Transcript Facts About Quality of Care (Rand)

Giving Patients A Voice
Empowering Better Health
Jerry Reeves MD
It’s All About Patients
 Doctors
advise
 Many advocate
 Patients decide
After 25+ years focused on doctors, hospitals, and health plans,
the quality movement has not substantially eliminated quality gaps.
Care Gaps
(Rand, NCQA, Nevada Health Division)

USA:

– Less than appropriate
care:
– U.S./ Nevada Averages
 Breast cancer= 75% / 64%
 Cervical ca.=
81% / 71%
 Angioplasty= 42%
 CABG=
9%
– U.S.: Testing & Treatment
 Diabetes-A1C =
 Asthma Rx=
– Missing proper care:






CAD=
Diabetes=
Pneumonia=
Wounds=
Falls=
End of life=
32%
55%
61%
59%
66%
91%
HEDIS Measures:

83%
68%
Culinary Fund




Breast cancer=
Cervical cancer=
Diabetes-A1C=
Asthma Rx=
60%
57%
67%
57%
Yesterday
patient
physician
medical
record
Today
patient
pharmacy
insurance
consultation
regulators
hospital
physician
lab, xray
QI
decision
support
other
medical
record
FLOW OF INFORMATION
DEM:
S,O:
A:
P:
Solution:
patient
pharmacy
insurance
consultation
regulators
hospital
online
health
record
lab, xray
QI
decision
support
other
physician
FLOW OF INFORMATION
DEM:
S,O:
A:
P:
Patients Influence Outcomes

Demographics
– Age/Sex, Race, Income, Insurance
– Health literacy, Culture

Clinical
– Chronic disease, Comorbidities
– Functional status- physical, mental

Health Risks
– Weight, fitness, diet, safety
– Family history

Behavior Change Likelihood
– Confidence, Readiness, Commitment
– Expectations
Cost Drivers- Doctor Visits

Emergency Department
– 6%
Emergent
– 56% Urgent
– 38% Non Urgent

Office
–
–
–
–
–
37%
30%
18%
6%
9%
New Symptom
Chronic Problem, Routine Check
Non-illness Care
Chronic Problem, Flare-up
Other
Informed Decisions Are Rare
1057 office visits; 3552 clinical decisions
 Overall:
9% of decisions informed

– Basic:
17% of decisions informed
– Complex:
0.5% of decisions informed
(Braddock CH. JAMA 1999; 282: 2313-20)

In one ear, out the other
– 50% to 80% of medical information in visit is
forgotten instantly
– 50% of retained information is later recalled
incorrectly. R Kessels. J Royal Soc Med, 2003
Cost Drivers- Physicians
Consumers Want Control
Patients Want to Control Health Care Decisions
Who influences health care decisions?
Current
Should Be
Self
1.9
5.4
Doctor
1.8
2.4
Insurer
3.3
0.7
Hospital
0.7
0.6
Government
1.1
0.6
Employer
1.2
0.3
Scores based on a 10 point allocation
Source: American Hospital Association
Patients want to make health care decisions alone or with their
doctors, not with insurers, hospitals, government or employers.
Self-diagnosis and self-care





Most people self-diagnose frequently
600+ prescription medications now are
available over the counter
For up to 40% of doctor visits, self-care turns
out to be the treatment of choice
For more than 100 conditions, home
remedies result in the same outcome as
doctor care
70% use Internet; 78% have email
Correct “self-diagnosis” is critical
Engaging People In Health Decisions:
Surround With Care

Multi-touch communications
– Web, phone, mail, print, media, onsite

Behavior change incentives- SMART
– Rules, Report Cards, Rewards, Penalties

Point of decision tools readily available
– Answers about benefits
(15% of spend)
– Help with health decisions (85% of spend)

Coaches and advocates
– Laypersons, professionals, coalitions
Decision Matrix

Patient

Prevention
– Home, Work, Office
 Early Treatment

Late Treatment

Low Cost

Doctor

Prevention

Early Treatment

Late Treatment
– Hospital, ER, Office, Home

High Cost
It Takes Incentives


Providers
Bonus, Recognition,
Steerage, “Gold Card”
–
–
–
–
–

Efficiency
Effectiveness
Generics
Access
Information Technology
Fines, Report Cards, P/A,
Termination
– Delays
– Safety
– Fraud


Patients
SMART- Coupons, Raffles,
$, Points, Copays, Discounts
– HRA, Prevention
– Steps, Weight
– Tests, BP, Meds, Visits

Penalties- Rules, Fines,
Surcharges, Hiring
– Smoking
– Safety
– Drugs
Point of Decision Tools
Personal Evaluation System (PES)
Health Risk Appraisals
interventions
(HRA)
with
risk
reduction
Online Personal Health Record – for patient and her doctors
and case managers
Telephone and Interpersonal Decision Support
Hospital & Doctor Performance Comparisons
Evidence Based Treatment Assessments
Prescription Comparisons
Chronic Care Assistance and Navigation
Health Campaigns at Work
Health Decision Support
www.culinaryhealthfund.org
Online Personal Health Record
Choose Your DoctorHelp in the Provider Directory
 Name
 Specialty
 Zip
Code
 Languages
 Extended Hours
 Gold Star Rating
Patients Desire E Visits
90% of US adult Internet users want
online with their doctor
 71% want online appointment scheduling
and prescription refills
 70% want online test results
 37% willing to pay for it out of pocket
 56% say online communication access
would influence their choice of doctor

http://www.harrisinteractive.com/ Harris Poll April, 2002
Health Services CoalitionLeverage

22 Large Employers and Health Trusts
– 320,000 lives in Las Vegas (including Culinary Fund)

Collaborations
– Hospital Contracts- Performance Expectations
 Rates, Quality, Safety, Patient Satisfaction
 LeapFrog/ National Quality Forum Participation
– Generics Campaign- Media, Ads, Doctor Visits
– Hospitalists- 2 groups, all hospitals
– Data Sharing- claims audits/ data warehouse
 Performance monitoring
Coalition Generics Campaign
Success Determinants





Program promotion / employee education
Employer’s and support groups’ engagement level
Intensity and types of incentive programs
Behavioral/demographic characteristics of the
employee population (predisposition to change
behaviors)
Patient’s understanding of personal diagnoses,
treatment options, and responsibility for decisions
under their control
“First, the patient, second the patient,
third the patient, fourth the patient,
fifth the patient,
and then maybe comes science.
We first do everything for the patient.”
Bela Schick MD (1877-1967 )
(Invented the Schick Test for diphtheria; helped eradicate diphtheria.)