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1、1,Richard E.Anderson,M.D.Chairman and Chief Executive Officer,Richard E.Anderson,MDChairman and Chief Executive OfficerJanuary 25,2011,Healthcare Reform and the Practice of Medicine,2,Introduction,Context of contemporary practiceHealth reform timelinePotential impactsConclusions,3,On Being a Doctor
2、Today,5 forces Excessive business and legal complexity in the provision of medical careDecreased medical spending without reduced demand for medical servicesThe increasing role of for-profit corporations in changing the traditional emphasis on patient care into concern for shareholder equityA growin
3、g population of uninsured patients adding to the financial stresses on physicians and healthcare institutionsProvider demoralization(Washburn),4,On Being a Patient.,“Patients,nominally the designated beneficiaries of these changes,seem the unhappiest of all.They have lost the unquestioned assurance
4、that the physician is their advocate.Shifts in the marketplace may force them to find new doctors without warning or cause.Medical costs are again rising rapidly,and patients are being asked to pay an increasing share of their own medical bills.Only 44%of Americans express a great deal of confidence
5、 in medicine.”,5,By The Way The Reality of Medical Student Debt,0%,10%,20%,30%,40%,50%,60%,70%,80%,90%,100%,2004,2005,2006,2007,2008,Total Student Debt(%),$200,000,$100,000-$199,000,$1-$99,999,No debt,Robert Steinbrook,NEJM Dec.18,2008,6,Challenges of Practicing Medicine Today,Managed careThird part
6、y holds most of the authority,All accountability rests with physicianPaperwork burden does nothing but growPressure to reduce healthcare spending while demand for services increases virtually without limitMandates,fear of litigation,time pressure favors action not discussion,unreasonable expectation
7、s,culture of entitlementMost savings come from simply reducing payment to the people who actually provide the care,7,Medical-Legal Context of Practice,Arguable standard of care is best imaginable outcomePractice guidelines:endless proliferation renders them practically meaningless,often in conflict,
8、and not infrequently wrong Virtually all medicine is defensive medicinePatients bear risk and costDevalues physician judgmentEconomic pressures compete with clinical imperativesNeed for through-put is not a defenseMore than one-third of doctors would not choose a career in medicine a second time,nor
9、 for their children,8,TDC Frequency,Frequency,0.0%,3.0%,6.0%,9.0%,12.0%,15.0%,95,96,97,98,99,00,01,02,03,04,05,06,07,08,09,Report Year,9,Source:AMAs 2007 2008 Physician Practice Information Survey,Medical Liability Claim Frequency,10,Medical Liability:Frequency by Specialty,Source:AMAs 2007 2008 Phy
10、sician Practice Information Survey,11,TDC Severity,*Compound Annual Growth Rate,$40,$60,$80,$100,1998,1999,2000,2001,2002,2003,2004,2005,2006,2007,2008,2009,Report Year,Severity($000s),12,Impact of Legal Reforms in PPACA,Grants to states to develop liability reforms thatAllow for dispute resolution
11、over injuries caused by healthcare providers or organizationsPromote reduction of healthcare errors through enhanced patient safetyBut,ineligible if that law“limits attorneys fees or imposes caps on damages”And plaintiffs may opt out at any time in the process,13,Future Prospects,Most Democrats oppo
12、sedMost Republicans would rather have the issueFocus will be elsewhereBattleground shifts back to states,Healthcare Reform:Mechanisms of Action,15,The Trick,Fast,Cheap,or Good,pick any twoCost,Coverage,Quality,16,Accountable Care Organizations,Entities that accept responsibility for:Cost and quality
13、 of care To a given population of patients and Provide data on their performanceTypically includes physicians and hospital(s),possibly nursing home,home health agency,etc.,Can we get there from here?,17,Barriers to ACOs,Even today,most physicians remain in small practicesLack of:capitalinfrastructur
14、eleadershipChallenge to(remaining)physician autonomyIncentives for each component not aligned Income redistributionAuthority/responsibility mismatch,18,Barriers to ACOs(2),PatientsNo incentives to cooperate or even joinEven less to help reduce costLegal and regulatoryAnti-trustCorporate practice of
15、medicine laws,19,Independent Payment Advisory Board,2015 Purpose:control Medicare spendingTarget growth rate If target rate exceeded Board makes proposals that reduce Medicare spending each year until target must be met in 2018BUT,20,Independent Payment Advisory Board(2015),Proposals must be directe
16、d at providers NOT beneficiaries i.e.may not“ration healthcare”Proposals go to President who forwards to CongressInaction is not an optionIf Congress does not adopt substitute provisions,HHS automatically implements Boards proposal,21,Daunting Math,Historically,healthcare spending exceeds GDP growth
17、 by 2.5 percentage pointsCollision course for 2018 If targets not met,the only alternatives would be:CutsIncreased taxes More borrowingGlobal budget set rates for all payers,Potential Impacts,23,Healthcare Leadership Council Survey:Impact of PPACA After 2017,24,Do you consider your organization part
18、 of an accountable care organization?,HLC Survey:Do you expect your organization will become part of an accountable care organization in the future?,No,31%,Yes,69%,25,HLC Survey:Which of the following strategies does your organization currently have in place?,26,HLC Survey:Which of the following str
19、ategies do you expect your organization to increase due to the enactment of PPACA?,27,Uncertainty,The ambiguity of the legislation itself Unknowns surrounding implementation even as writtenMultiplied by the political uncertaintyAs you look ahead,what are the advantages of remaining small?If national
20、 reform were actually repealed,what would happen?,28,Extrapolate Current Trends,Medical student debtGender balanceGen X,Gen YDisappearance of solo practicePhysician demoralizationIncreasing demand for more,and better,servicesBureaucracy of practiceLitigation pressure ConclusionUncertainty drives the
21、 same trends driven by the reform itself,29,One Example Specific Impact:EHR,How good is the old system?Paper chartsX-ray filmsRelied on direct communication among physiciansEHR could be(have been)a Holy GrailBetter(still imperfect)match of investment and returnStandardization of platform and infrast
22、ructureClinical optimizationIntegrated communication across the system,30,Potential Medical-Liability Risks of EMRs,During initial implementationTransition from paper to electronic record may create documentation gapsInadequate training on EMR systems may create new error pathwaysFailure of clinicia
23、ns to use EMRs consistently may lead to gaps in documentation and communicationSystem-wide EHR“bugs”or outages could adversely affect clinical care“Too err is human”,Source:NEJM Medical Malpractice Liability in the Age of Electronic Health Records,363:21 November 18,2010,31,Potential Medical-Liabili
24、ty Risks of EMRs(Contd),As systems mature Email advice:Facilitates response without thorough investigation and examination of the patient Multiplies the number of clinical encounters that can give rise to claims Temptation to copy and paste Risks missing new information and perpetuates previous mist
25、akesBright audit trailInformation overload may cause clinicians to miss important pieces of informationDepartures from clinical-decision support guidelines are obvious,Source:NEJM Medical Malpractice Liability in the Age of Electronic Health Records,363:21 November 18,2010,32,2005 RAND Study:Impact
26、of National EHR,Annual savings of$80 billionIs this still true today?,Can Electronic Medical Records Transform Health Care?Potential Health Benefits,Savings and Costs,Health Affairs,v.24,no.5,2005,33,Observation,“The one truly scary thing about health reform:Far from being a government takeover,it c
27、ounts on local communities and clinicians for success.We are the ones to determine whether costs are controlled and healthcare improves”Atul Gawande M.D.,34,Another Observation,“Relatively little of healthcare reform will make our nation healthier.The bigger impact will still come from addressing th
28、e underlying physical,social,and behavioral determinants of health.”Dr.Stephen Shortell,35,Conclusion,The next decade of medical practice will see a collision of massive economic interests,social concerns,and unintended consequences.This will occur in an extraordinarily polarized nation with inadequate resources and limited vision.It will not be smooth,and it is unlikely to be pretty,
