What's the fuss? If it's not bad enough that we are spending that much money, we are not getting value for the money we are spending, and in some cases patients are actually being harmed by the care they are provided. There's too much waste, and inefficiency in healthcare. The Institute of Medicine, or IOM as it is commonly shortened, in their 2012 report identified where the waste is in the health care system, and there is a lot of it. The IOM identified a framework with the six aims of a well-functioning health care system, often referred to as SEPTEE. Safe. Avoiding harm to patients from the care that is intended to help them. Effective. Providing services based on scientific knowledge, to all who could benefit, and refraining from providing services to those not likely to benefit. Avoiding under use, and misuse respectively. Patient-centered. Providing care that is respectful of, and responsive to individual patient preferences needs and values, and ensuring that patient values guide all clinical decisions. Timely. Reducing waits, and sometimes harmful delays for both those who receive, and those who give care. Efficient. Avoiding waste including, waste of equipment, supplies, ideas, and energy. Equitable. Providing care that does not vary in quality because of a personal characteristic, such as gender, ethnicity, geographic location, and socioeconomic status. With those goals in mind, let's take a look at this pie chart, and we can see some of the areas of waste identified by the IOM. The largest driver, is wasted spending due to services that are unnecessary, or having care in a setting that is more costly than another setting. For example, many tests and procedures are considered to be overused, and do not actually improve health. Additionally, too much care is provided in high cost settings, like hospitals rather than lower-cost settings like a doctor's office, or an urgent care center. As discussed in the previous session, the higher health care spending does not directly result in more favorable health outcomes. Rather, the correlation does not appear to exist. Some of this can be attributed to the inefficiencies, and perverse financial incentives found within the system. Excessive administrative costs across the entire spectrum add expense as well. Inefficiently delivered services, and missed opportunities also contribute to waste. High prices for health care services and fraud, cause unnecessarily higher spending. What does all of this mean? The system is broken, and is not sufficiently coordinated, so it produces less than optimal results. Since the patient is most affected by these inefficiencies and less than optimal health care delivery,let's further look at some of the areas where the system is failing the patients in the following graphic. Health care is complex, with many hand-offs that are not done effectively creating missed opportunities and errors. This graphic shows how complex it is for the elderly, where the average person takes 19 medication doses per day, and sees about seven doctors, across four different medical practices over the course of one year. Think about how challenging it is to make sure that all of that care is coordinated to avoid duplication, or adverse reactions. If the patient is hospitalized, they are not following up with their primary care doctor, after they are discharged. In fact, their primary care doctor may not even know they were in the hospital, and 20 percent of them are ending up back in the hospital in less than one month. To top it off, less than 50 percent of these patients, are getting the recommended preventive services. So, if there is so much waste, and the system is not delivering optimal results we have to ask, why? How long has this been happening? Well, let's take a look at some key milestones that have impacted health care delivery, and cost, as well as access. Both the practice of medicine, and access to the healthcare system through insurance, have evolved over the past few centuries. Improvements in medical care allowed us to live longer, and healthier lives. It also introduced new types of treatments, that expanded the use of hospitals, and pharmaceuticals. At the same time that medical care was exploding, people in the United States were accessing the health care system through new, and different coverage channels both private, and publicly provided. Health care is complex with many hand-offs that are not done effectively creating missed opportunities, and errors. Underlying the complexities of the health care system, is a continued deterioration in the health of the American population, with rising obesity rates, and chronic diseases like diabetes, COPD, CHF, cancer, hypertension, and stroke. If we are going to spend almost 18 percent of our GDP on health care, we should be getting far more value. And patients should not be caught in the middle of this poorly functioning system.