1. Making Care More Efficient: Promising Innovations and Options for Reinvesting Savings Christine K. Cassel, M.D., MACP The Commonwealth Fund Bipartisan Congressional Health Care Conference January 13, 2007

2. Physician Services Physician-Generated Services: Referrals/technology Hospital use Generating Patient Demand Who rewards the physician to reduce costs? Organization of Care Delivery Solo practice (20%) Multispecialty groups (20%) Rewarding Efficiency, Reducing Waste: The Physician's Role

3. Went to ER for Condition That Could Have Been Treated by Regular Doctor (2005) SOURCE: Schoen et al., Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries, Health Affairs Web Exclusive November 3, 2005 W5-509–W5-525; Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults Percent of adults who went to ER in past two years for condition that could have been treated by regular doctor if available

4. Physicians Use of Electronic Medical Records, U.S. Compared to Other Countries, 2000/2001 Percent of physicians *2000 SOURCE: 2001 European Union EuroBarometer and 2000 Commonwealth Fund International Health Policy Survey of Physicians (Harris Interactive 2002)

5. Percent reporting test results/records not available at time of appointment in past 2 years Test Results or Medical Record Not Available at Time of Appointment, Sicker Adults in Six Countries, 2005 SOURCE: Schoen et al., Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries, Health Affairs Web Exclusive November 3, 2005; DATA: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

6. Ways to Improve Care AND Reduce Costs Primary Care/Prevention Patient Engagement Redesign of Practice with Emphasis on Care Coordination

8. COMPARE Interventional Cardiologist hospital pays staff, technology pay for procedure 4-8 x annual incomes General Internist pay for visits no source of revenue for nurses, office staff, information systems no reward for avoiding visits and hospital use (email, phone, presentation) Primary Care - A Vanishing Species? GENERALIST SHORTAGE Physicians pursue specialties more than primary care Clinical demands Inadequate reimbursement No support for teams and systems

9. How can the best medical care in the world cost twice as much as the best medical care in the world? Uwe Reinhardt

10. Physician Training, Knowledge and Clinical Judgment ABIM Exam: "Conservative Management Score" High-intensity training areas correlated with worse performance on these questions EXCEPT for the top tier (20%) who did well on all questions

12. Care Management / Incentive Fees High-Need Population: multiple, complex chronic illnesses 8 states / 3 years Board certified physicians Interdisciplinary teams Patient empowerment Health Information Technology Demonstration inspired by ACP: http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/ jointprinciplesforpatientcenteredmedicalhome.Par.0001.File.tmp/patient- centered-medical-home.pdf Medicare Medical Home Demonstration Project H.R. 611 Tax Relief and Health Care Act of 2006 (Sec. 204)

13. 1.Accountability Standards for professionals and how they organize care Reform financing to reduce perverse incentives 2.Rewards for reducing costs can be reinvested More time with patients Information systems Interdisciplinary team Innovation, Reward and Reinvestment