Components of a Learning Health Care System Denis

Components of a Learning Health Care System Denis A. Cortese, MD BPC Health Care Reform Event April 24, 2008 1

Value* Individ- Science ualized of Health Medicine Care Delivery Integration and coordination Pay for value *Value = Quality/Cost = Outcomes, Safety, Service/Cost Over Time 2

Pay for Value = Quality (outcomes, safety, service) Cost over a span of care • Pay for results, outcomes, value, not process compliance • Purpose for process is to achieve better value 3

Increasing Value in Health Care Translational Research Clinical Practice Innovation New (New Idea, Old Idea, Clinical New Way) Practice Value Basic Research Time, people and capital Translational Education 4

Increasing Value in Health Care Basic Research Translational Research Clinical Practice Innovation New (New Idea, Old Idea, Clinical New Way) Practice Individualized Medicine Enterprise Learning System Value Science of Health Care Delivery Integration Time, people and capital Translational Education 5

Value* Individ- Science ualized of Health Medicine Care Delivery Integration and coordination Pay for value Insurance for all *Value = Quality/Cost = Outcomes, Safety, Service/Cost Over Time 6

Mayo Clinic Health Policy Center Goal Influence stakeholders to implement substantive health care reform before 2011 that will enhance quality and availability of health care for all patients Role Convening body 7

Mayo Clinic Health Policy Center • 10 sectors • 800 people • 400 patient comments – 9 -city tour • 1000 patients surveyed 8

MCHPC Cornerstones Insurance Coordinated for all: care FEHBP model Value Payment reform 9

Health Policy Center Action Steps: Public Sector • Insurance for all • Ensure/mandate insurance coverage for all • Interoperable EMR • Require all providers to have interoperable EMRs within a certain time (5 years) with patient accessibility • Federal Health Board/Reserve • Implement an independent board to set rules/standards to promote value in health care • Care coordination • Reward care coordination • Pay for value • Direct Medicare to pay for value/outcomes/prevention using innovative payment models 10

Insurance for All • FEHBP – Model • All people own insurance; All participate • Employers can purchase all or some • Government help finance in sliding scale • All insurers take All patients • No pre-existing condition exclusions • Adjust for initial conditions • Sunset Medicare and Medicaid 11

If Medicare Continues… Mayo Clinic Calls for Major Changes: • Congress must be out as BOD • Stop price controls in exchange for provider pricing transparency on a set of common visits/procedures/tests and quality • Pay for value • Focus on results ▫ O, S, S, and Cost over span of care • UHC ▫ Dartmouth Atlas ▫ NQF ▫ Leapfrog ▫ AHRQ • Let patients pay more if they chose • Coverage with evidence development • Allow comparative effectiveness considerations in benefit design and coverage decisions 12

Pay For Value: Concepts • FFS with reward for good outcomes • FFS with shared savings • Shared decision making • Episode based payments • Chronic disease coordinator payment 13

Role for President • Learning Organization • Value: O, S, S, / Cost over Time • Insurance for all • Pay for value 14

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Medicare Spending** and Quality of Care* 70 60 Best quality – Lowest cost SD HI ME ND IA WI UT VT MN NE NH CO MA CT MD NJ 50 Quality score ID VA 40 TX FL OK MS AR 30 LA Lowest quality – Highest cost 20 5 500 6 000 6 500 7 000 7 500 8 000 8 500 9 000 Medicare personal health care spending per enrollee *Quality from “National Health Quality Report, 2006” by AHRQ **Cost from Medicare Health Expenditures by State 2004, CMS website (www. cms. hhs. gov) 16

Teaching Hospital Variability in Value 1. 8 A 1. 6 1. 4 Case mix 1. 2 adjusted mortality (>1 is better) 1. 0 0. 8 Good Reward Effectiveness Good Efficiency Good Effectiveness Poor Efficiency Poor Effectiveness Incent Effectiveness to Poor move to Efficiency upper left Poor Good Efficiency 0. 6 C 0. 4 0 B D 10 20 30 40 50 60 Cost in last 6 months of life ($000 s) 17