1. Health Care in the Future Gloom, Doom and the Baby Boom Raymond J. Gibbons, MD Mayo Clinic Raymond J. Gibbons, MD Mayo Clinic CP988919-1

2. Disclosure Statement Research grants(significant) Radiant Medical KAI Pharmaceuticals TargeGenTherOx King Pharmaceuticals Raymond J. Gibbons, MD

3. Disclosure Statement Consultant(modest) Hawaii Biotech Cardiovascular Clinical Studies(WOMEN Study) Consumers Union TIMI 37A Raymond J. Gibbons, MD

4. CP1279194-7 Health care crisis Attention on imaging Quality Efficiency Health care crisis Attention on imaging Quality Efficiency

5. CP1279194-8 Health care crisis Attention on imaging Quality Efficiency Health care crisis Attention on imaging Quality Efficiency

6. Health Care Costs: 15-Year Cumulative Inflation Sources: AMA, Kaiser Family Foundation 1991 =100

7. Less Reimbursement for Medicare/Medicaid Services CP1246692-2 Cost Shifting to Non-Medicare Patients  Health Insurance Premiums  Employers Providing Insurance  Uninsured

8. Demographics and Cardiology CP941130-20 P(i,t) = P(i-l, t-l) – D(i,t) + I(i,t) – E(i,t)

9. Population Over 65 CP941130-21 % Year

10. U.S. Federal Spending Actual 2005 Congressional Budget Office CP1245974-1 All other programs 19.2% Defense 20% Medicare/Medicaid 20.8% Interest 7.4% Other mandatory 11.6% Social Security 21%

11. CP1279194-13 Workers per Medicare Retiree Health Care Financing Administration

12. CP1279194-19 Annual growth (%) Annual Health Care Spending Congressional Budget Office PublicPublic PrivatePrivate GDPGDP

13. CP1283309-6 Medicare and Medicaid Congressional Budget Office GDP (%) Total federal revenue ActualActualProjectionProjection Part A Trust Fund exhausted Foreign investors pull out

14. CP1279194-3 Medicare “The degree of uncertainty about whether future sources will be adequate to meet our current statutory obligations to the coming generation of retirees is daunting.” Alan Greenspan Chairman, Federal Reserve Bank January 25, 2004 Alan Greenspan Chairman, Federal Reserve Bank January 25, 2004

15. CP1279194-2 Medicare “The longer we wait, the more severe, the more draconian, the more difficult the adjustment is going to be… I think the right time to start is about 10 years ago.” Ben Bernanke Chairman, Federal Reserve Bank January 18, 2007 Ben Bernanke Chairman, Federal Reserve Bank January 18, 2007

16. Medicare Trustees CP1279194-4 2007 Annual Report The Hospital Insurance Trust Fund could be brought into balance with An immediate 122% increase in payroll tax (1.45  3.22%) An immediate 51% reduction in spending Some combination of the two The Hospital Insurance Trust Fund could be brought into balance with An immediate 122% increase in payroll tax (1.45  3.22%) An immediate 51% reduction in spending Some combination of the two

17. Little public discussion – “elephant in the corner” Required changes will increase Long overdue Further delay  Number of uninsured  Racial/ethnic disparities Wage stagnation  Commitment to education Threat to the country Little public discussion – “elephant in the corner” Required changes will increase Long overdue Further delay  Number of uninsured  Racial/ethnic disparities Wage stagnation  Commitment to education Threat to the country Need for Change in Health Care CP1243922-1

18. CP1243922-2 Inertia Status quo Short-term effects Necessity of long-term change

19. CP1279194-9 Health care crisis Attention on imaging Quality Efficiency Health care crisis Attention on imaging Quality Efficiency

20. “Blue Cross to require pre-approval for scans; MRI, other imaging costs up 20% in year” Boston Globe September 6, 2005

21. CP1218939-2 Medicare Cardiac Procedures Circ 113: 374, 2006 Rate/1,000 Stress imaging Cardiac catheterization Revascularization Acute MI

22. Less reimbursement for Medicare services CP1246692-3 “Make it up on volume” “Grow the business” Increases in procedures/tests “Grow the business” Increases in procedures/tests  Thought/time per patient/procedure  Quality, efficiency and value

23. CP1279194-1 Deficit Reduction Act of 2005 Good news: Elimination of 4.4% decrease in MD payment Bad news: Reduction in payments for imaging – 78465 decreased by $75 Good news: Elimination of 4.4% decrease in MD payment Bad news: Reduction in payments for imaging – 78465 decreased by $75

24. House Version CP1279194-5 SCHIP/Medicare Good news: Eliminates 9.9% decrease in 2008 and 5% decrease in 2009 Bad news: In 2010, SGR replaced with new system with 6 separate targets – imaging – growth limited to GDP Unknown: “comparative effectiveness” Good news: Eliminates 9.9% decrease in 2008 and 5% decrease in 2009 Bad news: In 2010, SGR replaced with new system with 6 separate targets – imaging – growth limited to GDP Unknown: “comparative effectiveness”

25. Imaging Stress Testing − Medicare 1.30 to 2.59(53) 1.10 to <1.30(36) 0.90 to <1.10(64) 0.75 to <0.90(53) 0.24 to <0.75(100) Not populated Ratio of rates of imaging stress testing to the U.S. average by hospital referral region (1996) Ratio of rates of imaging stress testing to the U.S. average by hospital referral region (1996) CP1279194-15 Wennberg et al: The Dartmouth Atlas of Cardiovascular Health Care, 1999