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Variation: How It Manifests, What to Do About It

Variation: How It Manifests, What to Do About It

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Variation: How It Manifests, What to Do About It

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  1. Variation: How It Manifests, What to Do About It Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality AHA Task Force on Variation in Health Care Spending Meeting Washington, DC – November 10, 2009

  2. Variation: How It Manifests, What to Do About It • A Major Public Policy Issue • Variation in Care Delivery and Spending • Comparative Effectiveness Research: Can It Help?

  3. The Status Quo Is Not Acceptable

  4. Not Just for Policy Wonks • Up to 30 percent of health care spending goes toward useless treatments that we don’t need • Overtreatment costs the U.S. system $700 billion a year • “Unnecessary treatment and tests aren’t just expensive; they also can harm patients.”

  5. The Public Is Paying Attention! • June 1 article became required reading in the White House • McAllen, TX, is the second most expensive health care market in the USA: why? • Medicare spending half of that of El Paso, TX, despite similar community profiles

  6. Health Care Spending Per Capita Source: Congressional Research Service. Washington, DC. Pub No. RL34175 Based on 2003 data from the Organisation for Economic Co-operation and Development (OECD)

  7. Pharmaceutical Spending Per Capita Source: Congressional Research Service. Washington, DC. Pub No. RL34175 Based on OECD data 2006

  8. Global Trends inHealth Expenditures From:,3343,en_2649_34631_2085200_1_1_1_1,00.html

  9. Per Capita Medicare Spending: Regional Variations From: Congressional Budget Office. Research on Comparative Effectiveness of Medical Treatments. 2008

  10. How Do They Do That? Multi-stakeholder effort examining high-performing regions Lowest region in state (actual-expected) • La Crosse, WI • Portland, ME (one of only two HRRs in Maine) • Asheville, NC Actual cost < expected • Temple, TX (second lowest after Lubbock) • Everett, WA (second lowest after Spokane) Four are problematic • Richmond, VA (highest actual-expected in state) • Sacramento, CA (actual > expected) • Cedar Rapids, IA (actual > expected, but in a low-cost state) • Tallahassee, FL (actual > expected) Source: Calculations from HCUP data using Dartmouth Atlas regions

  11. Variation in Employer-Sponsored Health Insurance • Among the 116.1 million private sector employees in the USA, 87.7 percent worked where employer-sponsored health insurance was offered in 2008 • For the 10 largest metro areas, premiums for single coverage ranged from $3,857 to $4,874 in 2008 • For the 10 largest metro areas, premiums for family coverage ranged from $11,454 to $13,835 in 2008 Crimmel BL. Offer Rates, Take-Up Rates, Premiums, and Employee Contributions for Employer- Sponsored Health Insurance in the Private Sector for the 10 Largest Metropolitan Areas, 2008. MEPS Statistical Brief #261, September 2009

  12. Variation in Family Premiums

  13. Health Care Spending Per Capita and Life Expectancy Source: Congressional Research Service. Washington, DC. Pub No. RL34175. Based on OECD data 2006

  14. Medicare Spending Per Beneficiary, 2006 (according to the Dartmouth Atlas of Health Care) $10,000 $9,000 $8,000 $7,000 $6,000 $5,000 30 35 40 45 50 55 60 65 70 75 25 Overall Quality of Health Care, 2008 (measures compiled by the federal Agency for Healthcare Research and Quality Lower Average Higher Higher Prices Don’t Always Mean Better Care New York Times, September 8, 2009

  15. AHRQ’s National Reports on Quality and Disparities • The median annual rate of change for all quality measures was 1.4% • Of 190 measures, 132 (69%) showed some improvement • Some reductions in disparities of care according to race, ethnicity, and income • Inequities persist in health care quality and access

  16. The Outcomes Movement • Geographic variation in practice patterns • Poor relationship between costs and outcomes • Need to establish best practices • Cost containment • Recognition of limited resources • System management • Improved management, accountability A. Epstein, NEJM 1990

  17. Comparative Effectiveness and the Recovery Act • The American Recovery and Reinvestment Act of 2009 includes $1.1 billion for comparative effectiveness research: • AHRQ: $300 million • NIH: $400 million (appropriated to AHRQ and transferred to NIH) • Office of the Secretary: $400 million (allocated at the Secretary’s discretion) Federal Coordinating Council appointed to coordinate comparative effectiveness research across the federal government

  18. Arthritis and non-traumatic joint disorders Cancer Cardiovascular disease, including stroke and hypertension Dementia, including Alzheimer Disease Depression and other mental health disorders Developmental delays, attention-deficit hyperactivity disorder and autism Diabetes Mellitus Functional limitations and disability Infectious diseases including HIV/AIDS Obesity Peptic ulcer disease and dyspepsia Pregnancy including pre-term birth Pulmonary disease/Asthma Substance abuse AHRQ’s Priority Conditions for the Effective Health Care Program

  19. IOM’s 100 Priority Topics • Topics in 4 quartiles; groups of 25. • First quartile is highest priority. Included in first quartile: • Compare the effectiveness of screening, prophylaxis and treatment interventions for eradicating MRSA • Compare the effectiveness of strategies for reducing HAIs • Compare the effectiveness of genetic and biomarker testing and usual care in preventing and treating clinical conditions for which biomarkers exist Initial National Priorities for Comparative Effectiveness Research

  20. Office of the Secretary’s Spend Plan for Recovery Act CER Funding • Designed to complement AHRQ and NIH activities • Data Infrastructure: Identify unique high-level opportunities to build the foundation for sustainable CER infrastructure to fundamentally change the landscape • Dissemination, Translation and Implementation: Innovative strategies that go beyond evidence generation and lead to improved health outcomes • Priority Populations and Interventions: Coordination of efforts across multiple activities to include subgroups that traditionally have been under-represented in research activity

  21. Specific Investments (Examples) • Data Infrastructure • Enhance Availability and Use of Medicare Data to Support Comparative Effectiveness Research • Distributed Data Research Networks, Including Linking Data • Dissemination and Translation • Dissemination of CER to Physicians, Providers, Patients and Consumers Through Multiple Vehicles • Accelerating Dissemination and Adoption of CER by Delivery Systems • Research • Optimizing the Impact of Comparative Effectiveness Research Findings through Behavioral Economic RCT Experiments • Comparative Effectiveness Research on Delivery Systems

  22. AHRQ Spend Plan for Recovery Act’s CER Funding • Stakeholder Input and Involvement: To occur throughout the program • Horizon Scanning: Identifying promising interventions • Evidence Synthesis: Review of current research • Evidence Generation: New research with a focus on under-represented populations • Research Training and Career Development: Support for training, research and careers The Right Treatment for the Right Patient at the Right Time

  23. Translating the Science into Real-World Applications • Examples of Recovery Act Evidence Generation projects: • Clinical and Health Outcomes Initiative in Comparative Effectiveness (CHOICE): First coordinated national effort to establish a series of pragmatic clinical comparative effectiveness studies ($100M) • Request for Registries: Up to five awards for the creation or enhancement of national patient registries, with a primary focus on the 14 priority conditions ($48M) • DEcIDE Consortium Support: Expansion of multi-center research system and funding for distributed data network models that use clinically rich data from electronic health records ($24M)

  24. Additional Proposed Investments • Supporting AHRQ’s long-term commitment to bridging the gap between research and practice: • Dissemination and Translation • Between 20 and 25 two-three-year grants ($29.5M) • Eisenberg Center modifications (3 years, $5M) • Citizen Forum on Effective Health Care • Formally engages stakeholders in the entire Effective Health Care enterprise • A Workgroup on Comparative Effectiveness will be convened to provide formal advice and guidance ($10M)

  25. Opportunities for Hospitals CER can: • Provide evidence to inform choices of drugs, devices • Enhance potential for understanding how research can benefit diverse populations and engage communities • Help develop infrastructure, training, registries, and non-government investment for future research

  26. Thank You