Joanne Schottinger , MD Assistant Medical Director, Quality & Clinical Analysis Kaiser Permanente

1. How can health care networks develop policy autonomy within an environment shaped by external mandates? Evidence-Based Guidelines Affecting Policy, Practice and Stakeholders (E-GAPPS)December 10, 2012 New York, NY Joanne Schottinger , MD Assistant Medical Director, Quality & Clinical Analysis Kaiser Permanente Southern California Permanente Medical Group

2. Statement of Disclosure • I have no commercial or academic conflicts of interest • Employed by the Southern California Permanente Medical Group (SCPMG), which contracts exclusively with the Kaiser Foundation Health Plan in the U.S. • Affiliations/Positions: • Assistant Medical Director for Quality & Clinical Analysis • Responsible for Medical Technology Assessment and Clinical Practice Guidelines Programs for KPSC • National Kaiser Permanente Clinical Lead for Cancer Care Programs • Practicing internist, specializing in oncology

3. About Kaiser Permanente (KP) • Description: • Largest nonprofit health plan in the U.S. (founded 1945) • Prepaid integrated health care delivery system • 9 million members (3.5 million in So. California Region) • 16,000+ physicians • 173,000+ employees • 37 hospitals and med centers • 600+ medical offices • Active National Guideline Program (Care Management Institute) Kaiser Permanente Kaiser Foundation Health Plan Kaiser Foundation Hospitals Permanente Medical Group + + 8 regions serving 9 states and the District of Columbia

4. 200 medical offices 5,700 physicians 19,500 nurses 60,000 employees KP Southern California (KPSC) Region • 3.5+ million members • 140+ languages spoken • 8 counties • 13 service areas • 14 medical centers

5. KP’s National Guideline Program (NGP) NGP identifies, develops and maintains a core set of 17 evidence-based clinical practice guidelines Preventive care: Immunizations, cancer screening (breast, cervical, colorectal, prostate), screening/counselingfor HIV/STIs Chronic conditions: Asthma, ADHD, depression, CVD risk reduction, heart failure, osteoporosis National Guideline Directors (NGD) Oversee all NGP efforts – at least one representative from each of 8 KP regions Sponsored by KP’s Care Management Institute, funded by regions Guideline Development Goal is to provide best available, systematically derived clinical guidance to improve care delivery and optimize the health of KP members

6. External Influences on Guideline Development Regulatory California Department of Managed Health Care Accreditation National Committee on Quality Assurance (NCQA) The Joint Commission Government Health care reform (PPACA) Medicare/Medicaid Legal California State Senate and Assembly Medical lawsuits

7. Case Example:Accreditation Organizations • Issue: NCQA HEDIS performance measures that lag behind or are inconsistent with current evidence • Breast Cancer Screening: Mammogram every 2 years for women aged 40-49 • Evidence suggests balance of benefit/harms of breast cancer screening uncertain in women 40-49 (USPSTF) • Increases unnecessary biopsies, overdiagnosis and anxiety due to false positive tests • Raises health system costs for potentially unnecessary/harmful procedures • Cervical Cancer Screening: Pap test every 3 years for women aged 21-64 • Evidence suggests change in screening interval for women 30-64 to Pap + HPV testing every 5 years (USPSTF, ACS, ASCCP, ACOG) • HEDIS measure will not change in 2013, delaying implementation and cost savings for patients and health systems

8. Case Example:Accreditation Organizations (cont.) • KPSC Response: • Breast Cancer Screening: Discuss benefits and harms of mammography, offer screening every 2 years • Cervical Cancer Screening: Change Pap + HPV screening interval to every 5 years • Implications: • Risk/harms of overdiagnosis and unnecessary/ineffective treatments • Lowers nationally reported performance rates; organizations appear to be “underperforming” • Influences large purchaser and consumer perceptions of health system performance • Potential loss of patients and small/large group purchasers • Increases cost to patient and health system

9. Case Example:Legislative & Regulatory Requirements • Issue: Medical practice by legislation, later incorporated into state regulatory requirements • CA Senate Bill 1538 – Breast Density Legislation: • Requires “…a health facility at which a mammography examination is performed to include in the summary of the written report that is sent to the patient a prescribed notice on breast density.” • CA Senate Bill 946 – Autism Legislation • Requires behavioral health treatment for patients with autism or pervasive developmental disorder, including applied behavioral analysis (ABA). • CA Senate Bill 1 (Section 2248) – Prostate Cancer Screening Legislation • Requires that physicians conducting prostate examinations must provide information to the patient about the availability of appropriate diagnostic tests, including but not limited to PSA.

10. Case Example:Legislative/Regulatory (cont.) • KPSC Response: • Breast Density: • Conducted repeat evidence search and technology assessment on automated breast ultrasound system (ABUS) • Required specific language added to letters to patients • Developed FAQ for primary care and educational materials for women • Autism: • Required creation of developmental specialist teams in each medical center to coordinate evaluation and treatment • Extensive external contracts initiated to provide services • Prostate Cancer Screening: • Required development of educational materials on benefits/harms of prostate-specific antigen testing and shared decision making • Emphasized not doing harm with PSA test in patients aged 75+

11. Case Example:Legislative/Regulatory (cont.) • Implications: • Large increase in costs to health system, leading to potential increases in health care dues for patients • Focuses resources and funding on interventions that may result in no benefit to patient or harm • Risk/harms of overdiagnosis and unnecessary/ineffective treatments • Limits research for more effective treatments

12. Conclusion/Comments • Guidelines reflect the evidence, but implementation also impacted by external influences • Regulations are a hard stop • NCQA/accreditation has room to finesse – more systematic interventions to achieve high rates where evidence supports doing so