MassTLC healthcare seminar, Patient Engagement and the Role of Technology to Improve Outcomes and Lower Costs

Dana Gelb Safran, ScDSenior Vice President Performance Measurement & Improvement

Realizing the Promise of Patient-Centered Care: What Will It Take?

Massachusetts Healthcare Technology Leadership CouncilWaltham, MA8 June 2012

2Blue Cross Blue Shield of Massachusetts

US Health Care Spending As a Percent of GDP Highest Among Economically Developed Nations

eOECD estimate. Source: Organisation for Economic Co-operation and Development. OECD Health Data 2006, from the OECD Internet subscription database updated October 10, 2006. Copyright OECD 2006, http://www.oecd.org/health/healthdata.

Total Health Expenditures as a % of GDP, U.S. and Selected Countries (2003)


US Annual Growth in % GDP Devoted to Health CareHighest Among Economically Developed NationsGrowth in Health Care Spending as a % of GDP, U.S. and Selected Countries, 1980-2003


Despite Highest Per Capita Spending in the World, US Health Lags Substantially

Per Capita Health Expenditures vs. Life Expectancy


Seeds of the Quality Imperative

2001RAND: Percent of US population receiving appropriate preventive and chronic care

IOM: Scoping the extent of medical errors and system-related harm

IOM: Six Pillars of High Quality Health Care

2000 2003


Twin Goals of Improving Quality & Outcomes While Significantly Slowing Spending Growth

MA health reform law (2006) caused a bright light to shine on the issue of unrelenting double-digit increases in health care spending growth (“Health Care Reform II).

In 2007, leaders at BCBSMA challenged the company to develop a new contract model that would improve quality and outcomes while significantly slowing the rate of growth in health care spending.

Sources: BCBSMA, Bureau of Labor Statistics

0.0%2.0%4.0%

6.0%8.0%

10.0%12.0%

14.0%16.0%18.0%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

8.2%

15.9%

13.8%

13.1%

12.1%

13.3%12.8%

BCBSMA Medical Trend

Workers’ Earnings Overall Inflation


Components of the AQC Model

Performance Incentives Financial Structure

Promotes Affordability and Efficiency

Promote Quality, Safety and

Patient-Centered Care

Providers receive upside payments for performance on a broad set of quality and patient

experience measures

Providers share risk on a health status adjusted Total Medical

Expense Budget

AQC Providers are Accountable for Quality and Cost


AMBULATORY HOSPITAL

PROCESS • Preventive screenings

• Acute care management

• Chronic care management• Depression• Diabetes• Cardiovascular disease

• Evidence-based care elements for: • Heart attack (AMI)• Heart failure (CHF)• Pneumonia• Surgical infection prevention

OUTCOME • Control of chronic conditions• Diabetes • Cardiovascular disease • Hypertension

• ***Triple weighted***

• Post-operative complications• Hospital-acquired infections• Obstetrical injury• Mortality (condition –specific)

PATIENT EXPERIENCE

• Access, Integration• Communication, Whole-person

care

• Discharge quality, Staff responsiveness

• Communication (MDs, RNs)

DEVELOPMENTAL Up to 3 measures on priority topics for which measures lacking

AQC Measure Set for Performance Incentives


AQC Improving Preventive and Chronic Care

2.3

0.5

1.2

2.7

0.91.1

3.3

1.8 1.7

3.3

2.5

1.8

0

1

2

3

4

5

Preventive Screenings

Op

tim

al C

are

Chronic Care Management

The 2009 AQC cohort continues to demonstrate success improving quality – achieving benchmarks significantly higher than non-AQC peers.

The 2010 AQC cohort made significant quality improvements in year-1 of their contract (2009 vs. 2010).

2010 AQCCohort

2009 AQC Cohort Non-AQC

1.7

1.1

2

2.5

1.7

2.1

3.6

2.6

2.2

3.9

2.7

1.9

2010 AQCCohort

Non-AQC 2009 AQCCohort

201020092007 2008 201020092007 2008 201020092007 2008201020092007 2008201020092007 2008201020092007 2008


Barriers to Adherence

Cognitive

Financial

Motivational

Logistical


Essential Attributes of Primary Care Measured by the

Ambulatory Care Experiences Survey (ACES)

14 2/7 %

14 2/7 %

14 2/7 %

14 2/7 %

14 2/7 %

14 2/7 %

14 2/7 %

InterpersonalTreatment

Access financial organizational

Continuity longitudinal visit based

Trust

Comprehensiveness knowledge of patient preventive counselingClinical Interaction

communication physical exams

PrimaryCare

Integration

Source: Safran DG et al. JGIM 2006; 21(1):13-21.


Clinical Relationship Quality Is A Leading Predictor of Outcomes

Loyalty to the practice (voluntary disenrollment)Malpractice RiskRecommending the practice

Adherence to Clinical AdviceSymptom ResolutionImproved Clinical Indicators

Business Outcomes

Health Outcomes


Patient Trust as a Predictor of Adherence: Successful Behavior Change

95th

75th

50th

25th

5th

0 20 25 30 35

32.9%

28.0%

31.7%

29.9%

24.3%

1996 Trust (percentile)

% Successful Change

Source: Safran et al. JGIM 2000; 15 (supp):116.


Patient Preference for Active Involvement in Medical Decision-Making: Effect of Patient Intervention

* p<0.001

Source: Greenfield, S., et al. Annals of Internal Medicine, 1985; 102:520-528

19.4

24.3*

19.2 18.7

0

5

10

15

20

25

30

Pre-Intervention Post-Intervention

Experimental GroupControl Group


Effect of a Patient Involvement on Clinical Outcomes: Diabetes Control

* p<0.001

Source: Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457

10.59

9.06*

10.26 10.61

0

2

4

6

8

10

12

14

Glycosylated HbA1 (%) Glycosylated HbA1 (%)

Experimental GroupControl Group

Pre-Intervention Post-Intervention


Patient Reported Outcome Measures (PROMs)

• Measures of a patient's health status or health-related quality of life

• Standardized patient reported data, collected over time in a consistent manner so results can be measured, analyzed, and used in research and care delivery.

• Provides information on key dimensions of patient functional status and well-being; inform diagnosis and treatment decisions.

• Quantifies the impact of treatments in ways that can inform clinical practice and quality measurement.

• Meaningful Use Phase II includes requirement for PROMs


Near- and Longer-Term Promise of PROMs

Patients and Families• Improved clinical interactions• Empirical basis for treatment decisions• Meaningful data on “quality” to inform choice

Clinicians/Systems• Monitor patient progress• Data to guide treatment decisions• Improved evidence-base for care• Compete on evidence of better results

Payers/Purchasers• Tools to promote focus on health and health outcomes• Improved evidence base on efficacy and basis for informed decision making• Ability to measure and improve outcomes

PROMs


Summary & Implications

♦ A payment system that has delivered unsustainable cost growth, unreliable quality, and inferior population health is giving way

♦ New models require accountability for quality, outcomes & resource use

♦ Success is impossible without patient engagement Clinical relationship quality is on the critical path What role can technology play – imagine!

♦ Patient reported outcome measures (PROMs) have the potential to revolutionize clinical encounters and value in health care The promise of PROMs cannot be realized without technology-based

solutions


[email protected]

Questions and Comments


Introducing Our Panelists

• Joshua Feast, CEO & Founder, Cogito Health• Kamal Jethwani, MD, MPH, Lead Research

Scientist, Partners Healthcare, Center for Connected Health

• David C. Judge, MD, Medical Director, Ambulatory Practice of the Future, Partners Healthcare

Health & Medicine

MassTLC healthcare seminar, Patient Engagement and the Role of Technology to Improve Outcomes and Lower Costs