Collaboration on Quality:Working together to improve health care delivery

Iowa Health Buyers AllianceWednesday, October 25, 2006

It is being reported

» 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

(High)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

Clinical Performance by Mean Risk Adjusted PMPM for Providers with 10+ Diabetes Episodes of Care

2005 Calendar Year

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

Overall Diabetes Performance by Clinical Standards

Mea

n R

isk

Ad

just

ed P

MP

M

grand mean = 58%

grand mean = $192

Iowa 2005 Performance

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

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

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

A Revised Approach

Focus on Outcomes

» Incent and Reward• Both outcome and process measures• Moving to standard goals

2006 – Collaboration on QualityClinical Award Chart

Clinical Evaluation Measurements - Diabetes Level 1 Level 2 Level 3

HgA1C test 85% 90% 94%

Lipid panel test 85% 90% 94%

Microalbumin test 85% 90% 94%

Eye Exam (By Optometrist or Ophthalmologist) 60% 70% 80%

Clinical Outcomes Measurements – Diabetes

HgA1c < 8% or 1% improvement from baseline measure

60% 70% 75%

LDL < 130 60% 70% 75%

Blood Pressure < 140/90 60% 70% 75%

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

Quality Standard Setting BodiesNCQA, NQF, AMA, AHA, CMS, etc.

Member Employer

Physician Hospital

Collaborating forInnovative CareFocused Learning Opportunities

WHPI Clinical InnovationShareholderProjects

PerformanceReportingPhysicianHospital

Hospital Quality ToolsMembers

Hospital Quality ToolsEmployers

Physician ReportingStandardMeasures

Physician Affordability Measures

Blue Distinction CentersCardiac

Blue Distinction CentersBariatric Surgery

Wellmark

National Vision: Local Innovation

National Best Practice ProjectsSpecialty

Italicized = future

Blue Distinction CentersOncology

Blue Distinction CentersTransplant

AdvancedMedicalHome

Work with many associations

Iowa Implementations

10 Iowa Communities

South Dakota Implementations

5 Iowa Communities

Questions?

Joel Hasenwinkel

Director, Clinical Collaboration

Wellmark Blue Cross and Blue Shield

515.245.5105

hasenwinkelja@wellmark.com

Redesigning Health Care Delivery in Iowa

David Swieskowski, MD, MBA

V.P.for Quality

Mercy Clinics, Inc.

Des Moines, Iowa

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

How Good is Current Physician Performance?

“Only 55% of evidence based recommended care is

provided”

New England Journal of Medicine 2003;348:2635-45

Why does this happen?

“Every system is perfectly designed

to get the results it gets”

-Don Berwick

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

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

How Do You Overcome the Barriers?

• Currently– Depend on physician memory and

Individual effort

• In the Future–Will depend more on the system

physicians work in than on individual effort

“Working harder is the worst plan” -W. Edwards Deming

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

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

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

SECAT Flowsheet

SECAT Diabetes Performance ReportMercy West FPALL PATIENTS Diabetes Data: 9/1/05-8/31/06Provider Belling Blomberg Brady Eckstat Halling Klock Onishi SarconeTotal Patients 61 68 118 154 70 81 57 61Process goals:HgAlc last 12 mo. 92% 94% 95% 88% 96% 96% 91% 93%LDL last 12 mo. 93% 91% 94% 86% 99% 96% 88% 95%

SBP last 12 mo. 95% 96% 97% 89% 97% 96% 93% 93%

Microalb last 12 mo. 85% 82% 80% 77% 83% 90% 82% 89%

Outcome goals:

% HgAlc < 8.0 72% 85% 92% 88% 82% 89% 86% 81%

% HgAlc < 7.0 43% 66% 71% 64% 64% 72% 67% 63%

% LDL < 130 88% 90% 91% 88% 85% 74% 83% 80%

% LDL < 100 53% 67% 67% 51% 57% 53% 63% 59%

% SBP < 140 88% 83% 74% 85% 74% 84% 91% 90%

% SBP < 130 60% 65% 54% 70% 59% 60% 74% 72%

Mercy NorthDiabetes Care Opportunites6/20/05-6/20/06

Has ResultTest Last Visit Last Name First NameNo Microalb 05/30/2006 KATHERINENo Microalb 05/04/2006 GLENNo Microalb 02/24/2006 WILLIAMNo BP 02/24/2006 WILLIAMNo Microalb 01/10/2006 GEORGENo Alc 01/10/2006 GEORGENo LDL 01/10/2006 GEORGENo BP 01/10/2006 GEORGENo Microalb 02/17/2006 DANIELNo Alc 02/17/2006 DANIELNo LDL 02/17/2006 DANIELNo Microalb 02/20/2006 MARYNo LDL 02/20/2006 MARYNo Microalb 04/04/2006 JIMMYNo LDL 04/04/2006 JIMMYNo Microalb 04/01/2006 CHRISTINENo Microalb 09/08/2005 TIMOTHYNo BP 09/08/2005 TIMOTHYNo Microalb 05/22/2006 LEONARDNo LDL 05/22/2006 LEONARD

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

DIABETES Laboratory Standing Orders

TEST INTERVAL CONDITIONS HgA1C 4 months All patients Lipid Profile 1 year Patients with no Dx of hyperlipidemia 4 months Patients with a Dx of hyperlipidemia ALT (SGPT) 4 months If on high risk medication (Statins,

Actos, Avandia) Creatinine 1 year Patients with no Dx of Hypertension Basic Metabolic Profile 1 year Patients with a Dx of Hypertension Glucose 4 months Do not order if a BMP is being done Urine Alb/Creat. ratio 1 year Patients with no Hx of Abn UACR 4 months If UACR was ever > 30

Complete these labs on all my patients with diabetes whenever the Standing Orders are due. ____________________________ __________ Signature Date

Diabetes standing

lab orders

Vitals: T: BP: P: Wt: Smoker: Y / N CC: DIABETES F/U CARE required HPI: Problems Addressed level 3: one Prob. level 4: three Probs. DIABETES: BP: LIPIDS: OTHER: (CAD, Nephropathy, Neuropathy, PVD) ADA Standards of Care: Up to Date Due HgA1C: Lipids: ALT: BMP (Creat): UACR: Eye exam: Glucose: Other Orders needed: Meds Reviewed required Care Coordinator sig._____________ Review of Systems: CHECK IF SYSTEM QUERIED level 3: one system CIRCLE ABNORMALS level 4: two systems ADD ITEMS AS NEEDED Constitutional: fever, wt. loss, fatigue EYES: change in vision ENT: nose congestion, sore throat CV: chest pain, palpitations RESP: cough, SOB GI: N / V / D / C, heartburn GU: dysuria, ED, frequency NEURO: foot numbness ENDOCRINE: hypoglycemia Ortho: muscle aches Psych: depression Other:

Physical Exam level 2: one bullet CONSTITUTIONAL: level 3: six bullets Appears in stable health, NAD vitals x 3 noted level 4: twelve bullets EENT: conjunctiva & lids nl, fundi benign CHECK Throat clear, Thyroid not palpable BOX CHECK IF LUNGS: BULLET nl. resp. effort, no rales, rhonchi or wheezes EXAMINED HEART: reg. rhythm, no murmur, carotids 2+/2+, no bruits ABD: soft, not tender, liver at costal margin CIRCLE

FEET: ITEM IF

skin intact digits & nails nl. NOT

pedal pulses 2+/2+ ( p. tibial, d. pedis) NORMAL

no pedal edema AND

sensation intact to filament EXPLAIN PSYCH: nl. judgement & insight mood happy ( sad / anxious / neutral) OTHER:

Assessment: Controlled - Not controlled Diabetes: level 2: Controlled diabetes Hypertension: level 3: Uncontrolled diabetes Hyperlipidemia: or two problems Co-Morbidities: level 4: Three problems Nephropathy CAD Retinopathy High risk med: Neuropathy Other: Plan: SELF MANAGEMENT GOAL: _______________________ DIABETES EDUCATION: Diet Home glucose monitoring Kidney disease HgA1c ADA standards of care Exercise Eye Care Hypertension, CV disease Aspirin Foot care Hyperlipidemia Hypoglycemia Insulin Medication compliance Other Order labs and referrals ‘due’ as in the History Continue meds unchanged F/U visit in 3-4 months or _________

Provider Sig._______________ Note dictated

MCI DIABETES CHRONIC CARE VISIT

Diabetes

Office Visit Form

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

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

BP <=140/90

Pt. adherentChange in

PlanRecheck BP in

1 monthBP up for3 months

Counseling andcall back

F/U in1 month

Routine F/U3-6 months

ChangePlan

Yes

NO

NO

NO NOYes

Yes

Yes

Hypertension Process Map

Results

SECAT Performance Report

Mercy SouthAll Patients Diabetes Data: September 1, 2005-August 31, 2006Provider Agey Borchardt Brightwell Brown Evert Herman McCoy Zachary Zea

Total Patients 82 117 43 154 92 6 112 50 16

Process goals:

HgAlc last 12 mo. 91% 97% 98% 94% 95% 100% 97% 100% 100%

LDL last 12 mo. 90% 97% 98% 92% 92% 100% 94% 100% 94%

SBP last 12 mo. 93% 97% 98% 94% 95% 100% 94% 100% 94%

Microalb last 12 mo. 82% 91% 91% 86% 82% 100% 87% 96% 94%

Outcome goals:

% HgAlc < 8.0 91% 91% 88% 89% 77% 67% 87% 76% 94%

% HgAlc < 7.0 63% 74% 64% 72% 47% 34% 66% 60% 63%

% LDL < 130 81% 96% 97% 94% 93% 83% 94% 94% 93%

% LDL < 100 65% 76% 71% 75% 71% 50% 72% 82% 73%

% SBP < 140 89% 74% 88% 92% 87% 84% 96% 86% 86%

% SBP < 130 64% 42% 74% 65% 51% 67% 75% 66% 53%

Diabetes Process Measures

% with test done Aug 05 – July 06

South Wellmark diabetes patients n = 170

95% 94%88%87%

75%

38%

20%

40%

60%

80%

100%

HgA1c LDL Microalbumin

South Wellmark 2005

Outcome MeasuresAugust 2005 – July 2006

All MCI diabetes patients n = 8873

90% 87%

63%69%

61%

35%

20%

40%

60%

80%

100%

% HgAlc < 9.0 % LDL < 130 % LDL < 100

MCI HEDIS 2004

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

Hypertension: % < 140/90August 2005 – July 2006

81%

62%

20%

30%

40%

50%

60%

70%

80%

90%

MCI

HEDIS 2004

MCI n = 1934

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

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

Mercy Clinics, Inc./Wellmark Quality Parameters

*If a parameter is not within goal, evidence of action to achieve the goal will meet criteria. ** Overall goal is the average of all the goals in the disease suite. *** This is a group goal paid to all or none Process Goals are whether or not a test was done within the last year (unless otherwise stated) and can often be determined by billing data. Outcome Goals reflect clinical measurements described in the left hand column.

Process Goal*

Outcome Goal*

Diabetes overall** 80% 70% Proportion with HgA1C < 8.0 or 1% improvement over the last year (i.e. 8.6 to 7.6)

85% 70%

Proportion with LDL < or = 130 85% 70% Proportion with BP < or = 140/90 85% 70% Nephropathy screening or evidence of disease 70% Documentation of Diabetes education or Patient refusal

Establish Baseline

Hypertension Quality overall** 80% 70% Proportion with BP < or = 140/90 85% 70% Lipids checked in last 30 months 85% Glucose checked in last 30 months 85% Proportion with microalbumin documented in the last year

70%

Patient education documented Establish Baseline

Quality Incentive Payment $ $

Pharmacy Targets*** Incentive Payment Per member per month cost: % < Wellmark Avg. 4.0% $ Per member per month cost: % < Wellmark Avg. 6.0% $

All goals were met by

all 25 providers in the pilot

Pay for Performance

Piloted in 4 clinics

(3 FP, 1 IM)

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