1. Targeting Prevention to Evidence Based, High Impact Interventions in Medicare George Isham, M.D., M.S. Chief Health Officer AHRQ Annual Conference Bethesda, MD. September 14, 2009

2. Is There Enough Time for Prevention? 54.9% of Adults are receiving recommended preventive care* To fully satisfy all services recommended by the USPSTF, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive care services by primary care physicians ** *McGlynn, et al, NEJM, 348:26. June 26, 2003 ** Yarnall KSH, et al, AJPH. Vol. 93. No.4., April, 2003

3. National Priorities Partnership 28 multi-stakeholder organizations Consumers Purchasers Quality alliances Health professionals/providers Public sector: CMS, NGA, CDC, AHRQ, NIH Accreditation/certification groups Health plans Co-Chairs: –Donald Berwick –Institute for Healthcare Improvement –Margaret O'Kane National Committee for Quality Assurance © National Priorities Partnership

4. Selecting the Priorities: Criteria © National Priorities Partnership Remove Waste Eradicate Disparities Eliminate Harm Reduce Disease Burden High Impact Areas

5. National Priorities Patient and family engagement Population health Safety Care coordination Palliative care Overuse © National Priorities Partnership High Impact Areas

6. NATIONAL PRIORITY Population health Improve the health of the population 3 Areas of focus: –Preventive care –Healthy lifestyle behaviors –Community index to assess health status © National Priorities Partnership

7. Underuse of Preventive Services is a Big Problem The first of the NPP Population Health Goals is that all Americans will receive the most effective preventive services recommended by the USPSTF

8. A Strategy for Promoting the Most Effective Preventive Services –Stratify the USPSTF A & B recommendations by Clinical Preventive Burden and Cost Effectiveness * –Develop a Clinical Practice Guideline that incorporates those most impactful recommendations. ** (must do, nice to do, discuss, don’t do. –Develop systems (decision support, standardized work flows, team assignments, etc) to support the implementation of the guideline Maciosek, M.V., et. al., 2006. Priorities Among Effective Clinical Preventive Services, AJPM; (31): 52-61. Institute for Clinical Systems Improvement Adult Preventive Services Guideline accessed at icsi.org

9. A Strategy for Promoting the Most Effective Preventive Services –Deploy an “all or none” measure that measures preventive services up to date by age and gender to monitor performance against the guideline* –Deploy educational materials for patients designed to reinforce the prevention expectations of patients that are consistent with the most impactful recommendations by age and gender. *Nolan T. and Berwick DM, JAMA. 295:10. March 2006.

10. 2006 Prevention Priorities Short NameCPB CE Total Aspirin Chemoprophylaxis – ‘high risk’5 5 10 Childhood Vaccination Series 5 5 10 Tobacco Cessation Counseling 5 5 10 Colorectal Cancer Screening 4 4 8 Hypertension Screening 5 3 8 Influenza Immunization - adults 4 4 8 Pneumococcal Immunization - adults 3 5 8 Problem Drinking Screening & Brief Counseling 4 4 8 Vision Screening - adults 3 5 8 Cervical Cancer Screening 4 3 7 Cholesterol Screening 5 2 7 Breast Cancer Screening 4 2 6 Maciosek, M.V., et. al., 2006. Priorities Among Effective Clinical Preventive Services, AJPM; (31): 52-61.

11. ICSI Adult Preventive Services Guideline - 2005 11 Institute for Clinical Systems Improvement, Bloomington, MN, 2005. icsi.org

12. ICSI Adult Preventive Services Guideline - 2005 12 Institute for Clinical Systems Improvement, Bloomington, MN, 2005. icsi.org

13. Examples of Measures Currently in the Field: HealthPartners Adults - % members in sample who received all preventive screening appropriate to age & gender –Cholesterol –Colon cancer screening –Breast cancer screening –Cervical cancer screening –Chlamydia screening –Pneumococcal vaccine –Blood pressure –Vision screening Member up to date rate = 78.7% 13 HealthPartners, Inc. 2008. Clinical Indicators Report.

14. Our Inability to Address Key Health Behaviors Leads to Premature Mortality For example, for middle aged Americans, optimal evidence based treatment at the time of an acute cardiac event would prevent or postpone only 8% of deaths. By comparison, 47% of deaths in this group could be prevented or postponed if everyone met dietary and activity guidelines and did not smoke * Therefore, the second of the NPP population health goals is that all Americans will adopt the most important healthy lifestyle behaviors known to promote health. (nutrition, activity, tobacco use, healthy alcohol use) * Kottke T, et al, AJPM. 2009; 36(1): 82-8

15. Actual Causes of Death: 1990 and 2000 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. JAMA. Mar 10 2004;291(10):1238-1245.

16. We Have no Standard Metric to help our Communities be Healthier What gets measured gets done 10 most important determinants of health do not include access to health care – Marmot “The nations heavy investment in the personal health system is a limited future strategy for promoting health” IOM Future of the Public’s Health “The pathways to better health do not generally depend on better health care” – Schroeder, NEJM Therefore, the third of the NPP population health goals is that The health of American communities will be improved according to a national index of health

17. Strategies for Improving Community Health We will develop a national health index that addresses not only the contribution of healthcare to good health, but also the health behaviors of individuals and the socioeconomic and physical environment factors that affect health. We will calculate and report the index for all counties in the United States

18. Examples of Types of Overuse (Waste) An preventive service could be harmful or ineffective – USPSTF D list. The American Public is being defrauded and doesn’t know it. An effective intervention could be deployed inefficiently in the target population. (Cervical Cancer Screening Example – Next Slide)

19. An effective intervention could be deployed inefficiently in the target population. Under Use ($1.9m) Overuse - $8.8m Appropriate Use

20. Some Questions - Is a single preventive visit the most effective strategy to address preventive services in Medicare? How will it integrate with our sophisticated IT strategies? Is addressing waste and overuse in preventive services in Medicare an opportunity to contribute to a more affordable Medicare benefit? 20

21. Conclusions New policies for Medicare based on A and B recommendations of the USPSTF move in the right direction. There remain significant opportunities to encourage the adoption of state of the art approaches to maximize the value and impact of preventive services for Medicare Beneficiaries.