Transcript Slide 1

Preventive Medicine and ACA:
Back to the Future – Or is it?
Growing & Strengthening
Preventive Medicine and Medical Quality in Multiple Contexts
Preventive Medicine 2011
Eduardo Sanchez, MD,MPH,FAAFP
Vice President and Chief Medical Officer
BlueCross and BlueShield of Texas
February 19, 2011
Disclosure
Statement
Employed as
Vice President and Chief Medical Officer
BlueCross and BlueShield of Texas,
Ancient History: 1995
• Prevention and Managed Care: Opportunities for Managed Care
Organizations, Purchasers of Health Care, and Public Health
Agencies (MMWR, 44(RR14);1-12, November 17, 1995)
• Public health agencies bring valuable skills and experience to
partnerships with MCOs and purchasers (e.g., experience with
surveillance and information systems, epidemiologic and laboratory
skills, health promotion skills, experience in developing and
implementing prioritized prevention strategies, experience in using
policy and legislation to promote the public's health, and experience in
case management and providing enabling services to promote access
to health services for vulnerable populations).
Prevention and Managed Care: Opportunities for
Managed Care Organizations, Purchasers of Health
Care, and Public Health Agencies
• Because HMOs offer the capacity to both characterize and influence the
services delivered to and the health status of enrolled populations,
these HMOs are held accountable by purchasers, consumers, and
regulators for delivering services and improving health status. This
accountability is an inherent advantage of managed care.
• Access to needed preventive services depends on more than insurance;
it also depends on provision of enabling services, such as transportation
and reduction of language barriers.
• Staff of public health agencies need more practical knowledge about
managed care and how it works.
• In a highly competitive health-care market, performance measurement
will be important to assure that the MCOs' need to contain costs does
not displace quality of care as a priority.
(MMWR, 44(RR14);1-12, November 17, 1995)
Prevention and Managed Care: Opportunities for
Managed Care Organizations, Purchasers of Health
Care, and Public Health Agencies
• The greatest potential for improving the health status of populations
results from community-based action (e.g., reduction of risk behaviors
such as tobacco use).
• Because of their clinical orientation, MCOs are more likely to be active
participants in the delivery of clinical preventive services than in the
delivery of nonclinical preventive services. However, MCOs can be
powerful partners in nonclinical preventive service areas (e.g.,
education, laws, and regulations to prevent the initiation of tobacco use
and to ensure environmental intervention for children with high bloodlead levels).
(MMWR, 44(RR14);1-12, November 17, 1995)
Prevention and Managed Care: Opportunities for
Managed Care Organizations, Purchasers of Health
Care, and Public Health Agencies
• MCOs have found that maintaining the health of their populations is an
important way to improve their cost effectiveness.
• As MCOs have become the primary provider of health care to large
segments of a community, they have become more involved with the
health of the community as a whole.
• Many preventive services, even though they may be highly cost
effective and may contribute to the quality of life, cost more to
implement than they save. Therefore, particularly in capitated systems,
additional incentives that favor investments in prevention are needed
(e.g., performance measures that are prevention oriented).
(MMWR, 44(RR14);1-12, November 17, 1995)
Prevention and Managed Care: Opportunities for
Managed Care Organizations, Purchasers of Health
Care, and Public Health Agencies
• Recommended High Priority Activities
• Work with MCOs, purchasers, and state and local health departments in key
areas of prevention effectiveness, including
• using information to determine the prevalence, incidence, and burden of
disease, and the availability, efficacy, acceptability, effectiveness, and costeffectiveness of interventions to specify highest-priority health problems for
prevention;
• assessing, through original research or review of the scientific literature,
the effectiveness and cost-effectiveness of population-based and clinical
strategies for prevention;
• and developing, disseminating, and evaluating a "Guide to Community
Preventive Health Services," science-based recommendations for choosing
and implementing community-based preventive services.
(MMWR, 44(RR14);1-12, November 17, 1995)
1998: The Changing Managed
Care-Public Health Interface
• “Changes in health care markets and regulatory
environments threaten some managed care-public
health collaborations…” related to clinical services.
• Opportunities for “new relationships to support
population-based, patient-focused health
interventions that provide health education,
information dissemination, and outreach”.
(JAMA, Vol. 280, No.20, November 25, 1998)
2000: Managed Care and Public
Health
• Two Questions
1 How can public health influence managed care by
integrating public health principles into the workings of
managed care?
2 How must public health adapt to compete [add value?]
in a managed care environment, collaborate with a
changed health care delivery system, or both?
(AJPH, Vol. 90, No. 12, December 2000)
Causes of Death, United States
2005
26.6%
Diseases of the heart
All cancers
22.8%
5.9%
Stroke
Chronic lower respiratory disease
5.3%
Unintentional injuries
4.8%
Diabetes mellitus
3.1%
Alzheimer’s disease
2.9%
Influenza and pneumonia
1.8%
Septicemia
1.4%
0%
Source: cdc.gov
9%
18%
27%
36%
The Preventable Causes of Death in the United States:
Comparative Risk Assessment of Dietary, Lifestyle,
and Metabolic Risk Factors (Danaei,2009)
Deaths attributable to individual risk (thousands) in both sexes
Our Health Care System?
“an expensive plethora of uncoordinated,
unlinked, economically segregated,
operationally limited microsystems each
performing in ways that too often lead to
suboptimal performance”
(Halvorson, 2007)
The future ain’t
what it used
to be
- Yogi Berra
The health reform debate
Access
Access: High numbers
and percentages of
uninsured
Cost: High cost of
medical care
Cost
Quality
Quality: Suboptimal
care delivery
Affordable Care Act of 2010
• No Preexisting conditions exclusions
• No lifetime limits
• Adult dependents can stay on parents health plans until age 26
• Maintains state regulation for insured business, under federal
framework of rules
• Largely maintains employer-based system
• ERISA protections maintained
• Makes far-reaching changes in health care coverage and financing
• Expands Medicaid (up to 133% FPL)
• Establishes state-based exchanges (133% - 400% FPL)
Prevention and Public Health Fund
• Expands and sustains national investment in prevention
and public health programs
• Grows from $500m to $2b annually
• Goal is to improve health and help restrain the rate of
growth in private and public sector health care costs
• Prevention, wellness, and public health activities including
prevention research
• Health screenings
• Immunization
(From Rein, Berger; CDC)
Prevention/Wellness
National strategy
Establish the National Prevention, Health Promotion and Public Health Council
to coordinate federal prevention, wellness, and public health activities.
Develop a national strategy to improve the nation’s health. (Strategy due one year
following enactment)
Create a Prevention and Public Health Fund to expand and sustain funding for
prevention and public health programs including prevention research and health
screenings, the Education and Outreach Campaign for preventive benefits, and
immunization programs. . (Initial appropriation in fiscal year 2010)
Create task forces on Preventive Services and Community Preventive Services
to develop, update, and disseminate evidenced-based recommendations on the use of
clinical and community prevention services. (Effective upon enactment)
Establish a grant program to support the delivery of evidence-based and communitybase prevention and wellness services aimed at strengthening prevention activities,
reducing chronic disease rates and addressing health disparities, especially in rural
and frontier areas. (Funds appropriated for five years beginning in FY 2010)
Kff.org
Improving Quality/Health System
Performance
National quality strategy
Develop a national quality improvement strategy that
includes:
• priorities to improve the delivery of healthcare services,
• patient health outcomes, and
• population health.
Create processes for the development of quality
measures involving input from multiple stakeholders and
for selecting quality measures to be used in reporting to
and payment under federal health programs. (National
strategy due to Congress by January 1, 2011)
Kff.org
Improving Quality/Health System
Performance
Disparities
Require enhanced collection and reporting of data on
race, ethnicity, sex, primary language, disability status,
and for underserved rural and frontier populations.
Also require collection of access and treatment data for
people with disabilities.
Require the Secretary to analyze the data to monitor
trends in disparities. (Effective two years following
enactment)
Kff.org
Work Force
Improve workforce training and development:
Establish a multi-stakeholder Workforce Advisory Committee to develop a
national workforce strategy. (Appointments made by September 30, 2010)
Increase the number of Graduate Medical Education (GME) training positions
by redistributing currently unused slots, with priorities given to primary care
and general surgery and to states with the lowest resident physician-topopulation ratios (effective July 1, 2011)
Increase workforce supply and support training of health professionals
through scholarships and loans; … establish a public health workforce
loan repayment program; provide medical residents with training in
preventive medicine and public health; promote training of a diverse
workforce; and promote cultural competence training of health care
professionals. (Effective dates vary)
Support the development of interdisciplinary mental and behavioral health
training programs (effective fiscal year 2010) and establish a training
program for oral health professionals. (Funds appropriated for six years
beginning in fiscal year 2010)
Kff.org
Challenges to ACA 2010
Obesity
Age
Demographix
Indicator 1 – Number of Older Americans
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1999, 2009
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1999
1990
2009
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
Cost of childhood obesity
The Biggest Reason Why Young
Americans Cannot Join the Military:
Physically unfit: 27 percent of young Americans
are too overweight to join the military.
Ready, Willing, And Unable To Serve (Mission: Readiness)
Projected Population
(census.gov)
2000
2010
2020
2030
2040
2050
Total Pop
282 M
309 M
336 M
364 M
392 M
420 M
White
69.4%
65.1%
61.3%
57.5%
53.7%
50.1%
Hispanic
12.6%
15.5%
17.8%
20.1%
22.3%
24.4%
Black
12.7%
13.1%
13.5%
13.9%
14.3%
14.6%
Asian
3.8%
4.6%
5.4%
6.2%
7.1%
8.0%
The Frame: Triple Aim
Coined by the Institute for Healthcare Improvement (IHI)
which believes that new designs can and must be
developed to simultaneously accomplish three critical
objectives
• Improve the health of the population;
• Enhance the patient experience of care
(including quality, access, and reliability);
and
• Reduce, or at least control, the per capita
cost of care.
ACA Alternative Payment
Legislation
Title III, Subtitle A, Part III
• Improving the Quality and Efficiency of Health Care
• Transforming the Health Care Delivery System
• Encouraging Development of New Patient Care
Models
§3022 – Medicare Shared Savings Program - ACOs
§3023 – National Pilot Program on Payment Bundling
27
Align Reimbursement & Incentives
for Desired Outcomes
Continuum of Payment Models
Episodic Cost
Fee-for-Service
Pay-forPerformance
Total Cost
Episodic
Bundling
Global
Payment
Full Risk /
% of
Premium
Variables to
consider:
• Provider
infrastructure
and appetite
for risk
• Patient
condition
• Benefit design
Provider Accountability
Patient Centered Medical
Home
Accountable Care Organization
28
Patient Centered Medical Home Model
Redesigning the Way Primary Care is Delivered and Financed
Hospital Care
Lab Services
Imaging Services
Specialist Care
Pharmacist Care
Patient




Personal Physician*
Trusted personal physician
Physician who provides, manages and facilitates care
Care is coordinated or integrated across healthcare system
More accessible practice with increased hours and easier
scheduling
 Payment mechanisms that recognize the added value
of delivering care through the PCMH model
 Assistance to practices seeking transformation
 Support to practices adopting HIT for QI
* Includes Non Physician Professionals
Accountable Care
Organizations (ACOs)
Defined as a set of providers associated with a defined set of
patients, accountable for the quality and cost of care for that
population.
The providers could include a hospital, a group of primary care
providers, specialists, and other health professionals who share
responsibility for the quality and cost of care provided to patients.
Hospitals are not a necessary part of ACOs, but seem to be taking
the lead.
An ACO is responsible for a patient wherever he or she elects to get
care.
ACO members receive a financial bonus for meeting certain
prescribed targets.
(AcademyHealth, 2009)
The future ain’t
what it used
to be
- Yogi Berra
Accountable Practice Model
Primary Care/Medical Home focus – in a POS/PPO environment
Standard practice evaluation criteria based on NCQA must pass elements
Standard set of quality metrics (primarily NCQA based)
Shared Savings model
•
•
•
•
Historical population trend performance
Year 1 Target Trend = historical 3 year average trend less trend reduction percentage
Year 2 – Year 3 Target trend – movement toward floor of general CPI
Savings only shared if quality metric performance is attained
Care coordination payment
•
Software, Outreach services, Mailers, Increased time with physician, IT support
Data sharing
Collaborative chronic condition, case and trend management
Performance measurement
Accountable Health
Organizations (AHOs)
Defined as a set of social services, health, and medical providers
associated with a defined population, accountable for the health
status and outcomes for that population.
The providers could include a local health department, health plans,
employers, primary care providers, specialists, and other health
professionals who share responsibility for the quality and cost of care
provided to patients in addition to the health of all.
Local health departments and health plans (public and private)
should be taking the lead.
Preventive medicine physicians are uniquely qualified to lead and
manage AHOs.
AHOs are rewarded for optimizing health.
(adapted from AcademyHealth, 2009)
Metabolic Syndrome Program
Down Under
• 10 Australian Aborigines
– Overweight
– With diabetes
– Living a western lifestyle
• Returned to traditional homeland for seven weeks
– Average weight loss of 18 pounds
– Blood pressure reduction
– Normal triglycerides
34
Diabetes Prevention Program (DPP)
Placebo
Metformin
Lifestyle
11.0%
7.8%
4.8%
Reduction in incidence
compared with placebo
–
31%
58%
Number needed to treat
to prevent 1 case in 3 years
–
13.9
6.9
Incidence of diabetes
(percent per year)
The DPP Research Group, NEJM 346:393-403, 2002
35
5 Healthy behaviors to lower
cardiovascular risk
physical activity,
not smoking,
higher healthy eating index,
moderate alcohol intake (1-2 drinks per week), and
maintaining weight or trying to lose weight in the past 12
months.
DMN, 11/30/2010, AHA scientific conferences
The Community Guide Obesity
Interventions in Community Settings
• Interventions to Reduce Screen Time
• Behavioral interventions to reduce screen time R
• Mass Media interventions to reduce screen time I
• Technology-supported interventions (computer/web applications)
• Multi-component counseling/coaching to effect weight loss R
• Multi-component counseling/coaching to effect weight loss R
Interventions in Specific Settings
• Worksite programs to control overweight and obesity
• Worksite programs to control overweight and obesity
R
I
(AHRQ)
Opportunities
Evidenced-based health
• The Community Guide
AHO – Accountable Health Organizations
• Be at the table
Health plans
• CMO, CEO, wellness and disease management
Conversion foundations
Opportunity in the business community
• Business groups on health
• Large employers
Fast forward: 2011
Prevention and ACOs:
Preventive medicine physicians can bring valuable skills and
experience to ACOs (e.g., experience with surveillance and
information systems, epidemiologic and laboratory skills, health
promotion skills; experience in developing and implementing
prioritized prevention strategies; experience in using policy and
legislation to promote the public's health, and experience providing
enabling services to promote access to and utilization of health
services for vulnerable populations).
Prevention and ACOs
Because health plans offer the capacity to both characterize and
influence the services delivered to and the health status of enrolled
populations, health plans should continue to be held accountable by
purchasers, consumers, and regulators for delivering services and
improving health status.
Access to needed preventive services depends on more than
insurance; it also depends on a system of care that enables
utilization.
Preventive medicine needs more practical knowledge about how the
health plan world works.
In a highly competitive health-care market, performance
measurement should include health outcomes and keep quality of
care ahead of cost containment .
Prevention and ACOs
The greatest potential for improving the health status of populations
results from community-based action (e.g., reduction of risk
behaviors such as tobacco use and sedentary living).
Because of their clinical orientation, health plans are more likely to be
active participants in the delivery of clinical preventive services than
in the delivery of nonclinical preventive services. However, they can
be powerful partners in nonclinical preventive service areas (e.g.,
education, laws, and regulations to prevent the initiation of tobacco
use and to ensure environmental intervention for children with high
blood-lead levels).
Prevention and ACOs
Health plans have found that maintaining the health of their
populations is an important way to improve their cost effectiveness.
As health plans become the primary provider of health care to large
segments of a community, they should be more involved with the
health of the community as a whole.
Many preventive services, even though they may be highly cost
effective and may contribute to the quality of life, cost more to
implement than they save. Therefore, particularly in capitated
systems, additional incentives that favor investments in prevention
are needed (e.g., performance measures that are prevention or
workplace oriented).
Prevention and ACOs
Recommended High Priority Activities
Work with health plans, purchasers, and state and local health departments
in key areas of health promotion and prevention effectiveness, including
• using information to determine the prevalence, incidence, and burden of
disease, and the availability, efficacy, acceptability, effectiveness, and
cost-effectiveness of interventions to specify highest-priority health
problems for prevention;
• assessing, through original research or review of the scientific literature,
the effectiveness and cost-effectiveness of population-based and clinical
strategies for prevention;
• and developing, disseminating, and evaluating a "Guide to Community
Preventive Health Services," science-based recommendations for
choosing and implementing community-based preventive services.
Concluding remarks