Business Case for Quality Recognizing Excellence in Practice

1. Business Case for QualityRecognizing Excellence in Practice Presented to the Institute for Quality in Laboratory Medicine by Dr. Robert Kropp Aetna Health Inc. Atlanta, Georgia April 29, 2005

2. Business Case for Lab Data • Managed care’s objective is getting and keeping people healthy • Our commitment is to improving the quality of health care and health outcomes • Access and availability of accurate and timely lab data plays a key role in monitoring and measuring quality of care

3. Application of Lab Data • Lab results are one of the few quantifiable clinical outcome measures available from easily accessible data (not chart review) • Because of the sensitivity and specificity of lab results, they are applicable as a proxy for health outcomes • Lab result data is strongly correlated with health outcomes and is applied in predictive modeling • Provides a standardized measure of the delivery of quality care

4. Care Management • Disease Management • Case Management

5. Disease Management • Disease management compares the care delivered to the care recommended • Lab results are used to identify members with the target disease, and to measure health care outcomes

6. Case Management • Case Managers have lab results on-line and available when contacting members to monitor their health status • HbA1c level history showing good control and adequate disease management

7. Quality Improvement • Appropriateness of Care • Effectiveness of Care • Patient Safety • Improving Quality of Care

8. Operational Definitions • Appropriateness of care • “What is being done” • The indicated lab test has not been ordered to monitor a known condition • Effectiveness of care • “How” effective is the treatment • The lab test test has been ordered, but the result is abnormal

9. Appropriateness of Care • Warfarin and no evidence of INR monitoring in the past 3 months. • Evidence for glitazones and no evidence of liver function monitoring in the past 6 months. • Member with diabetes and no evidence of screening for HbA1c or microalbuminuria in the past year. • Elevated LDL cholesterol level and no evidence of a lipid-lowering agent. MedQuerySM Care Considerations

10. Effectiveness of Care • Evidence of warfarin and lab data indicating persistent or recurrent sub-therapeutic INR values • Evidence of diabetes and lab data indicating elevated glycated hemoglobin (HbA1c) level • Evidence for diabetes and lab data indicating an LDL cholesterol greater than 100 mg/dl and/or HDL cholesterol less than 40 mg/dl

11. MedQuery • The MedQuery program alerts physicians to opportunities for improved care by applying state-of-the-art clinical algorithms to the medical information derived from claims, pharmacy claims, laboratory results and demographic information. • This technology generates specific recommendations applicable to a specific member and delivers these recommendations to the treating physician.

12. Patient Safety • Lab data assists Pharmacy Management to identify drug-to-disease interactions • The use of a beta blocker in a member diagnosed with asthma, based on a previous theophylline level • Abnormal lab results are used to identify unintended or potentially dangerous side effects of prescription drugs • Low platelet count and a drug that can cause thrombocytopenia

13. Patient Safety • Elevated lab results are used to identify drug toxicity or drug/drug interactions • Elevated serum level of carbamazepine and drug(s) that can interfere with its hepatic metabolism • Elevated serum phenytoin level and drug(s) that may increase phenytoin levels • Elevated liver transaminase and evidence of a drug that can cause abnormal liver function tests

14. Improving Quality of Care • Pay for Performance • Preferred Provider Networks • Physician Performance • HEDIS • Member Lists • Predictive Modeling

15. Pay for Performance • Pay for performance programs differentiate payment based on clinical performance criteria • The programs are designed to align doctor’s financial reward with improved outcomes • Lab data plays a key role in monitoring and measuring clinical performance and quality of care

16. Preferred Provider Networks • Preferred provider networks are selected based on measurable clinical outcomes and efficiency • Lab data provides a standardized measure for appropriateness and effectiveness of care

17. Physician Practice Management • Physicians have access to lists of members who may have treatment opportunities • Examples • Members with diabetes receiving an annual lipid screening • Members with diabetes with at least two HbA1c tests annually • Members with diabetes receiving an annual microalbuminuria screening

18. HEDIS • Appropriate Testing for Children with Pharyngitis • Group A Streptococcus tests • Colorectal Screening • FOBT • Cervical Cancer Screening • Pap smear • Chlamydia Screening in Women • Chlamydia trachomatis NCQA, HEDIS 2005 Technical Specifications

19. HEDIS • Cholesterol Management After Acute Cardiovascular Event • LDL screening and levels <130 and <100 • Comprehensive Diabetes Care • HbA1c testing and level >9 • LDL test and levels <130 and <100 • Micro and Macro albuminuria

20. Cholesterol Management After a Heart Attack • 65.1% had LDL controlled below 130 • 47.6% had LDL controlled below 100 • Cholesterol control after a cardiac event can result in a 31% reduction of fatal and nonfatal reinfarction and a 21% reduction in all causes of mortality • Cholesterol management can reduce the cost of cardiovascular disease in the U.S., estimated to be $368.4B in 2004, with heart disease accounting for $238.6B NCQA: The State of Health Care Quality 2004

21. Diabetes • More than 11 million Americans have been diagnosed with Diabetes • About 1 million new diabetics over age 20 are diagnosed every year • 32% of diabetics have HbA1c level greater than 9 • For every 1% reduction in A1c, the risk of developing eye, kidney and lower extremity amputation is reduced by 40% NCQA: The State of Health Care Quality 2004

22. Predictive Modeling • Mathematical calculation to predict which members will have an acute event related to their illness within the next 12 months • Lab data is integrated into the model • The model assists case and disease managers in prioritizing contact with those members at greatest risk

23. Business Case for Lab Data • Managed care’s objective is getting and keeping people healthy • Our commitment is to improve member care and health outcomes • Access and availability of accurate and timely lab data plays a key role • What role can IQLM play in achieving our commitment?