The Health Services Researcher of 2020:
A Summit on the Future of HSR Data and Methods
Learning 2.0:
Robust, Rigorous, Relevant, and Rapid
Paul Wallace MD
Permanente Federation
Kaiser Permanente
Paul.Wallace@kp.org
“Gray Areas”...
The last 115 new technologies examined:
Medically
appropriate
38
?
7
Insufficient evidence
because the
evidence is:
Generally not
medically
appropriate
A. Of insufficient
quantity
66
and/or quality
B. Conflicting or
inconsistent 3
C. There is no
evidence
1
3
“Gray Areas”...
The last 115 new technologies examined:
Medically
appropriate
7
38
Insufficient evidence
because the
evidence is:
Generally not
medically
appropriate
A. Of insufficient
quantity
66
and/or quality
B. Conflicting or
inconsistent 3
C. There is no
evidence
1
4
Comparative Population Effectiveness: The Kaiser
Permanente National Joint Replacement Registry
[Evaluation]
feedback
changed practice
with respect to:
implant selection,
minimally
invasive
procedures,
uncemented
knees, and
surgical
indications and
preoperative care.
Paxton,EW et al; The
Permanente Journal
15:12-16, 2008
Predictive Modeling...
In patients with
diabetes,
AspirinLisinoprilLovastatin
(ALL) as a daily
combination,
has a greater
impact on
cardiovascular
risk than
aggressive
HbA1c
(glucose)
control
Average annual risk of various events
0.045
0.04
Nothing
0.035
HbA1c control
0.03
ALL
0.025
0.02
0.015
0.01
0.005
0
MI
Stroke
ESRD
Blind
Dying
8
Sean Tunis, CMTP
The Business of Health Care in 2009… chronic health conditions
increasingly underlie the bulk of health care costs
1% of people
100%
80%
30 + %
of total
cost
60%
40%
Premium level
20%
0% total cost
0%
0%
20%
40%
20% of people
% of
People
60%
80%
70% of people
100%
Diabetes
Heart Failure
Coronary Artery
Disease
Depression
Chronic Pain
Cancer
Asthma and COPD
Dementia
Falls
Obesity
…
CO-MORBIDITIES

N Engl J Med 351;27 2870-2874 December 30, 2004
What is the “dose response” for
relating the number of things you do
to achieving clinical outcomes?
Desired Result
Is “more care better” for the patient with Multi-Morbidity?
# of Interventions
$
(Not to scale at higher ages –
not even close!)
A key challenge
FFS
Medicare
Usual Care
Prevention
20
30
40
50
Working Years
Phil
11 Madvig MD
The Permanente Medical Group
60
Working or Not?
Age
70
80
90
$
(Not to scale at higher ages –
not even close!)
A key challenge:
Living to utilize...
FFS
Medicare
Usual Care
DM +
End-of-Life
Prevention
20
Palliative
Care
30
40
50
Working Years
Phil
12 Madvig MD
The Permanente Medical Group
60
70
80
Working or Not? Mortality diff
Age
90
Care in the last 6 months of life...
$
(Not to scale at higher ages –
not even close!)
A key challenge:
Living to utilize...
KP
Medical
Centers
FFS
Medicare
Usual Care
DM +
End-of-Life
Prevention
20
Palliative
Care
30
40
50
Working Years
Phil Madvig MD
The Permanente Medical Group
60
70
80
90
Working or Not? Mortality diff
Age
45
The Dartmouth Atlas
Applied to Kaiser
Permanente: Analysis of
Variation in Care at the
End of Life
By Matt Stiefel, MPA, Paul
Feigenbaum, MD, and
Elliott S Fisher, MD, MPH
The Permanente Journal/
Winter 2008/ Volume 12/
Number 1
Non-KP
Medical
Centers
(Same Cities)
Non-KP
Medical
Centers
(All US)
Health 0.0
“Rules of the Game” model
 Coverage policies, prior approval,
‘utilization management’
 ? Evidence Based Medicine
Health 0.0
“Rules of the Game” model
 Coverage policies, prior approval,
‘utilization management’
 ? Evidence Based Medicine
“Skin in the game” model
 Co-payment and Deductibles
 Financial incentives
 High Deductible, Value Based and
Consumer Directed Health Plans
 (Shared Decision Making)
Health 0.0
“Rules of the Game” model
 Coverage policies, prior approval,
‘utilization management’
 ? Evidence Based Medicine
“Skin in the game” model
 Co-payment and Deductibles
 Financial incentives
 High Deductible, Value Based and
Consumer Directed Health Plans
 (Shared Decision Making)
“Brain in the game” model
 Sustainable behavior change
 Motivational interviewing and
coaching
 Shared Decision Making
Health 1.0...
Health 2.0
User Generated
Content
Patient Networks and
Communities
“Dis-intermediation”
Patient-centered
Personalized
Health 2.0
Health 2.0 ... Evidence Challenge
Research 2.0 ???
Cross cutting values...Health 0.0 thru 2.0
The Trusted source
Knowledge-based
Values-based
An Oncology Patient in 2020...
An Oncology Patient in 1996...
An Oncology Patient in 1996...

“Don’t tell me what to do, doc...

An Oncology Patient in 1996...


“Don’t tell me what to do, doc...
Help me understand what all this
information means for me.”