What will it Take to Improve Care for Chronic Illness for the Population?

1. What will it Take to Improve Care for Chronic Illness for the Population? Ed Wagner, MD, MPH MacColl Institute for Healthcare Innovation Center for Health Studies Group Health Cooperative Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation

2. What will it Take to Improve Care for Chronic Illness for the Population? Step 1: End the complacency! • U.S. 30th in life expectancy (Cuba is 29th) • Rank among the lowest of Western countries in other health indicators • 40-50% more expensive than any other country • Nearly 1 in 6 have no health insurance and they have a 25% greater mortality rate • Tragic racial, ethnic and income disparities

3. Johns Hopkins U.S. Survey about Chronic Care: % Agreeing With

4. Why focus on chronic illness care? • Primary care dominated by chronic illness care • Clinical and behavioral management increasingly effective, but complex and expensive • Inadequate reimbursement forcing primary care to increase throughput while limiting clinical staff—the hamster wheel • Roughly 50% of Americans not receiving evidence-based chronic illness care (Quality Chasm) and only 25-40% have their condition under good control • Trainees choosing other specialties • Loss of confidence in primary care by policy-makers and funders • Talk of the “demise of primary care”

5. Why the Focus on Chronic Illness Care? • Over 100 million Americans have one or more chronic conditions • They account for the vast majority of health care costs • Roughly 50% of Americans not receiving good chronic illness care (Quality Chasm) • Situation is worse for the uninsured and racial and ethnic minorities • Unhappy primary care clinicians leaving practice; trainees choosing other specialties

6. What will it Take to Improve Care for Chronic Illness for the Population? Step 2: Find the cause of inadequate care. IOM Quality Chasm Report:“The current care systems cannot do the job.” “Trying harder will not work.” “Changing care systems will.”

7. What will it Take to Improve Care for Chronic Illness for the Population? Step 3: Select a strategyThree Options:1. Assume that competition and computers willimprove care 2. Direct to patient disease management3. Improve medical care by changing care systems

8. Why Effective Medical Care is Essential to Improve Care and Reduce Costs for Chronic Disease • The human and financial costs result from poor control of the conditions • Good control requires appropriate drug treatment, careful follow-up, and changing treatment if needed • Continuity and satisfaction with medical care associated with better control

9. What kind of changes to practice systems improve care? Integrated changes with components directed at: • better use of non-physician team members, • plannedencounters, • modern self-management support • Care management for high risk • Links to effective community resources • guidelines integrated into care • enhancements to information systems (registries)

10. Lessons learned in chronic illness care improvement • Chronic care collaboratives have demonstrated that practices can make these changes and improve care • Mostly reaching early adopters • Practice redesign is very difficult in the absence of a larger, supportive “system”, especially for smaller practices • How to help isolated small practices where 80% of Americans receive their care? • Regional improvement efforts beginning to make make a difference

11. What will it Take to Improve Care for Chronic Illness for the Population? Step 4—Reach the Majority of Practices • Are there lessons from successful large systems like the VA or regions of Kaiser Permanente? • If so, might they be applicable to communities?

12. King’s Fund Study of Organizations with Best HEDIS Chronic Illness Scores Organizational factors supportive of high quality chronic care: • Strategicvalues and leadership that support long term investment in managing chronicdiseases • Well aligned goals between physicians and corporatemanagers • Investment in informationtechnology systems and other infrastructure to support chronic care • Useof performance measures and financial incentives to shape clinical behavior • Active programs of Quality Improvement based on explicit models

13. What’s needed to improve chronic illness care for the population? Step 5—Build a regional healthcare “system” • Commitment and Leadership • Measurement (and incentives) • Infrastructure – IT + • Active program of practice change

14. Care will not improve unless we changethe systems of care The goal is to transform health care deliveryeverywhere healthcare is delivered

15. Leadership • Someone needs to take and thenassure leadership • Major stakeholders need to be involvedand committed to improvement

16. Need outcome and patient experience dataas well as process data to assess effort, performance, and improvement Practices will have to be able to provide valid and complete data on these indicators; claims will not suffice Ideally practices should be able to use these data in clinical care, not just periodically send offmeasures Smaller practices need info. and technical support to develop such data systems

17. Need strategies andinfrastructure to helpALL practices change their delivery systems Strategies – QI methods,Provider networks Infrastructure—IT, guide-lines, care managers

18. More activated and informed consumers may help pushimprovement Public disclosure of performancedata may spur improvement

19. Create incentives for providers to make the investments needed to improve chronic care Create benefit plans that reward consumers for making cost-effectivechoices

20. Questions raised at recentconference: • Does the limited evidence of P4P effectiveness to date reflect problemsin P4P design? • or Is P4P an inadequate band-aid ona perverse payment system? • Should P4P more aggressively tryto remove payment barriers, not justadd bonuses?

21. A Framework for Regional Quality Improvement

22. Is geographic improvement possible? North Carolina • State leadership and money has created a visionary Medicaid care system • Measurement system, Guidelines, Physician networks, Care Managers, Collaboratives • Financial rewards for participating • Early results promising • Plans to extend to include all patients regardless of insurance coverage

23. Contact us: www.improvingchroniccare.org thanks