ADHD in Children

1. ADHD in Children

2. Antibiotic Use • Michigan and regional activities • MARR • Flint Health Coalition • Capital Area Health Coalition • Muskegon County Health Coalition • Why so many: • Emergence of Community-Acquired Methicillin-Resistant Staphylococcus aureus as the Predominant Cause of Skin and Soft-Tissue Infections • Ann Intern Med 2006;144 309-317 • And others…

3. Antibiotic Use in Adults

4. Antibiotic Use Within 7 Days of URI in Adults and Children

5. Antibiotic Use in Children

6. So Why Do We Care? • Appropriate use saves lives • Appropriate use improves quality of life • Appropriate use improves health expenditure model • And inappropriate use costs • Lives • Quality of life • More resources of all kinds

7. Programs and Patient Safety “The person who takes medicine must recover twice, once from the disease and once from the medicine.” - William Osler, M.D.

8. Medication Use in the United States • Very high proportion of adults in the U.S. take at least one medication in any given week. • The highest medication use is in males and females >/= 65 years of age. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent Patterns of Medication Use in the Ambulatory Adult Population of the United States. The Slone Survey. JAMA. 2002;287(3):337-344.

9. The Value of Pharmaceuticals • What is the value of pharmaceuticals?  The answer is complex • Direct Value > reduction in morbidity or mortality > symptom relief > prevention of disease • Indirect Value > improvement in quality of life > improved productivity at work > reduction in absenteeism at work Source: The Value of Pharmaceuticals and Managed Pharmaceutical Care. Foundation for Managed Care Pharmacy. 2001. www.amcp.org

10. The Value of Pharmaceuticals • When does risk outweigh value? > Vioxx® (rofecoxib) > Bextra®(valdecoxib) > Palladone® (hydromorphone extended release) • FDA under heavy scrutiny for safety reviews • Are there other drugs in the pipeline or on the market already that may pose unnecessary risk to patients?

11. Quality of Health Care • Survey of more than10,000 • adults in the U.S. • Follow-up chart review on • almost 7,000 of those adults • surveyed • Used nationally-accepted • quality indicators • Participants received 54.9 • percent of recommended • care • No significant differences in • quality of care for preventive, • acute care, or chronic care McGlynn EA, et.al. The Quality of Health Care Delivered to Adults in the United States. NEJM. June 26, 2003;348:26. 2635-2645.

12. Focus on Delivery of Care • Society spends billions of dollars on development of new drugs and technology but relatively little on improving systems to ensure the delivery of care to all of those in need.1 • We need markets that encourage integrated delivery systems, with incentives for teams of professionals to provide coordinated, efficient, evidence-based care, supported by state-of-the-art information technology.2 • Woolf SH, Johnson RE. The Break-Even Point: When Medical Advances are Less Important than Improving the • Fidelity with Which They are Delivered. Ann Fam Med 2005;3:545-552. • Enthoven AC, Tollen LA. Competition in Health Care: It Takes Systems to Pursue Quality and Efficiency. • Ann Fam Med 2005;3(6):420-434.

13. BCBSM Pay-for-Performance • 2000 BCBSM Physician Prescribing Pilot • 2004 Design physician group incentive program in collaboration with physician groups and medical societies • 2005 Implement physician group incentive program • 2006 Design and implement physician organization gain-sharing incentive program

14. Partnering for ValueProgram Goals Physician Group Incentive Program (PGIP) • Support and facilitate significant performance improvement by physician groups through financial incentives: • Improve care of “all-payer” patients with diabetes mellitus, persistent asthma, coronary heart disease and congestive heart failure • Increase generic prescribing for BCBSM members • Increase use of shared decision-making for BCBSM members • Gain-sharing program Physician Organization Gain-Sharing Incentive Program (POGS) • Achieve measurable savings: • Pharmacy costs • Laboratory costs • Diagnostic imaging • In-network referrals • Strengthen the performance improvement infrastructure available to clinicians • Share savings achieved from improved practices with physicians

15. Evaluation and Reward Process PGIP • Medical groups collaborate on focused committees and report progress to BCBSM describing progress and performance • BCBSM evaluates each group’s performance and provides written feedback • Share of incentive pool for each group based on BCBSM members served and performance in meeting program goals • Fourth quarter 2005 incentive based on pharmacy measure (generic prescribing) POGS • Physician organizations selected receive defined payments derived from incentive component of TRUST fee update. Payment made semi-annually based on size of BCBSM membership served by PO. • Share at least 50 percent of overall program savings with participating physicians through higher fees on Evaluation and Management services during follow-up payment period

16. Participating Physician Groups Physician Group Incentive Program (PGIP) Advantage Health Physicians, Grand Rapids Genesys Integrated Group Physicians, Flint Henry Ford Medical Group, Detroit (1Q06) Huron Valley Physicians Association, Ann Arbor Integrated Health Associates, Ann Arbor McLaren Medical Management, Flint Medical Network I, Rochester Michigan Medical, P.C., Grand Rapids ProMed Healthcare, Kalamazoo Regional Delivery Network of West Michigan Sparrow Family Medical Services, Lansing St. John Health, Medical Resource Group, Detroit United Oakwood Physicians, Dearborn (1Q06) United Physicians, Bingham Farms (4Q05) University of Mich. Health System Faculty Group Practice, Ann Arbor Upper Peninsula Health Plan, Marquette (4Q05) Physician Organization Gain-Sharing Incentive Program (POGS) • Contract with selected physician organizations • Criteria: • Physician organizations with 30 or more TRUST physicians with primary care focus • A partnership, association, corporation, individual practice association or other group that distributes income from the practice among members • Organizations will coordinate and facilitate practice improvements and program administration on behalf of their physicians • Physicians limited to participation with only one physician organization for purposes of gain sharing program • PGIP groups automatically eligible to participate

17. 2006 Performance Measures • PGIP / POGS will have identical measures • Generic dispensing rate • Improvement over baseline • One percentage point over control group • PMPM • PPIs (Proton Pump Inhibitors) • NSAs (Non – sedating antihistamines) • NSAIDs (Non-steroidal anti-inflammatory drugs)

18. Summary • Variation in pharmaceutical use and prescribing is common across all drug categories, some more than others • The Atlas is a tool to measure how we are doing and where we can focus attention for quality of care and patient safety • Improving quality and safety is a collaborative effort among all stakeholders in health care

19. Discussion • Thoughts about the data? • Thoughts about how unwarranted variation applies to pharmaceuticals? • Thoughts about using this data to promote patient safety? • Upcoming meetings/forums that would be interested in learning about the atlas?

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