changing the environment to improve chronic disease management september 20, 2007 sydney, australia...

Changing the Environment to Improve Changing the Environment to Improve Chronic Disease ManagementChronic Disease Management

September 20, 2007September 20, 2007Sydney, AustraliaSydney, Australia

George Isham, M.D., M.S.George Isham, M.D., M.S.Medical Director and Chief Health OfficerMedical Director and Chief Health Officer

HealthPartners, Minneapolis, MNHealthPartners, Minneapolis, [email protected]@healthpartners.com

“The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

Crossing the Quality Chasm, the Institute of Medicine, 2001

Care System

•Redesign of care processes based on best practice•Effective use of information technologies•Knowledge and skills management•Development of effective teams•Coordination of care •Incorporation of performance and outcome measurements for improvement and accountability

Supportivepayment and regulatoryenvironment

Organizationsthat facilitatethe work of patient- centered teams

High performingpatient- centeredteams

Outcomes:•Safe•Effective•Efficient•Pt Centered•Timely•Equitable

Adapted from the Institute of MedicineReport, Crossing the Quality Chasm, 2001

Population Health Population Health Improvement Model : 1994- Improvement Model : 1994-

20072007

SOURCE: Journal of the American Medical Association, 2000

Impact of Unhealthy Behavior Impact of Unhealthy Behavior on Mortalityon Mortality

Employee population Employee population health distributionhealth distribution

Health SupportHealth Support

Health Risks Drive Costs: Health Health Risks Drive Costs: Health Assessments Identifies Risks 1-2 Assessments Identifies Risks 1-2

Years Before They Show Up As Years Before They Show Up As ClaimsClaims

Paid Amount by Total Health Potential Score

5629

44894222

3422

28462351 2350

0

1000

2000

3000

4000

5000

6000

300-699

700-749

750-799

800-849

850-899

900-949

950-1000

Score Categories

0

20

40

60

80

100

Paid Dollars% of Employees

Paid Amount by Modifiable Health Potential Score

4095 43013900

35233018 2897

0100020003000400050006000

Low-300

301-350

351-400

401-425

426-450

451-High

Score Categories

020406080100

Paid Dollars% of Employees

Data reflects commercial population, N=9,981

ProgramsPrograms Provide incentive for

completing follow up programs• Diabetes prevention • Heart disease prevention • Weight mgt • Tobacco cessation • Back pain• Stress mgt • Healthy pregnancy • Blood pressure mgt • Cholesterol mgt • Nutrition • Healthy discounts • 10,000 steps • Frequent Fitness

Meaningful ResultsMeaningful Results

Achieve Program Results

• 10K Steps

• Weight management

• Tobacco cessation

• Health assessment

• Healthy Discounts

• $290 per person savings

• $103 per person savings

• $850,000 additional savings each year due fewer children exposed to tobacco

• $50 savings per person completing health assessment

Changing the Environment Changing the Environment to Improve Chronic Diseaseto Improve Chronic Disease

Agree on Best Care ICSI

Measure What’s Important

Composites, Outcomes

Set a Target ‘Aim High’

Align Incentives P4P, Compare Peers, Tier

Support Improvement

Registries, ICSI, Pt engagement, …

Publicly Report Results

Focus

Health Goals 2010 – Results Health Goals 2010 – Results Summary for June 2007Summary for June 2007

Health Goals 2010 – Results Health Goals 2010 – Results Summary for June 2007Summary for June 2007

FULL: Goal achieved / infrastructure in place with full spread ¾: Positive performance trend / infrastructure in place ½: Stable performance / infrastructure in design or early implementation ¼: Measurement development in progress or unstable performance / early infrastructure design in processEMPTY: Performance measurement not yet established / infrastructure in the planning stage

Changing the Environment to Changing the Environment to Improve Chronic DiseaseImprove Chronic Disease






Support Improvement



Focus

The Institute for Clinical The Institute for Clinical Systems Improvement (ICSI)Systems Improvement (ICSI)

A quality improvement collaboration of 55 medical groups & hospital systems

Sponsored by six health plans

Established 1993

Includes 60 hospitals and 56 medical practices with about 8300 physicians

www.icsi.org

Purposes of Our CollaborationPurposes of Our Collaboration

1. To champion the cause of health care quality

2. To accelerate improvement in the value of the health care we deliver

www.icsi.org

ICSI ProgramICSI Program Core commitment cycle Scientific groundwork

Evidence based document development & maintenance

Technology assessment Support for improvement

Education & training Coaching Action groups (improvement collaboratives) Knowledge products

Advocacy for quality

www.icsi.org

Requirements of MembersRequirements of Members

Initial orientation & training sequence

Core commitment cycle

Physician participation in workgroups & committees--as well as other professionals

Critical review of guidelines

Team-based continuous improvement

Staff adequate to support the improvement

A pattern of improvement over time

www.icsi.org

DIAMOND: Depression Improvement DIAMOND: Depression Improvement Across Minnesota - Offering a New Across Minnesota - Offering a New

DirectionDirection Redesign of Care

New model, PHQ-9 measures, registry, protocols, specialist agreements

Redesign of payment system Care management Psychiatric liaison







Support Improvement



Focus

All-or-None Composite MeasuresAll-or-None Composite MeasuresIndividual Patient = Unit of Individual Patient = Unit of

AnalysisAnalysis

Specific condition Key elements Individual patients

All processes? All treatment goals?

YES or NO

Minnesota Community Minnesota Community MeasurementMeasurement A nonprofit entity dedicated to improving the quality of health

care in Minnesota. Improving health through public reporting A community effort of providers, purchasers and health plans

Report results on health care quality measures Provide information for consumers Increase efficiency of reporting Improve care and support the quality initiatives of providers

and the Institute for Clinical Systems Improvement (ICSI). Reduce reporting-related expenses for medical groups,

health plans, and regulators through more efficient and effective regulation.

Communicate findings in a fair, usable and reliable way to medical groups, regulators, purchasers and consumers.

www.mnhealthcare.org

Results Are Improving for Results Are Improving for “Living with Illness” “Living with Illness”

MeasuresMeasures2003 2004 2005 2006 Move

Asthma Medications 71% 74% 76% 91% Blood Pressure < 140/90 57% 60% 64% 68% Depression Medications 49% 51% 49% 42% Diabetes I (looser targets) 12% 12% 16% 20% Diabetes II (tighter targets) 4% 6% 9%


New InitiativesNew Initiatives• Minnesota Bridges to Excellence (BHCAG program)

– Align measures in pay-for-performance arrangements

• Aligning Forces for Quality (Robert Wood Johnson Foundation)

– Expand measures

– Increase consumer engagement

– Support provider improvement efforts

• Better Quality Information Pilot (Federal HHS initiative)

– Includes Medicare data

– New measure test site

State of Minnesota’s QCARE initiative








Support Improvement



Focus

Partners in ExcellencePartners in Excellence 2007 Primary Care - 2007 Primary Care -

TargetsTargetsPrimary Care Groups: > 1,500 Excellent Superior

Optimal Depression Care 40% 45%

Optimal Diabetes Care 25% 30%

Optimal Coronary Artery Disease (CAD) Care 55% 60%

Combined BMI Assessment & Preventive Services 80% / 90% 90% / 95%

Generic Drug Use 68% 73%

Patient Satisfaction – Listen 75% 80%

Primary Care Groups between 100 - 1,500 Excellent Superior

Breast Cancer Screening (Mammography) 80% 85%

Cervical Cancer Screening (PAP) 85%


Pediatrics Excellent Superior

Pediatric Immunization Combo 3 70% 80%

Combined BMI Assessment & Preventive Services 80% / 90% 90% / 95%


Patient Satisfaction – Availability 75% 80%

2007 Primary PIP2007 Primary PIP

Primary Care MENU: PIP Measure Type Registry? Freq

Pharmacy Generic Drug Use Admin No Qrtly

Musculoskeletal Appropriate Use of Imaging Services Admin No Anl

Care Processes Anticoagulation Protocol** (Ψ) Self-rpt No Qrtly

Care Processes Care Process for Low Back Pain Management (Ψ) Self-rpt No Qrtly

Health Lifestyles BMI Measurement - Adults Self-rpt No Qrtly

Health Lifestyles BMI Measurement - Pediatrics Self-rpt No Qrtly

Depression Care Depression Symptom Assessment Tool (Ψ) Self-rpt No Qrtly

Prevention Lead Screening (PMAP/MNCare) Admin No Qrtly

Health IT Immunization Protocol: (MIIC) Self-rpt No Qrtly







Support Improvement



Focus

DistinctionsDistinctionsSMSM Plan PlanHow HealthPartners Tiers ProvidersHow HealthPartners Tiers Providers

Step 1. Quality Providers are evaluated on quality measures

Step 2. Affordability Providers are scored on case-mix adjusted

total cost of care. The score reflects the combined impact of price, efficiency and utilization management.

DistinctionsDistinctionsSMSM Plan PlanHow HealthPartners Tiers ProvidersHow HealthPartners Tiers Providers

Step 3. Combined Score Quality and affordability are weighted equally Providers need to meet both the quality test

and the affordability test to qualify for the best tier placement (Tier I).

Primary Care Tiering Primary Care Tiering MethodologyMethodology

Affordability Episodes of Care

– Classifies services into episodes– Total cost of episode attributed to provider

(significant contributor)– Case mix adjusted

Quality Composite measures 75 discrete measures (see Appendix B) Quality domains: Chronic condition care, acute and

preventive care, patient experience, safety

Primary Care QualityPrimary Care Quality Care of Chronic Condition

Optimal CAD care Optimal depression care Optimal diabetes care Optimal asthma care

Acute and Preventive Care Healthy lifestyle advice (Adult & Child) Preventive Services (Adult & Child) Immunizations up-to-date (Child) Pharyngitis care (Child) Appropriate use of antibiotics for upper respiratory infection

(Child) Appropriate low back pain imaging (Adult) Tobacco – assess and assist (Adult) Tobacco – second hand exposure (Child)

Primary Care QualityPrimary Care Quality Patient Experience (Adult and Child)

Access – scheduling convenience; routine versus acute; MD of your choice: medical advice by phone 24/7

Timeliness – rooming, exam room Communication

–Attention given to what you have to say–Explanations of medical procedures–Advice about ways to stay healthy –Amount of time the doctor spends with you

Use of well tested medications

BackgroundBackground Never Events Never Events

In 1999 IOM documented the prevalence of medical errors in hospitals – “To Err is Human.”

IOM recommended a mandatory reporting system to ID and improve persistent safety problems

In response in 2002 the National Quality Forum (NQF) Defined 27 Never Events - things that should

never, ever happen Established standards for reporting medical

errors

Some NQF Never EventsSome NQF Never Events Surgical Events

Wrong surgery, body part or patient

Retention of foreign object Product or Device

Contaminated drugs, devices, biologics

Patient Protection Infant discharged to wrong

person Patient death associated

with disappearance

Care Management Patient death or disability

– Medication error– Stage 3 or 4 pressure

ulcers Environmental Events

Patient death or disability– Wrong gas delivered– Burn while being cared

for Criminal Events

– Abduction– Sexual Assault

HealthPartners Payment Policy Never HealthPartners Payment Policy Never Events: Events:

Patients Should Never Have to Pay for Patients Should Never Have to Pay for a Never Eventa Never Event As of January 1, 2005:

Hospitals report Never Events to HPI HPI denies payment or recoups

payment Applies to hospitals only, not physicians Charges are provider liability Member cannot be billed!







Support Improvement



Focus

HealthPartners Care Model HealthPartners Care Model Process (CMP)Process (CMP)

A standard set of workflows for delivering evidenced-based care that provides a

consistent clinical experience for patients and a consistent process for Care Teams

*Consistency *Standardization *Teamwork

Principles in Principles in HealthPartners CMP designHealthPartners CMP design Support the physician/patient interaction Those providing and receiving the care

need to design the workflows and tools Maximize skill set Clinical workflow drives EMR workflow Embed evidence Make it easy Redesign to sustain

HealthPartners Medical HealthPartners Medical Group Group

Optimal Diabetes Care Optimal Diabetes Care MeasureMeasure

7.4%

8.6%

10.7%11.2%

12.0% 12.1%

13.7%

15.4%

16.6%17.3%

9.4%

11.9%12.9%

16.1%

19.1% 19.4%

21.9%

24.9%24.3%

27.5%28.3%

15.4%

13.9%

16.8% 16.8%

14.0%

16.9%

20.1%

24.1%

21.8%

20.5%

5.8%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

2nd Qtr 04 3rd Qtr 04 4th Qtr 04 1st Qtr 05 2nd Qtr 05 3rd Qtr 05 4th Qtr 05 1st Qtr 06 2nd Qtr 06 3rd Qtr 06 4th Qtr 06

HPMG&C Como Inver Grove Endo Goal







Support Improvement



Focus

Reliable Tobacco TreatmentReliable Tobacco Treatment1996

100% 100%

Amundson, Paying for Quality Improvement: Effect on Compliance with Tobacco Treatment Guidelines:JCJQS:2003;29(2):59-65

2004

Treating Tobacco AddictionTreating Tobacco Addiction

0%

20%

40%

60%

80%

100%

1998 1999 2000 2001 2002 2003 2004 2005

Ask Assist Tob Prev 2nd Hand Tob

Adult Prevalence 25% → 15% Second Hand Tobacco 23% → 8.6%

At HealthPartners – Improving At HealthPartners – Improving Population Averages for Population Averages for

DiabetesDiabetes

At HealthPartners - Fewer At HealthPartners - Fewer Diabetes ComplicationsDiabetes Complications

Prevents 320 eye complications each year

Prevents 80 heart attacks and 120 amputations each year

Thank You!George Isham, M.D., M.S.George Isham, M.D., M.S.Medical Director and Chief Health OfficerMedical Director and Chief Health OfficerHealthPartners, Minneapolis, MNHealthPartners, Minneapolis, [email protected]@healthpartners.com

changing the environment to improve chronic disease management september 20, 2007 sydney, australia...

Documents

health assessments

health assessmentchanging

health plansestablished

systems of care

cause of health care

current care systems

performance measurement

person savings