Title: PUTTING IT ALL TOGETHER: The Building Blocks to Create the 21st Century Health Care Delivery System
1PUTTING IT ALL TOGETHER The Building Blocks to
Create the 21st Century Health Care Delivery
System
- Jerome H. Grossman, MD
- Director, Health Care Delivery Policy Program
- Harvard University JFK School of Government
- June 2004
2 Roller Coaster Ride
1993-1997
1998-2003
HMO Backlash
Preferred Provider Orgs
Tightly Managed Care
Deep Cuts in Medicare Balanced Budget Act
0 Medical Inflation 4 Unemployment
13 Medical Inflation 5 ½ Unemployment
3The Next Blow
Myth of medical safety and quality burst
2001 To Err is Human 100,000 deaths from errors
2001 Crossing the Quality Chasm
2003 Less than 50 of chronic care patients receive best demonstrated practice care
4What Hasnt Happened
Medical Injuries Cost Billions Every Year
Researchers studying health-care quality have
concluded that medical injuries caused during
hospital stay kill tens of thousands of patients
annually, requiring at least 2.4 billion extra
hospital days resulting in potential medical
charges of 9.3 billion. The work underscores
both the scope of the problem and the relative
lack of action in solving it. In 1999, for
instance, the Institute of Medicine recommended
the creation of a nationwide mandatory reporting
system for medical errors. That hasnt
happened. Very little progress has been made.
Source Wall Street Journal
Very little progress has been made.
5The New New Thing
Preliminary Shift to Consumer
Medicare Modernization Act
2004
2001
2003
Consumer Directed Health Care
HEALTH SAVING ACCOUNTS
6 The Building BlocksFuture Hopes
Existing Trends
Financing Purchasing
Regulating Providing
HEALTH FEDERAL RESERVE
Catastrophic Account Cash Account
HSA (Consumer Defined Plans)
Health Value Added Tax
Universal Health Plan Voucher
Behavioral Economics
Based on Clinical Condition Monitoring
SEPARATE FEDERAL AGENCY
Productivity
Systems Management
Safety/Safety Improvement License and Monitoring
Vocab/Reporting Transparency
Licensure Arbitration Malpractice
Network Creation
7Financing
HEALTH FEDERAL RESERVE
Health Value Added Tax
Universal Health Plan Voucher
Based on Clinical Condition Monitoring
FDA
Productivity
Clinical Conditions
8Regulation
SEPARATE FEDERAL AGENCY
Safety/Safety Improvement License and Monitoring
Vocabulary and Reporting Transparency
Licensure Arbitration Malpractice
METAPHORS
FAA/NTSB
FASB
SEC/NASD Federal Reserve
RESEARCH
- Performance Based Regulations
- Management Based Regulations
- Risk Based Regulations
9Purchasing From Managed Care to Health Savings
Account From Defined Benefit to
Defined Contribution
- Catastrophic (Risk)
- Cash Account
- Carve In for Chronic Disease and Means Testing
- Reduced Payment for Good Health and Disease
Prevention
Government Corporation Individual
HSA Rollover Portable
401K
Behavioral Economics Libertarian Paternalism
10A Perfect Market
- Large numbers of consumers and firms
- Free entry and exit
- Marketability of all goods and services
including risk - Symmetric information with zero search costs
- Key Failures in Health
- Asymmetric information/costly search
- Marketability of risk
11Bearing More of the Burden
Employees annual healthcare costs, paid by . . .
Source New York Times, Hewitt Associates
Overall annual healthcare costs rose from about
4,000 in 1998 to about 7,000 in 2003, and are
projected to rise an additional 1,000 in 2004.
12The New 401(HEALTH)
401(HEALTH) Corporation Government
Self Defined Contribution
Risk Tolerance Auto Insurance Points for
healthy behavior for preventive tests for
chronic disease compliance Result Lower rates
next year
Must buy catastrophic insurance Medical Savings
Account Rollover Portable
13Catastrophic Insurance
- x 1,000,000 lives
- Epidemiologic (Incidence Prevalence)
- x
- Predictive Risk Modeling (Disease Severity and
Comorbidity) - x
- Normative Resources (From Productivity)
-
- Outcomes (Outputs)
- Technical
- Functional
- Trust
- Service
14Distribution of Responsibility
Providers
Populations
Public Health Disease Prevention At Risk Acute Self Limited Acute Care Cured by RX Chronic Disease At Risk High Cost Disease Deterioration Act of God
15Productivity Quality AND Cost Improvement
- Clinical Condition
- Input
- Arthritis of Hip
- with surgery
- without surgery
- mild
- moderate
- severe
- Quality
- Output
- Technical
- Functional
- Trust
- Service
Medical
Surgical
Rehab
All Resources () Used
16Providing Complex Interdependent Systems
Data Exchange 7 x 24 x 365 The Patient
Customized Protocol Front Line Team
Flexible Management Organization
Post Introduction Surveillance Bioterrorism Regulation Environment
Productivity
Reengineering Human Factors Job
Redesign Organization
17Engineering in the Service of Medicine
- Two Major Interconnected Opportunity Sets for
Engineering and Medicine - Information and information/communication
technologies and associated research to advance
connectivity, information flow, coordination. - System design, analysis and control tools
associated research to advance understanding of
processes and system interactions and
improve/optimize dimensions of system performance
in face of constraints.
18Information and Information/Communication
Technologies
- Information and information/communication
technologies and associated research to advance - Connectivity
- Information flow
- Coordination
19For Example
20Data Monitoring
21Wireless Endoscopy
22Biomonitoring Techniques
23Keeping Patients Connected
Source Boston Globe
24Every Home an ICU
Source Boston Globe
25Systems Design and Implementation
- System design, analysis and control tools and
associated research to - Advance understanding of processes and system
interactions - Improve/optimize dimensions of system
performance in face of constraints
26Integration of Multiple Subsystems
PCP
Triage
Lab
Surgery
Admitting
ICU
ED
Nursing
Library
Patient Ed.
Post-OP
Specialist
27Health Care System Quality
Protocols Procedures Best Practices Safety Service Timely
Credentialing EMR Staffing Facilities Volume Integrated Practice CPOE Educational Environment Teamwork Innovation Patient-Centered Systems Engineering
Process
- Patient Outcomes
- Mortality
- Morbidity
- Functional Status
- Quality of Life
- Cost of Care
- Satisfaction
- Patient Inputs
- Severity
- Comorbidities
- Age/Sex
- Socioeconomic Status
- Compliance
- Genetics
- Expectations
- Attitude
Infrastructure
Source Jim Naessens, Thesis Work
28The Tools of Systems Engineering
Systems Design Systems Administration Systems Control
Quality, Function, Development Human Function Engineering Failure Mode Effect Analysis Modeling and Simulation Enterprise Management Knowledge Discovery in Data Bases Predictive Risk Models Individual Decision Making Optimization Distributed Decision Making Statistical Process Control Scheduling
29Systems Engineering Research and Development
Clinical Conditions
Genome
Systems Biology
Systems Engineering
30Suggested Readings
For more information, see the website for the Harvard/Kennedy School Health Care Delivery Policy Group at http//www.ksg.harvard.edu/cbg/hcdp/
Suggested readings include Putting It All Together under Research Projects The Numbers