1. Physician and Society PatientPhysician Population Family Health Care Structure/Financing Scientific Paradigm (EBM) Other Care Providers Integrative Medicine Culture Culture of Biomedicine Care RecipientsCare Providers CARE EthicsLawEnd-of-LifeInformation Age Community

2. Physician and Society 1. Patients, Providers, and Quality 2. Models of Medical Care 3. Chronically Ill, Poor, and Uninsured 4. Use of Informatics in Health Care 5. Public Health Ethics Physician and Society Organizational Strategies Series

3. Physician and Society Disease Management of Chronic Illness Physician and Society

4. What is “Disease Management”? Packaging of familiar and longstanding clinical concepts centered around a condition Systematic, population-based approach to identify patients at risk, intervene with specific therapeutic programs, and measure clinical outcomes of interest Physician and Society

5. Proactive Chronic Care (Disease Management) Model Case Finding Assessment Management Physician and Society

6. Proactive Chronic Care (Disease Management) Model Case Finding Assessment Management Physician and Society

7. Identifying High-Risk Patients Recognition by clinicians Physician and Society

8. Identifying High-Risk Patients Claims data Physician and Society

9. Identifying High-Risk Patients Surveys Physician and Society

10. Proactive Chronic Care (Disease Management) Model Case Finding Assessment Management Physician and Society

11. Assessment of High-Risk Patients Performed by trained CM Straightforward vs multidimensional needs Medical and non-medical factors Physician and Society

12. Proactive Chronic Care (Disease Management) Model Case Finding Assessment Management Physician and Society

13. Management of High-Risk Patients Case management Primary care referral Specialty care Team care Pharmacy Home care Physician and Society

14. The Challenge of Chronic Diseases—the Chronic Care Model Ed Wagner MD, MPH MacColl Institute for Healthcare Innovation Group Health Cooperative Improving Chronic Illness Care, a national program of The Robert Wood Johnson Foundation Physician and Society

15. State of the Art in Chronic Illness Care Improvement Major clinical advances in most major chronic illnesses Growing appreciation that the patient’s (and family’s) self-management skill heavily influences outcomes But, patients not reaping benefits of new knowledge Physician and Society

16. Current status of Chronic Illness Care in the U.S. 27% of hypertensives are adequately treated 29% and 26% of diabetics have well controlled lipid and blood pressure levels, respectively 35% of eligible patients with atrial fibrillation receive anticoagulation 25% of people with depression are receiving adequate treatment 50 % of discharged CHF patients are readmitted within 90 days Physician and Society

17. Why are we doing so poorly? The IOM Quality Chasm report says: “The current care systems cannot do the job.” “Trying harder will not work.” Physician and Society

18. Usual Chronic Illness Care Oriented to acute illness Focus on symptoms and lab results Patient’s role in management not emphasized Care dependent on provider’s memory and time Interaction often not productive, and frustrating for both patient and doctor Physician and Society

19. What Will Improve Chronic Illness Care? The IOM Quality Chasm report says: “Changing care systems will.” Physician and Society

20. The Goal of System Changes to Improve Chronic Illness Care Patient Productive Interactions Practice Team a planned set of interactions over time during which the critical clinical and behavioral elements of care are performed reliably Physician and Society

21. What characterizes an “informed, activated patient”? Informed, Activated Patient They have the motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it Physician and Society

22. What characterizes a “prepared” practice team? Prepared Practice Team At the time of encounters, they have the patient information, clinical expertise, team, equipment, and time required to deliver evidence-based clinical management and self-management support Physician and Society

23. Randomized trials of system change interventions: Diabetes Cochrane Collaborative Review 41 studies, majority randomized trials Interventions classified as provider-oriented, organizational, information systems, or patient-oriented Patient outcomes (e.g., HbA1c, BP, LDL) only improved if patient-oriented interventions included All 5 studies with interventions in all four domains had positive impacts on patients Renders et al. Diabetes Care 2001;24:1821 Physician and Society

24. Randomized trials of system change interventions: Heart failure 11 randomized trials Most reduced hospitalization significantly Most successful employed a nurse case manager working with cardiology and primary care Care guided by protocol and strong emphasis on self-management support 7/8 examining costs found cost savings McAlister et al, Am J Med 2001 Physician and Society

25. Does improved chronic care reduce health care costs? 28 randomized trials studied interventions related to the chronic care model and examined costs (diabetes, CHF, asthma) 17 showed either cost savings or utilization decreases Bodenheimer et al. JAMA 2002;288:1909 Physician and Society

26. Interventions Supportive of Productive Interactions Provider-oriented Patient-oriented Practice-oriented Information Systems Physician and Society

27. The Goals of System Change Interventions to Improve Practice Provider-oriented—enable practice team to deliver evidence-based care to EVERY patient Patient-oriented—develop informed, activated patients who are competent self-managers Practice-oriented—design practice teams, patient encounters, and data systems that enable productive interactions Physician and Society

28. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model

29. Self-management Support Provide effective self-management interventions and ongoing collaborative goal-setting and problem-solving by the team. Physician and Society

30. Self-management Support What is self-management? “The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.” Barlow et al, person Educ Couns 2002;48:177 Physician and Society

31. Effective self-management Support patient major role in managing her illnesses and treatment emphasized her knowledge, behaviors and confidence routinely assessed goals for improving self-management set collaboratively with practice team advice based on evidence and presented as information not scolding Physician and Society

32. Effects of Self-management Education on Glycemic Control 31 RCTs evaluated effects on HbA1c Average 6 contacts and 9 contact hours Most often delivered by nurse-dietician-physician team 2/3 in groups Reduction in HbA1c increased with contact time (1% for every added 24 hours of contact) Effect diminished shortly after end of class Norris et al, Diabetes Care 2002; 25:1159 Physician and Society

33. Delivery System Design Practice team has defined roles, uses planned visits and clinical case management to support evidence-based care, and assures regular follow-up and care coordination Physician and Society

34. Nurse Case Management RCT-Aubert et al. Change in Treatment and Glycemic Control Between Baseline and 12 Months

35. Diabetes Cluster Visits, Sadur et al Change in Treatment and Glycemic Control Between Baseline and 12 Months

36. Decision Support Weave evidence-based guidelines into fabric of practice: e.g., reminder and fail- safe systems (e.g., standing orders), specialist involvement with primary care, problem-based learning Physician and Society

37. Clinical Information System: Registry A database of clinically useful and timely information on all patients provides reminders and feedback and facilitates care planning for individuals or populations Physician and Society

38. Health Care Organization Organization encourages and supports better care through leadership, quality improvement& incentives Physician and Society

39. Community Resources and Policies Health care organization has linkages with community organizations that can enhance practice capabilities, provide key patient services, or improve care coordination Physician and Society

40. Examples of Community Linkages Exercise programs in local Y or gym Peer support programs Hospital nurse educator loaned to practice Endocrine practice nurse loaned Physician and Society

41. The Quality Chasm Usual Care versus Improved Care Readmission rates of patients hospitalized with CHF reduced by about 50% Recovery rates from major depression increased 50- 100% Children with moderately severe asthma have symptoms 14 fewer days/year Anticoagulated patients in safe and effective range twice as frequently Physician and Society

42. Differences between Organized Programs and Usual Care of Chronic Illness Average HbA1c of type II diabetics will be 1%+ lower 1.5 - 2 times as many patients with major depression will be recovered at six months Readmission rates of patients hospitalized with CHF will be cut in half Asthmatic kids will be in school two more weeks a year Physician and Society

43. BPHC Diabetes Collaboratives 1and 2 involving 180 Community Health Centers and 38,000 diabetic persons Average HbA1c Values

44. Physician and Society How do you provide care for those who can’t afford it? Physician and Society

45. Structure and Financing of Care for the Poor and Uninsured in America Physician and Society

46. Medicaid Physician and Society Federal/state health insurance program For low-income persons 51 million enrollees in 2002 2002 Medicaid expenses: $259 billion 2002 Medicare expenses: $257 billion

47. Physician and Society Medicaid – Medicare Similarities Physician and Society Both enacted in 1965 Both are entitlement programs Both are overseen by CMS

48. Medicaid – Medicare Differences Champion –Medicare: President Johnson –Medicaid: Congress (Wilbur Mills, D-Ark) Financing –Medicare: purely federal –Medicaid: joint federal/state Physician and Society

49. Medicaid – Medicare Differences Beneficiaries –Medicare: Virtually all elderly –Medicaid: All ages Covered Benefits –Medicare: set by feds, same for all enrollees –Medicaid: set by states, different by states Physician and Society

50. Medicaid – Medicare Differences Enrollment Criteria –Medicare: age and/or disability only; set by feds –Medicaid: financial and other health and social criteria; set by individual states Physician and Society

51. Medicaid Financing Physician and Society

52. S.S. Taxes CMS Individual Providers Medicare + Choice Plans $$ Medicare

53. Physician and Society S.S. Taxes CMS Health Care Providers $148 billion $259 billion Medicaid (2002) State Taxes State Medical Assistance Programs

54. Physician and Society Medicaid Expenses

55. Physician and Society Medicaid Beneficiaries

56. Physician and Society Medicaid Expenses Physician and Society Disproportionately to disabled Disproportionately to elderly Disproportionately to long term care

57. Physician and Society Selection of Medicaid Beneficiaries Physician and Society Each state sets own criteria Based on financial need and eligibility

58. Physician and Society Selection of Medicaid Beneficiaries Physician and Society Each state sets own financial criteria for: –Families with dependent children on welfare –Families with parent getting off of welfare Feds establish mandatory eligibility groups: –Low-income pregnant women –Low-income children –Low-income elderly or disabled persons

59. Physician and Society MN MA Eligibility

60. Physician and Society Medicaid Covered Benefits Physician and Society Benefits package much more extensive than for private insurance Cost sharing by patients largely prohibited Restricting coverage to certain groups prohibited Caps for certain diagnoses prohibited

61. Physician and Society Challenges to States Physician and Society Budgetary problems Growth of Medicaid – projected to grow faster than national health expenditures Federally imposed eligibility criteria and restrictions on patient spending Federally imposed partial benefits package Matching federal funds

62. Physician and Society State Medicaid Fiscal Strategies Physician and Society Managed care (now 100% of MA enrollees) Controlling drug costs Decreasing physician payment rates Restricting eligibility (mostly financial criteria) Reducing benefits Increasing copays

63. Physician and Society S.S. Taxes CMS Medicaid Managed Care Plans $148 billion $259 billion Medicaid (2002) State Taxes State Medical Assistance Programs

64. Physician and Society The Uninsured Physician and Society Who are they? How do costs inhibit care? Where do they get care? How healthy are they?

65. Physician and Society

70. The Uninsured in Minnesota Physician and Society

72. How do we do it? Physician and Society Employer-provided commercial insurance Medicaid (Medical Assistance) MinnesotaCare General Assistance Medical Care (GAMC)

73. Physician and Society MinnesotaCare Physician and Society 1988 -- Children’s Health Insurance Program (CHIP) 1992 – MinnesotaCare enacted; CHIP folded into it shortly thereafter Provides insurance for low income persons who do not have access –Not on Medicaid (Medical Assistance) –Not on commercial insurance

74. Physician and Society MinnesotaCare Physician and Society Covers families with children with incomes up to 275% of federal poverty guidelines Covers individuals/families without children up to 175% of FPG Family SizeFPGMNCare Elig. 2$12,120$33,000 4$18,400$50,000

75. Physician and Society MinnesotaCare Financing Physician and Society State dollars 1.5% tax on hospitals and health care providers Federal funds Enrollee premiums, copays, deductibles –Average premium is $18/month –$3 copay per Rx, $25 per pair of glasses –$1,000 inpatient deductible

76. Physician and Society General Assistance Medical Care (GAMC) Physician and Society Covers low-income persons who do not qualify for other state or federal insurance programs –Primarily adults without dependent children 100% state funded

77. Physician and Society Health Care Coverage in Minnesota