Changing the Environment to Improve Chronic Disease Management September 20, 2007 Sydney, Australia George Isham, M.D., M.S. Medical Director and Chief Health Officer HealthPartners, Minneapolis, MN

“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 Supportive payment and regulatory environment Organizations that facilitate the work of patient- centered teams High performing patient- centered teams Outcomes: Safe Effective Efficient Pt Centered Timely Equitable Adapted from the Institute of Medicine Report, Crossing the Quality Chasm, 2001

Population Health Improvement Model :

SOURCE: Journal of the American Medical Association, 2000 Impact of Unhealthy Behavior on Mortality

Employee population health distribution

Health Support

Health Risks Drive Costs: Health Assessments Identifies Risks 1-2 Years Before They Show Up As Claims Data reflects commercial population, N=9,981

Programs  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 Results Achieve ProgramResults 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 to 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 Summary 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 process EMPTY: Performance measurement not yet established / infrastructure in the planning stage

Changing the Environment to 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

The Institute for Clinical 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

Purposes 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

ICSI 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

Requirements 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

DIAMOND: Depression Improvement Across Minnesota - Offering a New Direction  Redesign of Care  New model, PHQ-9 measures, registry, protocols, specialist agreements  Redesign of payment system  Care management  Psychiatric liaison

Changing the Environment to 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

All-or-None Composite Measures Individual Patient = Unit of Analysis  Specific condition  Key elements  Individual patients  All processes?  All treatment goals?  YES or NO

Minnesota Community Measurement  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.

Results Are Improving for “Living with Illness” Measures Move Asthma Medications71%74%76%91%    Blood Pressure < 140/9057%60%64%68%  Depression Medications49%51%49%42%  Diabetes I (looser targets)12% 16%20%  Diabetes II (tighter targets)4%6%9% 

New 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

Changing the Environment to 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

Partners in Excellence 2007 Primary Care - Targets Primary Care Groups: > 1,500ExcellentSuperior Optimal Depression Care40%45% Optimal Diabetes Care25%30% Optimal Coronary Artery Disease (CAD) Care55%60% Combined BMI Assessment & Preventive Services80% / 90%90% / 95% Generic Drug Use68%73% Patient Satisfaction – Listen75%80% Primary Care Groups between ,500ExcellentSuperior Breast Cancer Screening (Mammography)80%85% Cervical Cancer Screening (PAP)85% Generic Drug Use68%73% PediatricsExcellentSuperior Pediatric Immunization Combo 370%80% Combined BMI Assessment & Preventive Services80% / 90%90% / 95% Generic Drug Use68%73% Patient Satisfaction – Availability75%80%

2007 Primary PIP Primary CareMENU: PIP MeasureTypeRegistry?Freq PharmacyGeneric Drug UseAdminNoQrtly MusculoskeletalAppropriate Use of Imaging ServicesAdminNoAnl Care ProcessesAnticoagulation Protocol** (Ψ)Self-rptNoQrtly Care ProcessesCare Process for Low Back Pain Management (Ψ)Self-rptNoQrtly Health LifestylesBMI Measurement - AdultsSelf-rptNoQrtly Health LifestylesBMI Measurement - PediatricsSelf-rptNoQrtly Depression CareDepression Symptom Assessment Tool (Ψ)Self-rptNoQrtly PreventionLead Screening (PMAP/MNCare)AdminNoQrtly Health ITImmunization Protocol: (MIIC)Self-rptNoQrtly

Changing the Environment to 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

Distinctions SM Plan How 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.

Distinctions SM Plan How 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 Methodology  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 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 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

Background 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 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 Events: Patients Should Never Have to Pay for a 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!

Changing the Environment to 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

HealthPartners Care Model 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 HealthPartners 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 Group Optimal Diabetes Care Measure

Changing the Environment to 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

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

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

At HealthPartners – Improving Population Averages for Diabetes

At HealthPartners - Fewer Diabetes Complications Prevents 320 eye complications each year Prevents 80 heart attacks and 120 amputations each year

Thank You! George Isham, M.D., M.S. Medical Director and Chief Health Officer HealthPartners, Minneapolis, MN