Better Care and Lower Cost
High Performing Communities in
A
American
i
H
Health
lth C
Care
Donald M. Berwick, MD, MPP
President and CEO
Institute for Healthcare Improvement
Academy
cade y Health
ea t Annual
ua Research
esea c Meeting
eet g
Boston, MA: June 27, 2010
1
Health Care Expenditure
p
Out of GDP
Average Health Insurance Premiums and
Worker Contributions for Family Coverage,
Coverage 1999-2009
1999 2009
$13,375
131%
Premium
Increase
$5 791
$5,791
Wage and benefits1
Increase 37%
Note: The average worker contribution and the average employer contribution
may not add to the average total premium due to rounding.
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2009.
1. Bureau of Labor Statistics Employment Cost Index
“The First Law of Improvement”
p
Every system
E
t
is
i perfectly
f tl
designed to achieve exactly
the results it gets.
4
The “Triple
p Aim”
Population
Health
Experience
of Care
Per Capita
Cost
Medicare: 74 High Quality, Low
C t HRRs
Cost
HRR
$10,250 to 17,184
9 500 to < 10,250
9,500
10 250
8,750 to < 9,500
8,000 to < 8,750
6,039
,
to < 8,000
,
Not Populated
Source: Elliott Fisher and the Dartmouth Atlas Project
(55)
(69)
(64)
(53)
((65))
Commercial vs. Medicare Cost
ASR Adj M
Medicare Spen
nd per Beneficiary (A+B) 2007
7 (5%)
18000
16000
HWWDT HRRs
All other HRRs
US (yellow)
14000
12000
10000
8000
6000
4000
2000
0
7
0.50
0.75
1.00
1.25
1.50
1.75
Commercial Inpatient PMPM (excl. maternity) 2007
2.00
2.25
“The Tragedy of The Commons”
G
Garrett
tt Hardin.
H di Science
S i
1968 162
1968;
162:1243-8.
1243 8
The Tragedy
g y of the Commons
“Each
Each man is locked into a system that
compels him to increase his herd without
limit – in a world that is limited
limited. Ruin is the
destination toward which all men rush…”
A Hypothesis
yp
Successful Communities Learn
to Manage Their Health Care
“C
Commons
mm ns”
10
Two Views of “The Commons”
#1 All R
#1:
Resources A
Available
il bl ffor H
Health
lth C
Care
Two Views of “The Commons”
#2 All S
#2:
Social
i lR
Resources ffrom Whi
Which
hH
Health
lth C
Care D
Draws It
Its Sh
Share
Other
8%
Dental
D t l
8%
Nursing
Homes
6%
Hospitals
34%
Drugs/
nondurable
12%
Other health
professions
4%
Doctors
28%
Two Views of “The Commons”
#2 All Social Reso
#2:
Resources
rces from Which Health Care Dra
Draws
s Its Share
Innovation
Education
Recreation
Anything else
Healthcare
Environment
How Will We Do That? Intentionality
Everett, WA
Bend,
OR
La Crosse,
WI
Cedar Grand
Rapids Rapids,
Rapids,
IA
MI
Rochester,NY
Portland, ME
Buffalo,
NY
Manchester, NH
Newark, NJ
Asheville, NC
Standardized Medicare
payments per enrollee (2007)
Grand
Junction CO
Junction,
$9,300 to 15,750
8,600 to < 9,300
7 900 to < 8,600
7,900
8 600
7,200 to < 7,900
5,279 to < 7,200
Not Populated
p
Tallahassee, FL
(55)
(65)
(56)
(62)
(68)
Health Care Reform:
Th Apparent
The
A
t Choice
Ch i
 Spend More.
More
ccompl sh Less.
 Accomplish
Health Care Reform:
Th Better
The
B tt Choice
Ch i
 Spend More.
 Accomplish Less.
 Change
Ch
the
h System.
S
A Hypothesis
yp
Successful Communities Will Manage
Their Health Care “Commons”…
Population
Health
Experience
of Care
17
Per Capita
Cost
The Keyy Leadership
p Concept
p
• Someone has to “own” the Triple Aim for a
p p
population…
“The Integrator”
18
What Will Help…
p
• Very Strong Primary Care
• Intelligent Use of Specialty and High-Tech
High Tech
Care (without any loss to patients!)
• Highly
Hi hl Effi
Efficient
i tH
Hospitals
it l
• Focus
ocus o
on Each
ac Individual
d dua Patient’s
at e t s Goa
Goals
s
• Superb Systems for High Cost, Socially or
M di ll C
Medically
Complex
l P
Patients
ti t
• Integration
g
of Regional
g
Resources
19