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Choosing Wisely and Healthcare Resource Stewardship Council (HRSC)PGIP MeetingDecember 6, 2013

1Why stewardship? Why now?Health care expenditures are increasing at unsustainable ratesCommonwealth Fund National Scorecard on U.S. Health System Performance, 2011

There is waste in the health care systemsome say as much as 30%Jack Wennberg, Dartmouth Center for the Evaluative Clinical Sciences.

One third of all physicians acquiesce to patient requests for tests and procedureseven when they know they are not necessaryCampbell EG, et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med. 2007; 147(11):795-802

Physician decisions account for 80% of all health care expenditures Crosson FJ. Change the microenvironment. Modern Healthcare and The Commonwealth Fund [Internet]. 2009; Apr 27

From Reinhardt blog, NY Times, 12/24/2010Excess Cost Domain EstimatesIOM. The Healthcare Imperative, 2010.

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Overriding Issues in Health CareIssue of the decade starting in 2000: quality of care and patient safetyIssue of the decade starting in 2010: decreasing the cost of careRecent initiatives have called on physicians to reduce waste and exercise wise stewardship of resources.ABIM Foundation. Choosing wiselyAmerican College of Physicians. High value careAMA Council on Ethical and Judicial Affairs. Physician stewardship of health care resourcesJoint Commission & AMA. Two leading health care quality organizations hold national summit to build consensus around ways to minimize overuse of five treatments.In a paper released today by The Joint Commission and the American Medical Association-Convened Physician Consortium for Performance Improvement (PCPI), advisory panel work groups offer approaches to address the overuse of antibiotics for viral upper respiratory infections (URIs), over-transfusion of red blood cells (called appropriate blood management for purposes of the summit), tympanostomy tubes for middle ear effusion of brief duration, early-term non-medically indicated elective delivery, and elective percutaneous coronary intervention (PCI). Overuse has been described as the provision of medical interventions or treatments that provide zero or negligible benefit to patients, potentially exposing them to the risk of harm. Sometimes overlooked or neglected as a leading contributor to problems with quality and patient safety, overuse of these medical treatments and interventions affects millions of patients. Overuse also drives up health care costs, with an estimated $1 billion spent annually on unnecessary antibiotics for adults with viral upper respiratory infections alone. 7Are We Willing (and Able) to Address the Problem?

Healthcare Resource Stewardship CouncilInitially organized by BCBSM in 2011 to focus on the access to and affordability of care for Michigan citizens now and far into the futurePurpose: To engage in collaborative efforts to ensure judicious use and active stewardship of health care resources.Organizing principles:Principles and governance set by PGIP community leadersLarge scale representation from PGIP POs Integrate hospitals, patients, systems, and employer groups in future9Healthcare Resource Stewardship CouncilCurrent status: 26 PGIP POs engaged in initial planning sessionsVision and core tenets established in 2012 (see next slide)HRSC Core Group and Value Partnerships meet monthlyWorking with the Michigan Data Collaborative to establish a data reporting tool for PGIP POs to determine compliance rates with Choosing Wisely guidelines

10Organize care to put patients first while making wise choices about care and the use of healthcare resources .CORE TENETSCOMMUNICATIONACCESSADVOCACYEMPOWERMENTHRSC Vision and Core TenetsWHAT DOES SUCCESS LOOK LIKE?Movement from individual care to population managementAll partners in healthcare delivery are empowered, engaged and aligned

WHAT WILL WE ACCOMPLISH? Culture change Philosophy change Shift in accountability Measurement to support the accountabilityPayment reform to support the work and accountability

1124 by 3611HRSC and Choosing WiselyIn 2012, HRSC identified focus areas from Choosing Wisely guidelines Selected only guidelines that could be measured in BCBSM claims Of those guidelines, HRSC identified those that:Have a high impact on costAre evidence-basedAre easily amenable to change

12Choosing Wiselyis part of a multi-year effort of the ABIM Foundation to help physicians be better stewards of finite health care resources. Originally conceived and piloted by theNational Physicians Alliance through aPutting the Charter into Practicegrant, nine medical specialty organizations, along with Consumer Reports, have identified five tests or procedures commonly used in their field, whose necessity should be questioned and discussed. The resulting "Five Things Physicians and Patients Should Question" will spark discussion about the needor lack thereoffor many frequently ordered tests or treatments.

1213Choosing Wisely is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.

Consumer Reports leads consumer communication efforts for this campaign.

Choosing Wisely1313What is the Physicians Role in Choosing Wisely?The Charters commitment to a just distribution of finite resources specifically calls on physicians to be responsible for the appropriate allocation of resources and to scrupulously avoid superfluous tests and procedures.

14Choosing Wisely Partners

Societies Released Lists in April 2012 American Academy of Allergy Asthma & ImmunologyAmerican Academy of Family PhysiciansAmerican College of CardiologyAmerican College of PhysiciansAmerican College of RadiologyAmerican Gastroenterological AssociationAmerican Society of NephrologyAmerican Society of Nuclear CardiologyAmerican Society of Clinical Oncology

Societies Releasing Lists in Feb 2013 American Academy of Hospice and Palliative MedicineAmerican Academy of NeurologyAmerican Academy of OphthalmologyAmerican Academy of Otolaryngology-Head and Neck SurgeryAmerican Academy of PediatricsAmerican College of Obstetricians and GynecologistsAmerican College of RheumatologyAmerican Geriatrics SocietyAmerican Society for Clinical PathologyAmerican Society of EchocardiographyAmerican Urological AssociationSociety of Hospital MedicineSociety of Nuclear Medicine and Molecular ImagingSociety of Thoracic SurgeonsSociety of Vascular Medicine

Societies Releasing Lists in Sept 2013 AMDA Dedicated to Long Term Care Medicine - 9/4 American College of Surgeons - 9/4 Commission on Cancer a multidisciplinary program of the American College of Surgeons - 9/4 American Academy of Orthopedic Surgeons - 9/11 Society of General Internal Medicine - 9/12 American Psychiatric Association - 9/20 American Society for Radiation Oncology - 9/23 American Academy of Family Physicians** - 9/24 American College of Medical Toxicology and the American Academy of Clinical Toxicology - 9/26

Societies Releasing Lists in Oct 2013 American Association for Pediatric Ophthalmology and Strabismus - 10/8 North American Spine Society - 10/9 American College of Emergency Physicians - 10/14 American Association of Clinical Endocrinologists/The Endocrine Society - 10/16 American College of Chest Physicians/American Thoracic Society (Pulmonary) - 10/27 American College of Rheumatology* - 10/27 American Society of Dermatology - 10/29 American Society of Clinical Oncology* - 10/29 Society of Gynecologic Oncology - 10/31

Daniel: We can think of the Choosing Wisely in terms of three main components: Collaboration between the nine specialty societies and Consumers Union; Creating action around overuse and misuse of tests and procedures; and communicating widely about the effort, its goals, and what others can do to help.

Choosing Wisely Partners contd. Consumer Groups Through Partnership with Consumer ReportsAARPAlliance Health NetworksLeapfrog GroupMidwest Business Group on HealthMinnesota Health Action NetworkNational Business Coalition on HealthNational Business Group on HealthNational Center for Farmworker HealthNational Hospice and Palliative Care OrganizationNational Partnership for Women & FamiliesPacific Business Group on HealthSEIUUnion PlusWikipedia

November 2013American Headache Society - 11/21December 2013American Society of Hematology - 12/4January 2014American Association of Critical-Care Nurses/American College of Chest Physicians/American Thoracic Society/Society of Critical Care Medicine (Critical Care) - 1/11 Society for Cardiovascular Magnetic Resonance - 1/16February 2014Society for Maternal-Fetal Medicine - 2/3 Heart Rhythm Society - 2/10 American College of Occupational and Environmental Medicine - 2/24 The American Geriatrics Society* - 2/27 American Academy of Allergy, Asthma & Immunology - 2/28Release Date TBDAmerican Association of Blood Banks American Association of Neurological Surgeons American Society of Anesthesiologists American Society of Colon and Rectal Surgeons American Society of Plastic Surgeons

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How the Lists Were CreatedSocieties were free to determine the process for creating their lists Each item was within the specialtys purview and controlProcedures should be used frequently and/or carry a significant costShould be generally-accepted evidence to support each recommendationProcess should be thoroughly documented and publicly available upon request

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Dozens of 2-Page Brochures(in plain English & Spanish)

20Five guidelines account for 80% of Total Allowed CostsACR1ASNR1AAFP4ACP2AAAAI2Criteria 2 Costs associated with guidelinesBCBS HRSC Slides 2012HRSC Recommendations Bundled Focus Areas21IMAGING OF UNCOMPLICATED CONDITIONSThis particular topic has one of the biggest impacts for cost and patient overall wellbeing. I talked at length with one of our cardiologists about the issue of cardiac testing but he brought up the same radiation exposure issue brought up during our last teleconference. He noted that if we take the approach of total rads exposure for many of these issues, pts may start to demand some accountability of choosing wisely which test they are subjected to. In the cases of these three issues I bundled, headache, backache, and sinuses, the main issue comes down to defining uncomplicated. On the other hand, it may also be something where complicated is better defined. My favorite terminology in past years has been the concept of red flags that is brought up by the back folks. If we could get the neuro and sinus folks to define some additional red flags, we could at least put together some guidelines that would be a source of education to patients and doctors alike.CARDIOLOGY TESTS IN LOW-RISK INDIVIDUALSYes, EKGs are now covered by the welcome to Medicare visit but the majority of EKGs have been done, by my supposition, be done during some sort of it would be nice to know visit. We need to substantially lower expectations by patients that a normal EKG during their annual physical does anything but offer false reassurance. I have stopped calling these visits a physical because pts will typically respond to my question of what a physical is by saying: Its when you go into the doctors office and they tell you everything is ok. EKGs and stress tests are not appropriate if the pre-test probability is low enough that your post-test probability with a positive test is still going to be that the person is probably fine. (A reminder of Bayes Theorumwas also discussed with my cardiology colleague.)WOMENS HEALTHThe guidelines are out. There is NO reason we should be doing Paps on women younger than 21 NOR do Paps more often than 3 years if the pt is low-risk and HPV was negative. The Dexa falls into a similar age cutoff breakdown (in this case 65) unless other risk factors are present. This sort of educational intervention should be a no-brainer and be especially easy to convince women they are getting a test too often if they are getting Paps more often than q 3 y.

21ANALYSISLack of knowledgeTime constraints / Workflow disruptionFinancial disincentivesCost to develop and distribute materialsGOALSIncreased awarenessDecreased cost / capita

HRSC Choosing Wisely Guidelines A3BACKGROUND Unsustainable system of increased costsUnnecessary services (passive provider involvement and waste/harm)Uneducated consumerOpportunity for education of providers, patients, payers and employersCURRENT CONDITIONS

Per Capita Spending VariationsSMARTSpecificMeasurableActionableRelevantAchievableFOLLOW-UPDistribution of ToolEngagement of stakeholders

RECOMMENDATIONSTOOLS (Reports and Decision Aids)HandoutsAppSTRATEGIESEngagement with community partners (e.g. GDAC)Marketing (jingle We choose wisely together.FINANCIALIncent for wiser decisions by providers and patientsPLANWhat / Who / WhenChoosing Wisely analysis and dashboard

Choosing Wisely Reporting Tool

Ellen Bunting

23Finding the Choosing Wisely Reporting ToolPGIP Collaboration Site (must be a member of a participating PO and be registered to gain access)Choose the Analytics Tab Within Analytics choose MPACUnder MPAC Documents, click on Choosing Wisely Reporting Tool

The tool will be available as of December 6, 2013.24 Choosing Wisely WorkgroupConvened by GDAHC and MSMS in June 2013Workgroup comprised of various stakeholdersGoal to create uniform training curriculum for health care professionals and consumersTraining aligns with HRSC recommendations: Cardiology, Imaging and Womens HealthCurriculum and lead trainers are ready to test the tools and learning approach25

Gary Billotti

Choosing Wisely through the Michigan Health Information Alliance

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Choosing Wisely: http://www.choosingwisely.org/

ABIM Foundation: http://www.abimfoundation.org/

Consumer Reports Health:http://consumerhealthchoices.org/campaigns/choosing-wisely/

Ellen Bunting, Senior Business Analyst, Michigan Data Collaborativeebunting@med.umich.edu

Sheri Lee, Senior Health Care Analyst, Value Partnershipsslee2@bcbsm.com

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Chart12100130019001050550750

Cost in Billions of $$$Percentage

Sheet1Cost in Billions of $$$PercentageUnnecessary Services ($210 B)$210$0Inefficiently Delivered Services ($130 B)$130$0Excess Administrative Costs ($190 B)$190$0Excessive Pricing ($105 B)$105$0Missed Prevention Opportunities ($55 B)$55$0Fraud ($75 B)$75$0To resize chart data range, drag lower right corner of range.$765