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Lee Nash 072309

VIEWS: 4 PAGES: 26

									The Nash Equilibrium Breaks
Down

Thomas H. Lee, MD, MSc.
Network President, Partners HealthCare System
Professor of Medicine, Harvard Medical School
Professor of Health Policy and Management, Harvard School of Public
Health
Associate Editor, The New England Journal of Medicine
July 23, 2009


                                                                      1
The Good News in Massachusetts …
                   Enrollment Since April 2006
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   50,000

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             MassHealth   CommCare, No Premiums   CommCare, Premium-paying   CommChoice*




MA now has lowest uninsured rate in U.S. (2.6%) … But
MA didn’t make healthcare a right; we made it a
responsibility. And that has unmasked a major problem…

                                                                                           2
Health Care Affordability
Is Now a Middle Class Problem
                                                                                                                       98%
       Cumulative increase 2000-2007
                                                                                                 87%
                    Premiums
                                                                               73%
                    Workers'
                    Earnings                                     59%
                    Inflation

                                                   43%


                                 25%
                                                                                                                      24%
                                                                                                 20%
                11%                                                              15%
                                                10%                12%                                                21%
                                   7%                                                                 18%
                       4%                                                          14%
                                        5%            7%             10%
                        3%

 2000            2001            2002           2003            2004            2005            2006           2007
“Employer Health Benefits 2007 Annual Survey” (#7672), The Henry J. Kaiser Family Foundation & HRET, September 2007
This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation, base d in Menlo Park,
                                                                                                                                                       3
California, is a nonprofit, private operating foundation focusing on the major health care issues facing the nation and is no t associated with Kaiser
Permanente or Kaiser Industries.
Why We May Be Hitting Generosity‟s Brick Wall




                                                4
 Willingness of Healthier and Wealthier to Subsidize
 Care for Sicker and Poorer is Weakening

Harris Survey question: Do you agree or disagree?
The higher someone’s income is, the more he or she should expect to pay in taxes to
cover the cost of people who are less well off and are heavy users of medical services.
     100%
       80%              66%
       60%                                          51%
                                                                                39%
       40%
       20%
        0%
                        1991                        2003                        2006
             Implication: We shouldn’t expect help from taxpayers.
          http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=1076             5
The Bad News: Progress Raises Costs – and
Generates Chaos

  Flood of progress and knowledge imposed on
   fragmented delivery system leads to:
     Individual clinicians feel less knowledgeable
     Super-specialization, which means:
       — More MDs involved in care
        — Physicians knowing “more and more about less and
          less until they know everything about nothing” or
        — “less and less about more and more until they know
          nothing about everything”
        — Physicians approaching patient with question of “Is
          this what I do?”
  Too many people, too much to do, no one with all
   the responsibility or all the information
                                                                6
No Bad Guys to Blame for Our Issues
  Why are healthcare costs rising?
     Surprisingly small contributions from:
       — Profits of drug/device companies
       — Administrative costs
       — Malpractice
       — Aging of the population
       — Life-style choices
       — Personnel

  The dominant factor – progress (60-70%) is main
   driver of rising costs
  Safety and reliability issues are attributable to
   turbulence in the wake of progress as well.
                                                       7
Reason for Optimism…




                       8
John
Nash
       9
John Nash‟s Nobel Prize Work
  Nobel Prize for Economics in 1994 for
   describing an equilibrium concept for “non-
   cooperative games” in which binding
   agreements cannot be written.
  Nash Equilibrium -- Multiple parties frozen
   in current relationships because no party
   can change its strategies while the other
   parties keep their strategies unchanged.
  Nash Equilibriums break down when pain
   of status quo for multiple parties exceeds
   fear of unknown.
                                                 10
An Optimistic Long-term Perspective
                                                                                         Finale
                                                                                      Breakthrough
     High                                                        Act III
                                                                 Clinical              Large annual
                                                              Reengineering           gains in quality
                                                                                      and affordability
Efficiency of Health




                                            Act II
Benefits Spending
 (Health Gain / $)




                                         Performance             Faster uptake &
                                                              discovery of “better,
                                          Sensitivity          faster, leaner” care
                                                              delivery innovations
                            Act I           Performance-
                                          sensitive health
                        Transparency     plan design and/or
                                              provider
                                             payments
                           Universal
                         hospital & MD
                         performance
                         transparency

      Low
                       2005                       Evolutionary Path                             2015
                                                                                                     11
  Slide used with permission of Arnold Milstein, MD, of Mercer
Working to Achieve the Vision: EMR Adoption


  Percent of PCPs Using EMR
100%


 80%


 60%
                                                                             Success in adoption
 40%                                                                         has allowed focus to
                                                                             shift to effective use:
 20%
                                                                               • Rate of Computer
  0%                                                                             Generated
         2003      2004       2005        2006   2007   2008      2009
                                                                Projected
                                                                                 Prescriptions
       Percent of Specialists Using EMR                                          among PCPs is
100%                                                                             85%-88%.
80%                                                                            • Rate among
                                                                                 community
60%                                                                              specialists has
                                                                                 exceeded 70%.
40%


20%


 0%
        2003      2004        2005        2006   2007    2008      2009
                                                                 Projected
                                                                                                       12
Prospect Theory Explains Why Relatively Small
Incentives Can Produce Major Change




                        Perceived Gains


             Losses
                                             Gains




                            Perceived Losses

     Prospect Theory, Kahneman and Tversky, Econometria 1979
                                                               13
                       Evolving Reimbursement and Care Models
                        Full
                      Capitation                                                           Closed System
PAYMENT METHODOLODY




                        Sub-
                                                                                  *Team-Based Care
                      Capitation


                      Case Rates                                        *Disease Management

                         P4P
                                                              EMR
                       (Robust)


                          P4P
                                                     Registries
                        (“Lite”)


                       Fee-for-
                       Service
                                       Non-MD Clinicians
                                   Solo MD      Group         Multi-Specialty     Integrated      Clinic Model
                                   Practices   Practices      Group Practices   Delivery System

                                                           STAGE OF EVOLUTION                            14
Disease Management Averts a CHF
  Admission




                          MD notified of weight gain.
                          Patient called, and MD learned
                          she had stopped taking
                          furosemide twice daily. Regular
                          regimen restored




                                                            15
The Real Agenda: Two Revolutions

  Industrial Revolution – in which clinicians
   adopt systems that reduce errors of over-
   use, under-use, and mis-use.
  Cultural revolution
     Teamwork instead of MD as the lone cowboy
     Focus on care of populations over time
       — Chronic diseases like diabetes, heart failure
       — Complex, high risk patients with multi-system
        disease



                                                         16
Medicine‟s Cultural Revolution
  New types of responsibilities
     Responsibility for non-visit care of patient
     Responsibility for population of patients
  Evolving concepts of professionalism
     Not just highest possible individual standards of
      excellence
     Ability and willingness to work with teams that can
      assume new responsibilities. Examples:
       — Use of EMR
       — Computerized prescribing
       — Medication reconciliation at discharge
       — “Opt out” approach to team care
        — Exploration of variation in practice patterns
                                                            17
Variation: A Challenge and Opportunity

  Issues for which there is a clear right and
   wrong (.e.g, ASA for AMI) constitute
   minority of medical decisions.
  Most decisions are “gray zone” issues for
   which there is no clear “right” thing to do.
  But … if there is a bell-shaped distribution
   of what rational professionals (e.g., your
   colleagues) are doing in that gray zone,
   wouldn’t you want to know if you are at one
   end or the other?

                                                  18
Variation is Greatest When Right Thing to Do
Is Less Clear
Variation in rates of care across 306 Medicare regions (2000-01)*.

                                                    Hip Fracture        Back Surgery
                                                                   Implications
                   Procedure Rates of 306 Regions




                * [Adapted from The Dartmouth Atlas of Health Care; Jack Wennberg presentation 2005.]
                                                                                                        19
The approach to managing
variation differs depending on the
existence of a standard of care
        Standard of
        care exists     Gather and feed back data

                        Set guidelines, standards or protocols

                        Consider explicit financial/non-financial
                         incentives

                        Provide analytic services and peer support
Variation
in clinical
practice               Success requires mindset that variation is
                        undesirable even without a willingness to define a
        No
                        group norm
        standard of    Describe variation and agree to internal
        care exists     „standards‟
                          Can form basis for research to define
                            standard of care
         ?             Success requires very high will from clinicians to
                        reduce variation (bottom-up nature of project is
                        even more crucial)                                   20
     John Doe1, MD


     John Doe2, MD


     John Doe3, MD


     John Doe4, MD


     John Doe5, MD


     John Doe6, MD


     John Doe7, MD


     John Doe8, MD
                                                                   Data on Variation




     John Doe9, MD


     John Doe10, MD


     John Doe11, MD


     John Doe12, MD


     John Doe13, MD


     John Doe14, MD


     John Doe15, MD
                                                                   Are Reaching Individual MDs




     John Doe16, MD
                       HMA High Cost Radiology PCP Ordering
                       October 01 2006 thru September 30 2007
                      (normalized for 1000 PT Panel) by Modality




     John Doe17, MD
                                                                   PCHI Practice Variation Report




     John Doe18, MD


     John Doe19, MD


     John Doe20, MD


     John Doe21, MD


     John Doe22, MD


     John Doe23, MD
 1
21
Why Does Variation Exist Within
Small Groups?
   Clinicians are overwhelmed with information, and
    have gaps in knowledge
      Experts tend to get to answers in fewer iterative cycles
   Clinicians vary in tolerance of risk/uncertainty
      Experts can often live with greater level of uncertainty
   Clinicians are isolated, and do not have way to
    develop group consensus
   Clinicians are influenced by local norms from where
    they trained and their current environment
   But… ironically, clinicians often don’t know how they
    compare with local norms
                                                                  22
          Variation in physician risk thresholds drive individual
          propensity to act regardless of patient risk


                                                        Physician Risk Attitude Scores vs Hospital Admission Rates
                                                               for Acute Chest Pain Patients Evaluated in ED                                      (p < 0.10)

                                                                                                                (p < 0.04)            19 /19
                                             Risk-avoiding physicians                                                                           64 /66
                            100%                                                                       28 /30
                            90%              Middle-scoring physicians                                                                                     5 /6
                                                                                                                164 /201
                                             Risk-seeking physicians
Percent patients admitted




                            80%                                                                                              21 /29
                            70%               (p < 0.001)
                            60%    73 /139
                            50%              360 /826
                                                                             (p < 0.03)
                            40%
                                                        41 /132
                                                                    23 /82
                            30%
                                                                             104 /492
                            20%                                                         13 /89

                            10%
                             0%
                                         All patients                        Low-risk                          Medium-risk                     High-risk

                                                                                          Patient categories




                                       * [Pearson et al., Triage Decisions for Emergency Department Patients with Chest Pain. J Gen Intern
                                       Med. 1995; 10:557-564.]
                                                                                                                                                                  23
Taking on Variation: PHS Strategies

  Develop guidelines, and disseminate them
  Attack the “gray zone” where specific
   guidelines cannot be described yet:
     Increase group-ness and increase conversations
     Show data
       — Ideally, in unblinded, ranked formats for practice
       — Also provide data proximate to time to ordering of
          tests/drugs
     Follow-up on data with chart reviews
     Cultivate individual accountability through 1-1
      meetings and pairing of clinicians for chart
      reviews                                                 24
Can We Address Right Side of Curve?

          Rogers EM. Diffusion of Innovations, 1983




                                                      25
Conclusions
  An important root cause of our challenges in
   healthcare is tremendous progress imposed on a
   fragmented delivery system
  Result is chaos – leading to inefficiency and
   disappointing reliability and safety
  Regardless of how healthcare is financed,
   important strategy is for healthcare providers to
   become organized and adopt systems that
   improve quality and efficiency -- over episodes of
   care that matter to patients
  Organization as a goal poses challenges and
   opportunities for medicine’s leadership

                                                        26

								
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