Appendix B
Workshop Agendas

THE HEALTHCARE IMPERATIVE:

LOWERING COSTS AND IMPROVING OUTCOMES


An Institute of Medicine Workshop Series

THE KECK CENTER OF THE NATIONAL ACADEMIES

WASHINGTON, DC 20001


WORKSHOP I AGENDA


Understanding the Targets


May 21-22

MEETING AGENDA


Objectives: To identify, characterize, and discuss the major causes of excess healthcare spending, waste, and inefficiency in the United States, to consider strategies that might reduce per capita health spending in the United States while improving health outcomes, and to explore policy options relevant to those strategies.


DAY 1

9:00 am

Welcome, Introductions and Overview

Harvey V. Fineberg, Institute of Medicine

Denis A. Cortese, Mayo Clinic and Chair, IOM Roundtable on Value & Science-Driven Health Care



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Appendix B Workshop Agendas The healThcare ImperaTIve: lowerIng cosTs and ImprovIng ouTcomes An Institute of Medicine Workshop Series the KecK center of the national academies Washington, dc 20001 workshop I agenda Understanding the Targets May 21-22 meeting agenda Objectives: To identify, characterize, and discuss the major causes of excess healthcare spending, waste, and inefficiency in the United States, to consider strategies that might reduce per capita health spending in the United States while improving health outcomes, and to explore policy options relevant to those strategies. DAY 1 Welcome, Introductions and Overview 9:00 am Harvey V. Fineberg, Institute of Medicine Denis A. Cortese, Mayo Clinic and Chair, IOM Roundtable on Value & Science-Driven Health Care 

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 THE HEALTHCARE IMPERATIVE David M. Walker, Peter G. Peterson Foundation Keynote Address 9:30 am Peter R. Orszag, Office of Management and Budget What is the state of play of current spending on health care in the United States? What are the implications of unchecked spending on future generations? Session 1: Unnecessary Services 10:15 am Chair: Denis A. Cortese, Mayo Clinic and Chair, IOM Roundtable on Value & Science-Driven Health Care Qualitative description and quantitative estimates on the contribution of unnecessary services to excess healthcare spending, waste and inefficiency. Elliott S. Fisher, Dartmouth University Use of services beyond benchmarks where evidence is not established Amitabh Chandra, Harvard University Overuse of services, beyond evidence-established benchmarks David Wennberg, Health Dialog Choice of higher cost services, over evidence-established equivalents Mark B. McClellan, Brookings Institution Defensive medicine OPEN DISCUSSION Lunch Presentation 12:00 pm Eric Jensen, McKinsey & Co. How does U.S. spending on health care compare to international benchmarks? What are areas of specific excess spending and opportunities for cost savings? Session 2: Inefficiently Delivered Services 1:00 pm Chair: Arnold Milstein, Pacific Business Group on Health Qualitative description and quantitative estimates on the contribution of inefficiency in care organization

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 APPENDIX B and delivery to excess healthcare spending, waste, and inefficiency. Ashish Jha, Harvard University Costs from mistakes (medical errors, preventable complications) Mary Kay Owens, Southeastern Consultants, Inc. Costs from care fragmentation (including duplicate services, treatment delays) Gary S. Kaplan, Virginia Mason Medical Center Costs from inefficient use of higher cost providers William F. Jessee, Medical Group Management Association Arnold Milstein, Pacific Business Group on Health Costs from inefficiencies in physician offices and hospitals OPEN DISCUSSION Session 3: Excess Administrative Costs 3:30 pm Chair: Nancy H. Nielsen, American Medical Association Qualitative description and quantitative estimates on the contribution of excess administrative costs: (1) imposed on providers via external administrative requirements, and (2) incurred for health benefits plan administration. James L. Heffernan, Massachusetts General Physicians Organization Regulatory compliance-imposed costs beyond benchmarks James G. Kahn, University of California–San Francisco Lawrence P. Casalino, Cornell University Plan-imposed costs beyond benchmarks Andrew L. Naugle, Milliman Plan-incurred costs beyond benchmarks OPEN DISCUSSION Wrap-up Comments for the Day 5:15 pm Arnold Milstein, Pacific Business Group on Health

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 THE HEALTHCARE IMPERATIVE J. Michael McGinnis, Institute of Medicine Reception 5:30 pm DAY TWO Welcome and Re-cap of First Day 8:30 am Arnold Milstein, Pacific Business Group on Health Session 4: Prices That Are Too High 8:45 am Chair: Paul B. Ginsburg, Center for Studying Health System Change Qualitative description and quantitative estimates on the contributions of prices that are too high to excess healthcare spending, waste, and inefficiency. Cory S. Capps, Bates White Service prices (beyond competitive market benchmarks) Jack Hoadley, Georgetown Health Policy Institute Thomas J. Hoerger, RTI International Mark E. Wynn, Centers for Medicare & Medicaid Services Jeffrey C. Lerner, ECRI Institute Product prices (beyond competitive market benchmarks) OPEN DISCUSSION Session 5: Missed Prevention Opportunities 10:45 am Chair: J. Michael McGinnis, Institute of Medicine Qualitative description and quantitative estimates on the contribution of missed prevention opportunities, the treatment of which amounts to excess healthcare spending. Steven H. Woolf, Virginia Commonwealth University Economic implications of missed prevention opportunities Thomas J. Flottemesch, HealthPartners Research Foundation Costs from missed cost-saving primary and secondary prevention opportunities

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9 APPENDIX B Michael P. Pignone, University of North Carolina–Chapel Hill Costs from missed tertiary cost-saving prevention opportunities OPEN DISCUSSION Concluding Remarks, Upcoming Workshops and 12:30 pm Adjournment Arnold Milstein, Pacific Business Group on Health J. Michael McGinnis, Institute of Medicine workshop II agenda Strategies that Work July 16-17 meeting agenda Objectives: To identify, characterize, and discuss the major causes of excess healthcare spending, waste, and inefficiency in the United States, to consider strategies that might reduce per capita health spending in the United States while improving health outcomes, and to explore policy options relevant to those strategies. DAY ONE Welcome, Introductions and Overview 8:00 am J. Michael McGinnis, Institute of Medicine David M. Walker, Peter G. Peterson Foundation Keynote Address 8:30 am Glenn Steele, Jr., Geisinger Health System What strategies have been demonstrated to lower cost expenditures and improve health outcomes? What are the key success elements and the near- and long-term changes necessary? Reviewing the Targets 9:00 am Chair: J. Michael McGinnis, Institute of Medicine This session will review the analytics from the May workshop, which assessed the amount of potentially controllable waste and efficiency in five broad categories:

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0 THE HEALTHCARE IMPERATIVE Unnecessary services, Inefficiently delivered services, Excess administrative costs, Prices that are too high, and Missed prevention opportunities. Panelists: Len Nichols, The New America Foundation Robert D. Reischauer, Urban Institute OPEN DISCUSSION Session 1: Knowledge Enhancement-Based Strategies 10:30 am Chair: Nancy H. Nielsen, American Medical Association Discussion of knowledge-focused strategies for reducing waste and inefficiency, an assessment of their effectiveness and potential impact on health system efficiency, and a review of the specific opportunities for their implementation. Peter K. Smith, Duke University Enhancing clinical data as a knowledge utility Lucy A. Savitz, Intermountain Healthcare Evidence-based clinical protocols Rainu Kaushal, Weill-Cornell Medical College Electronic health records with decision support Carolyn M. Clancy, Agency for Healthcare Research and Quality Comparative effectiveness research OPEN DISCUSSION Lunch 12:30 pm Session 2: Care Culture and System Redesign-Based 1:00 pm Strategies Chair: Reed V. Tuckson, UnitedHealth Group Discussion of culture and system redesign-focused strategies for reducing waste and inefficiency, an assessment of their effectiveness and potential impact on health system

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 APPENDIX B efficiency, and a review of the specific opportunities for their implementation. Michelle J. Lyn, Duke University Caregiver profile, efficiency and team care Kim R. Pittenger, Virginia Mason Medical Center Care site efficiency and productivity initiatives and incentives Timothy G. Ferris, Massachusetts General Hospital Care site integration initiatives BREAK Roger Feldman, University of Minnesota Antitrust interventions Ashish Jha, Harvard University Promoting information technology interoperability/connectivity Frank A. Sloan, Duke University Service capacity restrictions Randall R. Bovbjerg, Urban Institute Medical liability reform OPEN DISCUSSION Session 3: Transparency of Cost and Performance 3:30 pm Chair: Robert S. Galvin, Global Healthcare/General Electric Discussion of transparency-based strategies for reducing waste and inefficiency, an assessment of their effectiveness and potential impact on health system efficiency, and a review of the specific opportunities for their implementation. John Santa, Consumer’s Union Transparency in prices

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2 THE HEALTHCARE IMPERATIVE G. Scott Gazelle, Institute for Technology Assessment Transparency in comparative value of treatment options Paul B. Ginsburg, Center for Studying Health System Change Transparency in comparative value of providers Peter K. Lindenauer, Tufts University Transparency in comparative value of hospitals and integrated systems Margaret E. O’Kane, National Committee for Quality Assurance Transparency in comparative value of health plans OPEN DISCUSSION Wrap-up Comments for the Day 5:30 pm Arnold Milstein, Pacific Business Group on Health J. Michael McGinnis, Institute of Medicine Reception 5:45 pm DAY TWO Welcome and Re-cap of First Day 8:00 am Arnold Milstein, Pacific Business Group on Health Session 4: Payment and Payer-Based Strategies 8:30 am Chair: Paul B. Ginsburg, Center for Studying Health System Change Discussion of payment and payer-based strategies for reducing waste and inefficiency, an assessment of their effectiveness and potential impact on health system efficiency, and a review of the specific opportunities for their implementation. Amita Rastogi, Bridges to Excellence Bundled and fee-for-episode payments Harold D. Miller, Center for Healthcare Quality and Payment Reform Value-based payment

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 APPENDIX B David R. Riemer, Community Advocates Managed competition Niteesh K. Choudhry, Harvard University Lisa Carrara, Aetna Value-based insurance design Robin J. Thomashauer, Council for Affordable Quality Healthcare David S. Wichmann, UnitedHealth Group Payer harmonization, coordination and/or consolidation OPEN DISCUSSION Session 5: Community-Based and Transitional Care 10:45 am Strategies Chair: Gail Shearer, Consumers Union Discussion of community-based and transitional care strategies for reducing waste and inefficiency, an assessment of their effectiveness and potential impact on health system efficiency, and a review of the specific opportunities for their implementation. Kenneth E. Thorpe, Emory Care management for medically complex patients Diane E. Meier, Mt. Sinai Hospital Reform in end-of-life care Jeffrey Levi, Trust for America’s Health Wellness/community programs OPEN DISCUSSION Lunch 12:00 pm Session 6: Entrepreneurial Strategies and Potential Changes 12:30 pm in the State of Play Chair: Kathleen Buto, Johnson & Johnson Discussion of entrepreneurial initiatives that may change the state of play in ways that substantially reduce waste and inefficiency, an assessment of their potential

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 THE HEALTHCARE IMPERATIVE effectiveness and impact on health system efficiency, and a review of the specific opportunities for their implementation. Sandeep Green Vaswani, Institute for Healthcare Optimization N. Marcus Thygeson, HealthPartners Highest known yield clinical service engineering applications (e.g., smoothing, retail clinics) Jason Hwang, Innosight Lower barriers to entry in health care (e.g. competency- based rather than credential-based clinical licensing) Adam Darkins, Department of Veterans Affairs Technological innovation Gerard F. Anderson, Johns Hopkins University Strategies importable from abroad OPEN DISCUSSION Concluding Remarks, Upcoming Workshops and 2:30 pm Adjournment Arnold Milstein, Pacific Business Group on Health J. Michael McGinnis, Institute of Medicine workshop III agenda The Policy Agenda September 9-10 meeting agenda Objectives: To identify, characterize, and discuss the major causes of excess healthcare spending, waste, and inefficiency in the United States; to consider strategies that might reduce per capita health spending in the United States while improving health outcomes; and to explore policy options relevant to those strategies.

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 APPENDIX B DAY ONE Welcome, Introductions and Overview 8:00 am J. Michael McGinnis, Institute of Medicine Arnold Milstein, Pacific Business Group on Health Keynote Address 8:30 am Karen Davis, The Commonwealth Fund The keynote will explore what we have learned about the relative contributions of the major sources of excessive, unnecessary, and wasteful U.S. healthcare expenditures; what we know about the forces in play, the key strategies necessary to address the problem, and the policy initiatives most likely to make a difference in the near- and longer-term; and how the necessary support might be mobilized. Session 1: Reviewing the Targets and Strategies 9:00 am Chair: J. Michael McGinnis, Institute of Medicine Opening Remarks: David M. Walker, Peter G. Peterson Foundation This session provides an overview of the state of understanding from the May and July workshops assessing the sources of excess costs (and some prominent examples) and the potential gains from various initiatives. Estimates of excess costs, by source: Unnecessary services, Inefficiently delivered services, Excess administrative costs, Prices that are too high, and Missed prevention opportunities. Estimates of potential gains, by initiative: Payment-based strategies, Care delivery efficiency-based strategies, Payer harmonization-based strategies, Transparency-based strategies, Tort reform, Knowledge enhancement-based strategies, and Community-based strategies. Joseph Antos, American Enterprise Institute CBO scoring methods and results OPEN DISCUSSION

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 THE HEALTHCARE IMPERATIVE Session 2: Policies Targeting Payments Bundled by 10:45 am Condition, Episode, or Outcome Chair: Arnold Milstein, Pacific Business Group on Health Opening Remarks: Harvey V. Fineberg, Institute of Medicine This session addresses the nature, status, and implementation issues for bundled payment strategies, the pivotal co-factors necessary to maximize the savings potential, and the options to minimize political barriers. John M. Bertko, The Brookings Institution Linda M. Magno, Centers for Medicare & Medicaid Services State of the science, implementation course, and cadence in bundling payments George J. Isham, HealthPartners Provider engagement issues Nancy Davenport-Ennis, National Patient Advocate Foundation Patient engagement issues OPEN DISCUSSION Lunch 12:15 pm Session 3: Policies Targeting Care for Medically Complex 12:45 pm Patients Chair: Peter M. Neupert, Microsoft This session considers policies that might foster delivery system innovations, ranging from care coordination and more efficient caregiver profiles, to shared services arrangements, and patient/family engagement initiatives, including consideration of policies promoting reform of palliative and end-of-life care. Arnold Milstein, Pacific Business Group on Health State-of-the-art initiatives Ronald A. Paulus, Geisinger Health System Provider perspective

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 APPENDIX B R. Sean Morrison, Mt. Sinai School of Medicine Anand K. Parekh, Department of Health and Human Services Policy perspective OPEN DISCUSSION Session 4: Policies Targeting Delivery System Integration 2:15 pm Chair: Helen Darling, National Business Group on Health This session addresses the current state and consequences of the fragmentation of health care, and considers the organizational, technical, and financial incentives for integrated and virtually integrated care. John Toussaint, ThedaCare Center for Healthcare Value Profile of system fragmentation and elements of integration Mark E. Miller, Medicare Payment Advisory Commission Harold S. Luft, Palo Alto Medical Foundation Research Institute Payment to promote integration Andrew M. Wiesenthal, The Permanente Foundation Health information technology to promote integration OPEN DISCUSSION Session 5: Policies Targeting Other Delivery System 3:45 pm Innovations Chair: Paul B. Ginsburg, Center for Studying Health System Change This session considers policies that might lower barriers to introduction of delivery system innovations, ranging from design of more efficient delivery systems to more efficient use of alternate caregivers. Steven J. Spear, Massachusetts Institute of Technology Policies to improve system efficiencies Mary D. Naylor, University of Pennsylvania Policies to improve provider profile and use OPEN DISCUSSION

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 THE HEALTHCARE IMPERATIVE Wrap-up Comments for the Day 4:45 pm Arnold Milstein, Pacific Business Group on Health DAY TWO Welcome and Re-cap of First Day 8:00 am Arnold Milstein, Pacific Business Group on Health Session 6: Policies Targeting Administrative Simplification 8:30 am Chair: Nancy H. Nielsen, American Medical Association This session considers policies aimed at harmonizing and standardizing payer plans, and billing and reporting requirements, including review of current initiatives, experiences, barriers, and possibilities. Lewis G. Sandy, UnitedHealth Group Payer perspective Linda L. Kloss, American Health Information Management Association Provider perspective Harry Reynolds, Blue Cross/Blue Shield of North Carolina Policy engagement issues OPEN DISCUSSION Session 7: Policies Targeting Consumer Preferences for 10:00 am Higher Value Care Chair: Robert S. Galvin, Global Healthcare/General Electric This session considers policies that aim to sharpen consumer awareness, focus, and choice of care that delivers higher value. Jennifer Sweeney, National Partnership for Women and Families Consumer engagement issues Dick Salmon, Cigna Payer perspective

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9 APPENDIX B Dolores L. Mitchell, Group Insurance Commission Purchaser perspective OPEN DISCUSSION Lunch 11:30 am Session 8: Pulling It All Together—Getting to 10 Percent 12:00 pm Chair: Arnold Milstein, Pacific Business Group on Health This session will engage key analysts in the task of each reflecting on the summary estimates from the previous meetings and related sources, and offering their views of the gains possible and the most important issues and strategies to reach the possible. Elizabeth A. McGlynn, RAND David O. Meltzer, University of Chicago Peter J. Neumann, Tufts University OPEN DISCUSSION Session 9: Pulling It All Together—The Policy Priorities and 1:30 pm Strategies Chair: J. Michael McGinnis, Institute of Medicine This session will engage participants in an open discussion of the policy priorities, how to mobilize support, and possible strategy approaches in the contemporary political environment. Mark B. McClellan, Brookings Institution Joseph Onek, Office of the Speaker of the House of Representatives Dean Rosen, Mehlman Vogel Castagnetti Short-term possibilities and goals Long-term possibilities and goals OPEN DISCUSSION Concluding Remarks and Adjournment 2:30 pm Arnold Milstein, Pacific Business Group on Health J. Michael McGinnis, Institute of Medicine

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0 THE HEALTHCARE IMPERATIVE workshop Iv agenda Reaching 10 Percent: Options and Requirements December 15-16 meeting agenda Objectives: To consider, identify, and characterize practical strategies to reduce per capita health spending in the United States by at least 10 percent within 10 years, without compromising health status, quality of care, or valued innovation. DAY ONE 9:30 am Coffee and light breakfast available Welcome, Introductions and Overview 10:00 am J. Michael McGinnis, Institute of Medicine Looking Back at The Healthcare Imperative Workshop 10:30 am Series Pierre L. Yong, Institute of Medicine Review the framework and estimates from the workshop series, and reflections on further needs to improve the numbers going forward. OPEN DISCUSSION Identifying the Primary Opportunities 11:15 am Develop the priority list of the domains of highest importance to target, the cost saving strategies of highest yield and importance. OPEN DISCUSSION Lunch 12:30 pm Consideration of Different Strategy Scenarios—Reaching 1:00 pm 10 Percent Presentation and discussion of different strategic scenario for reaching 10 percent, including the stakeholders affected and the relative savings potentially achievable in the current delivery system milieu.

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 APPENDIX B OPEN DISCUSSION Break Out Discussions 2:30 pm Three groups, each working on details of a different approach. Group Discussion 4:00 pm Report and feedback from each of the three break out groups. OPEN DISCUSSION Wrap-up Comments for the Day 5:00 pm J. Michael McGinnis, Institute of Medicine DAY TWO 8:00 am Coffee and light breakfast available Welcome and Re-cap of First Day 8:30 am J. Michael McGinnis, Institute of Medicine Identification of Strategic Options to Reach 10 Percent 9:00 am Development of strategic roadmap for achieving 10 percent health expenditure savings, including the policies needed to implement the strategies, the potential barriers to implementations, the critical co-factors needed to maximize success. OPEN DISCUSSION Cadence Issues 11:00 am Considerations of timing of implementation of the identified strategic options. OPEN DISCUSSION Summary and Adjournment 12:00 pm J. Michael McGinnis, Institute of Medicine

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