1. Scott Flinn, MD, Regional Medical Director
Blue Shield of California Participation in the Right Care Initiative 2018 Annual Update
Scott Flinn, MD, Regional Medical Director

2. Blue Shield of California and the Right Care Initiative
In October 2015, Blue Shield of California (BSC) was required by the Department of Managed Health Care (DMHC) to:
Participate in the Right Care Initiative (RCI) University of Best Practices (UBP) and
To develop a plan with a goal of achieving the 90th percentile in RCI metrics by end MY 2018.
Blue Shield of California is participating in the UBPs, and has developed a plan and is implementing that plan. This presentation is a review of progress to date.

3. BSC Quality Strategy and RCI
Hypertension, Diabetes, and Readmission Reduction are the top 3 quality initiatives for BSC.
Internal corporate incentives are tied to those goals.
Quality incentives for our Provider Organization partners include our participation in IHA and our quality incentive plan for our ACO partners.

4. University Of Best Practices Participation
BSC is participating in all 3 RCI chapters and is using the information gathered to augment its planning and execution of quality improvement efforts directed at preventing heart attacks, strokes, and diabetic complications.
BSC recognized the need for an additional University of Best Practices chapter in a previously unserved area and provided resources to establish a Bay Area RCI UBP chapter.

5. Provider Organization Engagement
BSC does not deliver care; our Provider Organization (PO) partners do. In order to reduce strokes, heart attacks and diabetic complications and improve the RCI metrics, BSC recognized the need to enlist PO partners in the effort. The 3 part plan developed included means to engage providers, a tool to do a self assessment, and a means to track progress.
The provider engagement presentation has been successful in enlisting over 26 PO in the RCI efforts, with 14 more targeted in the near future.

6. Provider Engagement Presentation
Presentation emphasizes 4 major points:
Hypertension control can have a dramatic impact in a short period of time
Implementing some of these Best Practices are relatively easy and cost effective
There is some published literature suggesting this actually works
You probably aren’t doing as well as you think you are….

7. How to Prevent One in Six of Your High Risk Hypertensive Patients from Dying from a Stroke or Heart Attack in the next 3 years!
Really!

8. Decrease Deaths in High Risk Patients
Decrease Deaths in High Risk Patients* by 17% (1 in 6) in 2 years… Treat them NOW
From Kaiser with permission
*Uncontrolled Hypertensive over 55
17 % !!!!
1 in 6!!!

9. Best Practices

10. Best Practices include:
Implementing a treatment algorithm
Intensifying treatment rapidly
Implementing a care team which includes a Pharmacist and Certified Diabetic Educator.
Continuously measuring success and publicly reporting the outcomes
Algorithms help
Pilots use them…

11. San Diego HTN med protocol
Adapted from Kaiser algorithm

12. Effect Of Therapies On Systolic BP
9.7 mm
24.9 mm
33 mm
34mm
42mm
Kaiser data – with permission
Biggest effect is adding a simple thiazide to ACE inhibitor
That’s why the combo pill is the first lien recommendation

13. Pharmacist on the care team
A 2007 NIH funded study at UCLA showed that pharmacist assisted management of hypertension was more effective at reducing hypertension than physician intervention alone.
Pharmacists practicing at the top of their license under Collaborative Practice Agreements:
intensifies of drug therapy per protocol
orders/monitors related labs
addresses side effects
works with patients & monitors for medication adherence
keeps the primary care physician (PCP) informed
Reports on HTN and DM medication prescriptions
Many benefits
Can pull data
Can do MTM under protocol – UCLA study in 2007 referenced earlier
Pharm tech under pharmacist can help with compliance

14. % of Patients on Combination Pill
As combination pill usage went up, hypertension control went up
Kaiser data
As use of combo pill (ACE/Thiazide) improved so did Kaiser BP control
JAMA. 2013;310(7): doi: /jama

15. BSC Pharmacy Program Support
BSC Advanced Practice Pharmacist network – credentialed additional pharmacist providers in 2018, engaged in medication management in partnership with PCPs
BSC provides subject matter expertise to provider organizations to launch medication management programs and to use of pharmacists on the care team
Collaborative Practice Agreement template available for adoption
BSC Medication Adherence support program available
Additional BSC incentives available to ACOs to hire/use pharmacists and pharmacy technicians

16. Reporting and Rewarding - Registry
Provides actionable data for identifying clinical opportunities
Provides means of tracking progress, reporting, and providing feedback for recognition
Peer competition # 1 motivator for providers
Public reporting – great motivator (and why medical directors only last 3.5 years…)
Not to shame – learn form those doing well
Hence- University of best Practices

17. BP control by Provider in a Medical Group in Southern California
60 primary care providers – measured patient BP control
Control ranged from 32% - 74%
Engaged pharmacist through Collaborative Practice Agreement with Clinical Champions
Overall HTN control rose form 55% to 78% in less than a year
The physician with 32% control was a cardiologist
Surprising to docs when they see the actual control numbers
Idea is to stimulate those not doing as well to find out what those who are doing well are doing

18. HTN Control Best Practice – Follow up high blood pressure before patient leaves clinic
Policy instituted – if patient checks into clinic and BP > 140/92 on check in, needs repeat before leaving the appointment
Referral to PCP / ER as appropriate if elevated
Tracking of repeats done – publicly reported to clinics and to Board of Directors
HTN control part of provider annual bonus structure

19. RCI – Does it Work?

20. Experience in San Diego
Countywide Physician Organization Learning Collaborative and Changes in Hospitalization Rates Brent D. Fulton, PhD, MBA; et al. Am J Manag Care. 2017;23(10):

21. HEALTH AFFAIRS 37,
NO. 9 (2018): 1457–1465

22. What has made San Diego Different?
Co-opetition
Data sharing group
Develop trust
Way to share Best Practices

23. What does the Data Show?

24. RCI Assessment- 8 metrics
RCI metrics - HEDIS data for HMO and POS patients
HTN control: BP < 140/90
Beta blocker after an MI for 6 months Diabetes Measures
% in Control: Hb A1C <8
% in Poor control: Hb A1C >9 or unmeasured
Hb A1C testing
Eye exam
Medical attention for nephropathy*
* Urine microalbumin test, ACE/ARB Rx, seen by nephrologist, kidney transplant, dialysis, shunt placement, etc.
These metrics are the same Hedis metrics for IHA, Medicare stars, etc. Focus on HTN , diabetes and post MI care 9

25. HEDIS data for BSC - HMO POS populations
Results to date
RCI Measure
Metric
MY 2014
MY 2015
MY 2016
MY 2017
Hypertension Control
Rate
60.5
65.2
61.7
57.66
Percentile
25th
50th
Beta Blocker after MI
80.58
82.73
83.1
81.35
Diabetes Control <8
63.14
61.56
64.92
59.31
75th
Diabetes Uncontrolled (>9)
27.55
26.56
25.8
30.47
Hgb A1C
90.33
89.69
88.87
Diabetic Nephropathy
84.49
89.84
90.73
89.78
90th
Diabetic Retinopathy
49.45
50.94
48.74
45.07
Hypertension Control in Diabetics
56.2
71.09
66.61
66.97
<25th
HEDIS data for BSC - HMO POS populations

26. MY 2017 Health Plan Results – HTN control

27. MY 2017 Health Plan Results – DM control

28. MY 2017 Health Plan Results – HTN control in DM

29. MY 2017 West LA Provider - HTN control

30. MY 2017 West LA Provider - HTN control

31. BSC Improvement Opportunities
Hypertension Control – Supplemental Data submissions. Effort underway to revamp supplemental data submission system.
Other elements of RCI work are hybrid and are affected by supplemental data submission.
Beta-blocker after MI workgroup launched to improve ability to address clinical opportunities. The discharge event is not always available to identify members for intervention.
Clinical Best Practices Community forums to share Best Practices
BSC Pharmacy - PO Pharmacy meetings and ACO colloquiums

32. Best Practices Self Assessment Tool

33. Best Practices Self Assessment Tool
Developed Best Practices self-assessment tool for HTN and DM care based on RCI University of Best Practices (UBP), AMGA Measure Up Pressure Down and Together 2 goal, Million Hearts, and other work.
Reviews performed with a BSC clinician
Essential elements highlighted
Tool has resource links embedded
Using Best Practices tool, conduct assessment, gap analysis, and help partner POs develop action plan
Quarterly follow up and annual reassessment.

34. Best Practices Self Evaluation Tool
HTN and DM tabs
3 categories – Leadership, Processes, Patient Engagement
23 items for HTN, 19 for DM
3 ratings –yes, no, sort of
Resource links embedded
BSC HTN Best Practices Worklist
Group Name:
Date Evaluation Completed:
Hypertension "Best Practices" Worklist Item
Group's Status
Notes
Resource
Action Item
Leadership
Multidisciplinary team that includes clinical champion(s)
Should include Clinical Champions
Best Practice: Zufall Health "Building a Team"
Engaged all providers and clinical staff through education
Engage Providers and direct support staff in importance of controlling BP - can reduce strokes and heart attacks in high risk individuals 17% in two years. Synergy with Million Hearts, AMGF Measure up Pressure Down, AHA and AMA Target: BP
RCI Template Presentation
Internal public reporting of HTN control by provider
Peer Collaboration
Recognition of providers with excellent performance
public recognition, financial incentives through quality program
Processes
Process map of clinic visit flow to evaluate delivery of care pre-visit, visit and post-visit
Hypertension is addressed at every primary care visit
Sample Chart Audit
Consistent Process to ensure HTN measurement part of every visit
Ensure every visit includes a BP reading; include specialty, and a process for routing back to primary care when reading is elevated >140/90
Staff trained to take accurate BP
Guidelines on patient posture, wait time, caffeine and smoking; retest all BP >140/90 after 5 minute rest. Co-assess with staff and providers Initial and annual refresher. Sign at eye level from patient instructions, such as uncrossing feet
AMGF measure up pressure down
BP rechecks done on all patients not in BP control prior to leaving office, and documented in chart
7 Simple steps to ensure ACCURATE reading
Point of Care reminders in EHR
Adopt Hypertension Algorithm
Template from SD RCI
Intensify treatment every 2-4 weeks until goal reached
No co-pay return visit with MA / RN to repeat BP
Monitor use of Algorithm
Pharmacy statistics: Number of medications per patient Chart Review
Patient registry for Hypertension
AMGA Best Practice in HTN Registry
Medical group participates in programs to improve HTN medication adherence
Leverage pharmacists/ pharmacy techs to improve adherence
Case Study for use of Pharmacist on team
Medical group reviews drug gap reports identifying members needing beta-blocker therapy after MI
Collaborative Practice Agreement with Pharmacist
Pharmacist help through Collaborative Practice Agreements greatly facilitates outcome
Template available
Adopted Standing Orders
UCSF Example: Center for Excellence in Primary Care
Specialists refer high BP to PCP
sample chart audit

35. What have we learned so far
As we engage PO partners, we find many have efforts towards RCI goals at various levels. And they are all unique…. if you’ve seen one provider group you’ve seen one provider group.
RCI synergizes with other programs that many groups are already doing – e.g. CDC/CMS Million Hearts, AMGF Measure Up Pressure Down and Together2Goal, AHA Target BP, Know Your Numbers
Achieving hypertension control in high risk patients has the biggest near term effects on patient outcomes; lipid control has biggest effect long term

36. Value add for the Partners
The Self Evaluation tool helps groups develop a QI plan and prioritization of efforts
Clinical Assistance
Quality expertise
Pharmacy
Cleaning up the data
Financial outcomes – e.g. ACO partners, P4P participants

37. Next Steps
Continue scaling work - enlisting provider organizations in the effort. Bay Area UBP will help in those efforts.
Continue to refine approach based on experience with PO partners and through participating in UBP and other venues
Reach 90th percentile in RCI Metrics
Eliminate preventable strokes and heart attacks