Future Now
The IFTF Blog
Dr Ken Shine interview summary
Overview
Guardedly optimistic that there will be some expansion ofcoverage at federal and state level
sees the economy as a driver: “itis possible that there could be some fundamental reorganization in the healtheconomy if the economy continues to be troubled”
<o:p> fundamental reorg of health care must come from pvt sector</o:p>
driver must be economicdisadvantage of private corporations based on magnitude of health care costs--this would include a move away from employer-sponsored care presently,does not see the will to complete transformation:
most important parameters are polls—consistentlyshow that 80-85% believe that hc system is broken; vast majority of Americansdo not want to see the change
anecdote: at a speech given to 350nurses, 92% of nurses said system is broken; 58% would not want to see a changein the way they receive their cover; 30% would accept marginal change
for decades, people have accepted that the system is broken
3 things preventing change:
1. economic self-interest (insurance and pharmaindustries)
2. inertia--people do not want to see change
3. inability to control costs
Must look at how to create a more effective system
Requires payment reform: As long asyou pay for all of that, people are going to do it
Neither FDA, nor CMS exercise anyjudgment with regard to efficacy to the things we pay for;
“As a scientist, I know thatincremental change is the way things progress. In health care, it is lesscertain if doing a test in 18 seconds instead of 30 seconds [is progress].”
Issues:
Workforce<o:p></o:p>
evidence is clear that both in Texasand nationally we need more physicians
Mix is not appropriate for what weneed
workforce very closely tied topayment reform—can’t really separate w/oa change to reimbursement, nothing will change betterways to reimburse advanced nurses paymentcontrol is connected to cost control.
Quality<o:p></o:p>
Dependentupon payment reform
Bundling of payments—if properlyundertaken would cause a major change in how care is delivered If you are responsible for anepisode of change for 90 days, you have a real incentive to take care of people
System organization <o:p></o:p>
systemhas been designed to produce what it produces, Incentives in health system aremisaligned, Unrelated tohealth outcomes,Based on how much you do via howwell you do is poorly designed way to produce health, Profession will have to move to onein which people get rewarded for the effectiveness of what they do and theextent to which they practice in a way that’s consistent with evidence. Guardedly optimistic—1/2 going intopractice are women; women are much less concerned about macho control,autonomy, attitude.
FORECAST: Pay for performance will grow, amount will increase, areasin which it applies will expand, 2020—as much as 1/3 of care will be linked to performance Tiedto increasing amounts of capitation, bundling will grow,
SIDE EFFECT: Adverse selection of patients is aproblem and we would need to risk stratify adverse selection is particularlychallenging when you deal with things in small numbers wouldrequire volume in bundling. eg: consolidation of peopleskilled in cardiac heart failure.
Adverse selection is overdone—wehave the skills to stratify risks
ANECDOTE: chair of NY cardiaccommittee for 12 years, when we saw bad outcomes, invariably the docs would saywell, we have the sickest patients, invariably it was a systems problem; theycreated the sickest patients
FORECAST: by 2020—Bundling expands and connected to volume, increasedconcentration of care of high volume programs
politicallyit will be very high to anoint places to be high volume communitybased ambulatory community sites will work with hospitals
example:Lone Star Circle of Care—FQHC—bankrolled by hospitals,Parkland(Dallas) using community based clinic
HIT<o:p></o:p>
HIT money in stimulus package offersopportunities to make a difference
Must have clear cut goals of the HER Switch—instead of the vendordriving the options, the providers should drive the needs
Must agreement on standards
Privacyissue is a false issue
EHRcan and will be safer than written health record
30% of time that patient goes tothe same hospital, there is no paper record
Real issue: connecting providers (in Texas, ½ ofpracticing doctors are 4 physicians or less)
Electronic billing—extraordinaryefficient in cost savings
Staffingissues—inertia (could result in job loss)
Payment reform must drive thechange: Medicare and others offering discounts to participate in electronicbilling
FORECAST: Vast majority of hospitals, and 2/3 of physicianswill have access to electronic health record by 2019
Partof it is generational—doctor replacement
Oneof the forcing function—family physicians
Consumers<o:p></o:p>
amount of information available topatients is exploding; explosion of chat rooms, that generation is going to use
role of patients and their familiesin controlling care and the kind of care they get care is increasing
FORECAST: Healthcare 2020 challenges:
Financing
Quality
Access
Add—howand what way do we deploy technology
Interview conducted by Rachel Maguire