Collaboration on Quality: Working together to improve health care delivery

1. Collaboration on Quality:Working together to improve health care delivery Iowa Health Buyers Alliance Wednesday, October 25, 2006

2. Beth McGlynn’s 2003 study of 80 communities reported patients received quality care 54.7% of the time1 Variation may result in patient safety issues, overuse and under use of health care services Overuse, underuse and patient safety issues are estimated by the Midwest Business Group on Health to be 30% of the health care costs2 Increased costs do not necessarily lead to increased quality Recent studies by the Institute of Medicine have focused on medical errors, patient safety and quality gaps It is being reported 1 Quality Opportunity Reference: E. A. McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States”, NEJM, 2003. 2 Efficiency Opportunity Reference: Midwest Business Group on Health, 2003 (High)

3. Iowa 2005 Performance

4. Why you should care • Employees are your greatest asset • Encouraging good health of your employees pays: • Improved productivity • Reduced absenteeism and presenteeism • Increased retention / recruitment • You should expect high quality health care • Health care costs impact the bottom line

5. Year 1 Pilot Learnings • Physician champion leadership is key • Actively involve the entire physician care team • Clearly define measures of performance • Use real-time performance feedback • Implement effective patient follow-up • Be willing to adapt and change • Apply technology to support new process • Manual data collection creates administrative work

6. A Revised Approach Improve information sharing on performance and efficiency • Identify national measures • Clinically relevant • Patient-focused • Share information privately with physicians and hospitals Support clinicians in creation of a more patient-focused health care system • Support processes that enable best practice performance • Support removal of waste and inefficiency Encourage patients to be more active in their own care • Identify effective communication tools • Further support the physician/member relationship • Provide more information to support health care decisions

7. Focus on Outcomes • Incent and Reward • Both outcome and process measures • Moving to standard goals 2006 – Collaboration on Quality Clinical Award Chart

8. Focus on Performance – Another approach • Learning collaborative for physicians • 11 care teams from Iowa • 2 care teams from South Dakota • Initial focus is on diabetes • Data collection, measurement, controls • Leveraging data through process • Clinical and Administrative re-design • Process coaching for care teams • Engagement of entire care team • Pre-planning of visits • Continual process improvement methods

9. National Vision: Local Innovation Blue Distinction Centers Cardiac Blue Distinction Centers Bariatric Surgery Blue Distinction Centers Transplant Hospital Quality Tools Employers Hospital Quality Tools Members Blue DistinctionCenters Oncology Wellmark Member Employer Physician Reporting Standard Measures Physician Affordability Measures National Best Practice Projects Specialty Performance Reporting Physician Hospital Physician Hospital WHPI Clinical Innovation Shareholder Projects Advanced Medical Home Work with many associations Collaborating for Innovative Care Focused Learning Opportunities Italicized = future Quality Standard Setting Bodies NCQA, NQF, AMA, AHA, CMS, etc.

10. Iowa Implementations 10 Iowa Communities

11. South Dakota Implementations 5 Iowa Communities

12. Questions? Joel Hasenwinkel Director, Clinical Collaboration Wellmark Blue Cross and Blue Shield 515.245.5105 hasenwinkelja@wellmark.com

13. Redesigning Health Care Delivery in Iowa David Swieskowski, MD, MBA V.P.for Quality Mercy Clinics, Inc. Des Moines, Iowa

14. Mercy Clinics, Inc. • Des Moines, IA & suburbs • 27 Clinics,130 Physicians • 70% Primary Care • 759,225 patient visits in FY06 • 100% Fee-for-Service • Virtual Private Practice • All revenue & expenses are tracked to individual doctors • The difference is the doctors’ salary

15. How Good is Current Physician Performance? “Only 55% of evidence based recommended care is provided” New England Journal of Medicine 2003;348:2635-45

16. Why does this happen? “Every system is perfectly designed to get the results it gets” -Don Berwick

17. Systemic Barriers • Information Explosion • 439 evidence based interventions in primary care • Time • 24.8 hours per day to deliver all interventions • Lack of measurement • Doctors think they are doing better than they are • Can’t manage what you don’t measure • Reimbursement system • Paid for quantity not quality • Culture • Biggest barrier

18. Cultural Barriers • Lack of urgency to change • No data to support need to change • Physicians unwilling to give up control • Keep responsibilities they can’t possibly fulfill • Reactive rather than proactive • Clinics always have a crisis • Clinics don’t plan for predictable urgencies • Silos & poor communication • Poor teamwork • Lack of systems thinking • No systems to prevent errors

19. How Do You Overcome the Barriers? “Working harder is the worst plan” -W. Edwards Deming • Currently • Depend on physician memory and Individual effort • In the Future • Will depend more on the system physicians work in than on individual effort

20. New Care Model • Population Based • Doctors will routinely review lists of their patients with a chronic disease • Proactive • Contact patients not meeting goals • Planned • Do all needed care at each visit (not 55%) • Patient Centered • Each patient will have a plan and help to meet their goals

21. First Step: Disease Registry • What is it? • Electronic list of patients with a chronic disease • Key data is kept on each patient • Allows you to create population based information • Provider specific performance reports • Lists of patients not meeting the goals on the reports • Leads to delivery system redesign to utilize the info • Contrast to Electronic Health Record • Most EHRs do not work well to provide population based data • EHRs are expensive and very disruptive to introduce • Registries are inexpensive and easy to introduce

22. MCI Diabetes Registry • SECAT disease registry • Iowa Foundation for Medical Care • Number of patients as of August 1, 2006 • Diabetes = 8733 (all insurance) • Hypertension = 4583 (Wellmark only) • Track 4 data points for diabetes • HgA1c, Lipids, BP, Microalbumin • Manual data entry takes about 3 minutes per visit • Identify patients for proactive care • 80%-90% will come in when contacted • Create performance reports

23. SECAT Flowsheet

24. SECAT Diabetes Performance Report

26. Delivery System Redesign • Charts of Chronic Care patients are marked • Diabetes Flow Sheet up to date on each chart • Status of all standards of care can be seen on one page • Standing Orders for Diabetes & HTN care • Nursing staff can independently arrange needed care • Diabetes Office Visit Form • Checklist so all critical elements are addressed • Population Health Coaches in each clinic • Reviews chart before the doctor sees the patient • They make everything work

27. Diabetes standing lab orders

29. Population Health Coach • Full time position in eight clinics (mostly RN’s) • New job description • Provides proactive care • Oversees registries • Contacts patients overdue visits or not meeting goals • Pre-visit chart review for chronic care patients • Pre-work saves Doctor time • Increases services allowing us to bill higher EM levels • Provide Self-Management Support (SMS) • Goal setting and health behavior change • Provide or arrange for education

30. Clinical InertiaReports from ADA Scientific Conference June ‘06 • 26% of patients diabetes patients with BP >139/89 had treatment intensified • Brigham and Woman’s Hospital – Boston • 57% of all diabetic patients had BP > 130/85 • 12% of patients diabetes patients with BP >140/90 had treatment intensified • Johns Hopkins University School of Medicine

31. Hypertension Process Map

32. Results

33. SECAT Performance Report

34. Diabetes Process Measures% with test done Aug 05 – July 06 South Wellmark diabetes patients n = 170

35. Outcome MeasuresAugust 2005 – July 2006 All MCI diabetes patients n = 8873

36. Yearly Cost Savings From a 1% Improvement in HgA1c Control Changes in HbA1c levels Patient Classification 10 to 9% 9 to 8% 8 to 7% 7 to 6% Diabetes with CAD & HTN $4,116 $3,090 $2,237 $1,504 Diabetes with heart disease $2,796 $2,088 $1,503 $1,002 Diabetes with hypertension $1,703 $1,260 $ 897 $ 588 Diabetes only $1,205 $ 869 $ 601 $ 378 Source: Diabetes Care, Volume 20, Number 12

37. Hypertension: % < 140/90August 2005 – July 2006 MCI n = 1934

38. Benefits of Lower BP(in the General Population) • Control of High Blood Pressure will reduce: • Strokes by 35-40% • Myocardial Infarction by 20-25% • Heart failure by 50% • A 12 point reduction in BP over 10 years will prevent 1 death for every 11 patients Source: JNC 7, NIH publication May 2003

39. Advantages of Clinic Based Disease Management The Physicians Office has: • A level of knowledge about the patient that no one else has • Access to the patient that no one else has • The trust of the patient that no one else has • Lower costs to deliver DM services than anyone else Physicians need modest help to overcome the barriers

40. Pay for Performance Piloted in 4 clinics (3 FP, 1 IM) All goals were met by all 25 providers in the pilot

41. Collaborating for Innovative Care • Sponsored by Wellmark • 30 Iowa and South Dakota practices • Uses the IHI learning model • Four in-person group learning sessions, e-mail, Web-site, conference calls, faculty visits • Test & measure practice innovations (PDSA) • Share experiences • Increases motivation