The Michigan Primary Care Transformation (MiPCT) Project 2013 Annual Summit Stewardship of our Health Care Resources Kevin Taylor MD, MS 1

The Need to Know Is Powerful ▫The following story is by Dr. Robert Fenster, a psychiatry resident based at Brown University in Rhode Island, and a winner of the 2012 Costs of Care Essay Contest. 2 Posted by Jordan on Feb 4, 2013 in Blog, Stories | 2 commentsJordanBlogStories2 comments

From Reinhardt blog, NY Times, 12/24/2010

Diagnostic Imaging Studies in Patients in Large Integrated Health Care Systems: Source: JAMA. 2012;307:

Why stewardship? Why now? Health care expenditures are increasing at unsustainable rates Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011 There is waste in the health care system—some say as much as 30%  Jack Wennberg, Dartmouth Center for the Evaluative Clinical Sciences. One third of all physicians acquiesce to patient requests for tests and procedures—even when they know they are not necessary  Campbell EG, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007; 147(11): Physician decisions account for 80% of all health care expenditures  Crosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund [Internet]. 2009; Apr 27

Cost of Health Care CMS, Office of the Actuary, National Health Statistics Group

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Data on regional performance Marked variations highlight opportunities to improve 9 Everett, WA Sacramento, CA La Crosse, WI Cedar Rapids, IA Temple, TX Portland, ME Sayre, PA Richmond, VA Asheville, NC Tallahassee, FL Lighter colors = lower spending Partici- pants Qualifying Regions All Others Medicare Spending $6,773$7,098$8,562 Hospital Days Spending for Imaging (last 2 yrs) $633$662$843 Hospital Quality Score 95% 93%

Benchmarks of efficiency Potential savings from achieving high performance 10 Everett, WA Sacramento, CA La Crosse, WI Cedar Rapids, IA Temple, TX Portland, ME Sayre, PA Richmond, VA Asheville, NC Tallahassee, FL Category of Care Potential Savings Medicare spending 16% Hospital days17% Specialist visits36% Lighter colors = lower spending

Excess Cost Domain Estimates IOM. The Healthcare Imperative, 2010.

Overriding Issues in Health Care Issue of the decade starting in 2000: quality of care and patient safety Issue of the decade starting in 2010: decreasing the cost of care Recent initiatives have called on physicians to reduce waste and exercise wise stewardship of resources. ▫ABIM Foundation. Choosing wisely ▫American College of Physicians. High value care ▫AMA Council on Ethical and Judicial Affairs. Physician stewardship of health care resources ▫Joint Commission & AMA. Two leading health care quality organizations hold national summit to build consensus around ways to minimize overuse of five treatments.

Are We Willing (and Able) to Address the Problem?

Do Physicians Agree That Health Care is Overused? Survey of primary care physicians ▫42% believe patients in their own practice are receiving too much care (vs. 6% who say “too little”) ▫Perceived factors leading to overuse  Malpractice concerns: 76%  Clinical performance measures: 52%  Inadequate time to spend with patients: 40% Arch Intern Med. 2011; 171:

Views of US Physicians about controlling health care costs. Who bears major responsibility to control health care costs? ▫Lawyers 60% ▫Insurance Companies 59% ▫Patients 52% ▫Physicians 36% ▫Physician professional societies 27% ▫Employers 19% ▫2556 Physicians surveyed 15 Tilburt JC, et al. JAMA, July 24/31,2013.

Attention to and role in addressing health care cost I am aware of the costs of the tests/treatments I recommend —76% Agree Physicians should adhere to clinical guidelines that discourage the use of interventions with small proven advantage over standard interventions but cost much more—79% Agree Trying to contain costs is the responsibility of every physician —85% Agree Doctors need to take a more prominent role in limiting use of unnecessary tests and procedures —89% Agree I should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more —15% Agree I should be solely devoted to my individual patients’ best interest, even if that is expensive —78% Agree 16 Tilburt JC, et al. JAMA, July 24/31,2013. Cost-ConsciousnessPatient Advocacy

It is unfair to ask physicians to be cost- conscious and still keep the welfare of the patient in their minds 17 Tilburt JC, et al. JAMA, July 24/31, % Agree 58% Disagree

Medicine's Ethical Responsibility for Health Care Reform — The Top Five List “A Top 5 list has the advantage that if we restrict ourselves to the most egregious causes of waste, we can demonstrate to a skeptical public that we are genuinely protecting patients’ interests and not simply ‘rationing’ health care, regardless of the benefit, for cost-cutting purposes.” Howard Brody, MD, PhD NEJM Jan 28, 2010

Conserving resources through rational care does not mean rationing! Rationing: decisions are made about the allocation of scarce medical resources and who receives them, leading to underuse of potentially appropriate care Rational care: assuring that care is clinically effective, thus avoiding overuse or misuse of care that is inappropriate

The “Top 5 Lists” Funded by an ABIM Foundation grant, the National Physicians Alliance conceived and piloted the concept through its Good Stewardship Working Group Developed lists of top five activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved Published in Archives of Internal Medicine Subsequent research published in Archives found a cost savings of more than $5 billion could be realized if the recommendations were put in to practice. Arch Intern Med 2011:171 (15);

21 Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices. Consumer Reports leads consumer communication efforts for this campaign. Choosing Wisely

What is the Physician’s Role in Choosing Wisely? The Charter’s commitment to a just distribution of finite resources specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures.

Choosing Wisely Partners Societies Released Lists in April 2012 American Academy of Allergy Asthma & Immunology American Academy of Family Physicians American College of Cardiology American College of Physicians American College of Radiology American Gastroenterological Association American Society of Nephrology American Society of Nuclear Cardiology American Society of Clinical Oncology Societies Releasing Lists in Feb 2013 American Academy of Hospice and Palliative Medicine American Academy of Neurology American Academy of Ophthalmology American Academy of Otolaryngology-Head and Neck Surgery American Academy of Pediatrics American College of Obstetricians and Gynecologists American College of Rheumatology American Geriatrics Society American Society for Clinical Pathology American Society of Echocardiography American Urological Association Society of Hospital Medicine Society of Nuclear Medicine and Molecular Imaging Society of Thoracic Surgeons Society of Vascular Medicine Societies Releasing Lists in Sept 2013 AMDA – Dedicated to Long Term Care MedicineAMDA – Dedicated to Long Term Care Medicine - 9/4 American College of SurgeonsAmerican College of Surgeons - 9/4 Commission on Cancer – a multidisciplinary program of the American College of SurgeonsCommission on Cancer – a multidisciplinary program of the American College of Surgeons - 9/4 American Academy of Orthopedic SurgeonsAmerican Academy of Orthopedic Surgeons - 9/11 Society of General Internal MedicineSociety of General Internal Medicine - 9/12 American Psychiatric AssociationAmerican Psychiatric Association - 9/20 American Society for Radiation OncologyAmerican Society for Radiation Oncology - 9/23 American Academy of Family PhysiciansAmerican Academy of Family Physicians** - 9/24 American College of Medical ToxicologyAmerican College of Medical Toxicology and the American Academy of Clinical Toxicology - 9/26American Academy of Clinical Toxicology Societies Releasing Lists in Oct 2013 American Association for Pediatric Ophthalmology and StrabismusAmerican Association for Pediatric Ophthalmology and Strabismus - 10/8 North American Spine SocietyNorth American Spine Society - 10/9 American College of Emergency PhysiciansAmerican College of Emergency Physicians - 10/14 American Association of Clinical EndocrinologistsAmerican Association of Clinical Endocrinologists/The Endocrine Society - 10/16The Endocrine Society American College of Chest PhysiciansAmerican College of Chest Physicians/American Thoracic Society (Pulmonary) - 10/27American Thoracic Society American College of RheumatologyAmerican College of Rheumatology* - 10/27 American Society of DermatologyAmerican Society of Dermatology - 10/29 American Society of Clinical OncologyAmerican Society of Clinical Oncology* - 10/29 Society of Gynecologic OncologySociety of Gynecologic Oncology - 10/31

Choosing Wisely Partners contd. Consumer Groups Through Partnership with Consumer Reports AARP Alliance Health Networks Leapfrog Group Midwest Business Group on Health Minnesota Health Action Network National Business Coalition on Health National Business Group on Health National Center for Farmworker Health National Hospice and Palliative Care Organization National Partnership for Women & Families Pacific Business Group on Health SEIU Union Plus Wikipedia November 2013 American Headache Society - 11/21 December 2013 American Headache Society American Society of Hematology - 12/4 American Society of Hematology January 2014 American Association of Critical-Care Nurses/American College of Chest Physicians/American Thoracic Society/Society of Critical Care Medicine (Critical Care) - 1/11 American Association of Critical-Care NursesAmerican College of Chest PhysiciansAmerican Thoracic SocietySociety of Critical Care Medicine Society for Cardiovascular Magnetic Resonance - 1/16 Society for Cardiovascular Magnetic Resonance February 2014 Society for Maternal-Fetal Medicine - 2/3 Society for Maternal-Fetal Medicine Heart Rhythm Society - 2/10 Heart Rhythm Society American College of Occupational and Environmental Medicine - 2/24 American College of Occupational and Environmental Medicine The American Geriatrics Society* - 2/27 The American Geriatrics Society American Academy of Allergy, Asthma & Immunology - 2/28 American Academy of Allergy, Asthma & Immunology Release Date TBD American Association of Blood Banks American Association of Neurological Surgeons American Society of Anesthesiologists American Society of Colon and Rectal Surgeons American Society of Plastic Surgeons 24

How the Lists Were Created Societies were free to determine the process for creating their lists Each item was within the specialty’s purview and control Procedures should be used frequently and/or carry a significant cost Should be generally-accepted evidence to support each recommendation Process should be thoroughly documented and publicly available upon request

Actions

Dozens of 2-Page Brochures (in plain English & Spanish)

MiPCT Objectives 28 The tie to budget neutrality and ROI Reduction in Unnecessary and Non-Value-Added Costs

How do they do that? Some preliminary insights Common elements across regions ▫Shared aims; “accountable” to the community; ▫Physician engagement as leaders; support for professional values ▫Strong primary care foundation ▫Use of data to support work; professional feedback; peer review Data feedback – a critical component ▫Organizational accountability – integrated systems to support feedback ▫Data itself – actual performance of providers

Health Policy Recommendations for transforming health care More Cost (or value) consciousness in medical decisions Increased emphasis on keeping patients healthy rather than treating acute exacerbations of chronic illness A move toward team-based care delivery and away from individual practitioners More process standardization with customization for selected patients Greater price and quality transparency Approximately 10% of the population consumes 64% of health care expenditures >75% of high cost beneficiaries had one or more chronic condition 22% ($570 B)of health care expenditures is related to potentially avoidable complications (ACS Hospitalizations, Re-admits, PCS ED visits) E. Emmanuel JAMA Jan 4th 2012 JAMA July 24/

Strategies for achieving… SHORT TERM SAVINGS High-risk patient intensive care management 24/7 clinical decision maker access to prevent unnecessary ED utilization and inpatient admissions Baseline data analysis for utilization outliers and focused root cause analysis (MDC and SPC) Educate on evidence-based approaches to care (e.g., Choosing Wisely Guidelines) LONG TERM SAVINGS Moderate Care Management Incentives for Chronic care outcomes (BP in diabetes, etc.) From Patient Centered Care to Population Centered Health. Shortell JAMA March 2013 Focus on all “tiers” of patient population Care delivery in home, workplace, school Expand providers to health educators, social workers, teachers, city planners, architects 31

MiPCT Working to Improve Performance Data Management and Reporting ▫MDC ▫Stewardship and Performance Committee Patient Engagement ▫Patient Advisory Committee Payment Models ▫Incentive Payments  Quality Process Measures  Quality Outcome Measures  Utilization Metrics Team Development ▫Learning Collaboratives ▫Care Management Webinars ▫PO and Practice Site Visits Physician Engagement ▫Town Hall Meetings ▫PO Advisory Committee ▫Choosing Wisely Initiative 32

Uncertainty and the Challenge of Being an Informed Patient ▫The following anecdote is by Erin Plute, a medical student at Emory University from Marietta, Georgia, and a winner of the 2012 Costs of Care Essay Contest. 33

The Moral Test “This is the threshold we have now come to, but not yet crossed: the threshold from the care we have, to the care we need. We can do this– we who give care. And nobody else can … The buck has stopped; it has stopped with you.” Don Berwick “The Moral Test” 2011 IHI National Forum keynote

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