1. Choosing Wisely and Healthcare Resource Stewardship Council (HRSC) PGIP Meeting December 6, 2013 1

2. 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):795-802 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

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

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

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7. 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.

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

9. Healthcare Resource Stewardship Council Initially organized by BCBSM in 2011 to focus on the access to and affordability of care for Michigan citizens now and far into the future Purpose: – To engage in collaborative efforts to ensure judicious use and active stewardship of health care resources. Organizing principles: – Principles and governance set by PGIP community leaders – Large scale representation from PGIP POs – Integrate hospitals, patients, systems, and employer groups in future 9

10. Healthcare Resource Stewardship Council Current status: – 26 PGIP POs engaged in initial planning sessions – Vision and core tenets established in 2012 (see next slide) – HRSC Core Group and Value Partnerships meet monthly – Working with the Michigan Data Collaborative to establish a data reporting tool for PGIP POs to determine compliance rates with Choosing Wisely ® guidelines 10

11. Organize care to put patients first while making wise choices about care and the use of healthcare resources. Organize care to put patients first while making wise choices about care and the use of healthcare resources. CORE TENETS COMMUNICATION ACCESS ADVOCACY EMPOWERMENT HRSC Vision and Core Tenets WHAT DOES SUCCESS LOOK LIKE? Movement from individual care to population management All partners in healthcare delivery are empowered, engaged and aligned WHAT DOES SUCCESS LOOK LIKE? Movement from individual care to population management All partners in healthcare delivery are empowered, engaged and aligned WHAT WILL WE ACCOMPLISH? Culture change Philosophy change Shift in accountability Measurement to support the accountability Payment reform to support the work and accountability WHAT WILL WE ACCOMPLISH? Culture change Philosophy change Shift in accountability Measurement to support the accountability Payment reform to support the work and accountability 11

12. HRSC and Choosing Wisely ® In 2012, HRSC identified focus areas from Choosing Wisely ® guidelines Selected only guidelines that could be measured in BCBSM claims – Of those guidelines, HRSC identified those that: Have a high impact on cost Are evidence-based Are easily amenable to change 12

13. 13 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

14. 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.

15. 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

16. 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 16

17. 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

18. Actions

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

20. 20 Five guidelines account for 80% of Total Allowed Costs ACR1 ASNR1 AAFP4 ACP2 AAAAI2 Five guidelines account for 80% of Total Allowed Costs ACR1 ASNR1 AAFP4 ACP2 AAAAI2 Criteria 2 – Costs associated with guidelines BCBS HRSC Slides 2012

21. HRSC Recommendations – Bundled Focus Areas ACR1 - Don't do imaging for uncomplicated headache ACP2 - Don't obtain back imaging studies in patients with non- specific low back pain AAAI2 - Don't order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis Imaging of Uncomplicated Conditions ASNC1 - Don't perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high- risk markers are present AAFP4 - Don't order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms Cardiology Tests in Low-Risk Individuals AAFP5 - Don't perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease AAFP3 - Don't use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors Women’s Health 21

22. ANALYSIS Lack of knowledge Time constraints / Workflow disruption Financial disincentives Cost to develop and distribute materials GOALS Increased awareness Decreased cost / capita HRSC Choosing Wisely Guidelines A3 BACKGROUND Unsustainable “system” of increased costs Unnecessary services (passive provider involvement and waste/harm) Uneducated consumer Opportunity for education of providers, patients, payers and employers CURRENT CONDITIONS Per Capita Spending Variations SMART Specific Measurable Actionable Relevant Achievable FOLLOW-UP Distribution of Tool Engagement of stakeholders RECOMMENDATIONS TOOLS (Reports and Decision Aids) Handouts App STRATEGIES Engagement with community partners (e.g. GDAC) Marketing (“jingle” – “We choose wisely together.” FINANCIAL Incent for wiser decisions by providers and patients PLAN What / Who / When Choosing Wisely analysis and dashboard

23. Choosing Wisely Reporting Tool Ellen Bunting 23

24. Finding the Choosing Wisely ® Reporting Tool 1.PGIP Collaboration Site (must be a member of a participating PO and be registered to gain access) 2.Choose the Analytics Tab 3.Within Analytics choose MPAC 4.Under MPAC Documents, click on Choosing Wisely Reporting Tool The tool will be available as of December 6, 2013. 24

25. Choosing Wisely ® Workgroup Convened by GDAHC and MSMS in June 2013 Workgroup comprised of various stakeholders Goal to create uniform training curriculum for health care professionals and consumers Training aligns with HRSC recommendations: Cardiology, Imaging and Women’s Health Curriculum and lead trainers are ready to test the tools and learning approach 25

26. Gary Billotti Choosing Wisely ® through the Michigan Health Information Alliance

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29. Choosing Wisely ® : http://www.choosingwisely.org/ ABIM Foundation: http://www.abimfoundation.org/ Consumer Reports Health: http://consumerhealthchoices.org/campaigns/choosing-wisely/ Ellen Bunting, Senior Business Analyst, Michigan Data Collaborative ebunting@med.umich.edu Sheri Lee, Senior Health Care Analyst, Value Partnerships slee2@bcbsm.com 29