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By: Tom Bartol, NP

bartolnp@gmail.com

Twitter: @tombartol

Truth Or Consequences

Where is our health care system going

and how NPs can make a difference

Objectives

Following your presentation, participants will be able to:

• Identify where health care is going and some reasons why

• Describe some consequences of the attempts to improve health care in the US

• Name some creative, innovative ways that individual clinicians can make health care different

Disclosures

• The presenter has no financial affiliations with pharmaceutical companies or the health care industry

• Most of the solutions I share with you have been taught to me by my patients

• Some of the ideas shared may make you feel uncomfortable. Be open

Stay curious

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Truth or UNINTENDED Consequences

Truth or Consequences: We spend more per capita on

healthcare in the US than any other nation in the world?

Per Capita Health Care Spending

$4,445

$4,349

$4,016

$3,717

$3,422

$3,213

$3,019

$8,247U.S.

Canada

Germany

France

Sweden

U.K.

Japan

Italy

$ Per Capita (2010)

http://www.oecd-ilibrary.org/social-issues-migration-health/total-expenditure-on-health-per-capita_20758480-table2, accessed 10/28/13

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National Health Expenditures 2014

• $3 Trillion (3,000,000,000,000)

• 17.5% of GDP spent on healthcare

• $9523 per person

• 5.3% increase from 2013

• Prescription drugs increased 12.2% to $297.7 billion

https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-

and-reports/nationalhealthexpenddata/downloads/highlights.pdf, National

Health Expenditures 2014 CMS, accessed 3/21/16

Life Expectancy

US ranks 42nd for life expectancy in the World http://www.oecd-ilibrary.org/social-issues-migration-health/life-expectancy-at-birth-total-population_20758480-table8, accessed 10/28/13

https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html, The World Factbook, accessed 5/7/15

http://www.cdc.gov/nchs/fastats/life-expectancy.htm, CDC faststats, accessed 5/7/15

International Health Care Ranking

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Truth or Consequences: For most people in the United States, healthcare is paid for by insurance?

$24,671/year!

http://www.forbes.com/sites/danmunro/2015/05/19/annual-healthcare-cost-for-family-of-four-now-at-

24671/#7d340564dfb7, Forbes/Pharma & Healthcare, May 19th 2015, Accessed 3/21/16

Millman Medical Index Average Cost for Family of 4 with PPO Coverage

Health Care Costs: 23 y/o female $35,000 annual salary

• $2,100 Annual employee premium

• $500.00 Annual deductible

• $6,190 Employer premium contribution

• $1,500 Payment to Federal and State for Medicare/Medicaid

Total: $10,290 Per Year! Estimated $1.8 Million over Lifetime

David Goldhill,Catasrtophic Care: How American Healthcare

Killed My Father—and How We Can Fix It, 2013

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Consequences of Health Insurance: Many can afford health care, but it is not

sustainable

Would you service your car this way?

• Mechanic tells you what repairs are going to be done to your car having no idea what they will cost nor do you

• Mechanic is paid for whatever they do, after it is done the “usual and customary” fees.

• You don’t shop around for parts, the mechanic just gets them and installs them

• The service done may not even make a difference in how the car runs.

If Auto Insurance were like Health Care Insurance

• Preventive maintenance with no co-pay, no deductible (oil changes, tires, routine maintenance)

• Service and repairs, in network covered with minimal co-pay

• Oil, additives, fluids, etc. covered with co-pay

• Catastrophic care (accidents, injuries) covered with deductible and co-pay

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If Auto Insurance were like Health Care Insurance…what would happen?

• We’d do more routine maintenance on our cars

• Mechanics would do more service

• New businesses would emerge to service cars in various different ways

• Would we take care of our cars as well if all service/repairs were covered by insurance?

• Premiums would go up!

Consequence: The “Health Profit” System

Reimbursement System

• Pays for doing more

• Pays for being quick

• Pays for “doing” prevention not preventing

• Looks at low hanging fruit

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Incentives for Providers

• Currently based on procedures and numbers of patients seen

• Transitioning to number of boxes checked

– PCMH and ACO’s are becoming a game to get the money

– Check the boxes, you get paid

– We are given lists of things we must check at each visit

– Patients’ Agenda is often neglected

Per Capita National Health Spending

Reached $4,637 in 2000

$82 $105 $141 $202$341

$582

$1052

$1733

$2690

$3637

$4637

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

SOURCE: Centers for Medicare and Medicaid Services

•Up to $9523 in 2014

The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults;

2009 International Health Policy Survey of Primary Care Physicians; OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

http://stats.oecd.org/Index.aspx?DataSetCode=SHA, accessed 9/25/12

https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-

reports/nationalhealthexpenddata/downloads/highlights.pdf, National Health Expenditures 2014 CMS, accessed 3/21/16

•In 1950 the US health status

rank was 7th, Now it’s 37th!

American Health Insurance Plans: Solutions to Cost

https://www.jasondavies.com/wordcloud/, accessed 3/23/16

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Truth or Consequence: Providing high quality care will improve

health?

A Tale of Two Patients: Who is Heathier?

55 y/o Patient A with diabetes

• A1c 6.8% on 3 oral agents and basal insulin, up from 6.4%

• B/P 118/80 on 3 B/P medications

• LDL-C 98 on simvastatin 40mg

• Asked about smoking and gave Rx for Chantix

• Weight measured: BMI 43, up from 39 six months ago

55 y/o Patient B with diabetes

• A1c 7.4, no meds, down from 8.1%

• B/P 142/88, no meds, down from 160/100

• LDL 108 on no meds, down from 157

• Quit smoking 2 weeks ago cold turkey

• Weight measured BMI 33, down from 40 a year ago

It’s not just getting to the goals but HOW they get there

that makes a difference!

“Quality” Reports

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Consequences

• Treating numbers

• More treatments/testing

• Incentives for doing things that may distract from what matters

• Quality measures that do not have improved outcomes

Clinical Guidelines • Quick , easy, costly and maybe ineffective

• Process, not outcome oriented (short term, not long term)

• “Cookbook” care treats everyone the same based on numbers or age but not necessarily on individual risk.

• “One size fits all” Not stratified by risk or patient desires

• Many guidelines don’t demonstrate significantly improved outcomes

• PCMH, Meaningful Use of EHR, ACO’s are using many guidelines to evaluate care leading to payment for box checking not necessarily good care.

• Businesses are springing up to take advantage of ACO, PCMH money

Problem: Clinical “guidelines” become “mandates”

Without clear outcomes or risks shared.

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“We need to measure true health outcomes rather than relying solely on process measures, such as compliance with practice guidelines, which are incomplete and slow to change.”

Porter, ME. N Engl J Med. 2009. 361:109-112

The Essential Guide to Quality Care NCQA’s 53 page guide to Quality Care

https://www.ncqa.org/Portals/0/Publications/Resource%20Library/NCQA_Primer_web.pdf,

accessed 3/24/16

Truth or Consequence: Health care is always helpful?

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All diagnostic tests are helpful

• Harms of the study such as radiation exposure from a CT scan

• Pre-test probability – Low leads to false positive tests

– High leads to false negative tests

• Overdiagnosis: discovering a disease that will never bother you in your lifetime

• Unnecessary care and testing may crowd out necessary care

The medical system had done what it so often does:

performed tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk.

Atul Gawande, “Overkill”

Causes of Death in the United States

http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm,accessed 3/22/16

http://www.hospitalsafetyscore.org/newsroom/display/hospitalerrors-thirdleading-

causeofdeathinus-improvementstooslow, accessed 3/22/16

Medical Errors Estimated to cause

440,000 Deaths per year in the US!

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Truth or Consequences: Evidence-based care will improve health

care?

Risk Reduction

• Reduction from Baseline Risk

• 50% off coupon

– Save $0.50 on a $1.00 item

– Saves $500.00 on a $1000.00 item

• Relative Risk Reduction is 50%

• Absolute Risk Reduction depends on the cost

• Higher baseline risk, higher the absolute reduction

• Baseline risk is important in using Relative Risk Reduction

AFCAPS/TexCAPS: Results

3304 Lovastatin 3301 Placebo

Number with

Primary Endpoint 116/3304 (3.5%) 183/3301 (5.5%)

Relative Risk Ratio 3.5÷5.5= 0.63

Relative Risk

Reduction 5.5-3.5/5.5 = .37 or 37%

Absolute Risk

Reduction (ARR) 5.5-3.5= 2%

JAMA 1998;279:1615-1622

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Early Detection Saves Lives

http://www.mammographysaveslives.org/facts, accessed 3/24/16

Breast Cancer Deaths

http://seer.cancer.gov/statfacts/html/breast.html, breast cancer statfacts, accessed 5/7/15

31 deaths/100,000 in 1975 to

21/100,00 in 2012

(from 0.03% to 0.02%)

Consequences of Evidence Based Medicine:

• More Studies

• More Treatment

• More Guidelines

• Changing Evidence

• More Cost

• Better Care…?

Is there good evidence for all we do?

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Daylight Saving Time Switch May Boost

Stroke Risk – 10 year study

– compared the incidence of ischemic stroke (IS) among 3033 patients hospitalized during the week after the daylight saving transition

– with the stroke rate among a control group of 11,801 patients hospitalized 2 weeks before and 2 weeks after transition

– 8% increased risk of ischemic stroke during 1st 2 days of transition (p=0.02)

American Academy of Neurology (AAN) 2016 Annual Meeting. Abstract 2952

http://www.medscape.com/viewarticle/860109, accessed 3/13/16

Evidenced Based Medicine or

Reimbursement Based Medicine?

Truth or Consequences: Patient experience makes a difference?

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VALUE =

Outcomes that Matter to the Patient

Cost Per Patient

“Compression of Morbidity”

• Extending healthy life expectancy more than life expectancy

• Chronic disease and disability are compressed into a smaller portion of a person’s life

• Lifelong health care costs are lower and quality of life is improved

• The goal is not the longest number of years but the best number of years alive.

Fries, JF. http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2005.00401.x/pdf, accessed 10/28/12

Solutions! Most can’t be legislated

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Threat or Opportunity

Threat

• Rigid Response

• Response with established patterns

• Convergent thinking

Opportunity

• Flexible

• Creative response

• New ideas

• Divergent thinking

Creative Thinking

• Be innovative

• Try new things

• Think outside of the box

• Erase past ways of thinking

• Be open to new perspectives and ideas

• Ask more questions to try to understand

• Remember even expert opinions and “evidence” change

Think Outside the Box

Think beyond

– the way everybody is doing things

– the way we have been paid to do things

A culture (way of thinking, behaving, or working) change

– not on minimizing cost of each intervention

– maximizing the value over the entire care cycle

Rather than treat the symptoms (rash, blood pressure, blood sugar, anxiety) engage patients to treat the cause (stress, low self-esteem, fear)

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Keys to Transforming Health Care

1. Building Relationships

2. Sharing Information

Building RELATIONSHIPS

• Build a relationship of HOPE

• Believe in the patient and help them to believe in themselves

• Affirmations for what they are doing positive

• What does the patient need, what is going on in their lives?

Engaging Patients

• Ask, “What matters to you?” as well as “What is the matter?”

• Ascertaining the patients needs, values and goals at that point in time.

• From telling the patient what is wrong and telling what to do, to listening for the patient to tell us what is wrong and exploring with the patient what to do

• Helping people find connection, purpose and hope in life.

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Creating “Magical Moments”

• Make each visit unique and special for the patient

• Really listen…to the why beyond the what

• Treat the person, not the numbers

• Use the patient’s name

• Smile

• Believe in the patients and help them to believe in themselves

• Make a follow-up call back

Networking the Healthcare System

• Build relationships in the healthcare system

• Talk to consultants don’t just send patients

• Create a 2-way dialogue with consultants

• Talk to radiologists and pathologists more about what tests to order and what results mean

• Track imaging done on your patients to manage radiation exposure

Shared Decision Making

• Stratify Risk

• Share information – Risks of problem/condition being checked or treated

– Risks of intervention

– Benefits of intervention

– Costs

• Let patients make choices

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How do we do Shared Decision Making outside of Health Care?

• Buying a car

• Auto repairs

• Choosing a college

• Financial investments

These are based on relationships, information, making rational decisions

…Are health care choices made like any of these?

https://www.harding-center.mpg.de/en/health-information/facts-boxes/mammography, accessed 12/5/14

http://www.cancer.gov/cancertopics/factsheet/prevention/physicalactivity

Additional ways to reduce risk:

“Physically active women have a lower

risk of developing breast cancer than

inactive women…risk reduction varies

(between 20-80%).

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http://www.thennt.com/nnt/strength-and-balance-programs-for-elderly-falls/, accessed 2/22/15

Strength and Balance Training Programs for Preventing Falls in the Elderly

Thennt.com

My Practice All Providers (n=44) % Change

Rx per User 3.47 5.57 -48%

Diagnostic Tests

User 0.13 0.50 -74%

Consult Referrals

per User 0.26 0.62 -58%

Rx per Encounter 1.15 1.60 -28%

Diagnostic Tests per

Encounter 0.04 0.14 -61%

Referrals per

Encounter 0.08 0.18 -66%

Results of Shared Decision Making

Data on file with speaker

Framing: The Way the Data is Presented

37% reduction in 1st major coronary events

3304 patients treated with lovastatin for 5 years:

– prevent 67 1st major coronary events

– Has no preventive effect on 3118 patients

Taking lovastatin for ~5 years can reduce risk of 1st major coronary event from 5.5 in 100 to 3.5 in 100

Risk of NOT having 1st major coronary event

– 94.5 out of 100 without taking simvastatin

– 96.5 out of 100 with taking simvastatin

JAMA 1998;279:1615-1622

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Focus on the 95%!

$97,956

$28,468

$43,058

Think Healthy!

• Think Positive

• Delete the negative thoughts

• Help patients focus thoughts on health, not illness or disease

• We become what we think

• “I want to run again.”

• “I decided to be happy.”

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Keep your eyes first on the goal

• Good patient care with improved outcomes

– Then, in light of this work on PCMH, ACO,NCQA, etc

• The goal should not be to meet the criteria for meaningful use, PCMH, and ACO…these should be pathways to better patient care, better outcomes.

Building a Relationship of Hope

Institute for Healthcare Improvement Vision and Mission

http://www.ihi.org/about/pages/ihivisionandvalues.aspx

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Changing Health Care Requires: Vision: – Seeing the need, keeping focused on the goal

– See something better…not just doing things the same

– Creating solutions

Creativity: – Thinking outside of the box/curiosity

– Things people never thought of may work

Risk – Listen to your gut.

– What we do is an art, not a science

Passion: Passion is the energy that comes from bringing more of YOU into what you do

Teamwork: We need to collaborate not dominate