Giving Patients A Voice

1. Giving Patients A Voice Empowering Better Health Jerry Reeves MD

2. It’s All About Patients • Doctors advise • Many advocate • Patients decide After 25+ years focused on doctors, hospitals, and health plans, the quality movement has not substantially eliminated quality gaps.

3. USA: Less than appropriate care: Angioplasty= 42% CABG= 9% Missing proper care: CAD= 32% Diabetes= 55% Pneumonia= 61% Wounds= 59% Falls= 66% End of life= 91% HEDIS Measures: U.S./ Nevada Averages Breast cancer= 75% / 64% Cervical ca.= 81% / 71% U.S.: Testing & Treatment Diabetes-A1C = 83% Asthma Rx= 68% Culinary Fund Breast cancer= 60% Cervical cancer= 57% Diabetes-A1C= 67% Asthma Rx= 57% Care Gaps(Rand, NCQA, Nevada Health Division)

4. Yesterday patient physician medical record

5. Today patient pharmacy insurance consultation regulators hospital physician QI lab, xray decision support other FLOW OF INFORMATION DEM: S,O: A: P: medical record

6. Solution: patient pharmacy insurance consultation regulators online health record hospital QI lab, xray decision support other FLOW OF INFORMATION DEM: S,O: A: P: physician

7. Patients Influence Outcomes • Demographics • Age/Sex, Race, Income, Insurance • Health literacy, Culture • Clinical • Chronic disease, Comorbidities • Functional status- physical, mental • Health Risks • Weight, fitness, diet, safety • Family history • Behavior Change Likelihood • Confidence, Readiness, Commitment • Expectations

8. Cost Drivers- Doctor Visits • Emergency Department • 6% Emergent • 56% Urgent • 38% Non Urgent • Office • 37% New Symptom • 30% Chronic Problem, Routine Check • 18% Non-illness Care • 6% Chronic Problem, Flare-up • 9% Other

9. Informed Decisions Are Rare • 1057 office visits; 3552 clinical decisions • Overall: 9% of decisions informed • Basic: 17% of decisions informed • Complex: 0.5% of decisions informed(Braddock CH. JAMA 1999; 282: 2313-20) • In one ear, out the other • 50% to 80% of medical information in visit is forgotten instantly • 50% of retained information is later recalled incorrectly. R Kessels. J Royal Soc Med, 2003

10. Cost Drivers- Physicians

11. Consumers Want Control Patients Want to Control Health Care Decisions Who influences health care decisions? CurrentShould Be Self 1.9 5.4 Doctor 1.8 2.4 Insurer 3.3 0.7 Hospital 0.7 0.6 Government 1.1 0.6 Employer 1.2 0.3 Scores based on a 10 point allocation Source: American Hospital Association Patients want to make health care decisions alone or with their doctors, not with insurers, hospitals, government or employers.

12. Self-diagnosis and self-care • Most people self-diagnose frequently • 600+ prescription medications now are available over the counter • For up to 40% of doctor visits, self-care turns out to be the treatment of choice • For more than 100 conditions, home remedies result in the same outcome as doctor care • 70% use Internet; 78% have email Correct “self-diagnosis” is critical

13. Engaging People In Health Decisions:Surround With Care • Multi-touch communications • Web, phone, mail, print, media, onsite • Behavior change incentives- SMART • Rules, Report Cards, Rewards, Penalties • Point of decision tools readily available • Answers about benefits (15% of spend) • Help with health decisions (85% of spend) • Coaches and advocates • Laypersons, professionals, coalitions

14. Patient Prevention Home, Work, Office Early Treatment Late Treatment Low Cost Doctor Prevention Early Treatment Late Treatment Hospital, ER, Office, Home High Cost Decision Matrix

15. Providers Bonus, Recognition, Steerage, “Gold Card” Efficiency Effectiveness Generics Access Information Technology Fines, Report Cards, P/A, Termination Delays Safety Fraud Patients SMART- Coupons, Raffles, $, Points, Copays, Discounts HRA, Prevention Steps, Weight Tests, BP, Meds, Visits Penalties- Rules, Fines, Surcharges, Hiring Smoking Safety Drugs It Takes Incentives

16. Point of Decision Tools Personal Evaluation System (PES) Health Risk Appraisals (HRA) with risk reduction interventions Online Personal Health Record – for patient and her doctors and case managers Telephone and Interpersonal Decision Support Hospital & Doctor Performance Comparisons Evidence Based Treatment Assessments Prescription Comparisons Chronic Care Assistance and Navigation Health Campaigns at Work

17. Health Decision Support www.culinaryhealthfund.org

20. Online Personal Health Record

21. Choose Your Doctor-Help in the Provider Directory • Name • Specialty • Zip Code • Languages • Extended Hours • Gold Star Rating

23. Patients Desire E Visits • 90% of US adult Internet users want online with their doctor • 71% want online appointment scheduling and prescription refills • 70% want online test results • 37% willing to pay for it out of pocket • 56% say online communication access would influence their choice of doctor http://www.harrisinteractive.com/ Harris Poll April, 2002

24. Health Services Coalition-Leverage • 22 Large Employers and Health Trusts • 320,000 lives in Las Vegas (including Culinary Fund) • Collaborations • Hospital Contracts- Performance Expectations • Rates, Quality, Safety, Patient Satisfaction • LeapFrog/ National Quality Forum Participation • Generics Campaign- Media, Ads, Doctor Visits • Hospitalists- 2 groups, all hospitals • Data Sharing- claims audits/ data warehouse • Performance monitoring

25. Coalition Generics Campaign

26. Success Determinants • Program promotion / employee education • Employer’s and support groups’ engagement level • Intensity and types of incentive programs • Behavioral/demographic characteristics of the employee population (predisposition to change behaviors) • Patient’s understanding of personal diagnoses, treatment options, and responsibility for decisions under their control

27. “First, the patient, second the patient, third the patient, fourth the patient, fifth the patient, and then maybe comes science. We first do everything for the patient.” Bela Schick MD (1877-1967 ) (Invented the Schick Test for diphtheria; helped eradicate diphtheria.)