1. Component 1: Introduction to Health Care and Public Health in the U.S. 1.5: Unit 5: Financing Health Care (Part 2) 1.5d: Controlling Medical Expenses

2. Section 5d:Objectives Review some potential methods of controlling rising costs in medicine –Examine the role of health information technology in reducing and limiting costs Use of electronic health records and evidence based medicine Clinical decision support Clinical practice guidelines Component 1/Unit 5d2 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

3. Section 5d:Objectives Examine briefly the Patient Centered Medical Home model for reducing healthcare expenditures Explore direct primary care or concierge medicine Component 1/Unit 5d3 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

4. Cost Drivers Technology –50 % total annual expenditures –Devices advance diagnosis and care Imaging - CT, MRI Surgery - da Vinci robot Artificial devices – hips, knees, pacemakers –Procedures treat the untreatable, minimize risk, improve outcomes Minimally invasive surgery Angioplasty New treatments Component 1/Unit 5d4 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

5. Cost Drivers Physician and hospital utilization –Aging Increasing number >65 y.o. Increasing cost >65 y.o. –Chronic disease Diagnostic tests Management of disease Component 1/Unit 5d5 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

6. Additional Cost drivers Administration –Reimbursement methods Fee-for-service encourage utilization Disparities within and among insurance plans –Billing Rules Process Other –Direct to consumer advertizing –Defensive medicine Tort reform Component 1/Unit 5d6 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

7. Fixing a Broken System? Limit available resources –Rationing Incentives to change utilization –Increase patient cost –Wellness and prevention Increase in efficiency –Health Information Technology (HIT) –Evidence-based medicine (EBM) –Clinical Practice Guidelines Adapted from: Nelson AR, 2005, Costs of Health Care: New Solutions for an Old Problem. The Commonwealth Fund 2005. Available from: http://www.commonwealthfund.org/Content/Publica tions/Commentaries/2005/May/Costs-of-Health-Care--New-Solutions-for-an-Old-Problem.aspxhttp://www.commonwealthfund.org/Content/Publica tions/Commentaries/2005/May/Costs-of-Health-Care--New-Solutions-for-an-Old-Problem.aspx Component 1/Unit 5d7 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

8. Health Information Technology Health information technology (HIT) –Best chance to lower costs HITECH Reward ($$$) for meaningful use of EHR –Facilitates coordination of care –Supports provider Clinical decision support (CDS) Clinical practice guidelines/EBM Shared information (health information exchange) Error avoidance Component 1/Unit 5d8 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

9. Evidence-based medicine Evidence-based medicine (EBM) –Systematic review of published research –Clinical practice guidelines –Standard of care Lower costs Defensive medicine Cook book medicine? Evaluating technology Component 1/Unit 5d9 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

10. The Medical Home Research: 5.6% lower costs Provides comprehensive medical care –Personal physician = director –Practice team Collective responsibility –Enhanced access Same day appointments Component 1/Unit 5d10 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

11. The Medical Home –Coordinated care Specialists, hospitals Other organizations –Active patient participation in decision making –Improves quality and safety Planned coordinated care EBM, CDS HIT measure quality performance Component 1/Unit 5d11 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

12. Concierge Medicine Also known as direct primary care Patient pays fee or retainer –Monthly or annual –Receives special service –Enhanced access Multiple models –Practice size limited –Limited or no insurance billing –Requires patient maintain health insurance for services not covered in the practice Component 1/Unit 5d12 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

13. Concierge Medicine Typical features –Same day urgent care appointments and next day non-urgent care appointments –24-hour telephone access –Extended office visits –Preventive care physicals/screenings –E-mail and mobile phone access Component 1/Unit 5d13 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

14. Concierge Medicine Typical features –Wellness and nutrition planning –Coordination of medical needs during travel –Patient’s home or workplace consultations –Smoking cessation support –Stress reduction counseling –Mental health counseling Component 1/Unit 5d14 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

15. Concierge Medicine Practice costs lower –Lower staff costs Fewer patients/fewer administration/fewer nursing –Lower overhead costs Rent smaller office Lower utility costs Perception of improved quality –No difference from traditional primary care Component 1/Unit 5d15 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

16. Concierge Medicine Challenges –Health insurance for specialty services, high- cost procedures, emergency treatments, and hospitalization. –No data on how model affects overall health care costs –Employers evaluating model for savings –Could exacerbate the shortage of primary care providers Component 1/Unit 5d16 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010

17. Summary Improved efficiency – prospective savings –Health information technology –Evidence-based medicine Medical home model –Lower costs 5.6% –Comprehensive care Concierge medicine –Retainer based model of the medical home –Direct primary care –Enhanced services –No research to support cost containment Component 1/Unit 5d17 Healthcare IT Workforce Curriculum Version 1.0/Fall 2010