1

Componentsof a Learning Health Care System

Denis A. Cortese, MD

BPC Health Care Reform EventApril 24, 2008

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Pay for value

Value*

Individ-

ualized

Medicine

Science

of Health

Care Delivery

Integration and coordination

*Value = Quality/Cost = Outcomes, Safety, Service/Cost Over Time

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Pay for Value

• Pay for results, outcomes, value,not process compliance

• Purpose for process is to achievebetter value

(outcomes, safety, service)(outcomes, safety, service)

Value =Value =

Cost over a span of careCost over a span of care

QualityQuality

Translational

Research

Translational

Research

Basic

Research

Basic

Research

Clinical

Practice

Clinical

Practice

New

Clinical

Practice

New

Clinical

Practice

Innovation

(New Idea, Old Idea,

New Way)

Innovation

(New Idea, Old Idea,

New Way)

Time, people and capital

Val

ue

Translational EducationTranslational Education

Increasing Value in Health Care

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Translational

Research

Translational

Research

Basic

Research

Basic

Research

Clinical

Practice

Clinical

Practice

New

Clinical

Practice

New

Clinical

Practice

Innovation

(New Idea, Old Idea,

New Way)

Innovation

(New Idea, Old Idea,

New Way)

Time, people and capital

Val

ue

Translational EducationTranslational Education

En

terp

rise

Lea

rnin

g

Sy

ste

m

En

terp

rise

Lea

rnin

g

Sy

ste

m

Individualized Medicine

Science of Health Care Delivery

Integration

Increasing Value in Health Care

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6

Pay for value

Insurance for all

Value*

Individ-

ualized

Medicine

Science

of Health

Care Delivery

Integration and coordination

*Value = Quality/Cost = Outcomes, Safety, Service/Cost Over Time

7

Mayo Clinic Health Policy Center

Goal

Influence stakeholders to implementsubstantive health care reform before 2011that will enhance quality and availabilityof health care for all patients

Role

Convening body

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Mayo Clinic Health Policy Center• 10 sectors

• 800 people

• 400 patient comments – 9-city tour

• 1000 patients surveyed

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MCHPC Cornerstones

Coordinated care Value

Insurance

for all: FEHBP

model

Payment reform

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Health Policy Center Action Steps:Public Sector• Insurance for all

• Ensure/mandate insurance coverage for all

• Interoperable EMR• Require all providers to have interoperable EMRs within

a certain time (5 years) with patient accessibility

• Federal Health Board/Reserve• Implement an independent board to set rules/standards

to promote value in health care

• Care coordination • Reward care coordination

• Pay for value• Direct Medicare to pay for value/outcomes/prevention

using innovative payment models

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Insurance for All

• FEHBP – Model• All people own insurance; All participate• Employers can purchase all or some• Government help finance in sliding scale• All insurers take All patients• No pre-existing condition exclusions• Adjust for initial conditions• Sunset Medicare and Medicaid

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If Medicare Continues…Mayo Clinic Calls for Major Changes:• Congress must be out as BOD

• Stop price controls in exchange for provider pricing transparency on a set of common visits/procedures/tests and quality

• Pay for value• Focus on results ▫ O,S,S, and Cost over span of care• UHC ▫ Dartmouth Atlas ▫ NQF ▫ Leapfrog ▫ AHRQ

• Let patients pay more if they chose

• Coverage with evidence development

• Allow comparative effectiveness considerationsin benefit design and coverage decisions

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Pay For Value: Concepts

• FFS with reward for good outcomes

• FFS with shared savings

• Shared decision making

• Episode based payments

• Chronic disease coordinator payment

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Role for President

• Learning Organization

• Value: O,S,S, / Cost over Time

• Insurance for all

• Pay for value

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16

5,500 6,000 6,500 7,000 7,500 8,000 8,500 9,00020

30

40

50

60

70

Medicare Spending** and Quality of Care*

*Quality from “National Health Quality Report, 2006” by AHRQ

**Cost from Medicare Health Expenditures by State 2004, CMS website (www.cms.hhs.gov)

Medicare personal health care spending per enrollee

Quality

score

LA

MS

OK

TX FL

AR

VA

ID

CT

MA

MDNJ

CO

NE

MNWI

NH

ME

SD ND

HI IA VT

UT

Best quality – Lowest cost

Lowest quality – Highest cost

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0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

0 10 20 30 40 50 60

Teaching Hospital Variability in Value

Good

Effectiveness

Good

Efficiency

Good

Effectiveness

Good

Efficiency

Good

Effectiveness

Poor

Efficiency

Good

Effectiveness

Poor

Efficiency

Poor

Effectiveness

Good

Efficiency

Poor

Effectiveness

Good

Efficiency

Poor

Effectiveness

Poor

Efficiency

Poor

Effectiveness

Poor

Efficiency

Cost in last 6 months of life ($000s)Cost in last 6 months of life ($000s)

Case mix

adjusted

mortality

(>1 is better)

Case mix

adjusted

mortality

(>1 is better)

AA BB

CC DD

RewardReward

Incent

to move

to upper left

Incent

to move

to upper left