Transcript Report Cards, Incentives and Reminders- Impacts on Health

Creating Change Locally Using Report Cards, Incentives and Reminders
To Impact Health and Costs
Jerry Reeves MD
Health Innovations
Overview
 Priorities for addressing root causes of
poor health & adverse cost trends
 Engagement strategies- providers and
patients
 Outcomes of interventions
Priorities for Better Health & Lower CostLifestyle Risks in Working Age Population
Health Risk Measure
High blood sugar
Added $ per Year
(diabetes)
$1,150
High weight by BMI (>27.3 women, >27.8 men)
$690
High tobacco use (Current smoker)
$447
High cholesterol (>239)
$428
High blood pressure (above 139 systolic or 89
diastolic)
$390
High sitting around (walk < 30 minutes per
week)
$339
No self-care book being used
$225
(not “engaged”)
From: University of Michigan Health Management Research Center and Wellness, Inc.- 2005
Priority: High Cost Clinical Conditions
CATEGORY
% OF ADMITS
Maternity/ Childbirth (OB)
17.8%
Heart & Blood Vessels
16.8%
Lung Disease
6.8%
Gastrointestinal (GI)
6.5%
Female Problems (GYN)
5.2%
Bone & Joint
4.3%
Priority:
Top Health Improvement Opportunities
9000
8000
Acute Illness Opportunity
Serious disease
7000
Minor Disease
6000
4000
Chronic Condition
Opportunity
No Disease
5000
Prevention/ Fitness
Opportunity
3000
2000
1000
0
Q_12
Q_9
Q_6
Medical and Drug Costs only
Q_3
Q0
Q3
Q6
Q9
Q12
From Dee Edington, University of Michigan
Priority:
MD Cost Variation; Same Outcome
Specialty
Condition
Low
Average
High
Otitis media $46
$109 (+137%)
$412 (+796%)
Bronchitis
$89
$150 (+69%)
$771 (+766%)
UTI
$81
$140 (+73%)
$778 (+860%)
Angina
$86
$297 (+245%)
$743 (+764%)
Angina
$241
$611 (+154%)
$1389 (+476%)
Knee surg.
$2,727
$4,473 (+64%)
$9,383 (+244%)
FP
IM
Cardiology
Orthopedics
Priority:
Physician Value Variability
Higher
High Quality
High TCC
High Quality
Low TCC
(Dream Docs & TX)
50th %ile
Lower
MD Quality Index
(outcomes or % adherence to EBM)
50th %ile
Low Quality
High TCC
(Nightmare on
Any Street USA)
Higher
Low Quality
Low TCC
Lower
Total Cost per Case mix-adjusted treatment episode (TCC)
Priority:
Engaging Patients on Chronic Medications
Self
Reported
Health
>60% of
Meds Filled
$/Pt/Yr
Number of
Patients
(Total= 239)
Total $/Yr
OK
YES
$4,716
106
$499.9 K
NOT OK
NO
$5,388
29
$156.3 K
NOT OK
YES
$5,580
46
$256.7 K
OK
NO
$10,560
58
$612.5 K
The 25% of patients who deny their illness
and don’t take their chronic medications are the most costly.
By courtesy of R. Singal, WorldDoc Inc.
Priority: Low Health LiteracyThe Case for Understandable Reminders,
Sustained Communications Campaigns
 Low literacy is the single best predictor
of health cost.






More hospitalizations
More emergency room visits
Less screening
Later stages of disease
Lower treatment adherence
Poorer understanding of treatment
Engagement StrategiesProviders and Patients
 Report Cards/ Transparency
 Provider Performance Transparency
 Patient Characteristics Transparency
 Incentives
 Rewards and Penalties
 Providers and Patients
 Understood Actionable Reminders
 Remote (Telephone Coaches)
 Face to Face (Medical Home)
Outcomes TrackingTransparency, Incentives, Reminders
 Health
 Process Measures – Care Gap Closure
 Guideline Adherence – Providers
 Evaluation and Treatment Adherence – Patients
 Outcome Measures
 Disease Control - BP, A1C, LDL, Weight, BMI, Waist Size
 Function – SF-36, Quality of Life Scales, Presenteeism,
 Cost
Absenteeism, Turnover, Productivity
 Changes in Health Cost Trends- Actual vs. Expected
 Unit Price & Volume Trends – Facility, Professional, Drug
 Total Health Cost Savings vs. Investment (ROI)
 Disability, Lost Time from Work Trends
Provider TransparencyHospital Quality Checklist
 Accreditation
 Joint Commission
 HFAP
 Leapfrog
 “Near Miss” Reporting
 Am. Coll. Cardiology
 Nat. CV Data Registry
 Door to Balloon Alliance
 Soc. Thor. Surgeons
 ACS Nat. Surg. Qual. Imp.
Program
 AHA Get With Guidelines
 CMS Core Measures
 Health Insight
 Magnet Recognition Program
(Nursing)
 AHRQ Patient Safety Culture
Survey
 Hosp. Infection Program
 MedMined
 TheraDoc
 IHI 5 Million Lives
 Baldridge Award
 Center of Excellence
Standards
From BCBS Illinois Annual Hospital Survey/ Public Reports
Physician Prescribing
Transparency
PacifiCare Medical Group P4P
Results
20 Quality Index® profile measures,
including Leapfrog
Payment thresholds set at 75th and 85th
percentiles
Incentive pool = $18M in ’04
17 of 20 measures improved an average
of 20% between 2004-2005
Physician P4P
In United Kingdom
“Quality of Primary Care
in England with the
Introduction of Pay
for Performance.”
NEJM 2007;357: 181-190.
Employee Health Risk Transparency
(30% of Employees Participated)




Personal history of diabetes
Personal history of heart disease, stroke or diabetes
Diabetes, high blood sugar (100+ fast, 140+ nonfast)
Excess weight (BMI.25, high waist girth or % body fat)
11%
17%
29%
75%






High total cholesterol
High blood pressure
Family history of heart disease
Tobacco use (all forms)
Low aerobic exercise score (inactivity)
Inadequate fitness program
26%
41%
37%
31%
56%
88%
 High Overall coronary risk
51%
 Less than 5 fruit/vegetable servings/day
92%
Consumer Incentives - Results
INDUSTRY
CONSUMER
GOODS
$ VALUE
TYPE
$360
Premium
Discount
PROGRAM
RESULTS
$180 to complete a (HRA) biometric
screenings; $180 to stop smoking
60% of employees completed the
HRA screenings
54% declared smoke-free
ENERGY
$50
Gift Cards
TELECOM
$200
Health
Savings
Account
Deposit
Complete a Health Risk Assessment
86% of employees and spouses
completed the HRA
Multiple programs, “points-based” for
screenings, annual physical,
health coaching, fitness and online education resources
33% participated in health coaching
25% received screening and annual
physical examination
HEALTH
SYSTEM
$150
Gift Cards
“Points-based” for completing an HRA 70% completed the HRA
in Phase 1 and additional health
and wellness programs in Phase 2
(2008)
ON-LINE
RETAILER
$100
Gift Cards
Complete a Health Risk Assessment
65% of employees did the HRA
INSURANCE
$20
Gift Cards
Complete a Health Risk Assessment
93% of employees did the HRA
ENERGY
$25
Gift Cards
Complete a Health Risk Assessment
95% of employees did the HRA
UTILITY
$50
Gift Cards
Complete an HRA, lose weight
36% of employees did the HRA
14% lost 5 pounds or more
From: www.incentone.com
Success largely relates to the communication & promotion campaign.
Primary Successful StrategiesLocal Interventions
 Eliminate waste and care gaps
 Better patient safety
 Better efficiency and effectiveness
 Better medication adherence
 Engage patients in better decisions
 Culture of health at the work place
 2080 hours at the work place
 Primary and secondary prevention
 Multiple touches
 Incentives
 Value based benefit design
Case Study – Nevada
Engaging Providers in Improvement
(50,000+ employees)
 Hospitals
 Effectiveness, Efficiency, Safety,
Patient Experience, Coordination
 Physicians
 Effectiveness, Efficiency
Nevada Hospital Improvements
 Patient Safety





LeapFrog, Rapid Response Teams
Ventilator Associated Pneumonia
DVT prevention, Pneumonia vaccine
Medication Errors, Fall Prevention
Primary C-sections
 Patient Experience
 NRC Picker/ HCAHPS
 Effectiveness
 CMS Core Measures
 Diabetes, Stroke Care, Heart Care
 Efficiency/ Care Coordination
 ALOS, Opportunity Days
Identifying & Steering To Better DoctorsPublic Reporting and P4P
 Recognition
 Directory: Gold Star Program (12/2003)
 Top half among specialty peers
 Effectiveness (Guideline Adherence)
 Efficiency (ETGs)
 Newsletters, Mailings, Meetings
 Steerage
 Case Managers
 Customer Service
(Medical Home Selection)
(Steerage)
 Incentives
 P4P; Network Changes
SteerageMarket Share Changes
’03
Pts.
’04
Pts.
Change
(N)
Change
(%)
Gold
Star FP
Doctors
9054
11788
+2734
+30%
All
Doctors
109702
113680
+3978
+1%
(Estimated savings in 2 years: $69 million)
Medical Cost Increases
(per Eligible Enrolled Employee – Includes Rx)
2 year savings $69 million
$6,000
Restructured
physician
network
$5,500
$5,000
Year 2
Savings:
$43 M
Year 1
Savings:
$26 M
8%
$4,500
13%
1%
4/03
4/04
$4,000
17%
$3,500
$3,000
4/01
4/02
Fiscal Year 2001 - 2005
4/05
West Virginia
1340 Employees
Avg. Age= 44
Results from Plan Incentives
HEREIU Fund
Engaging Patients in Improvements
PROBLEM
VALUE BASED DESIGN
14.5% Annual Medical Cost Trend
Enrollment requires coaching calls
for 8 years running
Generic drug co-pays waived
Overweight:
75%
Free self-care book
High BP:
41%
Free tobacco cessation program
RESULTS
Saved $2 million first year
3 Year Annual Cost Trend <3%
(Rest of WV Cost Trends +12%)
Drug Cost Trend: Negative 9%
Use Tobacco:
31%
On site clinic
Generic fill rate: Increased 18%
Diabetes:
29%
Cost transparency
60% + Know Their Numbers
Didn't Know Their Numbers
Prescribing transparency
Average Cholesterol: 8% lower
Outpt hosp pmpm:
88% higher
Co-insurance incentives
Quit Tobacco:
6% in first year
Radiology:
85% higher
Outpatient facility
Good nutrition:
50% increase
Ofc visits:
66% higher
CT scans
Good cholesterol: 29% increase
Drugs:
48% higher
Steer to better value providers
Good exercise:
25% increase
HEALTH FUNDamentals
Next Steps
NY, Chi, Pitt, Wheeling
HEREIU Welfare Fund
16,500 Employees
 We pay you if you play
 To $200/year
 HRA, Biometrics, Tests
 Medical Home, Adherence
 Medications, Tobacco Use
 Diabetes, Hypertension,
Cholesterol, Cancer
 $550 K/year Investment
 Cash Incentives
 Waive Generic Co-pays
 Free Tobacco Quit/ Drugs
 Self Care Book
 Personal Health Records
2009 - 2011





Steering committees
Communication/ Promotion
Track Participation/ Retention
Track Program Costs
In vs. Out Comparisons
 Total Med/Pharmacy Cost
 ER/ Hosp Cost & Use
 Medication Adherence
 % Know Their Numbers
 Biometrics/ Tests – Trends
 Care Gaps
 HEDIS
Summary
• Evaluate root causes of poor performance
and outcomes.
• Implement interventions that engage both
providers and patients.
• Measure, report, and continuously improve
the clinical, financial, and satisfaction
outcomes.