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Health Care Reform Where are we now? What might we do?

Health Care Reform Where are we now? What might we do? Beacon Community Meeting - Seattle, July 13, 2010. Elliott S. Fisher, MD, MPH Director for Population Health and Policy The Dartmouth Institute for Health Policy and Clinical Practice.

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Health Care Reform Where are we now? What might we do?

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  1. Health Care Reform Where are we now? What might we do? Beacon Community Meeting - Seattle, July 13, 2010 Elliott S. Fisher, MD, MPH Director for Population Health and Policy The Dartmouth Institute for Health Policy and Clinical Practice

  2. Some principles to guide reformHow might we reconnect our values to our work Underlying problem Key principles Clarify aims: Better health, better carelower costs – for patients and communities Confusion about aims Absent or poor data leaves practice unexamined, care uncoordinated, and public assuming that more is better. Better health information that engages physicians, supports improvement; informs consumers and patients Flawed conceptual model. Healthis produced only by individual actions of expert physicians. New model: It’s the system. Establish organizations accountable for aims and capable of learning and improving Wrong incentives reinforce model, reward fragmentation, induce morecare and entrepreneurial behavior. Rethink our incentives: Realign incentives – both financial and professional – with aims.

  3. The current opportunityHelp skate to where the puck should be? THE CURRENT CONTEXT WHERE THE PUCK SHOULD BE Measurement(for improvement and transparency) ONC-HIT -- EHR and HIE support Meaningful Use – 2013, 2015 ACOs – starter set & phase 2 HVMC – prototype advanced measures Evidence that it’s possible Better care Better health Reduced costs New models, new knowledge Advanced measures Engaged patients / clinicians Care redesign / Improvement Integrated care (real / virtual) Reformed payment Delivery and Payment Reform Center for Medicare Innovation ACO Multi-stakeholder initiative State activity – VT, CO, MN, NC, etc Independent Payment Advisory Board

  4. The current opportunityHelp skate to where the puck should be WHERE THE PUCK SHOULD BE Evidence that it’s possible Better care Better health Reduced costs Targeted populations Focused hypotheses Available measures • Principles: Focus and Parsimony • Who are you targeting? • What is the intervention? • What is a plausible and available primary outcome measure? • Health outcomes: blood pressure control? • Care coordination: readmissions? Patient survey? • Costs: avoidable admissions

  5. The current opportunityHelp skate to where the puck should be WHERE THE PUCK SHOULD BE Evidence that it’s possible Better care Better health Reduced costs Targeted populations Focused hypotheses Available measures New models, new knowledge Advanced measures Engaged patients / clinicians Care redesign / Improvement Integrated care (real / virtual) Reformed payment Early adopters (& their populations) Prototyping, piloting (e.g. ACO starter set) Advanced measures Advanced methods

  6. National PrioritiesNational consensus on aims Improve the health of the U.S. population Engage patients and families in managing health and making decisions Improve the safety of America’s health care system Ensure well-coordinated care across providers and settings Guarantee appropriate & compassionate care for those with life-limiting illness Eliminate waste

  7. ProgressAdvances in performance measurementThe current reality: A new national measurement framework NQF 2010

  8. Post AMI Trajectory 1 (T1) • Relatively healthy adult • Focus on: • Secondary prevention • Quality of Life • Functional Status • Advanced care planning Patient & Family Engagement: Patient Preferences Care Coordination Population Health 10 Prevention 20 Prevention (CAD with prior AMI) Post Acute/Rehabilitation Phase Acute Phase 20 Prevention • Post AMI Trajectory 2 • Adult with multiple co-morbidities • Focus on: • Palliative Care • Functional Status • Advanced Care Planning PHASE 3 PHASE 2 PHASE 4 Overuse:Cardiac Imaging/ Procedures PHASE 1 Staying Healthy Getting Better Living w/ Illness/Disability (T1) Coping w/ End of Life (T2) Population Health Palliative Care Cost & Resource Use Episode begins – onset of symptoms Episode ends – 1 year post AMI Safety • NQF Measures and Practices (MAPs for Quality): Acute Myocardial Infarction • Crosswalk to National Priorities & Goals

  9. Moving the field forward Population Health Bonnie Zell Clinical E-Measures Tom Tsang Consumer generated health status measures Gene Nelson Informed patient choice Lisa Weiss Efficiency and resource use Jim Chase, Tom Valuck

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