Physician and Society PatientPhysician Population Family Health Care Structure/Financing Scientific Paradigm (EBM) Other Care Providers Integrative Medicine

Physician and SocietyPhysician and Society

Patient Physician

Population

Family

Health Care Structure/Financing

Scientific Paradigm (EBM)

Other Care Providers

Integrative Medicine

Culture

Culture of Biomedicine

Care Recipients Care Providers

CARE

Ethics LawEnd-of-Life Information Age

Community

Physician and Society

1. Patients, Providers, and Quality

2. Models of Medical Care

3. Chronically Ill, Poor, and Uninsured

4. Use of Informatics in Health Care

5. Public Health Ethics


Organizational Strategies Series


Disease Management

of Chronic Illness


What is “Disease Management”?• Packaging of familiar and longstanding

clinical concepts centered around a condition

• Systematic, population-based approach to identify patients at risk, intervene with specific therapeutic programs, and measure clinical outcomes of interest


Proactive Chronic Care (Disease Management) Model

Case Finding

Assessment

Management



Case Finding

Assessment

Management


Identifying High-Risk Patients

• Recognition by clinicians



• Claims data



• Surveys



Case Finding

Assessment

Management


Assessment of High-Risk Patients

• Performed by trained CM

• Straightforward vs multidimensional needs

• Medical and non-medical factors



Case Finding

Assessment

Management


Management of High-Risk Patients

• Case management

• Primary care referral

• Specialty care

• Team care

• Pharmacy

• Home care


The Challenge of Chronic Diseases—the Chronic Care Model

Ed Wagner MD, MPHMacColl Institute for Healthcare Innovation

Group Health Cooperative

Improving Chronic Illness Care,a national program of The Robert Wood Johnson Foundation


State of the Art in Chronic Illness Care Improvement

• Major clinical advances in most major chronic illnesses

• Growing appreciation that the patient’s (and family’s) self-management skill heavily influences outcomes

• But, patients not reaping benefits of new knowledge


Current status of Chronic Illness Care in the U.S.

• 27% of hypertensives are adequately treated• 29% and 26% of diabetics have well controlled

lipid and blood pressure levels, respectively• 35% of eligible patients with atrial fibrillation

receive anticoagulation• 25% of people with depression are receiving

adequate treatment• 50 % of discharged CHF patients are

readmitted within 90 days


Why are we doing so poorly?

The IOM Quality Chasm report says:

• “The current care systems cannot do the job.”

• “Trying harder will not work.”


Usual Chronic Illness Care• Oriented to acute illness

• Focus on symptoms and lab results

• Patient’s role in management not emphasized

• Care dependent on provider’s memory and time

• Interaction often not productive, and frustrating for both patient and doctor


What Will Improve Chronic Illness Care?

The IOM Quality Chasm report says:

• “Changing care systems will.”


The Goal of System Changes to Improve Chronic Illness Care

PatientProductiveInteractions

Practice Team

a planned set of interactions

over time during which the critical clinicaland behavioral elements of care are performed reliably


What characterizes an “informed, activated patient”?

Informed,ActivatedPatient

They have the motivation, information, skills, and confidence necessary to

effectively make decisions about their health and manage it


What characterizes a “prepared” practice team?

PreparedPractice Team

At the time of encounters, they have the patient information, clinical expertise, team,

equipment, and time required to deliver evidence-based clinical management and

self-management support


Randomized trials of system change interventions: Diabetes

Cochrane Collaborative Review• 41 studies, majority randomized trials

• Interventions classified as provider-oriented, organizational, information systems, or patient-oriented

• Patient outcomes (e.g., HbA1c, BP, LDL) only improved if patient-oriented interventions included

• All 5 studies with interventions in all four domains had positive impacts on patients

Renders et al. Diabetes Care 2001;24:1821


Randomized trials of system change interventions: Heart failure

• 11 randomized trials• Most reduced hospitalization significantly• Most successful employed a nurse case

manager working with cardiology and primary care

• Care guided by protocol and strong emphasis on self-management support

• 7/8 examining costs found cost savings

McAlister et al, Am J Med 2001


Does improved chronic care reduce health care costs?

• 28 randomized trials studied interventions related to the chronic care model and examined costs (diabetes, CHF, asthma)

• 17 showed either cost savings or utilization decreases

Bodenheimer et al. JAMA 2002;288:1909


Interventions Supportive of Productive Interactions

• Provider-oriented

• Patient-oriented

• Practice-orientedInformation Systems


The Goals of System Change Interventions to Improve Practice

• Provider-oriented—enable practice team to deliver evidence-based care to EVERY patient

• Patient-oriented—develop informed, activated patients who are competent self-managers

• Practice-oriented—design practice teams, patient encounters, and data systems that enable productive interactions


Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Self-management Support

Provide effective self-management interventions

and ongoing collaborative goal-setting and

problem-solving by the team.


Self-management Support

What is self-management?

“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.”

Barlow et al, person Educ Couns 2002;48:177


Effective self-management Support

• patient major role in managing her illnesses and treatment emphasized

• her knowledge, behaviors and confidence routinely assessed

• goals for improving self-management set collaboratively with practice team

• advice based on evidence and presented as information not scolding


Effects of Self-management Education on Glycemic Control

• 31 RCTs evaluated effects on HbA1c• Average 6 contacts and 9 contact hours• Most often delivered by nurse-dietician-physician

team• 2/3 in groups• Reduction in HbA1c increased with contact time

(1% for every added 24 hours of contact)• Effect diminished shortly after end of class

Norris et al, Diabetes Care 2002; 25:1159


Delivery System Design

• Practice team has defined roles, uses

planned visits and clinical case

management to support evidence-based

care, and assures regular follow-up and

care coordination


Nurse Case Management RCT-Aubert et al.Change in Treatment and Glycemic Control

Between Baseline and 12 Months

-2.0%

-1.5%

-1.0%

-0.5%

0.0%

0.5%

1.0%

Change in HbA1c Change in % onInsulin

InterventionControl

Diabetes Cluster Visits, Sadur et al Change in Treatment and Glycemic Control Between

Baseline and 12 Months

-1.4%

-1.2%

-1.0%

-0.8%

-0.6%

-0.4%

-0.2%

0.0%

Change in HbA1c

InterventionControl

Decision Support

• Weave evidence-based guidelines into

fabric of practice: e.g., reminder and fail-

safe systems (e.g., standing orders),

specialist involvement with primary care,

problem-based learning


Clinical Information System: Registry

• A database of clinically useful and timely

information on all patients provides

reminders and feedback and facilitates

care planning for individuals or

populations


Health Care Organization

• Organization encourages and supports

better care through leadership, quality

improvement& incentives


Community Resources and Policies

• Health care organization has linkages with

community organizations that can enhance

practice capabilities, provide key patient

services, or improve care coordination


Examples of Community Linkages

• Exercise programs in local Y or gym

• Peer support programs

• Hospital nurse educator loaned to practice

• Endocrine practice nurse loaned


The Quality ChasmUsual Care versus Improved Care

• Readmission rates of patients hospitalized with CHF reduced by about 50%

• Recovery rates from major depression increased 50-100%

• Children with moderately severe asthma have symptoms 14 fewer days/year

• Anticoagulated patients in safe and effective range twice as frequently


Differences between Organized Programs and Usual Care of Chronic

Illness• Average HbA1c of type II diabetics will be 1%

+ lower• 1.5 - 2 times as many patients with major

depression will be recovered at six months• Readmission rates of patients hospitalized with

CHF will be cut in half• Asthmatic kids will be in school two more

weeks a year


8.35

9.19

8.108.54

6

7

8

9

10

A-9

9

J-99

O-9

9

J-00

A-0

0

J-00

O-0

0

J-01

A-0

1

J-01

O-0

1

J-02

A-0

2

J-02

O-0

2

J-03

A-0

3

J-03

O-0

3

J-04

Reporting Month

DC1_Avg DC2_Avg

Goal

BPHC Diabetes Collaboratives 1and 2involving 180 Community Health Centers

and 38,000 diabetic persons

Average HbA1c Values


How do you provide

care for those who

can’t afford it?



Structure and

Financing of Care for

the Poor and Uninsured

in America



Medicaid


• Federal/state health insurance program

• For low-income persons

• 51 million enrollees in 2002

• 2002 Medicaid expenses: $259 billion

• 2002 Medicare expenses: $257 billion


Medicaid – Medicare Similarities


• Both enacted in 1965

• Both are entitlement programs

• Both are overseen by CMS

Medicaid – Medicare Differences

• Champion

– Medicare: President Johnson

– Medicaid: Congress (Wilbur Mills, D-Ark)

• Financing

– Medicare: purely federal

– Medicaid: joint federal/state



• Beneficiaries

– Medicare: Virtually all elderly

– Medicaid: All ages

• Covered Benefits

– Medicare: set by feds, same for all enrollees

– Medicaid: set by states, different by states



• Enrollment Criteria

– Medicare: age and/or disability only; set by feds

– Medicaid: financial and other health and social criteria; set by individual states



Medicaid Financing



S.S. Taxes

CMS Individual Providers

Medicare + Choice Plans

$$

$$

Medicare


S.S. Taxes

CMSHealth Care

Providers

$148 billion

$259 billion

Medicaid (2002)

State Taxes

State Medical

Assistance Programs

Physician and Society Medicaid Expenses

Physician and Society Medicaid Beneficiaries


Medicaid Expenses


• Disproportionately to disabled

• Disproportionately to elderly

• Disproportionately to long term care


Selection of Medicaid Beneficiaries


• Each state sets own criteria

• Based on financial need and eligibility


Selection of Medicaid Beneficiaries


• Each state sets own financial criteria for:

– Families with dependent children on welfare

– Families with parent getting off of welfare

• Feds establish mandatory eligibility groups:

– Low-income pregnant women

– Low-income children

– Low-income elderly or disabled persons


MN MA Eligibility


Medicaid Covered Benefits


• Benefits package much more extensive than for private insurance

• Cost sharing by patients largely prohibited

• Restricting coverage to certain groups prohibited

• Caps for certain diagnoses prohibited


Challenges to States


• Budgetary problems

• Growth of Medicaid – projected to grow faster than national health expenditures

• Federally imposed eligibility criteria and restrictions on patient spending

• Federally imposed partial benefits package

• Matching federal funds


State Medicaid Fiscal Strategies


• Managed care (now 100% of MA enrollees)

• Controlling drug costs

• Decreasing physician payment rates

• Restricting eligibility (mostly financial criteria)

• Reducing benefits

• Increasing copays


S.S. Taxes

CMSMedicaid

Managed Care Plans

$148 billion

$259 billion

Medicaid (2002)

State Taxes

State Medical

Assistance Programs


The Uninsured


• Who are they?

• How do costs inhibit care?

• Where do they get care?

• How healthy are they?







The Uninsured in

Minnesota




How do we do it?


• Employer-provided commercial insurance

• Medicaid (Medical Assistance)

• MinnesotaCare

• General Assistance Medical Care (GAMC)


MinnesotaCare


• 1988 -- Children’s Health Insurance Program (CHIP)

• 1992 – MinnesotaCare enacted; CHIP folded into it shortly thereafter

• Provides insurance for low income persons who do not have access

– Not on Medicaid (Medical Assistance)

– Not on commercial insurance


MinnesotaCare


• Covers families with children with incomes up to 275% of federal poverty guidelines

• Covers individuals/families without children up to 175% of FPG

Family Size FPG MNCare Elig.

2 $12,120 $33,000

4 $18,400 $50,000


MinnesotaCare Financing


• State dollars

• 1.5% tax on hospitals and health care providers

• Federal funds

• Enrollee premiums, copays, deductibles

– Average premium is $18/month

– $3 copay per Rx, $25 per pair of glasses

– $1,000 inpatient deductible


General Assistance Medical Care

(GAMC)


• Covers low-income persons who do not qualify for other state or federal insurance programs

– Primarily adults without dependent children

• 100% state funded

69%

13%

9%

5%3%1%

Private Insurance

Medicare

Medical Assistance

General Assistance

MinnesotaCare

No Insurance

Physician and Society Health Care Coverage in Minnesota

Documents

Physician and Society PatientPhysician Population Family Health Care Structure/Financing Scientific Paradigm (EBM) Other Care Providers Integrative Medicine