1. Unwarranted Variation: Expanding the Agenda for Rebuilding the Health Care system in Louisiana January 16, 2007 REDESIGNING 10 th Annual Health Care Forum on Health Care Effectiveness LSU

2. 2 Backdrop

3. 3 Agenda  Unwarranted Variations  From Regions to Hospitals in Baton Rouge and New Orleans  Pushing the envelope

4. 4 Unwarranted Variation Defined  Unwarranted? Variations that cannot be explained by: –Illness, need, dictates of evidence based medicine or patient preferences  Categories of variation –Effective and safe care –Preference sensitive care –Supply sensitive services  Causes and remedies differ for each category

5. 5 Dartmouth Atlas of Health Care: United States Hospital Referral Regions (HRR)

6. 6 Shape of the Benefit-Utilization Curve: Effective Care & Patient Safety Benefit to Patients Intensity of Effective Care U.S. Is Somewhere in This Zone

7. 7 Percent of “Ideal” AMI Patients Receiving Beta Blockers at Discharge Following AMI 0.0 20.0 40.0 60.0 80.0 100.0 Percent of “Ideal” Patients Receiving Beta Blockers at Discharge

8. 8

9. 9 Shape of the Benefit-Utilization Curve: Preference-Sensitive Care (e.g. Revascularization) Benefit to Patients Intensity of Preference Sensitive Care

10. 10 Rates of Coronary Artery Revascularization Procedures Compared to Ontario, Canada 3.0 6.0 9.0 12.0 15.0 18.0 21.0 Cardiac Revascularization (1994-95) Ontario Benchmark

11. 11 Randomized Trial of the Coronary Artery Disease Shared Decision Making (SDM) Video, Ontario, Canada Revascularization Decision ( p = 0.01) % Choosing Revascularization Morgan MW, et al., JGIM. 2000; 15:685-93.

12. 12 Shape of the Benefit-Utilization Curve: Supply-Sensitive Services Benefit to Patients Intensity of Supply Sensitive Care U.S. Is Somewhere in This Zone

13. 13 Hospital Utilization and Local Capacity: Effective Care (Hip Fracture) vs Supply-Sensitive Services (Medical Conditions) 0 50 100 150 200 250 300 350 400 1.02.03.04.05.06.0 Acute Care Beds Discharge Rate All Medical Conditions R 2 = 0.54 Hip Fracture R 2 = 0.06

14. 14 Is more better?

15. 15 Effective Care: Ratio of Rates in Highest vs Lowest Spending Regions 1.001.52.00.5253.0 1.001.52.00.5253.0 Reperfusion in 12 hours for AMI Beta Blockers at admission Aspirin at admission Beta Blockers at discharge Aspirin at Discharge Acute MI Mammogram, Women 65-69 Flu shot during past year Pap Smear, Women 65+ Pneumococcal Immunization (ever) General Population Lower in High Spending Regions Higher in High Spending Regions Exercise Test w/in 30 d

16. 16 Preference-Sensitive Care: Highest vs Lowest Spending Regions 1.001.52.00.5253.0 1.001.52.00.5253.0 Coronary Artery Bypass Surgery (CABG) Coronary Angioplasty Procedures after AMI Cholecystectomy Hernia Repair Cataract Extraction Total Hip Replacement Major Surgery (all cohorts combined) Total Knee Replacement Back Surgery Carotid Endarterectomy Lower in High Spending Regions Higher in High Spending Regions Angiography Angiography among appropriate cases

17. 17 Supply-Sensitive Care : Highest vs Lowest Spending Regions 1.001.52.00.5253.0 1.001.52.00.5253.0 Office Visits Initial Inpatient Specialist Consultations Inpatient Visits Psychotherapy Visits % of Patients seeing 10 or more MDs Physician Visits Electrocardiogram Ambulatory ECG (Holter) Echocardiogram Diagnostic Cardiology Procedures Lower in High Spending Regions Higher in High Spending Regions Chest X-ray Ventilation Perfusion Scan CT / MRI Brain Imaging Tests

18. 18 Supply-Sensitive Care : Highest vs Lowest Spending Regions 1.001.52.00.5253.0 1.001.52.00.5253.0 Discharges Inpatient Days in ICU or CCU Total Inpatient Days Hospital Utilization Inpatient Days Feeding Tube Placement ICU or CCU days Emergency Intubation Care in Last Six Months of Life Vena Cava Filter Lower in High Spending Regions Higher in High Spending Regions Upper GI Endoscopy Pulmonary Function Test Bronchoscopy Electroencephelogram (EEG) Specialist Procedures

19. 19 Relative Risk of Death across Quintiles of Supply Sensitive Services Decreased Risk 1.001.051.100.95 Colorectal Cancer Q1 Q2 Q3 Q4 Q5 Hip Fracture Q1 Q2 Q3 Q4 Q5 Myocardial Infarction Q1 Q2 Q3 Q4 Q5 Increased Risk

20. 20 Decreased Risk Change in relative risk of death per 10% increment in regional practice intensity: Acute Myocardial Infarction Cohort 1.001.021.040.98 1.001.021.040.98 Age < 80 Age > 80 Increased Risk Female Male Black Non-black Other location Non-Q MI Anterior MI Inferior MI Low risk (<15% 1yr) Moderate (15-30%) High Risk (> 30%)

21. 21 Agenda  Unwarranted Variations  From Regions to Hospitals in Baton Rouge and New Orleans  Pushing the envelope

22. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 22

23. 23 Red Dots Indicate U.S. News’ “Ten Best Geriatric Hospitals” Supply Sensitive Care: Total Medicare Payments per Decedent During the Last Six Months of Life (1998-2000) 11,000 16,000 21,000 26,000 31,000 36,000

24. 24 Physician Visits During the Last Six Months of Life Among Patients Assigned to Selected Academic Medical Centers 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 NYU Medical Center76.2 UCLA Medical Center43.9 NY Presbyterian Hospital40.3 Mass. General Hospital38.8 Cedars-Sinai Medical Center66.2 Mount Sinai Hospital53.9 Brigham & Women's Hospital31.9 Boston Medical Center31.5 Beth Israel Deaconess29.2 UCSF Medical Center27.2 Stanford University Hospital22.6

25. 25 Association Between Hospital Day Rates in the Last Six Months of Life Among 77 Hospital Cohorts for Chronic Conditions R 2 = 0.73 5.0 10.0 15.0 20.0 25.0 30.0 35.0 5.010.015.020.025.030.035.0 Cancer cohort Congestive Heart Failure cohort

26. 26 Association Between Total Medicare Payments 18-24 Months and 0-6 Months Before Death R 2 = 0.79 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 1,5003,5005,5007,500 Total Payments 19-24 Mos. Before Death Total Payment in Last 6 Months

27. 27 R 2 = 0.75 10 20 30 40 50 60 100150200250300350400 Medicare Medical Admissions Adult Medical Admissions Relationship Between Medicare and Health Plan X All Adult Medical Admission Rates

28. 28 Hospital days (Part A) per decedent during the last six months of life (1999-2003) 27.0 18.0 15.0 12.0 9.0 21.0 24.0 National benchmark HospitalRates Lane Memorial Hospital16.7 North Oaks Medical Center16.4 Hood Memorial Hospital16.3 Prevost Memorial Hospital15.2 Summit Hospital14.1 National Benchmark13.9 St Elizabeth Hospital13.8 Lallie Kamp Regional Medical Center13.8 Our Lady of the Lake Regional Medical Center13.6 Pointe Coupee General Hospital13.3 Baton Rouge General Medical Center13.1 River West Medical Center11.4 St Helena Parish Hospital11.0 Earl K. Long Medical Center10.8

29. 29 Total physician visits (Part B) per decedent during the last six months of life (2000-2003) 81.0 72.0 45.0 36.0 27.0 18.0 54.0 63.0 National benchmark HospitalRates North Oaks Medical Center38.5 Summit Hospital34.3 National Benchmark33.5 Our Lady of the Lake Regional Medical Center33.5 Baton Rouge General Medical Center33.1 Lane Memorial Hospital30.3

30. 30 Hospital days (Part A) per decedent during the last six months of life (1999-2003) 27.0 24.0 15.0 12.0 9.0 18.0 21.0 National benchmark HospitalRates Chalmette Medical Center18.0 Pendleton Memorial Methodist Hospital15.9 Lakeland Medical Center15.8 Memorial Medical Center – New Orleans15.2 National Benchmark13.9 Touro Infirmary13.9 Ochsner Foundation Hospital13.1 Tulane University Hospital12.8 Meadowcrest Hospital11.5 West Jefferson Medical Center11.5

31. 31 Total physician visits (Part B) per decedent during the last six months of life (2000-2003) 81.0 72.0 45.0 36.0 27.0 18.0 54.0 63.0 National benchmark HospitalRates Chalmette Medical Center72.7 Lakeland Medical Center59.9 Touro Infirmary58.0 Pendleton Memorial Methodist Hospital52.8 Memorial Medical Center – New Orleans46.1 West Jefferson Medical Center43.9 Meadowcrest Hospital43.6 National Benchmark33.5 Tulane University Hospital29.9 Ochsner Foundation Hospital25.2

32. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 32 Implications of Katrina in Regards to Unwarranted Variation The impact of Hurricane Katrina on the heath care infrastructure within New Orleans presents a unique opportunity to design out unwarranted variation.

33. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 33 Health Dialog Project for the Louisiana Health Care Redesign Collaborative 1.Create a unified data set combining pre-Katrina: Commercial data Medicaid data Medicare data Uninsured data VA data 2.Analyze integrated data-set (at patient, market areas – tertiary and primary, and payer (including none) Disease prevalence/patterns Utilization patterns Cost patterns Quality patterns 3.Examine geographic differences both within Louisiana, and compared to national benchmarks 4.Data warehouse will serve as an important tool as decisions are made regarding what and where to rebuild, as well as an ongoing asset to be updated with current data

34. 34 Proportion of Health Care Costs Attributed to Unwarranted Variation Preference Sensitive Care Effective Care Supply Sensitive Care

35. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 35 Agenda  Unwarranted Variations  From Regions to Hospitals in Baton Rouge and New Orleans  Pushing the envelope on redesign

36. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 36 Shape of the Benefit-Utilization Curve: Effective Care & Patient Safety Benefit to Patients Intensity of Effective Care U.S. Is Somewhere in This Zone

37. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 37 Unwarranted Variations: expanding the agenda for redesign VariationCauseExpanding the Agenda Effective care and patient safety  Poorly understood care processes  Failure to learn  Inadequate systems to support delivery  Measures are expanded and transparency continues  Capital investment (HIT, safe design)  Operational investment (medical home, team based care, care management systems)  Provider payments include performance on measures of effective care

38. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 38 Shape of the Benefit-Utilization Curve: Preference- Sensitive Care Benefit to Patients Intensity of Preference Sensitive Care

39. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 39 VariationCauseExpanding the Agenda Effective care and patient safety Poorly understood care processes Develop systems of care capable of improvement Preference-sensitive carePhysician-dominated decisions  Decision quality measures developed and expanded  Shared decision making support for patients within and outside the practice  Provider payments include performance on ‘decision quality’ Unwarranted Variations: expanding the agenda for redesign

40. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 40 Shape of the Benefit-Utilization Curve: Supply- Sensitive Services Benefit to Patients Intensity of Supply Sensitive Care U.S. Is Somewhere in This Zone

41. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 41 VariationCauseExpanding the Agenda Effective care and patient safety Poorly understood care processes Develop systems of care capable of improvement Preference-sensitive carePhysician-dominated decisions Shared decision-making Supply-sensitive care  Variations in supply  Assumption that more is better  Efficiency is a measure of quality  Transparency  Benchmark-based capital investment (beds, MRIs, specialists, etc.)  Provider payments reward efficiency Unwarranted Variations: expanding the agenda for redesign

42. Copyright © Health Dialog Services Corporation 2006. All rights reserved. 42 Unwarranted Variations: expanding the redesign agenda