closed and the ED is the best place to get immediate reassurance. A college student thinks she has strep throat and decides that a few hours at the ED on a Sunday is better than waiting until the student health clinic re-opens on Monday. An elderly nursing home patient is taken to the ED with dehydration as his facility did not have a physician on site at the time.
It s s Not Just the Uninsured 25,000,000 Estimated Non-urgent and Preventable/Avoidable ED Visits in 2006 Total Number of ED Visits 20,000,000 15,000,000 10,000,000 5,000,000 Preventable/Avoidable Non-urgent 0 Private Medicaid Uninsured Medicare Source: CDC and MADHCFP
Reducing Emergency Department Root Causes Limited Access to Primary Care Solutions Telemedicine Improved Chronic Disease Management Convenience of the ED Worksite Wellness Programs Co-location of Urgent Care at the ED Perceived True Emergency Online Access to Healthwise After hours Telephone Triage
Innovations to Reduce
Reducing Emergency Department Root Causes Limited Access to Primary Care Solutions Telemedicine Improved Chronic Disease Management Convenience of the ED Worksite Wellness Programs Co-location of Urgent Care at the ED Perceived True Emergency Online Access to Healthwise After hours Telephone Triage
A unique partnership and opportunity Evidence-based research Convene multiple stakeholders Policy action and change C H A N G E Canvass network for new solutions Rapid assessment Health care improvement
We re Beating the Drum and People are Listening