BYU College of Health and Human Performance

Transcription

♪♪ >>THIS BYU FORUM ADDRESS WITH DOCTOR BRENT JAMES WAS GIVEN ON MARCH 18, 2014. >>GOOD MORNING BROTHERS AND SISTERS. I AM PLEASED TO WELCOME YOU HERE THIS MORNING FOR TODAY'S FORUM. MY NAME IS BRENT WEBB, AND PRESIDENT SAMUELSON HAS ASKED ME TO CONDUCT TODAY. WE ARE DELIGHTED TO WELCOME TO CAMPUS DR. BRENT C. JAMES, EXECUTIVE DIRECTOR OF THE INSTITUTE FOR HEALTH CARE DELIVERY RESEARCH AT INTERMOUNTAIN HEALTHCARE. HIS PRESENTATION TODAY IS ENTITLED "WE COUNT OUR SUCCESSES IN LIVES, HEALTH VERSUS HEALTH CARE". WE WELCOME HIS WIFE EVE, WHO IS SEATED ON THE STAND WITH HIM. DR. BRENT JAMES IS A MEMBER OF THE PRESTIGIOUS NATIONAL ACADEMY OF SCIENCE'S INSTITUTE OF MEDICINE AND PARTICIPATED IN MANY OF THAT ORGANIZATION'S SEMINAL STUDIES ON QUALITY AND PATIENT SAFETY. DR. JAMES GRADUATED MAGNA CUM LAUDE WITH BACHELOR OF SCIENCE DEGREES IN COMPUTER SCIENCE AND MEDICAL BIOLOGY FROM THE UNIVERSITY OF UTAH. HE HOLDS A MASTER'S DEGREE IN STATISTICS AND EARNED HIS MD FROM THE UNIVERSITY OF UTAH, WITH RESIDENCY TRAINING IN GENERAL SURGERY AND ONCOLOGY. DR. JAMES IS A FELLOW OF THE AMERICAN COLLEGE OF PHYSICIAN EXECUTIVES AND HOLDS FACULTY APPOINTMENTS AT THE UNIVERSITY OF UTAH SCHOOL OF MEDICINE, THE HARVARD SCHOOL OF PUBLIC HEALTH, AND THE UNIVERSITY OF SYDNEY SCHOOL OF PUBLIC HEALTH IN AUSTRALIA. DR. JAMES HAS BEEN HONORED WITH A SERIES OF AWARDS FOR HIS WORK IN ASSESSING QUALITY IN HEALTH CARE DELIVERY. IN 2011 HE WAS THE FIRST HEALTHCARE PROFESSIONAL TO BE AWARDED THE COLUMBIA UNIVERSITY SCHOOL OF BUSINESS'S DEMING CUP, A DISTINCTION RECOGNIZING WORLD LEADERS WHO HAVE MADE OUTSTANDING CONTRIBUTIONS IN FOSTERING OPERATIONAL EXCELLENCE AND CONTINUOUS IMPROVEMENT IN THEIR ORGANIZATION. JUST TWO WEEKS AGO, DR. JAMES WAS AWARDED THE PACKARD LECTURESHIP BY THE UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES, THE NATION'S ONLY FEDERAL HEALTH SCIENCES UNIVERSITY. THE PACKARD LECTURE IS THE UNIVERSITY'S MOST PRESTIGIOUS LECTURESHIP. DR. JAMES IS A MEMBER OF A NUMBER OF NATIONAL TASKFORCES AND COMMITTEES THAT EXAMINE HEALTH CARE QUALITY AND COST CONTROL, INCLUDING THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY AND HIS MOST RECENT APPOINTMENT BY THE FEDERAL CONTROLLER TO AN ADVISORY GROUP ON MAKING AMERICAN HEALTH CARE MORE ACCESSIBLE AND AFFORDABLE. DR. JAMES AND HIS WIFE, EVE, HAVE A SON WHO IS AN ALUMNUS OF BYU, AND TWO DAUGHTERS STILL AT HOME. WOULD YOU PLEASE JOIN ME IN GIVING A WARM WELCOME TO DR. BRENT JAMES. [APPLAUSE] >>THANKS VERY MUCH DOCTOR WEBB, IT'S A TRUE DELIGHT TO BE WITH YOU. I'VE BEEN ASSIGNED THE TOPIC OF HEALTH REFORM, A TOPIC THAT COULDN'T BE MORE TIMELY. THE CONGRESS OF THE UNITED STATES PASSED THE PATIENT PROTECTION AFFORDABLE CARE ACT BACK IN THE SPRING OF 2009 AND VERY RAPIDLY AFTER PRESIDENT BARACK OBAMA SIGNED IT INTO LAW IT OFFICIALLY TOOK EFFECT IN 2010, BUT RIGHT NOW, 2014 IS WHEN THE MAIN ELEMENTS OF THE LAW ARE ACTUALLY FINALLY COMING INTO PLAY, YOU MAY RECALL LAST FALL WE SAW THE INITIAL ROLLOUT OF THE FEDERAL GOVERNMENT'S HEALTHCARE INSURANCE EXCHANGES, WE'RE JUST TWO WEEKS AWAY, A LITTLE LESS, MARCH 31 BEFORE EVERY ADULT CITIZEN IN THE COUNTRY NEEDS TO EITHER HAVE HEALTH INSURANCE OR PAY A HEFTY FEDERAL FINE. IN TALKING ABOUT HEALTH REFORM, I REALLY WANT TO THINK OF IT IN TWO DIFFERENT WAYS. FIRST I'M GOING TO TALK ABOUT IS SEEKING AFTER MIRACLES, WHICH IS A PRETTY APT DESCRIPTION, AS IT TURNS OUT. IT'S TOP DOWN, IT'S HEALTH REFORM FROM A GOVERNMENT LEVEL, THE SECOND WAY TO MY MIND IS MUCH MORE INTERESTING, IT'S BOTTOM-UP, IT'S COMING OFF THE FRONT LINES OF THE HEALING PROFESSIONS AND BUILDING UP. I'VE TITLED THAT ONE BETTER HAS NO LIMIT. THE REASON FOR THAT IS IT'S THE DUTY OF EVERY GENERATION OF THE HEALING PROFESSIONALS TO PASS ALONG SOMETHING A LITTLE BETTER THAN WE OURSELVES RECEIVED, TO MAKE THE WORLD A BETTER PLACE, AND I THINK YOU'RE GOING TO SEE THAT COME THROUGH DRAMATICALLY. I'VE LABELED THAT "WE COUNT OUR SUCCESSES IN LIVES". WELL, LET'S RETURN TO THE FIRST TYPE OF HEALTH REFORM. WE REALLY NEED TO UNDERSTAND TWO THINGS. IT HAS TO DO WITH FOREST AND TREES, WHERE YOU CAN'T SEE THE FOREST FOR THE TREES, AS I HOPE YOU'LL SEE IN A MOMENT. YEAH, THE SECOND TOPIC IS CALLED "THE GREAT EQUATION", WE NEED TO GET THAT ON THE TABLE, BUT BEFORE THAT A MORE IMPORTANT ONE, THE TREES ARE SUPPLIED BY SOMETHING CALLED THE RULE OF RESCUE. IN 1986 A FELLOW NAMED JOHNSON DEFINED THE RULE OF RESCUE AS THE IMPERATIVE PEOPLE FEEL TO RESCUE IDENTIFIABLE INDIVIDUALS FACING SUFFERING OR DEATH. NOW, LATER COMMENTATORS ASKED AN IMPORTANT QUESTION, THEY SAID DO THE THINGS WE DO HAVE TO WORK? DO THEY HAVE TO BE EFFICACIOUS? THE ANSWER APPEARS TO BE NO. IT'S THE EFFORT THAT COUNTS, IT'S A DO-SOMETHING, SHE'S DYING. A CLASSIC EXAMPLE IS THAT NEW HOUSING DEVELOPMENT DOWN IN TEXAS, THE KIDS ARE OUT PLAYING IN THE FIELD BEHIND THE HOUSE, THEY COME RUNNING IN, YOU DISCOVER THAT YOUR FIVE-YEAR-OLD HAS STEPPED INTO THE UNCAPPED HEAD OF AN EXPLORATORY OIL WELL. SHE'S IN AN 18-INCH DIAMETER TUBE, 75 FEET BELOW GROUND, CAN'T MOVE, JAMMED INTO THE TUBE IN THE COMPLETE DARK, BUT YOU HAVE A SMALL VOICE CALLING UP FROM THE EARTH, MOM, DAD, HELP ME. TURNS OUT THAT ADULT HUMANS WILL SPEND EVERY RESOURCE WE POSSESS. WE'LL RISK AND EVEN LOSE ANY NUMBER OF ADULT LIVES AND WILL NOT COUNT THE COST TO RESCUE THE CHILD. THAT'S THE RULE OF RESCUE RIGHT THERE. INTERESTINGLY IT DOESN'T JUST APPLY TO HUMANS. WE REACT THE SAME WAY TO ANIMALS IN CERTAIN CIRCUMSTANCES, WHALES TRAPPED IN THE ARCTIC ICE. A REAL STORY OF A DOG ON AN ABANDONED FISHING BOAT IN HONOLULU, THE SAME RESPONSE. IN SOME WAYS IT'S THE BEST THING ABOUT US AS HUMAN BEINGS, THIS DEEP CONCERN FOR OTHERS. BUT INTERESTINGLY, IT'S AN EMOTIONAL RESPONSE, IT REQUIRES A NAME AND A FACE. WE DON'T REACT THIS WAY TO STATISTICS. A SUBCONSCIOUS EMPATHY TRIGGERS OUR REACTION. NOW, THAT APPLIES IN HEALTH CARE TOO. WHEN IT COMES TO RESCUE CARE, THE UNITED STATES DOMINATES THE WORLD. FOR EXAMPLE, TWO YEARS AGO WE HAD THE 20TH ANNIVERSARY OF PRINCESS DIANA'S DEATH IN AN AUTOMOBILE ACCIDENT IN PARIS. EVERY TIME THAT COMES UP, MOST OF THE ARGUMENT IS IN PARIS AND LONDON. IT REIGNITES AN OLD DEBATE, IF DIANA HAD HAD THAT ACCIDENT IN ANY MAJOR AMERICAN CITY, INCLUDING PROVO UTAH, SHE WOULD BE ALIVE TODAY. AS CLINICIANS WE DIAGNOSE HER INJURIES, DISSECT THE TREATMENT SHE RECEIVED, IT'S NOT THAT FRANCE DOESN'T HAVE A TRAUMA CARE SYSTEM, IT'S JUST NOT WIDELY AVAILABLE TO ALL CITIZENS. THEY HAVE THE TECHNOLOGY, JUST NOT WIDELY DEPLOYED. THESE STATISTICS THAT YOU'RE SEEING ON THE SLIDE COME FROM SOMETHING CALLED E.C.D, COLLABORATION INVOLVING FIRST-WORLD NATIONS, AND IT'S ACCURATE, IT'S STATISTICALLY SIGNIFICANT AS WELL. MORTALITY FOLLOWING MAJOR TRAUMA, THE UNITED STATES IS LITERALLY HALF OF WHAT IT IS IN EUROPEAN COUNTRIES, IN CANADA AND AUSTRALIA. BECAUSE OF THAT WIDELY DEPLOYED RESCUE SYSTEM. SECOND WONDERFUL EXAMPLE, HEART ATTACKS AND MORTALITY RATES ARE TWO-THIRDS OF WHAT THEY ARE IN OTHER FIRST-WORLD NATIONS. JUST AS AN ILLUSTRATION, LIVER TRANSPLANTS PER 100,000 POPULATION, WE ROUGHLY DOUBLE WHAT HAPPENS IN EUROPE. THE EXAMPLES OF THIS ARE ENDLESS, OR ALMOST ENDLESS, CANCER CARE, KIDNEY TRANSPLANTS. WELL, IT'S ASSOCIATED WITH VERY SOPHISTICATED, HIGH-TECHNOLOGY MEDICINE, SPECIALTY CARE IS ANOTHER NAME FOR THIS IDEA OF RESCUE. NOW SOME THINGS YOU NEED TO KNOW ABOUT IT. CARE IN THE UNITED STATES IS ROUGHLY TWICE AS EXPENSIVE AS ANY OTHER COUNTRY SPANS. ABOUT HALF OF THAT PRICE DIFFERENCE IS THE FACT THAT WE ENGAGE SO HEAVILY IN RESCUE. OTHER COUNTRIES DON'T, THEY RE-DEPLOY THEIR RESOURCES TO OTHER DESTINATIONS. THE SECOND HALF IS SOMETHING CALLED UNIPRICING, WE SPEND MORE PER PHYSICIAN THAN EUROPE DOES, MORE PER NURSE, MORE FOR A DOSE OF A SPECIFIC DRUG, MORE FOR A LAB TEST, WE BEAR MOST OF THE BURDEN OF RESEARCH IN THE WORLD IN THIS COUNTRY BY PAYING HIGHER PRICES. TRUTH IS, AS VERY OFTEN RESCUE CARE FEELS LIKE MIRACLES, AND THEY ARE MIRACLES, IF YOU'VE EVER EXPERIENCED THEM. I HAVE THAT PRIVILEGE OFTEN. BACK WHEN I WAS PRACTICING MEDICINE STILL SEE IT TODAY, YOU PULL SOMEBODY BACK FROM THE JAWS OF DEATH, LITERALLY SOMETIMES. THOSE ARE THE TREES. THOSE MIRACLES, THEY STICK IN PEOPLE'S MIND TO THE POINT WHERE YOU CAN'T SEE ANYTHING ELSE. THE KEY THING ABOUT RESCUE CARE, IT DOES NOT SIGNIFICANTLY INCREASE POPULATION LEVEL LIFE EXPECTANCY. BY LIFE EXPECTANCY I MEAN HOW LONG AND HOW WELL PEOPLE LIVE IN SUMMARY ACROSS A POPULATION. THE REASON IS AS AVERAGES INFORMATION, NUMBER TWO I MIGHT HAVE TO TREAT FIVE, TEN, EVEN MORE THAN THAT PEOPLE TO GET THE ONE MIRACLE. THE TECHNOLOGIES WE USE ARE INNATELY DANGEROUS, ANYTHING THAT'S POWERFUL ENOUGH TO HEAL CAN ALSO HARM AND IT'S USUALLY ASSOCIATED WITH SMALL LOSSES IN LIFE EXPECTANCY FOR THE ONES WHERE WE DON'T GET IN THE WIND, THE MISSES. BUT WHEN YOU SUM IT UP, NOT ONE PERSON BUT 10 ATTENUATES THE EFFECT OF THE ONE, DOESN'T IT. WHEN YOU GET THOSE SMALL LOSSES, IT ATTENUATES IT EVEN FURTHER, BUT IN SUMMARY, RESCUE CARE DOES NOT DRIVE LIFE EXPECTANCY IN THIS COUNTRY OR OTHERS. IN SOME SENSE THOUGH AGAIN, IT'S THE BEST THING ABOUT US, BEING WILLING TO STEP UP WHEN SOMEBODY'S FACING SOME OF LIFE'S MOST DIFFICULT CHALLENGES. WELL, THAT LEADS US TO THE SECOND KEY PRINCIPLE WE NEED ON THE TABLE. BACK IN 1977 A REALLY SMART MAN NAMED AARON MULDOWSKY CALLED IT THE GREAT EQUATION. IT'S THE IDEA THAT HEALTH, HOW LONG AND HOW WELL YOU LIVE, DEPENDS ON MEDICAL CARE. MEDICAL CARE, OF COURSE, IS MEANINGLESS WITHOUT ACCESS TO CARE AND ACCESS TO CARE MEANS HEALTH INSURANCE, SO LET ME JUST ASK THE QUESTION, IS HEALTH INSURANCE THE MOST IMPORTANT THING IN DETERMINING HOW LONG AND HOW WELL YOU WILL LIVE? JUST A COUPLE OF EXAMPLES, BACK IN 2002 THE WINTER OLYMPICS WERE COMING TO UTAH, THE WORLD WAS BEATING A PATH TO OUR DOOR AND LDS, WE REALLY ARE KIND OF A PECULIAR PEOPLE AND ONE OF THE MOST PROMINENT THINGS PEOPLE SEE IS OUR DIETARY HABITS, OUR NON-SMOKING AND ALCOHOL, THE WORD OF WISDOM. MY OFFICES HAPPENED TO BE RIGHT ACROSS THE STREET FROM THE CHURCH OFFICES IN SALT LAKE, AND ONE DAY WE GOT A REQUEST, WOULD WE GO OUT AND DO A LITERATURE REVIEW ABOUT THE HEALTH IMPACT OF THE WORD OF WISDOM, ARRAY THE EVIDENCE FOR PEOPLE WHO CAME WITH QUESTIONS DURING THE OLYMPICS AND WE DID, WE FOUND ABOUT 60 MAJOR ARTICLES JUST TO GIVE YOU A VERY BRIEF SUMMARY OF THE FINDINGS, THEY'RE MUCH BROADER THAN THIS. THIS WAS COMPARING RELIGIOUSLY ACTIVE LDS MEN IN SOUTHERN CALIFORNIA LITERALLY TO THEIR NEIGHBORS LIVING IN THE SAME ENVIRONMENT, THE SAME COMMUNITIES, BALANCED ON OTHER FACTORS, THE ONLY DIFFERENCE WAS ACTIVITY IN THE LDS CHURCH, MEMBERS OF THE LDS CHURCH LIVED ON AVERAGE SEVEN YEARS LONGER, THEY HAD ABOUT 50 PERCENT OF THE AGE-ADJUSTED MORTALITY RATE OF THEIR NON-LDS COUNTERPARTS, NOW THIS ISN'T UNIQUE TO THE LDS CHURCH, ANYBODY WHO FOLLOWS THOSE HEALTH ACTIVITIES GETS THE SAME EFFECT, SOMETIMES EVEN MORE PROFOUNDLY, JUST TO ILLUSTRATE THERE'S A LARGE GROUP OF PEOPLE IN THE UNITED KINGDOM, ABOUT 20,000 STRONG A COMMUNITY THEY'VE BEEN TRACKING NOW FOR OVER 25 YEARS, AND THEY WENT INTO THE PROJECT, THEY IDENTIFIED THOSE WHO USE NO TOBACCO, VERY VERY LIMITED ALCOHOL USE, THAT'S THE FIRST HALF OF THE WORD OF WISDOM THAT WE ALL TEND TO FOLLOW RELIGIOUSLY, THEY ALSO TRACK DIETARY HABITS AND REGULAR EXERCISE, THAT'S THE SECOND HALF OF THE WORD OF WISDOM, SOMETIMES IN LDS COMMUNITIES WE TEND TO IGNORE JUST A BIT. IN THAT STUDY THOSE WHO DID WELL ON THOSE FOUR FACTORS COMPARED TO THOSE WHO DID NOT ON ALL FOUR HAD ONE QUARTER THE MORTALITY RATE AND HAVE GONE ON AVERAGE 14 YEARS LONGER. THERE ARE DIFFERENT VISIONS OF THE SAME THING, FOR EXAMPLE, WE KNOW THE PEOPLE IN EUROPE LIVE ON AVERAGE ABOUT THREE YEARS LONGER THAN PEOPLE IN THE UNITED STATES, THIS IS USED AS A CRITICISM OF THE HEALTH CARE DELIVERY SYSTEM. A COUPLE OF YEARS AGO A GROUP CALLED THE NATIONAL RESEARCH COUNCIL, THEY'RE ALSO A PART OF THE NATIONAL ACADEMY OF SCIENCES DID A FORMAL EVIDENCE REVIEW, THEY WERE TRACKING DOWN THE REASON FOR DIFFERENCES IN LIFE EXPECTANCY. THEY FOUND THREE MAIN THINGS, NUMBER ONE, MUCH HIGHER SMOKING RATES IN THE UNITED STATES, WE'RE ACTUALLY SEEING THE TAIL OF THAT, THESE RATES WERE UP ABOUT 30-50 YEARS AGO, BUT THE HEALTH CONSEQUENCES OF THOSE BEHAVIORS ARE NOW JUST PLAYING THROUGH OUR POPULATION. FRANKLY, AMERICANS TEND TO BE MORE OBESE, EXHIBIT A MORE SEDENTARY LIFESTYLE, WHICH WE UNDERSTAND SHORTENS LIFE AS WELL. LESS EFFECTIVE PREVENTION, PREVENTATIVE MEASURES, USUALLY AT A PRIMARY CARE LEVEL. INTERESTINGLY, THEY CONCLUDED THAT THE HEALTH CARE DELIVERY SYSTEM OF THE UNITED STATES PROBABLY WAS A BIT BETTER THAN IN EUROPE. ANOTHER WAY OF LOOKING AT IT, A NATURAL EXPERIMENT PROSPECTIVELY TESTING THE IMPACT OF HEALTH CARE DELIVERY HAS HAPPENED IN THE STATE OF OREGON, THEY HAD ABOUT 90,000 ADULTS WHO WERE TECHNICALLY UNDER THE FEDERAL POVERTY LEVEL, BUT THE STATE DIDN'T HAVE SUFFICIENT BUDGET TO PLACE THEM ON THE HEALTHCARE INSURANCE PROGRAM, MEDICAID FOR THE POOR. THEY HAD A BUDGET WINDFALL, IT WASN'T SUFFICIENT TO FUND ALL 90,000 THOUGH, ABOUT 30,000 PEOPLE COULD COME INTO HEALTH INSURANCE. THEY IT RANDOMLY, THEY USED A LOTTERY TO SELECT THEM AND IN SO DOING CREATED WHAT WE CALL A RANDOMIZED CONTROL TRIAL, THE IDEAL PINNACLE STUDY DESIGN. AFTER 25 MONTHS UNDER THAT PLAN THEY CHECKED TO SEE WHAT IMPACT IT HAD, NOW IT DID HAVE A FAIRLY SIGNIFICANT IMPACT ON MONEY, ON AVERAGE THOSE NEW MEDICAID RECIPIENTS HAD $215 LESS OUT OF POCKET EXPENSES EACH YEAR, PROBABLY CLOSER TO $8000 DOLLARS ON STATE EXPENDITURES ON HEALTH CARE, AND THOSE WHO FACE CATASTROPHIC EXPENDITURES WITHOUT INSURANCE, THAT MEANS LESS THAN 30 PERCENT OF YOUR INCOME RELATIVE TO HEALTH CARE NEEDS, THAT'S A MORE DRAMATIC FALL, FROM 5.5 PERCENT TO 1 PERCENT, HOWEVER THERE WAS NO CHANGE IN HEALTH STUDIES. ACROSS A SERIES OF IMPORTANT CONDITIONS WITHIN THE CONTEXT OF THIS CONTROLLED TRIAL. DOES THAT SURPRISE YOU THAT THERE WAS NO CHANGE, GIVEN WHAT WE JUST TALKED ABOUT? YEAH, PROBABLY THE BEST SUMMARY STUDY ON THIS TOPIC COMES FROM A MAN NAMED MIKE MCGINNIS, HE'S A SURGEON'S WHO'S AT THE INSTITUTE OF MEDICINE IN WASHINGTON, HE SUMMARIZED LITERATURE IN TERMS OF WHAT DETERMINES TOTAL HEALTH, HOW LONG AND HOW WELL YOU'LL LIVE, LIFE EXPECTANCY. NOW, WITH HIS PERMISSION I'VE ROUNDED THESE OFF TO MAKE THEM MEMORABLE. 40 PERCENT, 30 PERCENT, 20 PERCENT, 10 PERCENT. IN FACT, BEHAVIORS WERE 42 PERCENT OF YOUR LIFE EXPECTANCY. IN THAT STUDY, THE MAJOR SOURCES OF LOSS OF LIFE TO BEHAVIORS, NUMBER ONE'S TOBACCO, NUMBER TWO'S ALCOHOL AND OTHER RECREATIONAL DRUGS, NUMBER THREE, JOANN GRAUDY, FORMER CHIEF OF BIOENGINEERING AT THE UNIVERSITY OF UTAH CALLS IT MDD, MOVEMENT DEFICIT DISORDER, I SUFFER FROM IT PERSONALLY, I WOULD MUCH RATHER ADMIT TO THAT MEDICALIZED CONDITION THAT I'M JUST A BIT OVERWEIGHT AND DON'T GET ENOUGH EXERCISE, ITS OBESITY OF COURSE, WHICH MAY BE SUPPLANTING ALCOHOL AT NUMBER TWO TODAY. NUMBER FOUR, SEXUALLY TRANSMITTED DISEASE INCLUDING AIDS, NUMBER FIVE I'VE LISTED IT AS UNWED TEENAGE PREGNANCY, TEENAGERS ARE PERFECTLY CAPABLE OF BEARING HEALTHY CHILDREN. THE PROBLEM IS THE LACK OF A SOCIAL SUPPORT NETWORK FOR THIS NEW SMALL FAMILY, MOST REALIZED IN DAMAGE TO HEALTH OF THE NEWBORN. FINALLY NUMBER SIX, SUICIDE, VIOLENCE, AND ACCIDENTS, PRIMARILY YOUNG MEN. THIS REPORT FROM THE AMERICAN MEDICAL ASSOCIATION HAS SUBMITTED THAT MORE THAN HALF OF ALL HEALTHCARE EXPENSE IN THE UNITED STATES OF AMERICA TODAY TRACK STRAIGHT BACK TO BAD BEHAVIORS IN THOSE SIX AREAS. WELL, IF THAT'S 42 PERCENT OF YOUR TOTAL HEALTH, ABOUT 30 PERCENT COMES FROM YOUR GENES. THE JOKE IS HOW WISE YOU WERE IN SELECTING YOUR PARENTS, WE'VE STARTED TO MAKE SOME MAJOR SCIENTIFIC INROADS INTO THIS CATEGORY, STILL TOO EARLY THOUGH TO HAVE WIDELY AVAILABLE INTERVENTIONS THAT CAN CHANGE A PATIENT'S FUTURE RELATIVE TO GENETIC PREDISPOSITIONS. 23 PERCENT TURNED OUT TO BE SOMETHING CALLED PUBLIC HEALTH. IT MOSTLY HAS TO DO WITH CONTROL OF EPIDEMIC INFECTIOUS DISEASE THROUGH IMMUNIZATION AND SANITATION, SO THOSE CHOLERA EPIDEMICS THAT WOULD KILL THOUSANDS, SMALLPOX, PROBABLY KILLED HALF OF THE PEOPLE IN NORTH AND SOUTH AMERICA, ALLOWING EUROPEANS TO SETTLE WHEN THAT WAS INTRODUCED AMONG NATIVE AMERICAN TRIBES, A POPULATION WITH NO NATURAL IMMUNITY INTRODUCED FROM EUROPE. PERTUSSIS, DIPHTHERIA IN CHILDREN, BEYOND CONTROL OF EPIDEMIC INFECTIOUS DISEASE IT'S CLEAN AIR, SAFE WATER, GOOD FOOD. IF I TURN INSTEAD THOUGH, TO THIS GRAND ENTERPRISE, THE HEALTH CARE DELIVERY SYSTEM, HOSPITALS AND CLINICS, DOCTORS AND NURSES THAT THEY CONSUME 2.8 TRILLION DOLLARS PER YEAR. 18 PERCENT OF OUR NATIONAL WEALTH. AT BEST IT ACCOUNTS FOR ABOUT 10 PERCENT OF HOW LONG AND HOW WELL YOU'LL LIVE. THIS IS WHERE THE MIRACLES HAPPEN THOUGH, DOWN THERE IN THAT SMALL MARGIN. ACTUALLY, IN SAYING 10 PERCENT I'M BEING GENEROUS, IF I PUT ON MY GREEN VISOR AND SHARPENED MY PENCIL AND GOT SCIENTIFICALLY RIGOROUS IT'S PROBABLY CLOSER TO FIVE. WELL, FIVE TO TEN PERCENT, THAT'S STILL THREE AND A HALF TO SEVEN YEARS IN LIFE EXPECTANCY. ACROSS THE ENTIRE POPULATION OF THE UNITED STATES ON AVERAGE, AT MY AGE THAT DOESN'T LOOK TOO BAD, LET'S NOT GET TOO CAVALIER HERE ABOUT WHAT THIS IS PRODUCING. HE NOTED EVEN WAY BACK IN 1977 THIS IDEA OF THE GREAT EQUATION, THAT HEALTH EQUALS MEDICAL CARE, AND MEDICAL CARE MEANS ACCESS TO INSURANCE. THE GREAT EQUATION IS FUNDAMENTALLY WRONG. THE EVIDENCE DOESN'T SUPPORT THE CONCLUSIONS ASSOCIATED WITH THAT VIEWPOINT. I SPENT MOST OF THE SPRING OF 2009 TRAVELLING BACK AND FORTH TO WASHINGTON DC, IT WAS A SEASON OF REFORM, I WAS ASKED TO TESTIFY TWICE IN THE SENATE FINANCE COMMITTEE, THAT'S THE MAIN SOURCE OF HEALTH POLICY IN WASHINGTON, SENATE FINANCE, ONCE TO TED KENNEDY'S HEALTH EDUCATION LABOR AND PENSIONS COMMITTEE, THAT'S NUMBER TWO, ONCE TO THE MONEY GUYS ON THE HOUSE SIDE, HOUSE WEIGHS THE MEANS. MORE THAN THAT I SPENT MANY MANY HOURS WORKING WITH THE SENIOR STAFF OF THOSE COMMITTEES, THAT'S WHERE THE REAL WORK OF LEGISLATION TAKES PLACE IN THOSE COMMITTEES, THAT'S WHERE THE ISSUES ARE DEBATED, THE COMPROMISES ARE FORGED, THE BIGGEST PART, WHERE THE LEGISLATION GETS DRAFTED, WE HAD TWO ISSUES ON THE TABLE, THE FIRST WAS 46 MILLION AMERICANS WITHOUT HEALTH INSURANCE, 46 MILLION AMERICANS UNDER 65 YEARS OF AGE, IT JUST SEEMS WRONG THAT THE RICHEST ECONOMY ON THE PLANET SHOULD HAVE THAT HOLD TRUE. 17 PERCENT OF OUR POPULATION WITHOUT ACCESS TO THAT ESSENTIAL RESOURCE, YOU SEE. THE SECOND IN SOME WAYS WAS EVEN MORE IMPORTANT, IT HAD TO DO WITH THE RATE OF COST INCREASES FOR HEALTH CARE DELIVERY. IN 1960 HEALTH CARE DELIVERY CONSUMED SIX PERCENT OF OUR TOTAL NATIONAL WEALTH OF GROSS DOMESTIC PRODUCT, 54 YEARS LATER, 2014, AS I MENTIONED EARLIER ALMOST 18 PERCENT, 2.8 TRILLION DOLLARS PER YEAR AND IT CONTINUES TO GROW RAPIDLY. I TRIED TO MAKE THE ARGUMENT THAT WE SHOULD FOCUS ON NUMBER TWO FIRST, THE COST OF HEALTHCARE, THEN IF WE FAILED TO DO SO EXPANDING INSURANCE WOULD BE POURING GASOLINE ON AN ALREADY RAGING FIRE, AND AS WE'LL SEE IN A MOMENT, HOLDING THE REAL POTENTIAL TO DESTROY THE UNITED STATES GOVERNMENT FINANCIALLY. THE TRUTH IS IS THAT OUR POLITICAL COLLEAGUES HAD NO APPETITE FOR DISCIPLINE, FOR RESTRAIN, EVEN, FOR EATING THEIR VEGETABLES, THEY MUCH PREFERRED EATING THEIR DESSERT, THEY WANTED TO EXPAND AN IMPORTANT ENTITLEMENT. IT'S FAIR TO SAY THAT THEY WERE SEEING THE TREES AND NOT NECESSARILY SEEING THE FOREST. INTERESTING STATISTIC, IT TURNS OUT THAT HEALTHY BEHAVIORS DEPEND PRIMARILY ON YOUR EDUCATION LEVEL. YOU CAN GET MORE HEALTH BENEFIT AT A POPULATION LEVEL FROM INVESTING IN GENERAL EDUCATION, I MEAN MORE HIGH SCHOOL GRADUATES, MORE COLLEGE GRADUATES WILL HAVE A BIGGER IMPACT ON THE HEALTH OF A POPULATION THAN INVESTING THE SAME DOLLARS IN HEALTH CARE DELIVERY. I ACTUALLY HAVE FOUR THINGS THAT TIE TOGETHER. HEALTHY BEHAVIORS DEPEND UPON EDUCATION LEVEL, EDUCATION LEVEL OF COURSE, DRIVES INCOME LEVEL. TWO-WAY STREET, ASSOCIATED WITH INCOME LEVELS AND OF COURSE THAT'S ASSOCIATED WITH LACK OF INSURANCE, YOU GET THOSE FOUR TIED TOGETHER, ALMOST IMPOSSIBLE TO PICK APART, BUT I THINK YOU GET AN IDEA OF WHAT I MEANT WHEN I SAID THAT WE'RE SEEKING AFTER MIRACLES. IT'S LIKE WE SELL LOTTERY TICKETS WHILE USING OTHER PEOPLE'S MONEY, VERY EXPENSIVE LOTTERY TICKETS AND EVERYONE WANTS A SHOT AT THE MIRACLE. YOU SEE, THE THING YOU NEED TO KNOW IS IT'S NOT WHAT WILL DETERMINE ON AVERAGE FOR MOST PEOPLE YOUR HEALTH ACROSS YOUR LIFE, YOUR OWN BEHAVIORS ARE DRAMATICALLY MORE IMPORTANT. PUBLIC HEALTH HAS A MUCH BIGGER IMPACT. YES, THE AFFORDABLE CARE ACT, IT REALLY WASN'T HEALTH REFORM, IT WAS INSURANCE REFORM. IT WILL REDUCE THE NUMBER OF UNINSURED IN THIS COUNTRY FROM ABOUT 46 MILLION TO 20-30 MILLION WHEN IT COMES FULLY UP ON PLAIN, IS FULLY DEPLOYED. IT WILL ALSO SIGNIFICANTLY INCREASE GOVERNMENT SPENDING ON HEALTHCARE. THE PROBLEM IS IT'S NOT HEALTH REFORM, AND THAT INCREASE IN HEALTH CARE COST, IF YOU THOUGHT THE DEBATE OVER HEALTH CARE WAS SETTLED, WAS GOING TO GO AWAY, WAS GOING TO ATTENUATE A BIT, SORRY. IF ANYTHING, IT'S GOING TO BECOME DRAMATICALLY MORE INTENSE THAN IT'S BEEN IN THE PAST. WE'LL GO INTO ROUND TWO ABOUT REAL HEALTH REFORM. CAN I TALK TO YOU ABOUT THAT FOR A BIT? REAL HEALTH REFORM? I BELIEVE THAT THE REASON THE CONGRESS OF THE UNITED STATES DIDN'T REALLY ADDRESS HEALTH REFORM IS BECAUSE THEY CAN'T. IT DOESN'T LEND ITSELF WELL TO TOP-DOWN PLANNING, IT'S SOMETHING THAT COMES MUCH MORE HEAVILY WITH BOTTOM-UP PLANNING, THE YEAR WAS 1986. I'D JUST LEFT THE HARVARD SCHOOL OF PUBLIC HEALTH AND THE HARVARD CANCER INSTITUTE IN BOSTON, HAD A PROFESSORSHIP THERE. CAME BACK TO THE MOUNTAINS AND WELL, A NEW IDEA. IT WAS A BUNCH OF TRAINED CLINICAL RESEARCHERS, WHO KNEW HOW TO MEASURE. WHAT WOULD HAPPEN IF YOU USED THE RIGOROUS TOOLS OF CLINICAL RESEARCH TO MEASURE ROUTINE CARE DELIVERY PERFORMANCE. NOW THE TRUTH IS IF YOU DID A MEDLINE SEARCH LOOKING FOR MAJOR ARTICLES AND PEER-REVIEWED JOURNALS PUBLISHED OVER THE LAST 50 YEARS AROUND THIS TOPIC, YOU'LL ROLL OUT MORE THAN 40,000 ARTICLES, AMAZINGLY CONSISTENT IN TONE, TENOR, AND FINDINGS. I'D LIKE TO BREAK IT DOWN INTO FIVE SUBCATEGORIES. I NEED YOU TO THINK ABOUT THIS IN A PARTICULAR WAY, THOUGH. I WANT YOU TO THINK OF IT AS OPPORTUNITY. IT'S EASY TO MAKE THE CASE THAT AMERICANS TODAY HAVE BETTER HEALTH CARE AND BETTER HEALTH THAN ANY PREVIOUS GENERATION OF PEOPLE LIVING ON THIS PLANET. IT'S EASY TO MAKE THE CASE, ESPECIALLY IF YOU LOOK ALONG THE LINE OF RESCUE CARE, THAT IT'S THE BEST YOU CAN FIND ANYWHERE IN THE WORLD. IT'S THE DUTY THOUGH OF EVERY GENERATION OF THE HEALING PROFESSIONS TO TAKE THAT NEXT STEP AHEAD. THIS IS REALLY A LIST OF AREAS WHERE WE FALL SHORT OF OUR THEORETIC POTENTIAL. THE FIRST STEP IN IMPROVEMENT IS NEARLY ALWAYS TO IDENTIFY OPPORTUNITIES, AND THAT'S HOW YOU NEED TO THINK ABOUT THIS. WE DO ROUTINE MIRACLES, BUT THEY COULD BE MUCH BETTER MIRACLES. FIVE MAJOR AREAS, IT STARTS WITH VARIATION, GEOGRAPHIC VARIATION. BACK IN 1973 A MAN NAMED JACK WINDBERG, A PROFESSOR AT DARTMOUTH UNIVERSITY PUBLISHED A SEMINAL PAPER IN THE JOURNAL SCIENCE. HE'D LOOKED AT DIFFERENT COMMUNITIES, OFTEN NEIGHBORING COMMUNITIES IN THE UNITED STATES AND LOOKED AT THE RATES AT WHICH PEOPLE WERE HOSPITALIZED FOR COMMON CONDITIONS. NOW I CAREFULLY BALANCED THE POPULATION FACTORS, AGE, GENDER, ETHNICITY, AND THE BIG ONE, BURDEN OF MORBID DISEASE, WHAT'S YOUR HEALTH STATUS GOING IN. BUT STILL SHOWED 20, 30, 40-FOLD VARIATION. SOMETIMES LITERALLY, 30 MILES APART, IT WAS DRAMATIC. IT TURNS OUT THAT WHERE YOU LIVED WAS MORE IMPORTANT THAN WHETHER YOU HAD INSURANCE IN DETERMINING THE CARE YOU WOULD ACTUALLY RECEIVE. STUNNING, IT CALLED INTO QUESTION THE WHOLE IDEA OF MEDICAL PRACTICE, WE CALL IT THE CRAFT OF MEDICINE, IT'S HOW I WAS TRAINED, HOW DOCTOR SAMUELSON WAS TRAINED AS WELL. IT'S THE IDEA THAT OWING A FOUNDATIONAL ETHICAL RESPONSIBILITY OF THE PATIENT, THAT I AGREE I'LL PUT A PATIENT'S HEALTHCARE NEEDS BEFORE ANY OTHER END RESULT, THEN DRAWING ON THIS MASSIVE KNOWLEDGE BASE GAINED FROM FORMAL TRAINING AND FROM PRACTICE EXPERIENCE, I CAN START LARGELY WITH RAW MATERIALS AND FOR EACH PATIENT THAT SEEKS MY HELP, I CAN CRAFT, AND CRAFT IS EXACTLY THE RIGHT WORD, A UNIQUE DIAGNOSTIC AND THERAPEUTIC EXPERIENCE FOR THAT INDIVIDUAL AND THE PROMISE WE MAKE AS A PROFESSION IS THAT APPROACH GUARANTEES THE BEST POSSIBLE MEDICAL OUTCOME. WELL, WHEN YOU LOOKED AT THE GEOGRAPHIC VARIATION, IT BECAME APPARENT THAT IT WAS PRETTY MUCH IMPOSSIBLE THAT ALL AMERICANS EVEN WITH FULL ACCESS TO CARE COULD POSSIBLY BE GETTING THE BEST CARE, IT QUESTIONED OUR WHOLE FOUNDATIONAL ETHIC, YOU SEE. OTHERS CAME BEHIND, SAID PERHAPS WE CAN EXPLAIN GEOGRAPHIC VARIATION BY INAPPROPRIATE CARE, THEY DEVELOPED RIGOROUS INSTRUMENTS FOR ASSESSING APPROPRIATENESS, NOW APPROPRIATENESS IS PURELY A MEDICAL DEFINITION, CARE IS INAPPROPRIATE IF THE RISK INHERENT IN THE TREATMENT OUTWEIGHS ANY POTENTIAL BENEFIT, THIS AMONG PROFESSIONS THAT HOLD AS THEIR FIRST MAXIM, FIRST DO NO HARM. GOT TWO MAJOR FINDINGS OUT OF THAT BODY OF RESEARCH, THE FIRST, INAPPROPRIATE CARE DOES NOT EXPLAIN GEOGRAPHIC VARIATION. LOW-UTILIZATION COMMUNITIES HAD ABOUT THE SAME AMOUNT OF CARE JUDGED CLINICALLY INAPPROPRIATE ON CAREFUL REVIEW BY ONE, AS HIGH-UTILIZATION COMMUNITIES. SECONDARY FINDING THAT WAS MUCH MORE TROUBLING, FOR SOME MAJOR TREATMENTS ROUTINELY PERFORMED IN U.S. HOSPITALS, AS MUCH AS 32 PERCENT OF ALL CARE DELIVERED JUDGED TO BE CLINICALLY INAPPROPRIATE, WHERE THE RISK OUTWEIGHED ANY POTENTIAL BENEFIT, IT SHOULD NEVER HAVE BEEN UNDERTAKEN, BUT WAS. USUALLY UNDER THE RUBRIC OF THE RULE OF RESCUE. NOVEMBER 30, 1999, THE INSTITUTE OF MEDICINES, COMMITTEE ON QUALITY OF HEALTHCARE IN AMERICA PUBLISHED A REPORT, YOU MAY HAVE HEARD OF IT. THAT'S WHERE WE ESTIMATED SOMEWHERE BETWEEN 44,000, 98,000 PREVENTABLE DEATHS EACH YEAR IN HOSPITALS, WHERE THE CAUSE OF DEATH WAS NOT THE PATIENT'S UNDERLYING DISEASE, BUT THE TREATMENTS THEY RECEIVED FOR THOSE DISEASES. WELL, TREATMENTS THAT TWO INDEPENDENT PHYSICIAN REVIEWERS SEPARATELY AGREED WERE COMPLETELY AVOIDABLE, UNNECESSARY DEATHS, TRUTH IN ADVERTISING, MY NAME IS ON THE REPORT, I WAS A MEMBER OF THAT COMMITTEE, WE'D DONE AN EVIDENCE REVIEW, FOUND ABOUT 60 MAJOR ARTICLES, BELIEVE IT OR NOT WE WERE TRYING TO BE CONSERVATIVE. BY THE WAY, THE 44,000 NUMBER COMES FROM UTAH WHERE WE'D DONE A PARTICULAR STUDY THEY USED IN THAT REPORT. SINCE THEN, WE'VE HAD SUBSEQUENT RESEARCH, IT SHOWS WE WERE CONSERVATIVE, JUST THREE OR FOUR MONTHS AGO A MAN NAMED JOHN JAMES, NO RELATION PUBLISHED AN UPDATED ESTIMATE OF 200,000 PREVENTABLE DEATHS. NOW, DON'T BE TOO JUDGMENTAL ABOUT THAT. YOU HAVE TO REMEMBER THAT ON NET, HEALTH CARE DELIVERY ADDS THREE AND A HALF TO SEVEN YEARS OF LIFE TO EVERY PERSON IN THE UNITED STATES, AND THAT'S NET WITH THESE INJURIES. THE UPSIDE IS USUALLY GREATER THAN THE DOWNSIDE, AND ANY CLINICIAN UNDERSTANDS THAT YOU'RE VERY OFTEN WALKING A THIN LINE BETWEEN HELP AND HARM, AND MEDICATION THAT'S ABSOLUTELY LIFE-SAVING IN A THERAPEUTIC DOSE, SLIGHT OVERDOSE CAN BE AS DEADLY AS YOU CAN IMAGINE, AND IT'S ALMOST IMPOSSIBLE TO STOP STEPPING OVER THE LINE. IT MEANS YOU DIDN'T READ THE SECOND HALF OF THE REPORT. WE UNDERSTOOD HOW DIFFICULT IT WAS TO DELIVER THAT LEVEL OF CARE. WE LAID OUT A SYSTEM BY WHICH YOU COULD DRAMATICALLY REDUCE INJURY RATES, BY AS MUCH AS 60 OR 70 PERCENT AND STILL GET ALL THE BENEFITS, THAT WAS THE POINT, THAT WE COULD BE SO MUCH BETTER. NUMBER FOUR ON THE LIST, WE HAVE SOME THINGS THAT WE KNOW FOR A FACT WORK, HARD EVIDENCE OF BENEFIT, USUALLY WITH STRONG RANDOMIZED CONTROLLED TRIAL EVIDENCE. THEY TEND TO BE NON-CONTROVERSIAL WITHIN THE MEDICAL PROFESSION, WELL, BETH MCGLINNET RAND MEASURED HOW WELL WE EXECUTE IT, TURNS OUT WE GOT IT RIGHT 54.9 PERCENT OF THE TIME FOR ADULTS, 46 PERCENT OF THE TIME FOR CHILDREN. NOW IF I CAN ROUTINELY ACHIEVE MIRACLES DOING IT CORRECTLY 50 PERCENT OF THE TIME ROUGHLY, WHAT KIND OF MIRACLES COULD I ACHIEVE IF I COULD DO IT SOMETHING MUCH CLOSER TO 100 PERCENT OF THE TIME, WE CALL THESE INJURIES OF OMISSION. THE LAST ON THE LIST IN SOME WAYS IS THE MOST IMPORTANT THOUGH, A FEW YEARS AGO A COLLEAGUE AND I, DOCTOR LUCY SABOTT GOT A LITTLE GRANT FROM THE AGENCY FOR HEALTH CARE RESEARCH AND QUALITY. WE TRIED TO TAKE ED DEMMING'S METHODS, THE FATHER OF QUALITY IMPROVEMENT THEORY AND MAP THEM OVER INTO HEALTHCARE, YOU SEE HE DEFINED A VERY BROAD DEFINITION OF WASTE IN CARE DELIVERY. WHEN WE DID THAT WE ENDED UP WITH A SIX-PART MODEL. WE COULD FIND NATIONAL ESTIMATES FOR TWO OF THE SIX, THE OTHER FOUR WERE NON-TRIVIAL BUT ON THE BASIS OF THOSE TWO ALONE, WE ESTIMATED THAT AT LEAST 50 PERCENT OF ALL RESOURCES CONSUMED IN HEALTHCARE DELIVERY TODAY ARE TECHNICALLY WASTE, NON-VALUE ADDING FROM A PATIENT'S PERSPECTIVE, WAIT A MINUTE, THAT'S 50 PERCENT OF A 2.8 TRILLION DOLLAR PER YEAR BUDGET. WHEN PRESIDENT OBAMA SAYS THE KEY TO THE U.S. ECONOMY IS HEALTHCARE, HE IS EXACTLY TECHNICALLY CORRECT, WELL, ON THAT FOUNDATION WE WERE ONE OF THE MAJOR CONTRIBUTORS TO THE VARIATION RESEARCH AND STARTED TO STUDY AND LEARN FROM VARIATION IN CARE DELIVERY. YEAH, WHY IS THAT IMPORTANT? IT'S CALLED THE FISCAL GAP. THE DEFICIT PART OF THAT, CURRENTLY AT 17.4 TRILLION DOLLARS, BUT FAR MORE IMPORTANT IS THE RATE AT WHICH IT WILL GROW IN THE FUTURE. SOCIAL SECURITY, FOR EXAMPLE, FOR PEOPLE ALIVE IN 2009, 7.7 TRILLION DOLLARS SHORT OF MEETING ITS OBLIGATIONS. THAT'S WHY YOU YOUNG PEOPLE SHOULDN'T COUNT ON IT TOO MUCH, AT LEAST IN ITS PRESENT FORM. THAT'S DESPITE CONSUMING 13 PERCENT OF ALL WAGES AND SALARIES, ROUGHLY. SIX AND A HALF PERCENT ON YOUR PAY STUB, SIX AND A HALF PERCENT WITH MATCHING FUNDS FROM YOUR EMPLOYER, IT PALES IN COMPARISON TO MEDICARE. 38.7 TRILLION DOLLARS SHORTFALL, THAT TOTALS TO ABOUT 63 TRILLION DOLLARS, NOW THIS COMES FROM A FELLOW NAMED WALKER AT THE GOVERNMENT ACCOUNTING AGENCY BACK IN 2009, A FAR BETTER ANALYST THAN MOST RESPECTED MEN IN WASHINGTON, I THINK ON THIS TOPIC, A FELLOW NAMED FOSTER, ALSO AT MEDICARE, BUT HE RUNS THE OFFICE OF THE ACTUARY. HE SAYS THE REAL NUMBER FOR PEOPLE ALIVE IN 2009 IS ABOUT TWICE THAT, 120 TRILLION. HE SAID IF WE DO IT INTO THE FAR FUTURE AS AN AT-PRESENT VALUE, 211 TRILLION, WAIT A MINUTE, 211 TRILLION, THAT'S A REALLY BIG NUMBER. I WONDER WHAT THAT MEANS. THE BEST WAY I KNOW TO PUT IT INTO PERSPECTIVE FOR YOU, THE PRESENT VALUE OF THE UNITED STATES OF AMERICA, ALL PUBLIC AND PRIVATE, PHYSICAL AND INTELLECTUAL PROPERTY, YOUR HOMES, YOUR CARS, THE APARTMENTS IN WHICH YOU LIVE, THE MARRIOTT CENTER, THIS WHOLE UNIVERSITY, MY SUIT, EVERYTHING, ABOUT 75 TRILLION. TECHNICALLY, THE GOVERNMENT OF THE UNITED STATES IS BANKRUPT, I MEAN NOT JUST MORALLY AND POLITICALLY, BUT FINANCIALLY IS THE JOKE, DID YOU NOTICE THAT TWO-THIRDS OF THE SHORTFALL IS HEALTHCARE? IN THAT CONTEXT, GO BACK TO ME TO 1991, LDS HOSPITAL IN SALT LAKE CITY. DOCTOR ALLEN MORRIS IS A MAJOR PULMONARY RESEARCHER, WE WERE STUDYING AS HE'S CALLED ACUTE RESPIRATORY DISTRESS SYNDROME. NOW I DON'T NEED TO GO INTO THE DETAILS OF THE DISEASE EXCEPT TO SAY THAT IT'S A REALLY REALLY NASTY KILLER. NORMALLY WE MANAGE THIS DISEASE IN AN ICU WITH MECHANICAL VENTILATOR, PUT YOU ON A VENTILATOR, USE HIGH RESPIRATORY PRESSURE AND OXYGEN CONCENTRATIONS TO TRY AND GET OXYGEN INTO YOUR BLOOD THROUGH A LUNG THAT'S FLUID-FILLED, TISSUE FLUID INTO THE AIRSPACES OF THE LUNG, NO MORE GAS EXCHANGE. WELL, A GROUP IN ITALY HAD COME UP WITH SOME BEAUTIFUL RESCUE CARE, IT WAS AN ARTIFICIAL LUNG CALLED ECORE WHERE YOU CIRCULATED THE PATIENT'S BLOOD OUT OF THEIR BODY TO REMOVE CARBON DIOXIDE AND ADD OXYGEN, AS WE PUT TOGETHER THE TRIAL, AN ISSUE CAME UP. UP TO THIS POINT IN TIME, EVERYONE JUST ASSUMED THAT EXPERT INTENSIVUS MANAGED VENTILATORS, SOME OF THE FINEST SCIENCE WE HAVE IN ALL OF MEDICINE, STRONG PHYSIOLOGIC MODELS, BUT FOR THE FIRST TIME IN LIGHT OF THE VARIATION LITERATURE WE THOUGHT TO LOOK, WHAT WE FOUND WAS MASSIVE VARIATION, NOW THIS IS ABSOLUTELY DEADLY TO A TRIAL. THAT'S WHY WE USE PROTOCOLS IN THE ARMS OF TRIALS, IF YOU DON'T DELIVER THE CARE IN A CONSISTENT FASHION IN THE ARMS OF TRIALS YOU CAN'T TELL IF THE TREATMENTS USED ARE CAUSALLY LINKED TO PATIENT OUTCOMES, WHICH IS WHAT YOU'RE SEEKING, OR IF IT'S SECONDARY TO THE BIAS ASSOCIATED WITH INCONSISTENT TREATMENT. WE THEREFORE SET OUT TO DEVELOP A PROTOCOL FOR VENTILATOR MANAGEMENT, IT'S RIFE WITH DIFFICULTY, I WON'T GO INTO THE DETAILS, BUT ALLEN CHOSE TO USE IT IN A REALLY CLEVER WAY. BASED AROUND BODY OF QUALITY THEORY CALLED LEAN, SOMETHING CALLED MASS CUSTOMIZATION. HERE'S THE FUNCTIONAL VERSION THAT WE ROUTINELY DEPLOY WITHIN INTERMOUNTAIN HEALTH CARE TODAY. YOU IDENTIFY A HIGH-PRIORITY CLINICAL PROCESS, THE BIGGEST SINGLE ONE WE DO IS PREGNANCY, LABOR, AND DELIVERY, WE DELIVER ABOUT 34,000 BABIES A YEAR. SECOND BIGGEST IS MANAGEMENT OF ASCHEMIT HEART DISEASE, HEART ATTACKS AND RELATED DISEASES, THAT'S THE SECOND-BIGGEST IN UTAH, SOMEWHERE ON THAT LIST IS ACUTE RESPIRATORY DISTRESS SYNDROME AS WELL, YOU BUILD AN EVIDENCE-BASED PRACTICE PROTOCOL RIFE WITH DIFFICULTIES, BUILD IT ANY WAY, I GUARANTEE IT'LL BE IMPERFECT. NEXT THING, YOU BLEND IT INTO CLINICAL WORKFLOW SO IT DOESN'T RELY ON HUMAN MEMORY. TODAY'S ENVIRONMENT IS TOO COMPLEX, EVEN FOR TRULY MASTERFUL EXPERTS TO KEEP TRACK OF ALL THE DETAIL. WHEN YOU RELY ON HUMAN MEMORY, PIECES FALL OFF, ROUTINELY. DON'T RELY ON MEMORY. WE HAVE ABOUT 20 TOOLS, STANDING ORDER SET, SPATIAL FLOW SHEETS, PATIENT WORKSHEETS, WHOLE SERIES OF TOOLS, SO THAT IF YOU JUST LET IT HAPPEN, DOCTOR, WHAT YOU GET IS EVIDENCE-BASED PRACTICE. NUMBER FOUR, YOU ALSO INVENT A DATA SYSTEM, IT'S GOING TO TRACK TWO THINGS, PROTOCOL VARIATIONS, MORE ON THAT IN A MINUTE, AND ALSO WHAT HAPPENS TO YOUR PATIENT'S SHORT AND LONG-TERM PATIENT OUTCOMES. STEP FIVE IS MY FAVORITE, THE WAY I SAY IT TO PHYSICIANS AND NURSES IN INTERMOUNTAIN GOES SOMETHING LIKE THIS, LADIES AND GENTLEMEN, IT'S NOT JUST THAT WE ALLOW OR EVEN THAT WE ENCOURAGE, WE DEMAND THAT YOU MODIFY OUR SHARED BASELINE PROTOCOL BASED ON INDIVIDUAL PATIENT NEED, I HAVE HARD EVIDENCE THAT YOU CANNOT WRITE A PROTOCOL THAT PERFECTLY FITS ANY PATIENT. HUMANS WHO COME TO US FOR CARE ARE JUST TOO VARIABLE FROM ONE ANOTHER. BUT YOU SEE WE DON'T STOP THERE. WE TAKE THE VARIATION DATA AND SOMEONE NEEDS TO VARY, AND FEED IT BACK SO THAT WE CAN LEARN ABOUT BEST CARE, IN SOME SENSE THERE ARE LITTLE HOMING MISSILES, CAN I SHOW YOU WHAT HAPPENED WITH THE RDS? IN THE MOST SERIOUSLY ILL SUBCATEGORY OF PATIENTS, SURVIVAL INCREASED FROM 9.5 PERCENT, 44 PERCENT. FIRST TIME SINCE THIS SYNDROME WAS DEFINED IN THE 1960S THAT ANYONE HAD SHOWN AN IMPROVEMENT IN CLINICAL OUTCOME. ACROSS THE ENTIRE DISEASE, SURVIVAL INCREASED FROM ABOUT 50 PERCENT TO 70 PERCENT. AT THE SAME TIME, COSTS DROPPED. NOW I HAVEN'T GONE THROUGH THE THEORY, THIS COMES FROM DEMMING. NEARLY ALWAYS, HIGHER QUALITY MEANS LOWER COST. IT ELIMINATES WASTE. AT 1.4 TRILLION DOLLARS OF WASTE, THIS IS HOW YOU GET AFTER IT. INTERESTINGLY, IT ALSO IMPROVES CLINICIAN PRODUCTIVITY. CAN I SHOW YOU ANOTHER QUICK EXAMPLE JUST TO MAKE A COUPLE OF POINTS AS WE WRAP UP. THE NUMBER ONE CAUSE OF DEATH IN AMERICAN HOSPITALS TODAY IS SEPSIS, A BODY-WIDE INFECTION. MORE THAN HALF OF THOSE CASES ENTER THE HOSPITAL THROUGH THE EMERGENCY DEPARTMENT. WELL, DOCTOR TODD ALLEN, ONE OF OUR EMERGENCY ROOM PHYSICIANS, DOCTOR TREY CLAMER, ONE OF THE FATHERS OF INTENSIVE MEDICINE IN THE COUNTRY, RUNS ICUS, CAME TOGETHER TO BUILD A SHARED BASELINE PROTOCOL FOR THIS CONDITION, FAIRLY COMPLEX ONE, 13 MAJOR STEPS. THIS SHOWS CHANGE IN COMPLIANCE AS THEY TUNED IT ACROSS THREE YEARS BY FEEDING THE DATA BACK, LETTING PEOPLE VARY THEN FEEDING IT BACK. THEY WENT FROM 30 PERCENT COMPLIANCE TO 90 PERCENT COMPLIANCE. NOW NATION-WIDE, MORTALITY FOR THIS CONDITION RANGES FROM ABOUT 20 PERCENT TO ABOUT 50 PERCENT, AS MANY AS HALF OF THESE PEOPLE DIE. WHEN WE STARTED, WE WERE AMONG THE BEST IN THE NATION. 20 PERCENT MORTALITY. IN ASSOCIATION WITH THAT PROTOCOL, ONCE AGAIN, MORTALITY DRAMATICALLY DROPPED, IT'S NOW BEEN THREE YEARS SINCE WE'VE GONE OVER NINE PERCENT AT ANY OF OUR FOUR BIGGEST TERTIARY HOSPITALS IN THE INTERMOUNTAIN SYSTEM. A DRAMATIC IMPROVEMENT IN CARE, A NEW NATIONAL STANDARD. IT'S ANOTHER 125 LIVES PER YEAR, ROUGHLY. SEE, THE TRICK IS I HAVE MORE THAN 100 OF THESE. I CAN DOCUMENT MORE THAN 1,000 LIVES PER YEAR OF PEOPLE WHO A FEW YEARS AGO WOULD HAVE DIED WHO DON'T TODAY, AND AS SOME OF YOU PROBABLY UNDERSTAND, MORTALITY IS THE TIP OF THE ICEBERG. FAR MORE DRAMATIC EFFECTS IN TERMS OF FUNCTION RESTORED, SUFFERING AVERTED. LESSON NUMBER ONE FROM THIS WORK, IN THIS PROFESSION WE COUNT ON OUR SUCCESSES IN LIVES, LITERALLY. WE COULD BE MUCH BETTER FOR THE PATIENTS WE SERVE IN THAT NEW EVOLVING HEALTHCARE SYSTEM. NUMBER TWO, OUR COSTS FALL AS USUAL AT SAVING THE PEOPLE OF THE STATE OF UTAH ABOUT 1.3 MILLION DOLLARS PER YEAR IN TERMS OF ACTUAL OPERATING CAPITAL FOR INTERMOUNTAIN ABOUT $700,000. THE SECOND BIG MESSAGE, BETTER CARE IS USUALLY CHEAPER CARE, IN FACT I CAN DOCUMENT ABOUT 350 MILLION DOLLARS PER YEAR, TAKING OUT OF THE COSTS OF OPERATIONS OF INTERMOUNTAIN MONEY THAT INDIRECTLY COMES BACK TO YOU, THE MEMBERS OF THIS COMMUNITY. WELL, THAT'S WHERE I WANT TO LEAVE YOU. I WANTED YOU TO SEE REAL HEALTHCARE REFORM, IT'S HAPPENING, IT'S HAPPENING BROADLY. WE HAVE NOT YET BEGUN TO UNDERSTAND HOW GOOD WE CAN BE FOR OUR PATIENTS AND OUR GREATEST NEEDS, BUT THAT'S THE GOAL. WE HAVE A THEME AT MY INSTITUTE OF HEALTHCARE DELIVERY RESEARCH, IT'S AN OLD YIDDISH PROVERB. BETTER HAS NO LIMIT. IT'S THE DUTY OF EVERY GENERATION TO MAKE LIFE BETTER. WITH THAT, LET ME SAY THANKS FOR YOUR TIME AND ATTENTION, AND RETURN THE TIME TO DOCTOR WEBB. [APPLAUSE] >>THIS BYU FORUM ADDRESS