Scott Flinn, MD, Regional Medical Director Blue Shield of California Participation in the Right Care Initiative 2018 Annual Update Scott Flinn, MD, Regional Medical Director

Blue Shield of California and the Right Care Initiative In October 2015, Blue Shield of California (BSC) was required by the Department of Managed Health Care (DMHC) to: Participate in the Right Care Initiative (RCI) University of Best Practices (UBP) and To develop a plan with a goal of achieving the 90th percentile in RCI metrics by end MY 2018. Blue Shield of California is participating in the UBPs, and has developed a plan and is implementing that plan. This presentation is a review of progress to date.

BSC Quality Strategy and RCI Hypertension, Diabetes, and Readmission Reduction are the top 3 quality initiatives for BSC. Internal corporate incentives are tied to those goals. Quality incentives for our Provider Organization partners include our participation in IHA and our quality incentive plan for our ACO partners.

University Of Best Practices Participation BSC is participating in all 3 RCI chapters and is using the information gathered to augment its planning and execution of quality improvement efforts directed at preventing heart attacks, strokes, and diabetic complications. BSC recognized the need for an additional University of Best Practices chapter in a previously unserved area and provided resources to establish a Bay Area RCI UBP chapter.

Provider Organization Engagement BSC does not deliver care; our Provider Organization (PO) partners do. In order to reduce strokes, heart attacks and diabetic complications and improve the RCI metrics, BSC recognized the need to enlist PO partners in the effort. The 3 part plan developed included means to engage providers, a tool to do a self assessment, and a means to track progress. The provider engagement presentation has been successful in enlisting over 26 PO in the RCI efforts, with 14 more targeted in the near future.

Provider Engagement Presentation Presentation emphasizes 4 major points: Hypertension control can have a dramatic impact in a short period of time Implementing some of these Best Practices are relatively easy and cost effective There is some published literature suggesting this actually works You probably aren’t doing as well as you think you are….

How to Prevent One in Six of Your High Risk Hypertensive Patients from Dying from a Stroke or Heart Attack in the next 3 years! Really!

Decrease Deaths in High Risk Patients Decrease Deaths in High Risk Patients* by 17% (1 in 6) in 2 years… Treat them NOW From Kaiser with permission *Uncontrolled Hypertensive over 55 17 % !!!! 1 in 6!!!

Best Practices

Best Practices include: Implementing a treatment algorithm Intensifying treatment rapidly Implementing a care team which includes a Pharmacist and Certified Diabetic Educator. Continuously measuring success and publicly reporting the outcomes Algorithms help Pilots use them…

San Diego HTN med protocol Adapted from Kaiser algorithm

Effect Of Therapies On Systolic BP 9.7 mm 24.9 mm 33 mm 34mm 42mm Kaiser data – with permission Biggest effect is adding a simple thiazide to ACE inhibitor That’s why the combo pill is the first lien recommendation

Pharmacist on the care team A 2007 NIH funded study at UCLA showed that pharmacist assisted management of hypertension was more effective at reducing hypertension than physician intervention alone. Pharmacists practicing at the top of their license under Collaborative Practice Agreements: intensifies of drug therapy per protocol orders/monitors related labs addresses side effects works with patients & monitors for medication adherence keeps the primary care physician (PCP) informed Reports on HTN and DM medication prescriptions Many benefits Can pull data Can do MTM under protocol – UCLA study in 2007 referenced earlier Pharm tech under pharmacist can help with compliance

% of Patients on Combination Pill As combination pill usage went up, hypertension control went up Kaiser data As use of combo pill (ACE/Thiazide) improved so did Kaiser BP control JAMA. 2013;310(7):699-705. doi:10.1001/jama.2013.108769

BSC Pharmacy Program Support BSC Advanced Practice Pharmacist network – credentialed additional pharmacist providers in 2018, engaged in medication management in partnership with PCPs BSC provides subject matter expertise to provider organizations to launch medication management programs and to use of pharmacists on the care team Collaborative Practice Agreement template available for adoption BSC Medication Adherence support program available Additional BSC incentives available to ACOs to hire/use pharmacists and pharmacy technicians

Reporting and Rewarding - Registry Provides actionable data for identifying clinical opportunities Provides means of tracking progress, reporting, and providing feedback for recognition Peer competition # 1 motivator for providers Public reporting – great motivator (and why medical directors only last 3.5 years…) Not to shame – learn form those doing well Hence- University of best Practices

BP control by Provider in a Medical Group in Southern California 60 primary care providers – measured patient BP control Control ranged from 32% - 74% Engaged pharmacist through Collaborative Practice Agreement with Clinical Champions Overall HTN control rose form 55% to 78% in less than a year The physician with 32% control was a cardiologist Surprising to docs when they see the actual control numbers Idea is to stimulate those not doing as well to find out what those who are doing well are doing

HTN Control Best Practice – Follow up high blood pressure before patient leaves clinic Policy instituted – if patient checks into clinic and BP > 140/92 on check in, needs repeat before leaving the appointment Referral to PCP / ER as appropriate if elevated Tracking of repeats done – publicly reported to clinics and to Board of Directors HTN control part of provider annual bonus structure

RCI – Does it Work?

Experience in San Diego Countywide Physician Organization Learning Collaborative and Changes in Hospitalization Rates Brent D. Fulton, PhD, MBA; et al. Am J Manag Care. 2017;23(10):596-603

HEALTH AFFAIRS 37, NO. 9 (2018): 1457–1465

What has made San Diego Different? Co-opetition Data sharing group Develop trust Way to share Best Practices

What does the Data Show?

RCI Assessment- 8 metrics RCI metrics - HEDIS data for HMO and POS patients HTN control: BP < 140/90 Beta blocker after an MI for 6 months Diabetes Measures % in Control: Hb A1C <8 % in Poor control: Hb A1C >9 or unmeasured Hb A1C testing Eye exam Medical attention for nephropathy* * Urine microalbumin test, ACE/ARB Rx, seen by nephrologist, kidney transplant, dialysis, shunt placement, etc. These metrics are the same Hedis metrics for IHA, Medicare stars, etc. Focus on HTN , diabetes and post MI care 9

HEDIS data for BSC - HMO POS populations Results to date RCI Measure Metric MY 2014 MY 2015 MY 2016 MY 2017 Hypertension Control Rate 60.5 65.2 61.7 57.66 Percentile 25th 50th Beta Blocker after MI 80.58 82.73 83.1 81.35 Diabetes Control <8 63.14 61.56 64.92 59.31 75th Diabetes Uncontrolled (>9) 27.55 26.56 25.8 30.47 Hgb A1C 90.33 89.69 88.87 Diabetic Nephropathy 84.49 89.84 90.73 89.78 90th Diabetic Retinopathy 49.45 50.94 48.74 45.07 Hypertension Control in Diabetics 56.2 71.09 66.61 66.97 <25th HEDIS data for BSC - HMO POS populations

MY 2017 Health Plan Results – HTN control

MY 2017 Health Plan Results – DM control

MY 2017 Health Plan Results – HTN control in DM

MY 2017 West LA Provider - HTN control

MY 2017 West LA Provider - HTN control

BSC Improvement Opportunities Hypertension Control – Supplemental Data submissions. Effort underway to revamp supplemental data submission system. Other elements of RCI work are hybrid and are affected by supplemental data submission. Beta-blocker after MI workgroup launched to improve ability to address clinical opportunities. The discharge event is not always available to identify members for intervention. Clinical Best Practices Community forums to share Best Practices BSC Pharmacy - PO Pharmacy meetings and ACO colloquiums

Best Practices Self Assessment Tool

Best Practices Self Assessment Tool Developed Best Practices self-assessment tool for HTN and DM care based on RCI University of Best Practices (UBP), AMGA Measure Up Pressure Down and Together 2 goal, Million Hearts, and other work. Reviews performed with a BSC clinician Essential elements highlighted Tool has resource links embedded Using Best Practices tool, conduct assessment, gap analysis, and help partner POs develop action plan Quarterly follow up and annual reassessment.

Best Practices Self Evaluation Tool HTN and DM tabs 3 categories – Leadership, Processes, Patient Engagement 23 items for HTN, 19 for DM 3 ratings –yes, no, sort of Resource links embedded BSC HTN Best Practices Worklist Group Name:   Date Evaluation Completed: Hypertension "Best Practices" Worklist Item Group's Status Notes Resource Action Item Leadership Multidisciplinary team that includes clinical champion(s) Should include Clinical Champions Best Practice: Zufall Health "Building a Team" Engaged all providers and clinical staff through education Engage Providers and direct support staff in importance of controlling BP - can reduce strokes and heart attacks in high risk individuals 17% in two years. Synergy with Million Hearts, AMGF Measure up Pressure Down, AHA and AMA Target: BP RCI Template Presentation Internal public reporting of HTN control by provider Peer Collaboration Recognition of providers with excellent performance public recognition, financial incentives through quality program Processes Process map of clinic visit flow to evaluate delivery of care pre-visit, visit and post-visit Hypertension is addressed at every primary care visit Sample Chart Audit Consistent Process to ensure HTN measurement part of every visit Ensure every visit includes a BP reading; include specialty, and a process for routing back to primary care when reading is elevated >140/90 Staff trained to take accurate BP Guidelines on patient posture, wait time, caffeine and smoking; retest all BP >140/90 after 5 minute rest. Co-assess with staff and providers Initial and annual refresher. Sign at eye level from patient instructions, such as uncrossing feet AMGF measure up pressure down BP rechecks done on all patients not in BP control prior to leaving office, and documented in chart 7 Simple steps to ensure ACCURATE reading Point of Care reminders in EHR Adopt Hypertension Algorithm Template from SD RCI Intensify treatment every 2-4 weeks until goal reached No co-pay return visit with MA / RN to repeat BP Monitor use of Algorithm Pharmacy statistics: Number of medications per patient Chart Review Patient registry for Hypertension AMGA Best Practice in HTN Registry Medical group participates in programs to improve HTN medication adherence Leverage pharmacists/ pharmacy techs to improve adherence Case Study for use of Pharmacist on team Medical group reviews drug gap reports identifying members needing beta-blocker therapy after MI Collaborative Practice Agreement with Pharmacist Pharmacist help through Collaborative Practice Agreements greatly facilitates outcome Template available Adopted Standing Orders UCSF Example: Center for Excellence in Primary Care Specialists refer high BP to PCP sample chart audit

What have we learned so far As we engage PO partners, we find many have efforts towards RCI goals at various levels. And they are all unique…. if you’ve seen one provider group you’ve seen one provider group. RCI synergizes with other programs that many groups are already doing – e.g. CDC/CMS Million Hearts, AMGF Measure Up Pressure Down and Together2Goal, AHA Target BP, Know Your Numbers Achieving hypertension control in high risk patients has the biggest near term effects on patient outcomes; lipid control has biggest effect long term

Value add for the Partners The Self Evaluation tool helps groups develop a QI plan and prioritization of efforts Clinical Assistance Quality expertise Pharmacy Cleaning up the data Financial outcomes – e.g. ACO partners, P4P participants

Next Steps Continue scaling work - enlisting provider organizations in the effort. Bay Area UBP will help in those efforts. Continue to refine approach based on experience with PO partners and through participating in UBP and other venues Reach 90th percentile in RCI Metrics Eliminate preventable strokes and heart attacks