1. New Approaches to Disease Management Get Connected Knowledge Forum Larry G. Anderson MD MMC Physician-Hospital Organization June, 2005

2. Maine Medical Center Physicians-Hospital Organization Recent transition from contracting to quality improvement focus 200 PCPs, 770 specialists, 4 hospitals in southern and central Maine Largely independent practices Low EHR penetration

3. Chronic Illnesses Are Costly Costly to employers  productivity and absenteeism (8.3 days compared to 1.7 days/year) Costly to society  44% with chronic illness drive 78% of healthcare $ Costly to patients and their families

4. Cost Burden of Diabetes 18.5 % of healthcare $  care of diabetes ($132 billion annually) Annual cost of healthcare:  $13,243 for patient with diabetes  $2,560 for patient without diabetes MMC: diabetes-related care $100 million annually!

5. The Burden of Diabetes Complications for Patients Retinopathy: leading cause of new blindness Amputations: half from diabetes Nephropathy: 40% of kidney failure requiring dialysis, from diabetes Death from heart attacks and stroke quadrupled

6. There Is Hope: “Best Practice” Care for Diabetes Following evidence-based guidelines (“best practice”) lowers the risk of complications:  heart attack and stroke by 53%  retinopathy (eye) by 58%  nephropathy (kidney) by 61% New England Journal of Medicine, January, 2003

7. But Is “Best Practice” Care Delivered? Only about half the time. Care delivered by evidence-based guidelines:  Diabetes: only 46% of the time  Chronic illness: 56%  Preventative care: 55%  Acute care: 54% RAND New England Journal of Medicine, June, 2003

8. Institute of Medicine (IOM): Crossing the Quality Chasm As medical science and technology have advanced at a rapid pace, the health care delivery system has floundered. Between the care we have and the care we could have lies not just a gap, but a chasm The “quality gap.”

9. IOM Conclusion The problem: bad systems, not bad doctors We have a healthcare delivery problem, solved by redesigning systems of care delivery

10. Medical Errors and Quality Improvement IOM QUALITY GAP Overuse Misuse Under use (the most common gap in chronic illness care) BEST PRACTICE Do less Do it right Do more (by office system redesign)

11. PHO Clinical Improvement Plan (CLIP) Goals Promote best practice care Prevent or delay illness complications Develop reward system for best practice care

12. New Systems in CLIP The MaineHealth Chronic Illness Registry: a new system to make best practice easier for physicians and their office staffs The PHO Chronic Illness Care Management Program: a new system to engage the patients to take responsibility for caring for their diseases

13. The MaineHealth Chronic Illness Registry (CIR) What the CIR is: –A secure web-based tool for physicians to consolidate and track data (key clinical information) for patients with specific chronic illnesses –Homegrown –Applicable to all patients, regardless of payer source

14. The MaineHealth Chronic Illness Registry What the CIR is: –Available at no cost to PHO physicians –Technically supported by the MMC What the CIR is NOT: –An electronic medical record (EMR) –Expensive like an EMR

15. What the Registry Provides Reminders based on best practice –A summary of updated patient information for today’s visit - quality gaps for that patient –Population management reports: identify opportunities to improve care for all the patients with a chronic illness - quality gaps for the practice

17. Population Based Care

18. Old Way  Reactive care, visits triggered by problems, focus on acute care  Missed appointments, lab  Other health concerns distract doctor from details of caring for diabetes  Thick paper chart: when and what was last LDL?

19. New Way  Systematic care, with proactive outreach for appointment and lab, focus on prevention  Important clinical data organized at time of visit  Prompts of need to treat blood pressure, blood sugar, LDL “to target”  Motivating the patient: self-management

20. New System to Engage Patients: Chronic Illness Care Management Program An intensive, personalized approach to motivating and supporting the patient to embrace self-management skills RN Care Managers –Practice-based, at no cost to practice –All chronic illnesses, all patients

21. Pay for Performance (P4P) New provider reimbursement model that promotes and rewards behavior changes and best practice system changes that produce better, more cost-effective outcomes

22. MMC PHO Internal P4P: Quality Care Rewards Program Cash awards for both physicians and staff teams for achieving good and superior levels of care delivery for childhood asthma and adult diabetes $270,000 distributed to primary care physicians and their practice teams for their work in achieving 2004 goals Rewards ranged up to $7240 for individual physician

23. 2004 Quality Care Goals “Good Performance” measure examples –At least 80% of patients seen in 2004 –80% of patients with asthma classified –80% of patients with persistent asthma on controller med –80% of patients with diabetes tested for HbA1c and LDL

24. 2004 Quality Care Goals “Superior Performance” measure examples –90% visits, classification, lab testing –90% flu shots in asthma –90% aspirin in diabetes

26. What is Next? More chronic illnesses Focus on preventive health Specialist engagement New technology to improve patient safety (electronic prescribing)

27. Idealized IT-supported Illness Management Standardized evidence-based data sets Decision support with knowledge links and prompts Customizable documentation Workflow efficiency with one system, integrated with office management system and central data repository that push data and pre-populate data fields

28. MMC PHO Addresses Chronic Illness Management New systems (CIR and care managers) to focus on areas of opportunity to strive for best practice care Well designed, significant financial incentives to accelerate the necessary system changes

29. If Innovative Approaches to Illness Management are Successful…. Potential for tremendous payoffs –improved quality of life for our patients –cost savings from averted complications Win-win-win for patients-providers- community