Transcript Washington State`s Efforts to Transform Health Care

Washington State’s Efforts to
Transform Health Care
Academy Health/State Coverage Initiatives
Annual Meeting
August 5, 2010
Richard K. Onizuka, PhD
Health Policy Director
Governor Gregoire’s strategy : Improve
quality in health care
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Governor Gregoire’s five point plan to improve health care
(2005)
– Emphasize evidence based health care
– Create more transparency in the health care system
– Promote prevention, healthy lifestyles, and healthy choices
– Better managed chronic care
– Make better use of information technology
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Blue Ribbon Commission (2006)
– Goals set for 2012
– Four strategies
– 16 recommendations
– Health reform legislation, 2007 (5930)
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HCA and State Health Reform
Efforts
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Cabinet level agency purchasing health care for over
400,000 Washingtonians
Over 330,000 public employees and retirees
– State, higher ed, some K-12, some local governments
– Self insured PPOs and fully insured Plans/MCOs
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About 70,000 low income in Basic Health Program (BHP)
– Until budget reduction in 2009, program enrollment around 100,000
– Now over 100,000 on wait list
– Entirely state funded, waiver request for early expansion
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Key implementation of cross-agency health reform efforts
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Health Technology Assessment (HTA)
Prescription Drug Program (PDP)
PDA/SDM and AIM
Health Information Technology and Health Information Exchange
Health Insurance Partnership
Medical homes/payment reform pilot
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The State Budget, Health Care, and
National Health Reform
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Projected shortfall for 2011-2013 is $3 billion
Total health care spending now about 1/3 of state budget, was
about 1/5 in 2005
Waiver request to sustain BHP, Medical Care Services
programs
Executive order to consolidate Medicaid, public employees
health purchasing, eventually all state health purchasing,
under HCA
Executive implementation of NHR, Joint Legislative Select
Committee on Health Reform Implementation
– Low income expansion
– Health insurance exchange
– Health care workforce
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How a Large Purchaser Can Impact the
Market
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Must change the delivery system to impact cost and quality
– Driving change through purchasing
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Must target manageable changes for the long haul (lesson
learned from 1993)
Governor targeted key initiatives early and stuck with them
– Five point plan, BRC
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Focus has endured despite a bad economy and political
pressure
This focus has helped other employers, health plans and
provider groups to think differently
Working together with private sector
– Puget Sound Health Alliance
– Multi-payer medical homes payment reform pilot
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Health Care Quality Defects Occur at
Alarming Rates
Sources: modified from C. Buck, GE; Dr. Sam Nussbaum, WellPoint; Premera 2004 Quality Score Card; March of Dimes
Treatment of
Bronchitis (WA)
Recommended
well-child visits (WA)
Defects per million
1,000,000
100,000
10,000
1,000
100
Detection &
treatment of
depression
IRS Phone-in Tax Advice
Breast cancer
Screening (WA)
Hospital acquired infections
Adverse drug
events
U.S. birth defects
Hospitalized patients
injured through negligence
Overall Health Care
Quality in U.S.
Airline baggage handling
(Rand Study 2003)
U.S Airline
flight fatalities/
U.S. Industry
Best of Class
NBA
Free-throws
10
1
1
2
3
4
5
6
(69%)
(31%)
(7%)
(.6%)
(.002%)
(.00003%)
∑ level (% Defects)
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Evidence Based Health Care
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Cutting edge programs that have become part of our offerings:
– Health Technology Assessment (HTA)
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State pays for procedures and medicine that show evidence of efficacy, costeffectiveness, and safety
– Prescription Drug Program (PDP)
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Preferred drug list used by PEBB, Medicaid, and workers compensation programs
– Drug Purchasing Consortium
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Pools state purchasing power for any Washingtonian
– Patient decision aid pilot (PDA)
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Focus on high-variation, preference-sensitive areas that involve multiple options and
tradeoffs, e.g. cardiac disease; breast & prostate cancer
– Advanced imaging management (AIM)
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Using evidence based guidelines, identify highest cost/utilization advanced diagnostic
imaging services for state programs
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Why Health Technology?
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Part of an overall strategy
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Medical technology is a primary driver of cost
– The development and diffusion of medical technology are primary
factors in explaining the persistent difference between health
spending and overall economic growth.
– Some health experts arguing that new medical technology may
account for about one-half or more of real long-term spending
growth.
Kaiser Family Foundation, March 2007: How Changes in Medical Technology Affect Health Care Costs
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Medical Technology has quality gaps
– Medical technology diffusing without evidence of improving quality
Highly correlated with misues, overutilization, underutilization.
Cathy Schoen, Karen Davis, Sabrina K.H. How, and Stephen C. Schoenbaum, “U.S. Health System
Performance: A National Scorecard,” Health Affairs, Web Exclusive (September 20, 2006): w459
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HTA Program Elements
1. HCA Administrator Selects Technology
Nominate, Review, Public Input, Prioritize
Semi-annual
2. Vendor Produce Technology Assessment Report
Key Questions and Work Plan, Draft, Comments, Finalize
2-8 Months
3. Clinical Committee makes Coverage
Determination
Meet
Quarterly
Review report, Public
hearing
4. Agencies Implement Decision
Implements within current process unless statutory conflict
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HTA Outcomes
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Technologies selected
– 17 technologies selected since 2007
 3 first year; 5 second year; 8 third year
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Analysis completed
– Over 6,000 articles/trials reviewed
– 15 comprehensive technology assessment reports
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Coverage Decisions
– 9 public meetings and 13 decisions, where reliable evidence:
 7 show benefit and support coverage for certain situations
 5 do not yet show benefit and are not covered
 1 shown unsafe or ineffective
– Estimated $27 million cost avoided
– Projected Utilization impact: 3 increased; 3 same; 7 decrease
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HTA Outcomes
Topic
Health Technology Assessment Program
Evidence
CostDate
Safe
Effective
Effective
Decision
Health
Benefit Coverage
Utilization
Impact
(annual figure)
Upright MRI
May-07
Equal
Insufficient
Less
N/A
No
$2,990,000
Ped Bariatric Surgery <18
Aug-07
Insufficient
More
Insufficient
No
$0
Ped Bariatric Surgery 18-21
Aug-07
Less
More
Insufficient
Yes
Lumbar Fusion
Nov-07
Less
Equal/More
Less
Yes
No
Yes/
Conditions
Yes/
Conditions
$5,240,639
$589,485
Discography
Feb-08
Insufficient
Insufficient
Insufficient
No
No
$324,000
Virtual Colonoscopy (CTC)
Feb-08
Equal
Equal/More
Less
No
No
$11,100,000
Insufficient
Equal
No
No
$691,326
Equal
Less
No
No
$400,000
Intrathecal Pump for chronic noncancer
Feb-08 pain
Insufficient
Arthroscopic Knee Surgery
Aug-08
Less
Artificial Disc Replacement
Nov-08
Equal
Computed Tomographic
Angiography (cardiac)
Nov-08
Equal
Equal
Equal/More
Yes
Cardiac Stents
May-09
Equal
Equal/More
Less
Yes
Equal/More Insufficient
Yes
Yes/
Conditions
Yes/
Conditions
Yes/
Conditions
0*
$5,063,928
$966,760
$27,366,138
*Insufficient current data to calculate conservative estimate.
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ConsumerReports.org
10 overused tests and treatments
November 2007
1 BACK SURGERY. … surgery, which can cost $20,000 plus physician's fees …..
2 HEARTBURN SURGERY. operation, costs $14,600 or more
3 PROSTATE TREATMENTS. . over treated with surgery that costs $17,000, or by
radiation therapy for $20,700
4 IMPLANTED DEFIBRILLATORS. … cost some $90,000 over a lifetime.
5 CORONARY STENTS. Billions are spent each year….
6 CESAREAN SECTIONS. ..cost almost $7,000, about 55 percent more than natural
delivery...
7 WHOLE-BODY SCREENS. CT scans, which can cost $1,000 … no proven benefits
for healthy people. A few CT scans a year can increase your lifetime risk of cancer.
8 HIGH-TECH ANGIOGRAPHY. Using a CT …costs an average of $450...standard
angiography is sometimes still needed.
9 HIGH-TECH MAMMOGRAPHY. Using software to flag suspicious breast X-rays
would add $550 million a year to national costs if used for all mammograms. But a 2007
study found that this technique failed to improve the cancer-detection rate significantly,
yet resulted in more needless biopsies.
10 VIRTUAL COLONOSCOPY. …Though less costly than a standard colonoscopy, the
virtual test isn't cost-effective because any suspicious finding requires retesting with the
real thing.
Copyright © http://www.consumerreports.org/cro/health-fitness/index.htm 2000-2006 Consumers Union of U.S., Inc.
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Prescription Drug Program
State preferred drug list
 Evidenced based review of drug classes, efficacy and
effectiveness
 Reviewed by Pharmacy and Therapeutics committee (P&T), at
least ten independent clinicians
 Recommendations to self funded plan, Medicaid FFS, workers
comp
Drug purchasing consortium
 WA and OR collaboration on publicly purchased PBM
contracts
 Available to all residents, no fee
 Average savings per prescription – 40% or $20
 Average percentage of generics – 88%
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Other Evidence Based Health Care
Programs
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Patient Decision Aids/Shared Decision Making (PDA/SDM)
– 2007 BRC legislation directed HCA to establish pilots
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Did not provide any state funding
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Provided “safe harbor” for clinicians
– HCA convened community collaborative to seek funding
– Two pilots funded by FIMDM
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Group Health: live January, 2009, results pending
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UW: live January, 2010
Advanced Imaging Management
– 2009 legislation directing HCA to convene workgroup
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July, 2009 report on guidelines for direct state purchased health
care
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January, 2011 report for use with other purchased health care
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Change is a Journey
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Lessons learned
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Be transparent
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Engage the provider community
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Find common values
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Make consistent coverage decisions
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Make bias free zones
Challenges
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Resource intensive
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Collaborations involve time and tradeoffs
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Cultural change - new decision model (not persuasion, expert opinion,
advocacy or political clout)
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Often identifies information gaps
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Thank you!
Additional resources:
 HTA: http://www.hta.hca.wa.gov/
 PDP: http://www.rx.wa.gov/
 Discount Card: http://www.rx.wa.gov/discountcard.html
 AIM: http://www.hta.hca.wa.gov/aim.html
 PDA/SDM:
http://www.informedmedicaldecisions.org/washington_state_l
egislation.html
 Joint Select Committee:
http://www.leg.wa.gov/jointcommittees/HRI/Pages/default.aspx
 Governor Gregoire:
http://www.governor.wa.gov/priorities/healthcare/reform.asp
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