1. Foundation for American Healthcare Leadership Summit John E. Wennberg, MD, MPH Chicago, IL June 17-18, 2004

2. Developing New Financing and Care Delivery Models: How Should Your Sector Respond? Practice Variations can now be understood & interpreted normatively for all 3 categories of care.Practice Variations can now be understood & interpreted normatively for all 3 categories of care.

3. Benefit to Patients % Use of Effective Care U.S. is some- where in this zone Underuse of Effective Care

4. Benefit to Patients UNKNOWN Units of Discretionary Care Misuse of Preference-Sensitive Care (e.g. discretionary surgery)

5. U.S. is some- where in this zone Frequency of Care Life Expectancy Overuse of Supply-Sensitive Services

6. Developing New Financing and Care Delivery Models: How Should Your Sector Respond? Variations can now be understood & interpreted normatively for all 3 categories of care.Variations can now be understood & interpreted normatively for all 3 categories of care. Remedies are available but have yet to be widely implemented.Remedies are available but have yet to be widely implemented.

8. Knowledge of relevant treatment options and outcomes Concordance between patient values and care received Toronto trial Impact of improved decision quality on surgery rates: CHD

9. S P O R T S P O R T Spine Patient Outcomes Research Trial(s) model of new of potential partnerships Funded by: The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Office of Research on Women's Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention

10. Copyright  1999, Trustees of Dartmouth College **

11. Acknowledgements: Improving Chronic Illness Care, a national program of The Robert Wood Johnson Foundation

12. Developing New Financing and Care Delivery Models: How Should Your Sector Respond? Variations can now be understood & interpreted normatively for all 3 categories of care.Variations can now be understood & interpreted normatively for all 3 categories of care. Remedies are available but have yet to be widely implemented.Remedies are available but have yet to be widely implemented. Reform requires population-based provider- specific performance monitoring for various sectors of care.Reform requires population-based provider- specific performance monitoring for various sectors of care.

13. Supply-Sensitive Care can be measured for specific providers Days in Hospitals During Last Six Months of Life 8.0 12.0 16.0 20.0 24.028.0 NYU Medical Center27.1 Mount Sinai Hospital22.8 NY Presbyterian Hospital21.6 Cedars-Sinai Medical Center21.3 Mass. General Hospital16.5 UCLA Medical Center16.1 Boston Medical Center15.6 Brigham & Women's Hospital13.9 Beth Israel Deaconess12.2 UCSF Medical Center11.5 Stanford University Hospital10.1

14. Supply-Sensitive Care can be measured for specific providers Physician Visits During the Last Six Months of Life 10.0 20.0 30.0 40.0 50.0 60.0 70.080.0 NYU Medical Center76.2 UCLA Medical Center43.9 NY Presbyterian Hospital40.3 Mass. General Hospital38.8 Cedars-Sinai Medical Center66.2 Mount Sinai Hospital53.9 Brigham & Women's Hospital31.9 Boston Medical Center31.5 Beth Israel Deaconess29.2 UCSF Medical Center27.2 Stanford University Hospital22.6

15. 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.080.0 Preference-sensitive care for specific providers Invasive Cardiac Procedures (1998-2001) Non-Black Males Black Males Non-Black Females Black Females

16. Resource Inputs can be measured for specific providers Physician Labor Inputs in Managing Cohorts of Chronically Ill Patients During Last Six Months of Life FTE Physicians per 1,000 Hosp A Hosp B Hosp C Hosp D Primary Care Care Medical Spec. 19 76 76 31132 26 20 20 30 27 27

17. Resource Inputs can be measured for specific providers Physician Labor Inputs in Managing Cohorts of Chronically Ill Patients During Last Six Months of Life FTE Physicians per 1,000 Hosp A Hosp B Hosp C Hosp D Primary Care Care Medical Spec. Med Spec./l Med Spec./l Primary MD 19 76 76 4.1 4.1 31132 4.3 4.3 26 20 20 0.8 0.8 30 27 27 0.9 0.9 /

18. Estimating Actuarial Costs of Managing Patient Cohorts with Chronic Illness

19. Actuarial Costs estimated for specific providers Medicare Spending During the Last Six Months of Life For Hospitals and Physicians 10,000 15,000 20,000 25,000 30,000 35,000 40,000

20. Association Between Medicare Payments 18-24 Months and 0-6 Months Before Death R2R2 = 0.79 5,000 10,000 15,000 20,000 25,000 30,000 35,00040,0001,5003,5005,5007,500 Total Payments 18-24 Mos. Before Death Total Payment in Last 6 Months

21. Developing New Financing and Care Delivery Models: How Should Your Sector Respond? Variations can now be understood & interpreted normatively for all 3 categories of care.Variations can now be understood & interpreted normatively for all 3 categories of care. Remedies are available but have yet to be widely implemented.Remedies are available but have yet to be widely implemented. Reform requires population-based provider- specific performance monitoring.Reform requires population-based provider- specific performance monitoring. Reform requires partnerships between providers and payers to redesign care process and allow high quality providers to prosperReform requires partnerships between providers and payers to redesign care process and allow high quality providers to prosper

22. What “High Quality” Providers need to do: Eliminate Underservice of Effective CareEliminate Underservice of Effective Care Reduce Medical MistakesReduce Medical Mistakes Learn What Works (Outcomes Research)Learn What Works (Outcomes Research) Assure Informed Patient Choice (Shared Decision Making)Assure Informed Patient Choice (Shared Decision Making) Promote Conservative Practice Patterns (When More Isn’t Better)Promote Conservative Practice Patterns (When More Isn’t Better) Achieve Efficient Allocation of ResourcesAchieve Efficient Allocation of Resources

23. What payers need to do: Demand Excellence in all 3 categoriesDemand Excellence in all 3 categories Partner with Centers of Excellence who agree to reduce unwarranted variation in all 3 categoriesPartner with Centers of Excellence who agree to reduce unwarranted variation in all 3 categories Work with Centers of Excellence to design new payment methods to promote and reward quality and efficiencyWork with Centers of Excellence to design new payment methods to promote and reward quality and efficiency Support outcomes research as part of everyday practiceSupport outcomes research as part of everyday practice Create incentives for the wide redesign of U.S. health careCreate incentives for the wide redesign of U.S. health care

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