The Department of Medicine held its third annual strategic planning retreat at the Golden Gate Club in the Presidio on September 19, 2012. One hundred members of the department and distinguished guests engaged in earnest discussions centered on the department’s ability to continue to be a leader in improving value in healthcare. The goals for the retreat were to raise awareness about the unsustainable growth of healthcare spending and to encourage disruptive thinking that will identify solutions that can be implemented by the UCSF health system.
Sunita Mutha, chairperson of the retreat planning committee, welcomed guests and introduced Talmadge King, who opened the program by reviewing reasons why physicians get “stuck” when trying to improve value in healthcare. These reasons include: that we don’t have sufficient data on outcomes that matter, and we don’t have data on costs. In addition, physicians are not incentivized to improve value.
Mark Smith, President and CEO of California HealthCare Foundation, was the keynote speaker for the retreat. Mark chaired the Institute of Medicine’s committee on The Learning Health Care System in America, a two-stage consensus study that began in January 2011 and issued a report in September 2012. This study, Best Care at Lower Costs, identifies three major imperatives for change: the rising complexity of modern health care, unsustainable cost increases, and clinical outcomes below the system’s potential.
Mark recited a number of statistics to illustrate the high cost of healthcare. He emphasized that today’s healthcare costs have grown beyond what individuals, governments and corporations can afford. For example, the total health insurance family premium has increased to 101% of the US minimum wage earnings (compared to 15% in 1970) and among adults, between the ages of 19-64, 15% spend 10% or more of their income on healthcare premiums. Health care reform alone will not solve the cost problem because it allows more people into a system that is too expensive. Mark argued that UCSF cannot expect its reputation to maintain its position as a preferred place for patient care: in a recent survey, consumers rated as the most important benefits from their health plan was a low monthly premium and the coverage for dependent adults, and the least important benefit was access to prestigious institutions such as the Mayo Clinic (and UCSF).
Mark closed by saying the way we can ease cost pressure is to improve value. We need to obtain pertinent data and to find the intellectual commonality of what constitutes good value in healthcare. Is it “No chemotherapy in the last two weeks of life?” or “No MRI’s for run of the mill back pain?” We might not be able to educate every physician to change their mind, but protocols can be designed which don’t involve the physician, whose involvement, by nature, is expensive.
Catherine Lucey,followed Mark’s presentation with a pertinent question for discussion: If we don’t take charge, then who will? She invited the audience to discuss in small groups the issue of improving value in healthcare. She asked three key questions:
- Who should be in the tent? Patients, providers, administrators, legislators?
- How do we motivate people to change?
- What structure can we put in place to make lives easier to make wise choices?
Among the audience responses were from Adams Dudley who said that fundamental change in the system will occur when we work with different partners who are willing to pilot new models of patient care, for example, reimbursing for telephone patient visits. Rita Redberg explained that today there aren’t negative consequences if physicians do more than is necessary. We have to embrace a culture change that encourages us to do less without jeopardizing care.
Robert Wachter, moderated a panel discussion highlighting work that is being done today in the department to encourage healthcare value. Panelists were Chris Moriates, Jinoos Yazdany and Rita Redberg. Chris gave a brief overview of the Cost Awareness curriculum he developed as a second and third-year resident. Jinoos summarized lessons learned in developing a Top 5 List of what patients and physicians should question in Rheumatology. Rita Redberg asked the audience, “What evidence is there that patients want tests?” She noted that studies show that patients usually opt for more conservative treatment, if they are informed of those options.
Larry Shapiro, Managed Care Medical Director, Palo Alto Medical Foundation, began the afternoon session with a very compelling presentation on variation data. He remarked that physicians need un-blinded data to focus on the root cause of variation. Looking at this data together will allow physicians to create a proxy for evidence-based medicine where none currently exists. By reducing variation physicians can affect the overall cost of care.
In the afternoon the retreat participants were assigned two Breakout Group sessions. In the first session they were grouped by mission area (clinical activities, education or research). In the second session they were grouped by hospital site. Their charge was to develop ideas that would improve health value in the Department and could be viable submissions to the 2012 Quality and Safety Innovation Challenge.