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

2. It is being reported »Beth McGlynn’s 2003 study of 80 communities reported patients received quality care 54.7% of the time 1 »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 costs 2 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

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. 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

7. Focus on Outcomes »Incent and Reward Both outcome and process measures Moving to standard goals 2006 – Collaboration on Quality Clinical Award Chart Clinical Evaluation Measurements - DiabetesLevel 1Level 2Level 3 HgA1C test85%90%94% Lipid panel test85%90%94% Microalbumin test85%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 < 13060%70%75% Blood Pressure < 140/9060%70%75%

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. Share Metrics Hospital Performance Physician Performance Physician Performance Reports - Diabetes Hospital Quality Tools – Blue Distinction Provider Measurement and Improvement Program for employers WebMD Quality Services for members Enablers Measure Performance National Measures Available Consistent Measurement 2006 Core Measures: Diabetes 2007 measures add: Prevention, Cardiac CMS Inpatient Hospital Measures (2006) AMI, Pneumonia, Surgical Infection, Heart Failure Blue Distinction Centers Bariatric, Transplant, Cardiac; 2007 - Oncology Projects Improve Process Process Change & Implementation Skills Data Collection Physician Leadership Collaborating for Innovative Care Structured training to support process change 13 physician teams ~ 70 people Clinical Data Collection tool Wellmark Health Plan of Iowa Clinical Innovation Strategy Collaboration Activities

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

11. Iowa Implementations 10 Iowa Communities

12. South Dakota Implementations 5 Iowa Communities

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

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

15. 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

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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. SECAT Flowsheet

25. SECAT Diabetes Performance Report

27. 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

28. Diabetes standing lab orders

30. 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

31. Clinical Inertia Reports 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

32. Hypertension Process Map

33. Results

34. SECAT Performance Report

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

36. Outcome Measures August 2005 – July 2006 All MCI diabetes patients n = 8873

37. Yearly Cost Savings From a 1% Improvement in HgA1c Control Changes in HbA1c levels Patient Classification10 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

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

39. 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

40. 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

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

42. 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