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Changing the Environment to Improve Chronic Disease Management September 20, 2007 Sydney, Australia. George Isham, M.D., M.S. Medical Director and Chief Health Officer HealthPartners, Minneapolis, MN [email protected]

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Changing the environment to improve chronic disease management september 20 2007 sydney australia

Changing the Environment to Improve Chronic Disease ManagementSeptember 20, 2007Sydney, Australia

George Isham, M.D., M.S.

Medical Director and Chief Health Officer

HealthPartners, Minneapolis, MN

[email protected]


“The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

Crossing the Quality Chasm,

the Institute of Medicine, 2001


Care System fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

Adapted from the Institute of Medicine

Report, Crossing the Quality Chasm, 2001

Supportive

payment and

regulatory

environment

Organizations

that facilitate

the work of

patient-

centered teams

High

performing

patient-

centered

teams

  • Outcomes:

  • Safe

  • Effective

  • Efficient

  • Pt Centered

  • Timely

  • Equitable

  • Redesign of care processes based on best practice

  • Effective use of information technologies

  • Knowledge and skills management

  • Development of effective teams

  • Coordination of care

  • Incorporation of performance and outcome measurements

  • for improvement and accountability


Population health improvement model 1994 2007
Population Health Improvement Model : 1994- 2007 fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”


Impact of unhealthy behavior on mortality
Impact of Unhealthy Behavior on Mortality fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

SOURCE: Journal of the American Medical Association, 2000


Employee population health distribution
Employee population fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”health distribution


Health support
Health Support fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”


Health Risks Drive Costs: Health Assessments Identifies Risks 1-2 Years Before They Show Up As Claims

Data reflects commercial population, N=9,981


Programs
Programs Risks 1-2 Years Before They Show Up As Claims

  • Provide incentive for completing follow up programs

    • Diabetes prevention

    • Heart disease prevention

    • Weight mgt

    • Tobacco cessation

    • Back pain

    • Stress mgt

    • Healthy pregnancy

    • Blood pressure mgt

    • Cholesterol mgt

    • Nutrition

    • Healthy discounts

    • 10,000 steps

    • Frequent Fitness


Meaningful results
Meaningful Results Risks 1-2 Years Before They Show Up As Claims


Changing the environment to improve chronic disease
Changing the Environment to Improve Chronic Disease Risks 1-2 Years Before They Show Up As Claims

Focus

Publicly Report Results

Agree on Best Care ICSI

Support Improvement Registries, ICSI, Pt engagement, …

Measure What’s Important Composites, Outcomes

Align IncentivesP4P, Compare Peers, Tier

Set a Target ‘Aim High’


Health goals 2010 results summary for june 2007
Health Goals 2010 – Results Summary for June 2007 Risks 1-2 Years Before They Show Up As Claims


Health goals 2010 results summary for june 20071
Health Goals 2010 – Results Summary for June 2007 Risks 1-2 Years Before They Show Up As Claims

FULL: Goal achieved / infrastructure in place with full spread

¾: Positive performance trend / infrastructure in place

½: Stable performance / infrastructure in design or early implementation

¼: Measurement development in progress or unstable performance / early infrastructure design in process

EMPTY: Performance measurement not yet established / infrastructure in the planning stage


Changing the environment to improve chronic disease1
Changing the Environment to Improve Chronic Disease Risks 1-2 Years Before They Show Up As Claims

Focus

Publicly Report Results

Agree on Best Care ICSI

Support Improvement Registries, ICSI, Pt engagement, …

Measure What’s Important Composites, Outcomes

Align IncentivesP4P, Compare Peers, Tier

Set a Target ‘Aim High’


The institute for clinical systems improvement icsi
The Institute for Clinical Risks 1-2 Years Before They Show Up As ClaimsSystems Improvement (ICSI)

  • A quality improvement collaboration of 55 medical groups & hospital systems

  • Sponsored by six health plans

  • Established 1993

  • Includes 60 hospitals and 56 medical practices with about 8300 physicians

www.icsi.org


Purposes of our collaboration
Purposes of Our Collaboration Risks 1-2 Years Before They Show Up As Claims

  • To champion the cause of health care quality

  • To accelerate improvement in the value of the health care we deliver

www.icsi.org


Icsi program
ICSI Program Risks 1-2 Years Before They Show Up As Claims

  • Core commitment cycle

  • Scientific groundwork

    • Evidence based document development & maintenance

    • Technology assessment

  • Support for improvement

    • Education & training

    • Coaching

    • Action groups (improvement collaboratives)

    • Knowledge products

  • Advocacy for quality

www.icsi.org


Requirements of members
Requirements of Members Risks 1-2 Years Before They Show Up As Claims

  • Initial orientation & training sequence

  • Core commitment cycle

  • Physician participation in workgroups & committees--as well as other professionals

  • Critical review of guidelines

  • Team-based continuous improvement

  • Staff adequate to support the improvement

  • A pattern of improvement over time

www.icsi.org


Diamond depression improvement across minnesota offering a new direction
DIAMOND: Depression Improvement Across Minnesota - Offering a New Direction

  • Redesign of Care

    • New model, PHQ-9 measures, registry, protocols, specialist agreements

  • Redesign of payment system

    • Care management

    • Psychiatric liaison


Changing the environment to improve chronic disease2
Changing the Environment to Improve Chronic Disease a New Direction

Focus

Publicly Report Results

Agree on Best Care ICSI

Support Improvement Registries, ICSI, Pt engagement, …

Measure What’s Important Composites, Outcomes

Align IncentivesP4P, Compare Peers, Tier

Set a Target ‘Aim High’


All or none composite measures individual patient unit of analysis
All-or-None Composite Measures a New DirectionIndividual Patient = Unit of Analysis

  • Specific condition

  • Key elements

  • Individual patients

    • All processes?

    • All treatment goals?

  • YES or NO


Minnesota community measurement
Minnesota Community Measurement a New Direction

  • A nonprofit entity dedicated to improving the quality of health care in Minnesota.

  • Improving health through public reporting

  • A community effort of providers, purchasers and health plans

    • Report results on health care quality measures

    • Provide information for consumers

    • Increase efficiency of reporting

    • Improve care and support the quality initiatives of providers and the Institute for Clinical Systems Improvement (ICSI).

    • Reduce reporting-related expenses for medical groups, health plans, and regulators through more efficient and effective regulation.

    • Communicate findings in a fair, usable and reliable way to medical groups, regulators, purchasers and consumers.

www.mnhealthcare.org


Results are improving for living with illness measures
Results Are Improving for a New Direction“Living with Illness” Measures

www.mnhealthcare.org


New initiatives
New Initiatives a New Direction

  • Minnesota Bridges to Excellence (BHCAG program)

    • Align measures in pay-for-performance arrangements

  • Aligning Forces for Quality (Robert Wood Johnson Foundation)

    • Expand measures

    • Increase consumer engagement

    • Support provider improvement efforts

  • Better Quality Information Pilot (Federal HHS initiative)

    • Includes Medicare data

    • New measure test site

  • State of Minnesota’s QCARE initiative

www.mnhealthcare.org


Changing the environment to improve chronic disease3
Changing the Environment to Improve Chronic Disease a New Direction

Focus

Publicly Report Results

Agree on Best Care ICSI

Support Improvement Registries, ICSI, Pt engagement, …

Measure What’s Important Composites, Outcomes

Align IncentivesP4P, Compare Peers, Tier

Set a Target ‘Aim High’


Partners in excellence 2007 primary care targets
Partners in Excellence a New Direction 2007 Primary Care - Targets


2007 primary pip
2007 Primary PIP a New Direction


Changing the environment to improve chronic disease4
Changing the Environment to Improve Chronic Disease a New Direction

Focus

Publicly Report Results

Agree on Best Care ICSI

Support Improvement Registries, ICSI, Pt engagement, …

Measure What’s Important Composites, Outcomes

Align IncentivesP4P, Compare Peers, Tier

Set a Target ‘Aim High’


Distinctions sm plan how healthpartners tiers providers
Distinctions a New DirectionSM PlanHow HealthPartners Tiers Providers

  • Step 1. Quality

    • Providers are evaluated on quality measures

  • Step 2. Affordability

    • Providers are scored on case-mix adjusted total cost of care. The score reflects the combined impact of price, efficiency and utilization management.


Distinctions sm plan how healthpartners tiers providers1
Distinctions a New DirectionSM PlanHow HealthPartners Tiers Providers

  • Step 3. Combined Score

    • Quality and affordability are weighted equally

    • Providers need to meet both the quality test and the affordability test to qualify for the best tier placement (Tier I).


Primary care tiering methodology
Primary Care Tiering Methodology a New Direction

  • Affordability

    • Episodes of Care

      • Classifies services into episodes

      • Total cost of episode attributed to provider (significant contributor)

      • Case mix adjusted

  • Quality

    • Composite measures

    • 75 discrete measures (see Appendix B)

    • Quality domains: Chronic condition care, acute and preventive care, patient experience, safety


Primary care quality
Primary Care Quality a New Direction

  • Care of Chronic Condition

    • Optimal CAD care

    • Optimal depression care

    • Optimal diabetes care

    • Optimal asthma care

  • Acute and Preventive Care

    • Healthy lifestyle advice (Adult & Child)

    • Preventive Services (Adult & Child)

    • Immunizations up-to-date (Child)

    • Pharyngitis care (Child)

    • Appropriate use of antibiotics for upper respiratory infection (Child)

    • Appropriate low back pain imaging (Adult)

    • Tobacco – assess and assist (Adult)

    • Tobacco – second hand exposure (Child)


Primary care quality1
Primary Care Quality a New Direction

  • Patient Experience (Adult and Child)

    • Access – scheduling convenience; routine versus acute; MD of your choice: medical advice by phone 24/7

    • Timeliness – rooming, exam room

    • Communication

      • Attention given to what you have to say

      • Explanations of medical procedures

      • Advice about ways to stay healthy

      • Amount of time the doctor spends with you

  • Use of well tested medications


Background never events
Background a New Direction Never Events

  • In 1999 IOM documented the prevalence of medical errors in hospitals – “To Err is Human.”

  • IOM recommended a mandatory reporting system to ID and improve persistent safety problems

  • In response in 2002 the National Quality Forum (NQF)

    • Defined 27 Never Events - things that should never, ever happen

    • Established standards for reporting medical errors


Some nqf never events
Some NQF Never Events a New Direction

  • Surgical Events

    • Wrong surgery, body part or patient

    • Retention of foreign object

  • Product or Device

    • Contaminated drugs, devices, biologics

  • Patient Protection

    • Infant discharged to wrong person

    • Patient death associated with disappearance

  • Care Management

    • Patient death or disability

      • Medication error

      • Stage 3 or 4 pressure ulcers

  • Environmental Events

    • Patient death or disability

      • Wrong gas delivered

      • Burn while being cared for

    • Criminal Events

      • Abduction

      • Sexual Assault


Healthpartners payment policy never events patients should never have to pay for a never event
HealthPartners Payment Policy Never Events: a New DirectionPatients Should Never Have to Pay for a Never Event

  • As of January 1, 2005:

    • Hospitals report Never Events to HPI

    • HPI denies payment or recoups payment

    • Applies to hospitals only, not physicians

    • Charges are provider liability

    • Member cannot be billed!


Changing the environment to improve chronic disease5
Changing the Environment to Improve Chronic Disease a New Direction

Focus

Publicly Report Results

Agree on Best Care ICSI

Support Improvement Registries, ICSI, Pt engagement, …

Measure What’s Important Composites, Outcomes

Align IncentivesP4P, Compare Peers, Tier

Set a Target ‘Aim High’


Healthpartners care model process cmp
HealthPartners Care Model Process (CMP) a New Direction

A standard set of workflows for delivering evidenced-based care that provides a consistent clinical experience for patients and a consistent process for Care Teams

*Consistency *Standardization *Teamwork


Principles in healthpartners cmp design
Principles in HealthPartners CMP design a New Direction

  • Support the physician/patient interaction

  • Those providing and receiving the care need to design the workflows and tools

  • Maximize skill set

  • Clinical workflow drives EMR workflow

  • Embed evidence

  • Make it easy

  • Redesign to sustain


Healthpartners medical group optimal diabetes care measure
HealthPartners Medical Group a New DirectionOptimal Diabetes Care Measure


Changing the environment to improve chronic disease6
Changing the Environment to Improve Chronic Disease a New Direction

Focus

Publicly Report Results

Agree on Best Care ICSI

Support Improvement Registries, ICSI, Pt engagement, …

Measure What’s Important Composites, Outcomes

Align IncentivesP4P, Compare Peers, Tier

Set a Target ‘Aim High’


Reliable tobacco treatment
Reliable Tobacco Treatment a New Direction

2004

1996

100%

100%

Amundson, Paying for Quality Improvement: Effect on Compliance with Tobacco Treatment Guidelines:JCJQS:2003;29(2):59-65


Treating tobacco addiction
Treating Tobacco Addiction a New Direction

Adult Prevalence 25% → 15% Second Hand Tobacco 23% → 8.6%



At healthpartners fewer diabetes complications
At HealthPartners - Fewer Diabetes Complications Diabetes

Prevents 80 heart attacks and 120 amputations each year

Prevents 320 eye complications each year


Thank You! Diabetes

George Isham, M.D., M.S.

Medical Director and Chief Health Officer

HealthPartners, Minneapolis, MN

[email protected]


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