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Transcript of Applying Evidence-based Medicine and Best Practices to Improve Healthcare Outcomes and Control Costs...
Applying Evidence-based Medicine and Best Practicesto Improve Healthcare Outcomes and Control Costs
July 17, 2005
Presented by:
Reed V. Tuckson, M.D.SVP Consumer Health and Medical Care Advancement
We’re All In This Together
• It’s not about who pays
– Private Employers
– Individuals
– Federal Government
– State Government
• It is about making healthcare work better
“The system falls short in translating knowledge into practice and applying technology safely in a manner that decreases waste.”
Institute of Medicine
• 45% didn’t receive recommended treatment
• 11% received care that wasn’t recommended or was harmful
• 35% of hypertensives not diagnosed or correctly treated
• 55% of diabetics not adequately monitored for glucose control
Suboptimal Healthcare Delivery
30% of direct health care costs result from poor quality Poor quality care costs approximately $2,000 per covered employee year
Overuse of Antibiotics
35-60% of antibiotics are prescribed inappropriately
$ Billions Total Use
AppropriateUse
Suboptimal Care: Overuse of Interventions
$0
$2
$4
$6
$8 Over $2.5 Billion potential savings
Under Use of Antihypertensives
Medical cost per person to treat MI, Unstable Angina, Stroke avg $10,500 leads to potential cost of approx $15B
Total
Diagnosed
0
10
20
30
40
50
60 30% of people with hypertension are
undiagnosed
Suboptimal Care: Under Use of Interventions
Inappropriate Use of Cox-2s
Optimally the population at risk for bleeding should use Cox-2s
$ BillionsTotal NSAID & Cox-2
AppropriateUse of Cox-2
0
2
4
6
8
10$ 6 Billion potential
savings
48,000 to 98,000 preventable medical errors
Suboptimal Care: Misuse of Interventions
1. New Knowledge, Drugs and Technology
Dual Chamber
ICDSignificant New Challenges Lie Ahead
2. Consumptive Society: Everybody Wants Everything
• Pharma marketing expenditures increased
14.1% annually since 1999
• DTC $4B in 2004
Patient’s requests for clinical services are persuasive and influential: successful 45% of time
Significant New Challenges Lie Ahead
Significant New Challenges Lie Ahead
3. New Public Health Threats
O B E S I T Y
Significant New Challenges Lie Ahead
4. Aging and Chronic Disease
• Fragmented Care Delivery System
• People with 5 or more chronic
conditions account for 2/3 of medical care costs
Best Data and Information Infrastructures
Best Evidence for Clinical Practice and Medical Decisions
Best Clinical Expertise for Product and Policy Development
Discounted, Broad and Deep Networks of Hospitals and Physicians
Integrated Care Management Teams
Improve Physician and Hospital Performance
Facilitate Access to Best Hospitals and Physicians
Improve Coordination of Care
Performance Evaluation and Elimination of Variation
Effective Cost Management and Purchasing
Inform Patient Decision-Making
Consumer Decision Support Infrastructures
Improving Quality, Accessibility, Usability, and Affordability, that Meet the Needs of Consumers/Patients and Private/Public Purchasers
Interconnected Chain of Tools and Supports: Right Care to the Right Person at the Right Time From the Right
Professional and the Right Facility
Best Data and Information Infrastructures
Best Evidence for Clinical Practice and Medical Decisions
Best Clinical Expertise for Product and Policy Development
Discounted, Broad and Deep Networks of Hospitals and Physicians
Integrated Care Management Teams
Improve Physician and Hospital Performance
Facilitate Access to Best Hospitals and Physicians
Improve Coordination of Care
Performance Evaluation and Elimination of Variation
Effective Cost Management and Purchasing
Inform Patient Decision-Making
Consumer Decision Support Infrastructures
Applying Best Evidence and Expertise to Improve Physician and Hospital Performance
Supported by UnitedHealth Foundation
Advocacy for Clinical
Evidence
Evidence-based Medicine: “…the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Sackett,et al
The Keys to Making a Difference
• 635K physician user sites• 59% user penetration• 287M transaction run rate
Best Data and Information Infrastructures
Best Evidence for Clinical Practice and Medical Decisions
Best Clinical Expertise for Product and Policy Development
Discounted, Broad and Deep Networks of Hospitals and Physicians
Integrated Care Management Teams
Improve Physician and Hospital Performance
Facilitate Access to Best Hospitals and Physicians
Improve Coordination of Care
Performance Evaluation and Elimination of Variation
Effective Cost Management and Purchasing
Inform Patient Decision-Making
Consumer Decision Support Infrastructures
Applying Data and Information Infrastructures
to Assess and Improve Quality and Cost Effective Care
Medical Claims Pharmacy Personal Health Risk Assessment
Data Warehoused and Aggregated into Clinically Relevant Groups (280 discrete ETG’s)
Laboratory
Sophisticated Analytics
Risk Adjusters
Evidence-based
Guidelines
Other Databases
(NCDR, STS, MEDPAR)
Administrativeand Costs
AssessQuality
and
Use of Resources
The Keys to Making a Difference
Network Differentiation to Meet the Needs of the Individual
National Network
Premium Performance
Primary Care Physicians
Musculoskeletal Care
Cardiac Care
Cancer Care
Hospital-based Specialists
Ambulatory Specialists
such as Diabetes,
Respiratory, Neurology,
KidneyCongenital
Heart Surgery
Transplantation
Radiology Services
90 days Pre-event 360 Days Post-event
“Anchor” Cardiac Procedure Performed
Analyze all of the tests, interventions, complications and outcomes that occurred
after the procedure
Longitudinal tracking of total episode of care risk-adjusted data
Analyze all of the diagnostic tests used
before the intervention
RestudiesInitial Diagnostic Studies
Example: Assessing the Quality and Efficiency of Cardiac Care to Identify Best Performers and Most Efficient Care Delivery Settings
Rework
40
37
55
17
9
23
-150.00%
-100.00%
-50.00%
0.00%
50.00%
100.00%
150.00%$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000 $20,000
Ov
era
ll C
om
pli
ca
tio
n R
ate
Co
mp
are
d t
o E
xp
ec
ted
Complication Rate vs. Cost Per Admission for a Percutaneous Cardiovascular Procedure Over 12 Months
Expensive &poorer quality
Less expensive &lesser quality
Less expensive &better quality
Expensive &better quality
Differentiation by Quality and EfficiencyFacilitates Patient Choice, Physician Referral, Network
Contracting, and Continuous Quality Improvement
The Complete Picture: Hospital-based Physician Quality Plus Hospital Efficiency Analysis
Overall Complication Rate by Physician vs. Hospital Cost/Admission
13
21
14
1314
35
9085 79
59
43
26
-5.00%
0.00%
5.00%
10.00%
15.00%
20.00%
$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000
Cost Per Admit
Co
mp
lic
atio
n R
ate
(# C
om
pli
cat
ion
s/C
ases
)
COSTS
Best Data and Information Infrastructures
Best Evidence for Clinical Practice and Medical Decisions
Best Clinical Expertise for Product and Policy Development
Discounted, Broad and Deep Networks of Hospitals and Physicians
Integrated Care Management Teams
Improve Physician and Hospital Performance
Facilitate Access to Best Hospitals and Physicians
Improve Coordination of Care
Performance Evaluation and Elimination of Variation
Effective Cost Management and Purchasing
Inform Patient Decision-Making
Consumer Decision Support Infrastructures
Coordinating Care Across Diseases and Care Settings: Right Care to the Right Person at the Right Time From the Right
Professional and the Right Facility
Care Coordination Nurse
The Keys to Making a Difference: Combining Data and Decision Support/Care Coordination
Clinical Information Systems Facilitate Efficient andSeamless Coordinated Comprehensive Health Teams
CareOne
Coordinating Care for the Vulnerable Elderly
Care Management Model
evidence-based
Individual
Comprehensive
Care PlanCare One
Behavioral
Medical
Social
ADL
Home and CommunityBased Services
• Home Health• Meals• Attendant Care• Rehabilitation Services• Transportation
Out Patient Care
• Physician Services• Behavioral Health• Urgent/Emergency Services
In Patient Care
• Acute Hospital Care• Long Term Care• Hospice
COORDINATIONC
are
coor
dina
tion
and
on-s
ite
mon
itorin
g
Integrating Medicaid and Medicare to Meet Individual Needs
• Integration of medical, behavioral, and long term care
• Coordination of funding
• Individual care plan
• Constant monitoring and evaluation of care plan status
• Incentives for quality and focus on prevention
• Increase community services and providers
• Consumer direction and involvement
• Rely on aging network and community partnerships
• Strong state oversight and high standards for organizations (quality, financial, clinical)
Medicaid OnlyCovered
MedicareCovered
Adult Day HealthCare
Attendant Care /Personal Care
Home Meals
Nursing Home
Non-Emergent /Urgent
TransportOutpatient Services
Urgent/EmergencyServices
Hospice
Physician Services
Acute CareHospital
Post-Acute / Rehab
DME / Supplies
Home Health
Home Mods
Assisted Living
Behavioral Health
Pharmacy
Care One
+
• Flexibility in Medicaid & MedicareProgram Requirements
• State Flexibility in SupportingHome and Community-based Care
• Incentives for Cost EffectiveQuality Care Organization
• Financial Support for CareManagement
MostRestrictive
LeastRestrictive
AssistedLiving/
ResidentialCare
AdultFosterCare
Home
AdultCare
HomeHome or
Apartment
SpecialtyUnit
within a NursingFacility
SkilledNursingFacility
Hospital Setting
The bottom line has been significant savings to State Government budgets.
• Arizona reduced the percentage of its Medicaid long-term care population living in nursing homes from 95% to 40%.
• For every person Florida’s Medicaid diversion program maintains in a community setting, the State saves roughly $10,000-$15,000 each year.
• Expansion of the program recently approved.
• Implementation of the STAR+PLUS program in one county in Texas saved approximately $123 million over two years.
• Statewide expansion recently approved.
The Model Works: Proven Results
Best Data and Information Infrastructures
Best Evidence for Clinical Practice and Medical Decisions
Best Clinical Expertise for Product and Policy Development
Discounted, Broad and Deep Networks of Hospitals and Physicians
Integrated Care Management Teams
Improve Physician and Hospital Performance
Facilitate Access to Best Hospitals and Physicians
Improve Coordination of Care
Performance Evaluation and Elimination of Variation
Effective Cost Management and Purchasing
Inform Patient Decision-Making
Consumer Decision Support Infrastructures
Supporting the “Activated” Patient: Helping People Make the Right Choices
• Influence their own health• Participate in the selection and delivery of health services• Maximize value • Share the consequences of their choices and actions
Activating the Individual to Take Informed Action
Benefit, TransactionCapabilities
(How much do I have in my PBA or FSA?)
Evidence-basedCondition/Procedure
Management(What do I have/need?
What are my alternatives?)
Facility Selection(Which hospital hasthe best quality for
my condition?)
Physician Selection(Who’s performanceis best to treat me?)
Cost Estimation Tools
(What are my alternatives likely to cost?)
Health Risk Assessment
(What am I at risk for?How can I intervene early?)
Integrating Data and Information to Support Consumer and Patient Decisions
Facilitation of besthealth care decisions
Data and Technology Infrastructures:Helping People Make Better Decisions
Eligibility and payment cards are merging into one card that will include access to a pre-populated
“Personal Health Record”
“Activating” Behavior Through Timely and Relevant Outreach
The right information at the right time saves money and improves therapeutic compliance
Explanation of Benefits StatementExplanation of Benefits Statement
Multiple touch points reinforce “activation” campaign messages
“Activating” Behavior Through Timely and Relevant Outreach
Integrating All “Touch-points” to Maximize Appropriate Choices for “Influenceable” Events
Employers
Employer-Provided InformationNurselineNurseline
Health RiskAssessment
High Risk Patients
Health RiskAssessment
High Risk Patients
DecisionSupport
By Phone
DecisionSupport
By Phone
Member ServicesMember Services
Care Coordination
Care Coordination
Physician PortalPhysician Portal
ClinicalOperations
ClinicalOperations
UnitedHealthcare
Education & Steerage
Welcome Kit
Mailings and Call-outs
Premium NetworkSM InfoCardiac Care Clinical
Content E-mails to users
“Health Coach” Inbound Calls
Mailings
Premium NetworkSM InfoTargeted
Communications
THE KEY: Getting the right person, the right care, at the right time, from the right place, from the right health professional!
“Best”Physicians
Premium
Hospital
HealthiestBehavior
Consumers/Patients
THERESULT
The Results of Our Strategy and Execution Are Clear
Best Data and Information Infrastructures
Best Evidence for Clinical Practice and Medical Decisions
Best Clinical Expertise for Product and Policy Development
Discounted, Broad and Deep Networks of Hospitals and Physicians
Integrated Care Management Teams
Improve Physician and Hospital Performance
Facilitate Access to Best Hospitals and Physicians
Improve Coordination of Care Performance Evaluation and Elimination of Variation
Effective Cost Management and Purchasing
Industry Leading Medical Cost Control and Improved Quality Outcomes:
• Medical Trend of 8% for commercially insured services
• Pharmacy Trend of 4% for 2004
Inform Patient Decision-Making
Consumer Decision Support Infrastructures