Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
May 24, 2013
John E. Wennberg, The Dartmouth Institute
Ahmedabad Call Girls Book Now 9630942363 Top Class Ahmedabad Escort Service A...
Keynote Address: Jack Wennberg
1. Ke y n o t e A d d r e s s
Aligning Incentives for Patient
Engagement
May 24, 2013
2. Unwarranted Variation in Health Care Delivery
and the Struggle for Reform
Aligning Incentives for Patient Engagement
Washington D.C.
May 24, 2013
John Wennberg
3. The Research in a nutshell
In Health Care, Geography is Destiny
Medical practice occurs within a local context: Per capita
expenditures, resource use and utilization vary extensively
among regions, communities and health care organizations.
4. The Research in a nutshell
In Health Care, Geography is Destiny
Medical practice occurs within a local context: Per capita
expenditures, resource use and utilization vary extensively
among regions, communities and health care organizations.
Much of this variation is unwarranted: It isn’t explained by
illness, evidence-based medicine or patient preferences.
The causes and remedies of unwarranted variation differ
according to the category of care.
5. Preference-Sensitive Care
• Involves tradeoffs -- more than one treatment exists and the
outcomes are different
• Decisions should be based on the patient’s own preferences – On
the ethic of informed patient choice
• But provider opinion often determines which treatment is used
8. The Dartmouth Atlas Project: 306 Hospital Referral Regions
Ongoing Study of Traditional Medicare Population USA
9. Knee replacement per 1,000 Medicare
enrollees
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
1992 2000 2007
Red dot = US average: 4.0 5.4 8.6
10. Relationship between rates of knee replacement per
1,000 Medicare enrollees in 1992 and 2007
0.0
4.0
8.0
12.0
16.0
0.0 4.0 8.0 12.0 16.0
Knee replacement (1992)
Kneereplacement(2007)
R2 = 0.62
11.
12. Determining the Need for Hip and Knee Arthroplasty:
The Role of Clinical Severity and Patients’ Preferences
• . . . Among those with severe arthritis, no more than 15%
were definitely willing to undergo (joint replacement), emphasizing
the importance of considering both patients’ preference and
surgical indications in evaluating need and appropriateness of
rates of surgery
13. Which Rate is Right?
Medical Necessity = clinically appropriate + informed patient choice
14. Which Rate is Right?
Medical Necessity = clinically appropriate + informed patient choice
Informed patient choice is an ethical imperative for uncovering “true”
demand for surgery & learning which rate is right.
15. Which Rate is Right?
Medical Necessity = clinically appropriate + informed patient choice
Informed patient choice is an ethical imperative for uncovering “true”
demand for surgery & learning which rate is right.
In the absence of informed patient choice, surgeons are at risk for
operating on the wrong patient: on patients who preferred another
treatment.
16. Which Rate is Right?
Medical Necessity = clinically appropriate + informed patient choice
Informed patient choice is an ethical imperative for uncovering “true”
demand for surgery & learning which rate is right.
In the absence of informed patient choice, surgeons are at risk for
operating on the wrong patient: on patients who preferred another
treatment.
Effective tools are available to improve decision quality and avoid
wrong patient surgery.
17.
18. Supply-Sensitive Care
Everyday services provided mainly to patients with medical
(non-surgical) conditions: physician visits, referrals to
specialists, MRIs, laboratory tests, screening exams and
hospitalizations, and stays in ICUs
19. Supply-Sensitive Care
Everyday services provided mainly to patients with medical
(non surgical) conditions: physician visits, referrals to
specialists, MRIs, laboratory tests, screening exams and
hospitalizations, and stays in ICUs
At issue is the frequency of use of such care, particularly in
managing chronic illness over time: “Which rate is Right?”
20. Supply-Sensitive Care
Everyday services provided mainly to patients with medical
(non surgical) conditions: physician visits, referrals to
specialists, MRIs, laboratory tests, screening exams and
hospitalizations, and stays in ICUs
At issue is the frequency of use of such care, particularly in
managing chronic illness over time: “Which rate is Right?”
Supply-sensitive care accounts for most of the more two-fold
variation in Medicare spending among regions.
22. Hospital resources invested in health care of Bostonians
compared to New Havenites
Resources Ratio: Boston
to New Haven
Beds per 1,000 1.55
Employees per 1,000 1.89
Per capita Spending 1.87
23. Standardized hospital discharge rates for medical
conditions: Boston and New Haven region (1994-95)
(Discharge ratio: Boston/New Haven in black)
Figure 8.2
1.64
1.14
1.66
1.58
1.72
2.17
1.52
1.89
3.06
1.50
0.0
0.5
1.0
1.5
2.0
2.5
AllMedical
Discharges
Uncomplicated
Pneumonia
Heart
Failure
Gastro-
enteritis
Cellulitis
COPD
Diabetes
Kidney&Urinary
TractInfections
Bronchitis
&Asthma
Angina
Pectoris
RatiotoU.S.average(1994-95)
Boston
New Haven
:
24. Hip Fracture
R2 = 0.06
All Medical
Conditions
R2 = 0.54
0
50
100
150
200
250
300
350
400
1.0 2.0 3.0 4.0 5.0 6.0
Acute Care Beds
DischargeRate
Association between hospital beds per 1,000 and discharges
per 1,000 among Medicare Enrollees: 306 Hospital Regions
26. A behavioral interpretation of variation in
frequency of use of supply-sensitive care
• The frequency of use is governed by the assumption that
resources should be fully utilized, i.e. that more is better.
• Specific medical theories and medical evidence play little role in
governing frequency of use.
27. Supply-Sensitive Care
Physician Visits per Decedent During Last Six Months of Life Among
Patients Assigned to Academic Medical Centers (2010 deaths)
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Cedars-Sinai Medical Center 72.6
NY-Presbyterian Hospital 39.1
Mass. General Hospital 34.7
Brigham & Women's Hospital 31.5
Beth Israel Deaconess 30.3
Boston Medical Center 29.2
UCSF Medical Center 28.3
Mayo Clinic-St. Mary's 21.3
Scott & White Memorial Hosp 19.8
NYU Langone Medical Center 58.5
Ronald Reagan UCLA Med Ctr 49.7
Mount Sinai Hospital 49.1
28. A behavioral interpretation of variation in
frequency of use of supply-sensitive care
• The frequency of use is governed by the assumption that
resources should be fully utilized, i.e. that more is better.
• Specific medical theories and medical evidence play little role in
governing frequency of use.
• In the absence of evidence and under the assumption that more is
better, available supply governs frequency of use.
29. Which Rate is “Right”?
More frequent use of supply-sensitive care isn’t resulting in better
outcomes:
30. Which Rate is “Right”?
More frequent use of supply-sensitive care isn’t resulting in better
outcomes:
• More than two-fold variation in frequency of use is uncorrelated
with prevalence of severe chronic illness and with outcome
measured by mortality.
31. Which Rate is “Right”?
More frequent use of supply-sensitive care isn’t resulting in better
outcomes:
• More than two-fold variation in frequency of use is uncorrelated
with prevalence of severe chronic illness and with outcome
measured by mortality.
• Technical quality of care tends to be better in low use regions.
32. Which Rate is “Right”?
More frequent use of supply-sensitive care isn’t resulting in better
outcomes:
• More than two-fold variation in frequency of use is uncorrelated
with prevalence of severe chronic illness and with outcome
measured by mortality.
• Technical quality of care tends to be better in low use regions.
• Patients rank their hospital experiences higher in low use regions.
33. Which Rate is “Right”?
More frequent use of supply-sensitive care isn’t resulting in better
outcomes:
• More than two-fold variation in frequency of use is uncorrelated
with prevalence of severe chronic illness and with outcome
measured by mortality.
• Technical quality of care tends to be better in low use regions.
• Patients rank their hospital experiences higher in low use regions.
• Care coordination is better in low use regions.
34. Which Rate is “Right”?
More frequent use of supply-sensitive care isn’t resulting in better
outcomes:
• More than two-fold variation in frequency of use is uncorrelated
with prevalence of severe chronic illness and with outcome
measured by mortality.
• Technical quality of care tends to be better in low use regions.
• Patients rank their hospital experiences higher in low use regions.
• Care coordination is better in low use regions.
• End of life care is less aggressive in low use regions.
35. Supply-Sensitive Care
Percent of Deaths Associated with ICU Admission Among Patients
Assigned to Academic Medical Centers (2010 deaths)
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
Boston Medical Center 27.8
NYU Langone Medical Center 23.8
UCSF Medical Center 22.7
Beth Israel Deaconess 22.2
Brigham & Women's Hospital 19.4
Mass. General Hospital 17.9
Mount Sinai Hospital 17.0
Mayo Clinic-St. Mary's 16.8
NY-Presbyterian Hospital 16.2
Scott & White Memorial Hosp 15.7
Ronald Reagan UCLA Med Ctr 40.6
Cedars-Sinai Medical Center 38.2
36.
37. Conclusion: Song et al.
The use of clinical or claims-based diagnoses in risk adjustment may
introduce important biases in comparative effectiveness studies, public
reporting and payment reforms.
Conclusion: Welch et al.
There is an inverse relationship between regional frequency of diagnosis
and the case fatality rate for chronic conditions.
Conclusion: Wennberg et al.
Adjusting for illness using HCCs, Iezzoni chronic illness and Charlson co-
morbidity index make regions with high visit rates seem to have lower
mortality and lower costs and visa versa.
In the states, despite early efforts to conduct health planning, the population served by a given health care organization is not know or ignored, despite 40 years of small area analysis. In the UK, budgets and other aspects of resource allocation have more or less been made on a geographic, per capita basis. However, under the new commissioning strategy, the UK is moving away from population-based medicine.
In the states, despite early efforts to conduct health planning, the population served by a given health care organization is not know or ignored, despite 40 years of small area analysis. In the UK, budgets and other aspects of resource allocation have more or less been made on a geographic, per capita basis. However, under the new commissioning strategy, the UK is moving away from population-based medicine.
Communities served by the nation’s leading academic medical centers show just as much variation.
Add 115% increase to match format for previous slde
In the states, despite early efforts to conduct health planning, the population served by a given health care organization is not know or ignored, despite 40 years of small area analysis. In the UK, budgets and other aspects of resource allocation have more or less been made on a geographic, per capita basis. However, under the new commissioning strategy, the UK is moving away from population-based medicine.
In the states, despite early efforts to conduct health planning, the population served by a given health care organization is not know or ignored, despite 40 years of small area analysis. In the UK, budgets and other aspects of resource allocation have more or less been made on a geographic, per capita basis. However, under the new commissioning strategy, the UK is moving away from population-based medicine.
In the states, despite early efforts to conduct health planning, the population served by a given health care organization is not know or ignored, despite 40 years of small area analysis. In the UK, budgets and other aspects of resource allocation have more or less been made on a geographic, per capita basis. However, under the new commissioning strategy, the UK is moving away from population-based medicine.
Communities served by the nation’s leading academic medical centers show just as much variation.
The effect of hospital bed capacity is to exercise a subliminal effect on the clinical threshold for admitting patients to hospital; the effect is seen across most acute and chronic medical conditions; but not for elective surgery, which generally isn’t correlated with regional variation in bed capacity.