Variation in the Use, Cost and Quality of Health Care: Creating Solutions January 17, 2011 IOM Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Care Washington, DC Sam Nussbaum, MD Executive Vice President, Clinical Health Policy and Chief Medical Officer

2 Key Drivers in Variation of Care Poor integration and coordination across delivery system Lack of information on effectiveness or alternatives Increased supply triggers increased demand Rewards volume over quality or outcomes Reimbursement System Expanding Capacity Clinical Decision- Making Patient “Preference”

3 Hospital Value: Good for Medicare, Good for All? Medicare PMPMCommercial PMPMHospital Profit Source: High Value for Hospital Care: High Value for All? NBGH / Milliman, March 2010)

4 WellPoint Coronary Services: Quality and Cost Performance

5 Coronary Artery Bypass Graft Cost Variances (by State)

6 Coronary Artery Bypass Graft Cost Variances - Hospital (CA)

7 Quality Incentives and Paying for Value Q-HIP ℠ Hospital Pay-for-Performance rewards quality, safety, outcomes, and patient satisfaction Patient Safety Section (35% of total Q-HIP® Score) Joint Commission National Patient Safety Goals Computerized Physician Order Entry (CPOE) System ICU Physician Staffing (IPS) Standards NQF Recommended Safe Practices IHI 5 Million Lives Campaign – ADE Medication Reconciliation and WHO Surgical Safety Checklist CDC/APIC Flu and Pneumonia Vaccine Guidelines NQF Perinatal Measures Member Satisfaction Section (10% of Total Q-HIP® Score) H-CAHPS Survey Results Patient Health Outcomes Section (55% of total Q-HIP® Score) PCI Indicators 5 ACC-NCDR/Indicators for Cardiac Catheterization/PCI Joint Commission / CMS National Hospital Quality Measures Acute Myocardial Infarction (AMI) Indicators Heart Failure (HF) Indicators Pneumonia (PN) Indicators Surgical Care Improvement Project (SCIP) NSC Indicators 4 JC/NQF Nursing Sensitive Care Indicators CABG Indicators 5 STS Coronary Artery Bypass Graft (CABG) Measures

8 Blue Distinction Centers of Excellence Improve Quality Qualified facilities demonstrate $4K - $9K lower costs per event Improved quality through outcome metrics Reduced complications Programs Transplant Bariatric Surgery Cardiac Surgery Rare Complex Cancer Orthopedics: Lower Back Pain Spine, Hip, and Knee Surgery

9 Advanced Imaging: Increased Utilization, Costs and Safety Risk

10 MRI Average Cost and Percent of Procedures Meeting Clinical Standards

11 Imaging Site Assessment for Quality Assurance Quality Assurance: 25% Accreditation (ACR, JCAHO, etc.) Quality programs Safety programs Staffing: 45% Physician staff board certified Technicians modality certified Volume of exams annually by modality Equipment: 15% Age of equipment Number of CT detectors/slices MR field strength Service: 15% Accessibility Hours Multiple modalities

12 Program Imaging Shopper was launched 12/01/10 in Indianapolis where MRI can vary from $545 to $1655. Program Imaging Shopper was launched 12/01/10 in Indianapolis where MRI can vary from $545 to $1655. Outreach Anthem’s Health Outreach Specialists make calls to encourage use of high quality, cost effective sites. Outreach Anthem’s Health Outreach Specialists make calls to encourage use of high quality, cost effective sites. Timing Member redirection occurs after physician ordering advanced imaging chooses not to select the most cost effective site with equal or greater quality score. Timing Member redirection occurs after physician ordering advanced imaging chooses not to select the most cost effective site with equal or greater quality score. Imaging Shopper: Consumer Engagement for Cost and Quality

13 facility Choose Facility Facility Name Anthem Care Comparison Click here to view original Anthem Care Comparison Anthem Care Comparison: Providing Consumers Information on Cost and Quality Consumer can see side- by-side comparisons of inpatient and outpatient procedures; diagnostic tests and office visits; and provider service frequency. Cost and Quality Included

14 Anthem Care Comparison: Variance in Cost for Hip Replacement

15 Closing Gaps in Evidence-Based Care: Guiding Cost Effective Drugs

16 Guiding Members to Higher Value Services in New Hampshire Anthem The employee requires one of 39 common elective medical services The employee calls Compass which uses Anthem data to recommend lower cost options After the employee undergoes the procedure, Anthem processes the claim The Program educates and incents the consumer for choosing lower cost options for care If the employee used a lower cost facility, he receives $100 Compass City / State Employees

17 ER Appropriate Use and Cost Provides Opportunity for Alternate Sites for Care Source: CDC/NCHS National Hospital Ambulatory Medical Care Survey, American Hospital Association ER Departments (millions) ER Visits (millions) Retail Health Clinic Emergency Room Urgent Care

18 Non-Emergent Care From ER to Alternative Sites in Virginia Educate Members on ER-alternatives Video on member websites Educational brochures, letter, and 24/7 Hotline provides care guidance and educates on appropriate setting for condition Google-Map and Smart Phone Applications Point-and-click contact info, hours, location Directions from home or location Member Incentives A co-pay increase for ER visits Results Non-emergent ER use decreased 20% Members in program twice as likely to choose retail clinic

19 Breast Cancer Inequities in Care African American women are 50% more likely to be diagnosed later than Stage 2 Caucasian African-American III III IV V % of Patients Diagnosed by Cancer Stage Stage of Cancer Source: HealthCore: Louise J. Short, MD et. al.; Disparities in Medical Care Among Commercially Insured Patients With Newly Diagnosed Breast Cancer; (CANCER, 1/2010; ) “Of all the forms of inequality, injustice in health care is the most shocking and inhumane” Dr. Martin Luther King, Jr.