Dr. Ezekiel Emanuel, chair of Medical Ethics & Health Policy at the University of Pennsylvania School of Medicine and the Wharton School and former Obama administration healthcare advisor, shared his thoughts on healthcare transformation and how to succeed in a bundled payment world in his keynote address at the Remedy Partners National Innovation Collaborative held in Philadelphia, November 14-15, 2016. More than 300 physicians, clinicians, and executives representing 77 organizations involved in value-based care attended the invitation-only event.
Dr. Emanuel, long an advocate for healthcare reform, remarked that the U.S. healthcare system alone would be the fourth largest economy in the world—the $3.207 trillion spent on healthcare in 2015 is greater than the GDPs of Great Britain, France or India. Despite that, he stated, the U.S. as a nation is 37th in terms of quality on the latest World Health Organization (WHO) ranking of health systems. Healthcare is a “big squeeze on family income,” Emanuel said, with healthcare premium costs increasing 61% from 2005 to 2015. Drug prices, too, are out of line compared to other countries, as Emanuel, an oncologist, illustrated with a commonly-used cancer treatment drug that costs six times more in the U.S. than in Canada.
Dr. Emanuel, one of the architects of the Affordable Care Act (ACA), shared that the bundled payment provisions in the ACA were a compromise from the broader plan he had advocated, but expressed optimism about the future, even under the new administration. “I think we’re safe for the long haul,” he said, because “BPCI [Bundled Payments for Care Improvement] results have been shown to save money,” which would be a significant consideration given that healthcare costs are twice the size of the defense budget and nearly a quarter of the federal budget, and there are “not that many levers to control costs.”
He cited the example of Baptist Health Systems, a six-hospital system in Texas with 2,600 physicians, that was involved in CMS’ ACE bundling demonstration and then in BPCI for 28 cardiac and nine orthopedic DRGs. Statistics for that time (2009-2015) show that fewer patients were admitted to an ICU after surgery, fewer had blood transfusions, with no increase in complications, and there was no decline in quality as measured by readmissions and unscheduled ER visits. The switch to bundled payments had a positive impact on costs as well. Between 2009-2015, spending declined 22.6% for lower extremity joint replacement without complications, and rehabilitation was shifted to include more home care.
Dr. Emanuel shared that his research has pointed to 12 transformational practices that improve quality, eliminate unnecessary care, and reduce costs.
These 12 Transformational Practices, which will be the topic of his forthcoming book, are:
- Scheduling
- Registration and rooming
- Shared decision-making
- Performance measurement and reporting
- Standardization of care
- Chronic care management
- Behavioral health management
- Site of service: centers of excellence and referrals
- De-institutionalization of care: moving out of hospitals, SNFs, nursing homes, etc.
- Home and hospice care
- Community interventions
- Lifestyle interventions
He used medication management as a powerful illustration of how best practices can have a significant impact on outcomes. He pointed out that 50% of Medicare beneficiaries have five or more prescriptions, yet 50% of medications for chronic diseases are not taken as prescribed, and 20-30% of medication prescriptions are never filled. This non-compliance comes with costs. Compared with patients who follow instructions, non-compliant patients have a risk for hospitalization, re-hospitalization, and premature death that is:
- 5.4 times higher if they have hypertension
- 2.8 times higher if they have dyslipidemia
- 1.5 times higher if they have heart disease
Dr. Emanuel shared the story of an elderly, diabetic patient who benefitted from a care management program. Her blood sugar used to be poorly controlled, leading to frequent ER visits and hospitalizations. Now, her blood sugar is well-controlled, and she has not gone to a hospital in years. What changed for the patient was the “high-touch” care she received from the care managers working with her physician, including:
- Physician office visits every 2-3 weeks as part of “call or come” policy, where open slots allow patient visits 7 days per week
- Regular rapid hemoglobin A1C tests, whose results are explained to the patient and her daughter
- Weekly diabetic education sessions with a nutritionist
- Twice-weekly calls from her care coordinator to ensure the patient is following her care regimen properly
- And like any of their high-risk patients, she has access to a clinician 24/7, including evenings and weekends.
Dr. Emanuel noted that no single healthcare organization had instituted all 12 of the transformational practices. To improve outcomes and care, and transform the efficiency and effectiveness of U.S. healthcare, he recommended prioritizing the approaches on his list and starting with a few key practices. The practitioners of bundled payments in the audience are already on the way.