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All Eyes are on Capitol Hill

All Eyes are on Capitol Hill. The Quality World is Flat. We spend twice as much as any nation on health care People only get the correct care about 50% of the time (RAND) 100K deaths/yr due to medical errors (IOM) We could prevent 165,000 –272,000 deaths if all plans performed like top 10%.

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All Eyes are on Capitol Hill

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  1. All Eyes are on Capitol Hill

  2. The Quality World is Flat

  3. We spend twice as much as any nation on health care People only get the correct care about 50% of the time (RAND) 100K deaths/yr due to medical errors (IOM) We could prevent 165,000 –272,000 deaths if all plans performed like top 10% The Status Quo is Unacceptable

  4. Quality Must be the Foundation of Health Reform ACCESS COSTS QUALITY

  5. Quality Improvement Saves Lives! * Gross estimate of lives saved; does not take into account co-morbidities or expected mortality over time

  6. HEDIS® Measures of effective, appropriate care and resource use Based on medical evidence Key areas of care including diabetes, cardiac care, cancer screening, immunizations, smoking CAHPS® 4.0H Survey of access, timeliness, satisfaction Independently collected and audited What We Measure

  7. Total of 979 plan submissions:an all-time high 702 HMO submissions (+9) 277 PPO submissions (+16) Data reported in 2009 reflects care delivered in ‘08 116 Million Americans Benefit Who Reported Data?

  8. That’s almost 2 in every 5 Americans! 38% of Americans are in an Accountable Health Plan Accountable

  9. Millions of Americans in Accountable Health Care Systems: 2000-2009 +127% 00 01 02 03 04 05 06 07 08 09

  10. The Good News PPO performance is improving Success stories: Beta Blockers, Smoking Cessation, Asthma Areas for Concern Gains overall are small Vulnerable populations: care not measuring up Variation: inconsistency abounds Value: Are we getting our money’s worth? Have We Reached a Plateau? The State of Health Care Quality 2009

  11. Commercial PlansAnnual Monitoring of Patients on Persistent Medications +4.6 points

  12. Medicare Plans Persistence of Beta Blockers +10.1 points

  13. Universal High Performance, Commercial Plans: Medications for Asthma Average Performance Above 90%

  14. So Why Is theQuality World Flat? • Commercial Plans • 57% of measures show no statistically significant improvement • Medicaid Plans • 64% of measures show no statistically significant improvement • Medicare Plans • 86% of measures show no statistically significant improvement

  15. Payment systems do not reward quality Medicare Advantage doesn’t pay for performance Some measures are flat but high (i.e., asthma) But some measures are flat and low (i.e., behavioral health, overuse) Reporting is still mostly voluntary Why Is Quality Flat?

  16. The Performance Plateau: Commercial Plans Lower is better for this measure Medication Use for Arthritis Cervical Cancer Screening Diabetes – Poor HbA1c Control

  17. The Performance Plateau: Medicare Plans Breast Cancer Screening Diabetes LDL <100 Monitoring High Risk Medications

  18. The Performance Plateau: Medicaid Plans Appropriate Imaging for Low Back Pain Initiation of Alcohol/Drug Treatment Diabetes Blood Pressure Control <130

  19. Stuck in the Middle: Measures Below 50% Monitoring of patients on antidepressants 46.4% Follow up with children prescribed meds for ADHD 34.1% Follow up with patients hosp. for mental illness 49.8% Initiation of alcohol/drug dependency treatment 42.6%   Colon cancer screening 45.3%

  20. Vulnerable Populations

  21. Alcohol/Drug Abuse Treatment: Medicaid Plans +0.7 points

  22. Follow Up After Hospitalization for Mental Illness: Medicare +0.2 points

  23. VARIATION

  24. Quality varies by: What region of the country you live in The type of health plan you join Who pays for your care Quality Is All Over The Map

  25. Variation in the Quality of Care for Cardiovascular Disease New England: +5.3 East North Central: +2.0 Middle Atlantic: +2.3 Pacific: -0.5 West NorthCentral: -0.7 Mountain: -1.5 +2.5% or more +1.0% to 2.5% Within 1.0% of mean -1.0% to 2.5% -2.5% or more South Central: -4.9 South Atlantic: -1.5 Regional Performance Relative to National Average: Commercial plans, 2009

  26. Variation in the Quality of Care for Diabetes New England: +5.6 East North Central: +1.8 Middle Atlantic: +0.5 Pacific: +1.2 West NorthCentral: +1.3 Mountain: -0.8 +2.5% or more +1.0% to 2.5% Within 1.0% of mean -1.0% to 2.5% -2.5% or more South Central: -5.3 South Atlantic: -1.7 Regional Performance Relative to National Average: Commercial plans, 2009

  27. We lack comprehensive data for: 83% of Medicare beneficiaries (most are FFS) 75% of Medicaid beneficiaries 44% of commercially insured Large portions of the country lack data to know where they are-let alone todrive quality improvement Variations in Reporting Also Pervade the System

  28. Commercial HMOs Outperform PPOsSelect HEDIS Measures, Commercial HMO and PPO, 2009 The average HMO/PPO gap: 2.59 points

  29. AMERICANS PAY A HIGH PRICE FOR VARIATIONS IN QUALITY

  30. What Is vs. What Could Be What Could Be: The 90th Percentile Average “quality gap” in 2009: 12.6 points What is: System-wide Average Performance

  31. Quality Gaps Cost Up to 115,000 Lives...

  32. VALUE

  33. Plans report resource use across various service categories Plans report on six conditions Diabetes, asthma, low back pain, COPD, hypertension, cardiovascular disease Plans compared to one another on relative resource use Costs are standardized, data are risk-adjusted In concert with quality measures, can assess relative health plan value (e.g.,quality + resource use) Relative Resource Use MeasuresAssess the Value of Care

  34. Relative Resource Use: Total Medical Costs (exc. Rx) For Patients with DiabetesCommercial Plans, 2009

  35. RECOMMENDATIONS FOR REFORM

  36. Create Insurance Exchanges and require Accreditation with HEDIS and CAHPS reporting Provide report cards to consumers about the plans in their communities Create benchmarks and targets for improvement Hold Health Plans Accountable

  37. Tie payment to performance. No longer pay for piecework Focus on the whole patient Expand demonstrations of the Patient-Centered Medical Home And increase payments for primary care Promote the Accountable Care Organization model Build on the PCMH model Seek cost savings and quality improvements Reform Payment & Delivery Systems

  38. Create a framework for quality measurement Set priorities for improving (using NPP as a start) Focus on overuse, misuse, inappropriate care Fund measure development, maintenance and updates Tie funding to priorities Involve stakeholders in all steps Expand & Support Measurement

  39. Introduce quality bonuses for Medicare Advantage plans Reward performance and improvement Invest in Medicaid measure development Focus on frail elderly, disabled Create incentives for states to collect core measures Create ongoing oversight of Special Needs Plans Focus on Medicare/Medicaid Quality

  40. SPEAKERS

  41. Cristie Upshaw Travis, CEO, Memphis Business Group on Health Vernon K. Smith, Ph.D., Principal, Health Management Associates Martin Lustick, M.D., Corporate Medical Director, Excellus BC/BS of Rochester Nancy Van Vessem, M.D., Chief Medical Officer, Capital Health Plan Speakers

  42. Manage Chronic Disease Efficiently: Reduce Rescue Care Nancy Van Vessem, M.D. Executive V.P./ Chief Medical Officer

  43. Capital Health Plan • Tallahassee, Florida • Non profit, HMO • 113,000 members • Deep South demographics • Ranked #1 in the South by NCQA • Top 10 nationally in health plan satisfaction for all years CAHPS has been done

  44. Capital Health Plan • Primary Care focus • Average single digit premium increases per year over last 6 years • Administrative overhead <5% for 20 years • Less than 2% voluntary disenrollment • Relative Resource Use for Diabetes and Cardiovascular care below predicted

  45. Quality matters • Capital Health Plan • 90th percentile for Diabetes HEDIS • 90th percentile for Cardiovascular HEDIS • However, high quality scoring on measures doesn’t necessarily correlate with efficient care.

  46. Goal: Triple Aim (*IHI) • Improve the health of the population (quality) • Enhance the patient experience of care (satisfaction) • Reduce, or at least control, the per capita cost of care (efficiency) *Institute for Healthcare Improvement

  47. What makes the difference for people with chronic disease? • High quality evidenced-based care • Primary Care relationship (Medical Home) • Stable patient population • Stable benefits • Consistent messages/ education • In order to avoid complications, chronic disease must be managed over time by both the individual and their healthcare providers.

  48. What works against this? • Switching healthcare providers • No Medical Home – fragmentation of care • Not applying evidence-based care • Switching benefits – higher cost shares can reduce ability to follow a care plan • It’s tough to change the lifestyle habits that largely contribute to the chronic disease.

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