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1、The Value of HealthcareSetting the Stage:Looking to the Future,Ian Morrison,Outline,The Economic Value of Health and HealthcareValues,Perceptions and AttitudesThe Case of PharmaceuticalsScenarios for the Next DecadeThe Value of Healthcare:Toward an Action Agenda,The Emerging Value Context,Rising cos
2、tsRising cost shifting to consumersThe Fat Trapper,Bariatric Surgery and the“Swaning of America”Infatuation with Technology based care Evidence that Innovation makes a differenceExpect more Innovation in long term although gaps in the short runPotential Paradigm EmergingHigh cost,High efficacy,High
3、Customization but unaffordable The Concorde SyndromeThe Quest for Value IOM:Balancing cost,quality,access and equityEvidence based medicine and evidence based benefit designPay for PerformanceValue Purchasing,Attitudes toward Value,Strong argument that American healthcare is a poor valueThe Internat
4、ional StoryThe Dartmouth StoryAmericans love high technology medicine and think we as a society should spend more on it.but,OPM(Other Peoples Money)Healthcare is a superior good,as we grow economically we will spend more,but it has to flow fromGovernmentEmployersHouseholdsValue is in the eye of the
5、beholder.and the payerValue is being redefined as we move to engage the consumer as payer and decision-makerWhat is value to the millions left behind?,Value and the Transformation of the National Debate,Its not just about cost containmentIts not just about affordabilityIts not just about pricesIts n
6、ot just about life expectancy Its not just about societal level valueIts not just about the best,no matter how much it costsIts not just about healthcare as the last industry to go offshore to China or India,Innovation Imperatives,Consumers love new technologyInnovation is the pharmaceutical industr
7、ys ace in price control debatesBut if you dont truly innovate in a way consumers appreciate and pay for.The new environment shifts responsibility for payment increasingly and transparency of pricing to consumers for all aspects of healthcare not just drugsDelivering innovation to an end user consume
8、r that has value they are willing to pay their own money forDo not overestimate(even)Americans willingness to trade upAre we comfortable with overt tiering?,How Consumers Rate Industries,*In 1997“computer companies”were rated together(I.e.hardware and software companies were not measured separately*
9、Because airlines were not included in 1997,the trend for airlines is from 1998-2002,Health Care Tops List of Industries Public Wants to See More Regulated,Should Be More Regulated,Generally Honest&Trustworthy,Hospitals,Managed Care Companies,Health Insurance Companies,Pharmaceutical Companies,The Va
10、lue of Health Care,14%,21%,24%,32%,35%,36%,43%,63%,Health insurance companies,Brand name prescription drugs,Hospitals,Pharmacies,Doctors,OTC(non-prescription)drugs,Medical devices,Generic prescription drugs,Percentage of consumers rating each of the following a very good or fairly good value,Source:
11、Harris Interactive/Wall Street Journal.Aug 19,2003,The Argument For Consumer Responsibility for Payment,Consumers have been progressively insulated from the cost of care for the last 40 yearsIf they only knew how much healthcare cost and had to pay they would use it lessIf they were responsible for
12、paying they would also take more responsibility to become healthy and cost the system lessConsumers should have the right to choose and to trade up to better quality with their own moneyWhen they are make rational consumer choices the market will be working and whatever is spent will be appropriate
13、like any other market or sector of the economy,The Argument Against Consumer Responsibility for Payment,The 5/50 Problem:Most consumers that are heavy users have significant co-morbidity or serious illness like cancer,they didnt choose this health statusOne day in an American hospital and they are o
14、ver their maximum deductible,soCatastrophic coverage is a green light for excessive care by hospitals and procedure-oriented specialists While skin in the game can clearly move people around does it save money overall?The equity problems:A de facto reallocation of resources from poor to rich(my acce
15、ss to the collective social capital of health insurance is better because I can come up with the economic down payment for physician visits and tests)Poor people with chronic illnesses will be disproportionately affected by consumer responsibility for payment,Consumer Exposure to Health Care Costs i
16、s About to Increase,Percentage of total personal health care expenditures paid out-of-pocket,Source:Centers for Medicare and Medicaid Services,Projected,Per capita amount of personal health care expenditures paid out-of-pocket,The Case of Pharmaceuticals,Coverage and ValueTiering and consumer strate
17、giesHow do consumers behave?What are the challenges?,Who Pays for Drugs?,Source:Kaiser Family Foundation and Sonderegger Research Center analysis of CMS data,Percent of Total National Prescription Drug Expenditures by Type of Payer,Private insurance,Out-of-pocket,Government programs,The Five-Tier Fo
18、rmulary,Lowest Copay,Highest Copay and/or Coinsurance,James Brown and Fernando Lamas Effect,Mortality,Morbidity,Mobility,Feel Good,Look Good,Quality of Life,Affluence of the Individual or Society,End-Point,“Skin in the Game”Matters,Trading down twice as often as trading upRapid increase in generic a
19、nd therapeutic substitutionPoor,chronically ill most effectedStarting to lead to adverse health outcomes like the uninsuredSimple cost shifting without sophisticated disease management is not the right answer in the long-term,Big Increase in Trading Down on Drugs,Base:Total cost of prescription drug
20、s increased last year(53%),Rx co-pay increase:More bargain-hunting since 2002.Low-and middle-income equally likely to“trade-down”,Percentage of consumers who did the following in response to an increase in prescription drugs cost sharing,Base:Copays for prescription drugs increased a lot or a little
21、 in past year,The Transformation of Pharmaceuticals,Discover a unique white powderSearch for a therapeutic actionEstablish safety and efficacyMake sure its better than available alternativesPromote to the professionGet a passive payer to pay for it,Design a white powder with a predictable therapeuti
22、c actionEstablish safety,efficacy and cost-effectivenessMake sure it meets a previously unmet medical need or has an effect that is detectable to human beingsPromote to all the Ps(patient,physician,PBM,payer,pharmacist,politician,press)Get an active payer to pay for it,Past,Future,%of Patients,Do no
23、thing,Chronic pill popping(Rolaids for Yuppies),Me-too Fast Followers&Generics,Higher PriceHigher EfficacyInnovativeTechnology,Big Pharma Success,Heavy-duty traditional therapy,Evidence-based medicine,Consumer payment,Marketing,Demonstration of clinical efficacy,Traditional Pharmaceuticals vs.Advanc
24、ed Therapeutics,Cost,Happy Biotechnologist Scenario,We have the best stuffSure its expensive,but it worksBecause it works there are savings elsewhereThis is complex do not try this stuff at homeAs generic competition makes costs go down for some technologies,there will be more gross margin left for
25、usCatastrophic drug coverage insulates consumers from caring about price,Biotechnologists Nightmare Scenario,Public,physicians,policymakers could care less about large molecules;we dont buy drugs by the atomIts complex brewing not chemistry,but how hard could it be?Big ugly buyers and providers ince
26、nsed about price of technologyHigh efficacy focused on small sliver of needy,desperate patientsPayers/purchasersMedicare inpatients the stent effectMedicare hospital outpatient the value caseAdministering Physicians e.g.oncologistszero-sum game on incomes“Plop,plop”vs clinical efficacyConsumersCo-in
27、surance on top tierAll drugs in CDHPCan you pass the NICE/Kaiser Test?,Demonstrating“Value”,What is value?Benefit/Cost?Quality/Cost?Access/Cost?Benefit to whom?Patient,physician,payer,insurer,employer,government,public(?),politician?Cost to whom?Patient,physician,payer,insurer,government,public(taxp
28、ayer)?Is“value”(for money)the same as cost-effectiveness?Remember if you cut the price in half,you double the value,Minor Delivery System Reform,Major Delivery System Reform,Four Scenarios for Health Care2004-2010,Tiers RUs,NationalRational Healthcare,Bigger Government,Scenario 1:Tiers R Us,The SUVi
29、ng of American HealthcareWe pay more for choice and controlWIPDBS brings the market to MedicareChronically ill,low income bewareCatastrophic coverage for the very sick The benefits of benefit design:save employers moneyTrading down more often than trading upA world of opportunity and riskPrivate sec
30、tor celebrated,Scenario 2:Bigger Government,Major backlash against cost shifting to consumers2008 election run on the retirement and health security issues of the middle classProtect the baby-boom at all costsMedicare Advantage for All orPay or Play orExpanded Medicare and FICA tax orFill the donut
31、holes,stick it to pharma,shore up the entitlementLive with the consequencesPoliticization of healthcare spendingRationing and restrictionLower InnovationLower profitsEquity over efficiencyRising costs and taxes,Scenario 3:Market Nirvana,Break the Culture of EntitlementConsumers learn to discriminate
32、 and payWe buy care not carsIncentives for health and personal responsibilityCatastrophic coverage and retail medicine for allUtilization based on ability to payThe rise of cheapo plans and delivery systemsReaching high end retail customers is keyDelivery reform is market-based not evidence-basedOpp
33、ortunities abound for the entrepreneurialAmericas economic base as private sector healthcareHigh quality,high service,low equity,Scenario 4:National Rational Healthcare,Universality and Delivery System RedesignEvidence-based floors and ceilingsPay for PerformanceReference-pricing and cost-effectiven
34、ess criteria for new technologyFinancial rewards for clinical redesignUniversal Mandated CoverageEmployer and individual mandates orExpanded Medicare Advantage orExpanded Safety Net Delivery FloorExpanded Access and Rational DesignDelivery System Innovation rewardedAll enabled by a 21st century IT a
35、nd bioscience infrastructure,Implications for Value,No matter what,we will need better value measures and more transparency of measuresValue based purchasing will become more prevalent and have a powerful influence on providers and vendorsConsumers will become more engaged in value decisions but we
36、cannot rely on them absolutelyThe systems of healthcare need to be continuously improved to deliver greater value,Towards an Action Agenda,The Need for LeadershipStakeholder DialogueNot just IOM or NHIConversation for ActionNot about figure pointingConstructive Engagement about Value Improvement in HealthcareRedesign of the systems of healthcare Generate EnthusiasmCultivate Broad Community DialogueIdentify Quick Victories,
