The Myra Kraft Open Classroom Series Fall 2013: Policy for a Healthy America

1. The Myra Kraft Open Classroom Series Fall 2013:Policy for a Healthy America • Every Wednesday, 6pm – 8pm • September 4, 2013 through December 4, 2013 • West Village F, Room 20 • Northeastern University • School of Public Policy and Urban Affairs

2. This Week (October 9, 2013) “Is there a doctor in the house? Maybe not, but will it matter?” Timothy Hoff, PhD Associate Professor of Management, Organizational Development, Healthcare Systems, and Healthcare Policy, Northeastern School of Public Policy and Urban Affairs Gregory Sawin, MD, MPH Program Director, Tufts Family Medicine Residency at Cambridge Health Alliance; Assistant Clinical Professor, Tufts University School of Medicine; Clinical Instructor, Harvard Medical School School of Public Policy & Urban Affairs | Northeastern University

3. School of Public Policy & Urban Affairs | Northeastern University

4. Is There a Doctor in the House?(Maybe, maybe not, but how much will it matter?) Timothy Hoff, Ph.D. For the Open Classroom Series

5. Let’s Get Some Things on the Table • If the system continued to look like it does now, we WOULD NOT have enough doctors (or nurses) to meet the needs of patients in the US • We certainly DO NOT and WILL NOT have enough primary care physicians to meet demand • Nurses WILL GET greater autonomy to practice medicine independently • Our system WILL BEGIN to outsource traditional physician and nurse work to NEW types of health care workers and technology • Patients WILL INTERACT much differently with the system in the near future • All of the DOES NOT mean better or cheaper patient care per se

6. What are some key facts and imperatives around the health care workforce? • How will the system promote massive shifts in health workforce distribution and use? • What will the future look like?

7. I always liked this view of my health care

8. How About This View?

9. www.guardian.com Or This One?

10. Or This?

11. http://www.businessweek.com/articles/2013-08-29/private-equitys-hospitals-a-business-model-for-the-obamacare-erahttp://www.businessweek.com/articles/2013-08-29/private-equitys-hospitals-a-business-model-for-the-obamacare-era Coming to an ICU Near You…..

12. http://www.engadget.com/2009/11/05/irobot-creates-new-business-unit-for-healthcare-robotics/http://www.engadget.com/2009/11/05/irobot-creates-new-business-unit-for-healthcare-robotics/ Robot, Anyone?

13. http://www.robots.com/articles/viewing/healthcare-robots-used-to-improve-medical-carehttp://www.robots.com/articles/viewing/healthcare-robots-used-to-improve-medical-care

14. All Probable Futures Given the Access Needs, Workforce Misalignments, and Expected Innovation to Occur in US health Care

15. Here are Some Things We Know • Docs: • Expected shortages across almost all specialties and geographic regions (e.g. 50K PCPs needed by 2020) • An aging physician workforce about to retire • A younger, very different physician workforce • Nurses: • Upskilling is occurring, and with that fragmentation (APRNs, RNs, LPNs) • 16 states—can diagnose, prescribe, and treat without physician oversight; more states to follow

16. More Things We Know • Physicians and Nurses are an unhappy lot at present • Will medicine still get the best and brightest? • Physicians are becoming employees fast and permanently • Specialization, technology, and business models are deskilling doctors and nurses • Medical knowledge is being codified, stored, and “protocolized” at a rapid rate • Emphasis on access, value, and cost control are pushing the development of new types of “disruptive” health care workers (e.g. health coaches, patient navigators, health aides, care coordinators)

17. Will Computers, Robots, and Lower-Skilled Workers Replace Doctors and Nurses?

18. Answer? Yes, to Some Degree • Venture capital sees health care as the next great “profit frontier” • We cannot turn out enough professionals • Hospitals and “big systems” will employ most physicians—they will have scale, dollars, and incentive to use these disruptive innovations • See law firms, construction industry, and education • We are enamored with technology

19. Will the New Structures in Health Care Deskill, Demoralize, or Lift Everyone?

20. Accountable Care Organizations • Shared risk, stronger accountability, more integration, business models rule • Possible: Docs lose, everyone else wins • Possible: Docs take on employee mindset • Possible: Docs can focus more on medicine • Possible: We need fewer workers

21. Teams • Every setting takes a multi-worker approach to care, some places formal and others not • Possible: Greater camaraderie among workers • Possible: Same conflicts, tensions, alienation • Possible: Improves job satisfaction, reduces burnout, and makes a more productive workforce

22. Technology-assisted care • Every clinician and health care worker has immediate access to already interpreted information • Possible: Creates a workforce that is more efficient and informed • Possible: Creates a happier workforce • Possible: Deskills some, upskills others

23. What Does the Future Hold? • New access points for health care services: • Retail clinics, ATM-like kiosks, Your home and car • The doctor morphs into “the system” or “brand” • These access points will not use physicians as much • A “visit” by any other name, would smell as sweet? • Virtual visits, Real-time monitoring, group visits • Will create efficiencies, increase capacity (maybe), and reduce the need for some health care workers while inventing new ones

24. The Future Again • Medical schools will either revolutionize or become increasingly marginalized • What happens to the relational aspects of health care delivery? • Will patients even notice?

25. School of Public Policy & Urban Affairs | Northeastern University

26. Northeastern Health Policy Open ClassroomOctober 9, 2013 Gregory Sawin MD MPH Program Director Tufts University Family Medicine Residency at Cambridge Health Alliance gsawin@challiance.org

27. Gregory Sawin MD MPHProgram Director My Mission: Train Transformational Leaders to Drive the Primary Care Revolution that will save the U.S. Healthcare system. Tufts University Family Medicine Residency at Cambridge Health Alliance

28. National Health Expenditures Per Capita, 1990-2019 Historical Projected $13,387 (2019) $8,047 (2009) $2,814 (1990) Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (Historical data from NHE summary including share of GDP, CY 1960-2008, file nhegdp08.zip; Projected data from NHE Projections 2009-2019, Forecast summary and selected tables, file proj2009.pdf).

30. Health Care Expenses Health Education Defense

31. Americans Spend More Out-of-Pocket on Health Care Expenses Total health care spending per capita United States France Canada a Germany b Australia Netherlands OECD Median a Japan New Zealand Out-of-pocket spending per capita a2003 b2003 Total Health Care Spending, 2002 OOP Spending Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

33. Racial Disparity:

34. How do we rate overall?World Health Organization, 2000 Report CountryOverall Rank France 1 Japan 10 UK 18 Canada 30 US 37 Cuba 39

35. Tufts University Family Medicine Residency at Cambridge Health Alliance

36. Systems are perfectly designed to get the results they get. Dr. Paul Batalden Traditional fee-for-service payment rewards piecemeal work and volume of services rather than prevention of illness and coordination of care. The more procedures a physician and health system performs and the more patients they see, the more they are paid.

37. We need more Primary Care Docs • By 2015 ACA estimated to insure an additional 30 million Americans leaving us needing about 15-30,000 more primary care physicians in our current models (FM Graduates ~2,400/year) • >50% current family medicine residency slots are filled by foreign grads • >$3.5 million career pay differential between primary care and subspecialists • Our med schools are in tertiary care centers many without robust primary care departments. Tufts University Family Medicine Residency at Cambridge Health Alliance

38. Tufts University Family Medicine Residency at Cambridge Health Alliance

39. You’re too smart to be a primary care doctor! Tufts University Family Medicine Residency at Cambridge Health Alliance

40. What do we want from our health system? Tufts University Family Medicine Residency at Cambridge Health Alliance

41. The Triple (or quadruple) Aim Improve Health Improve the health of the population Enhance the patient experience of care (including quality, access, and reliability) Reduce, or at least control, the per capita cost of care. Cost Patient Experience (quality, access, reliability)

42. Preparing Personal Physicians for Practice Tufts University Family Medicine Residency at Cambridge Health Alliance

43. Our P4 Pillars • Longitudinal Primary Care Based Curriculum • Experts in Information Mastery • Competency Based Education • Areas of Concentration • Executive Skills Curriculum Tufts University Family Medicine Residency at Cambridge Health Alliance

44. laws alone won’t do the trick “effecting change in the US heath care system from the federal level is like trying to sew a quilt wearing three pairs of mittens.” Don Berwick MD Former Chief Center for Medicaid and Medicare Services (CMS) Former CEO & Co-Founder of IHI. Tufts University Family Medicine Residency at Cambridge Health Alliance

45. Model for Improvement Executive Skills Tufts University Family Medicine Residency at Cambridge Health Alliance

46. Current Improvement Projects • MyChart Sign up • Urine flow • Call Routing • Improvement Tree • Continuity by Teamlet Tufts University Family Medicine Residency at Cambridge Health Alliance

47. what is the #1 health risk Tufts University Family Medicine Residency at Cambridge Health Alliance

48. Health and Social Services spending Bradley, Elizabeth H., et al. "Health and social services expenditures: associations with health outcomes." BMJ quality & safety 20.10 (2011): 826-831. Tufts University Family Medicine Residency at Cambridge Health Alliance

49. Institute of Medicine Report Tufts University Family Medicine Residency at Cambridge Health Alliance

50. Tufts University Family Medicine Residency at Cambridge Health Alliance