Health Plan Strategies to Improve Public Health
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Transcript of Health Plan Strategies to Improve Public Health
Health Plan Strategies to Improve Public Health
CDC Heart Disease and Stroke Prevention Annual MeetingSeptember 15, 2009
Lisa M. Latts, MD, MSPH, FACPVP, Programs in Clinical Excellence
Slide 2
Agenda
• Introduction to WellPoint
• Challenges to Improving Health
• Member Health Index
• State Health Index
• Health Disparities
• Local/National Partnerships to Improve Health
• Physician Partnerships to Improve Cardiovascular Health
• Childhood Obesity – A Case Study
Slide 3
Blue Cross or Blue Cross Blue Shield
UniCare >100K members
34 Million Members Across the United States,34 Million Members Across the United States,1 in every 9 Americans covered by WellPoint Plans1 in every 9 Americans covered by WellPoint Plans
WellPoint, Inc.
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The State of U.S. Population Health
Obesity
PhysicalActivity
Smoking
Stress
66% obese or overweight
28% inactive
23% smokers
36% high stress
Key Drivers of Health Status
Aging 22% > 55 years, aging population
Driver Prevalence
Population health status continues to deteriorate
Schroeder S. N Engl J Med 2007;357:1221-1228
Proportional Contribution to Premature Death
Genetic predisposition
30%
Social circumstances
15%
Environmental exposure
5%
Health care10%
Behavioral patterns
40%
Slide 5
Prevalence of Chronic Illnesses
More than 130 million Americans suffer from chronic conditions
100
105
110
115
120
125
130
135
140
145
1995 2000 2005 2010
42
43
44
45
46
47
48
Chronic Conditions % of Population
Po
pu
lati
on
in
Mil
lio
ns
% o
f P
op
ula
tio
n
Chronic Condition
Prevalence in America
Annual Cost
Diabetes 16 million
• $105 billion in health expenses
• 11 million lost work days
Heart Disease 60 million
• $300 billion in health expenses
• 1 million deaths
Asthma 14 million
• $5.1 billion in medical expenses
• 2.1 million missed work days
Depression 17 million • $43 billion
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Patients do not receive care in
accordance with best practices
Patients receive care in
accordance with best practices
45% 55%64.7% Hypertension
63.9% Congestive Heart Failure
53.9% Colorectal Cancer
53.5% Asthma
45.4% Diabetes
39.0% Pneumonia
22.8% Hip Fracture
% of Recommended Care Received
Source: Elizabeth McGlynn et al, RAND, 2003
Nearly one-half of physician care not based on established best practices
Inconsistent Quality in Care Delivery
Slide 7
1
10
100
1,000
10,000
100,000
1,000,000
Defectsper
million
level (% defects)
U.S. IndustryBest-in-Class
Anesthesia-relatedfatality rate
Airline baggage handling
Outpatient ABX for colds
Post-MIb-blockers
Breast cancerscreening (65-69)
Detection &treatment ofdepression
Adverse drugevents
Hospital acquired infections
Hospitalized patientsinjured through negligence
1(69%)
2(31%)
3(7%)
4(.6%)
5(.002%)
6(.00003%)
Source: modified from C. Buck, GE
Overall Health Care in U.S. (RAND)
Health Care Quality Defects Occur at Alarming Rates
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Measuring Health Improvement:WellPoint Health Indices
MissionMission Health Health IndicesIndices
DomainsDomains
Maternity and Prenatal CareMaternity and Prenatal Care
LifestyleLifestyle
Mortality and MorbidityMortality and Morbidity
Clinical OutcomesClinical Outcomes
Care ManagementCare Management
Patient SafetyPatient Safety
Preventive CarePreventive Care
Prevention and ScreeningPrevention and Screening
Member Health Index
Member Health Index
State Health Index
State Health Index
Improve the lives of the people we
serveand
the health of our
communities
Improve the lives of the people we
serveand
the health of our
communities
Slide 9
WellPoint Member Health Index: Improving Population Health
Screening and PreventionScreening and Prevention
• Diabetes ER visits
• Congestive heart failure ER visits
• Asthma ER visits
• Select hospital admissions
• Select 30-day readmissions
• Diabetes compliance
• Hypertension compliance
• Behavioral health follow-up
• Controller medications for asthma
• Appropriate treatment for upper respiratory infection
• Participation in disease management programs
Patient SafetyPatient SafetyClinical OutcomesClinical Outcomes
Care ManagementCare Management
• Breast cancer screening
• Cervical cancer screening
• Colorectal cancer screening
• High cholesterol screening
• Childhood immunizations
• Patient safety hospital structural index
• Patient safety outcome index
• Persistent medication monitoring
4 Domains of health care services covering 20 Clinical Areas; comprised of 40 Measures4 Domains of health care services covering 20 Clinical Areas; comprised of 40 Measures
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Screening and Prevention: Why these measures?
• Preventive screenings decrease cancer and heart disease mortality
• Early diagnosis of breast, cervical and colorectal cancer significantly decrease treatment costs
• Timely colorectal cancer screening can prevent colorectal cancer
• High cholesterol is major risk factor for cardiovascular disease
• Childhood immunization is the most important intervention to prevent childhood illness and reduce costs
Breast cancer screening
% getting mammography
Cervical cancer screening
% getting pap smear
Colorectal cancer screening
% getting screening
High cholesterol screening
% getting cholesterol test
Childhood immunizations
% getting full series for six immunizations
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• 40% - 50% of health care costs attributed to five chronic diseases
Diabetes, asthma, congestive heart failure, hypertension, and coronary artery disease
• Clinical guidelines are not consistently followed 45% of the time (RAND)
• Chronic illnesses prevalence increasing More prevalent in African Americans and
Latinos
• Established methods for measuring results
• DM programs are designed to improve care guideline compliance
Care Management: Why these measures?
Diabetes compliance
A1c lab testing
Cholesterol lab testing
Eye exams
Kidney disease monitoring
Hypertension compliance
% on antihypertensive drugs
% getting cholesterol tests
Behavioral health follow up
% getting follow up care
Controller meds for asthmatics
% getting controller meds
Appropriate treatment for URI
% getting antibiotics
HMC participation
% high intensity participating
HMC Blood Pressure control
% that know their BP
% that have a controlled BP
Slide 12
• Immediate results from better management of chronic illnessesCommon, expensive, manageable
• Improving compliance with evidence-based clinical guidelines results in:Better outpatient management of chronic
diseases
Decreases ER visits and inpatient stays
• Care management of specific diseases after acute hospitalization reduces unnecessary readmissionsCoordinated care
Pharmaceutical compliance
Follow-up visits
Clinical Outcomes: Why these measures?
Diabetes ER visits ER visits/1000 for diabetes
complicationsCHF ER visits ER visits/1000 for congestive
heart failure complicationsAsthma ER visits ER visits/1000 for asthma
complicationsSelect hospital admits Acute myocardial infarction Stroke TIA (mini-stroke)Select 30-day readmits Congestive heart failure Diabetes Asthma
Slide 13
• Serious patient safety events increase
1.18 million to 1.24 million of 40 million Medicare hospitalizations
Cost to Medicare $8.6 billion 2003-2005
• Computerized order entry and e-prescribing reduce errors
• Adequate ICU physician staffing reduces risk of death by 40%
• Certain medications require monitoring of side-effects and toxicity
Over-use can cause death
Under-use is ineffective and wasteful
Patient Safety: Why these measures?
Patient Safety Hospital Index% publicly reporting to and meeting LeapFrog
• Critical care physicians in ICU• Required electronic ordering tests and
treatments
Patient Safety Outcome index% hospital improvement 3 AHRQ measures
• Post operative infection• Post operative DVT/PE• Acquired infections
Persistent Meds Monitoring% patients getting recommended lab tests
• Seizure, digoxin for heart failure, diuretics for heart failure, ACE/ARB for diabetes and kidney disease
Slide 14
The Member Health Index
45
50
55
60
2006 2007 2008 2009 2010
5.6% Reduction
1.9% Reduction
Goal: 5% Reduction
Goal: 5% Reduction
The MHI was created to demonstrate WellPoint’s commitment to health improvement and care management and to measure
our success
2005-2006
MHI concept developed and implemented Initial baseline determined
2007• First year of enterprise-wide measurement• MHI/HEDIS workgroups identify and
implement improvement projects
2008• 2007 results announced • 770 million total impressions
2009 • Streamlined Reporting methodology (EDL)
2010• Enhance MHI with focus on new WellPoint
programs
Reduction in Quality GapMHI Timeline
Slide 15
WellPoint Health Status Rankings
WellPoint Health Status and State Health Index
• Diabetes in adult population• 5-year trend in diabetes in adult population• Diabetes death rate• Cancer death rate• Heart disease death rate• Obstructive pulmonary disease death rate
Morbidity and Mortality
• Self-reported poor mental health• Persistent poor mental health• Suicide rate
Behavioral Health
• Meet recommended levels of physical activity• Overweight/obesity• Cigarette smoking• Sexually transmitted diseases
Lifestyle
• Childhood immunizations• Adult influenza immunization• Adult pneumococcal immunization• Breast cancer screening• Cervical cancer screening• Prostate cancer screening
Preventive Care
• Prenatal care in the first trimester• Cesarean delivery rate• Low/very low birth weight• Newborn mortality rate
Maternity and Prenatal Care
• Diabetes in adult population• 5-year trend in diabetes in adult population• Diabetes death rate• Cancer death rate• Heart disease death rate• Obstructive pulmonary disease death rate
Morbidity and Mortality
• Self-reported poor mental health• Persistent poor mental health• Suicide rate
Behavioral Health
• Meet recommended levels of physical activity• Overweight/obesity• Cigarette smoking• Sexually transmitted diseases
Lifestyle
• Childhood immunizations• Adult influenza immunization• Adult pneumococcal immunization• Breast cancer screening• Cervical cancer screening• Prostate cancer screening
Preventive Care
• Prenatal care in the first trimester• Cesarean delivery rate• Low/very low birth weight• Newborn mortality rate
Maternity and Prenatal Care
1 to 10
21 to 30
31 to 40
41 to 51
WellPoint Health Status Ranking
11 to 20
1 is Best, 51 is Worst
Current Performance for the composite State Health Index is 77.6 (out of 100 points).
Red Italicized Measures = SHI measures
Slide 16
Slide 17
State Health Index:Local Health Improvement Collaboration
• Analyze state-specific results
• Identify improvement opportunities with government and community leaders
• Develop state-specific improvement plans
• Deploy collaborative programs
“Anthem shares our commitment to improving public health… We’ll have the greatest impact on public health when the private, public and non-profit sectors work together.” – Judy Monroe, M.D., Commissioner of the Indiana State Department of Health.
“It is important that we continue to see faster and safer access to flu and pneumococcal vaccines for Georgians...The donation of these vaccines will aid in the overall wellness of the citizens of our state.” – Georgia Lt. Governor Casey Cagle.
Legislative Initiatives
Local Initiatives and Health
Departments
Clinical & Health
Services Research
Community Partnerships
Improvement in State Health
Collaborative, Multi-Faceted Approach:
Slide 18
• Team with the American Lung Association of California
• Targeting smokers for quit smoking programs
• Advocating for an increased state tobacco tax to enhance funding for prevention
• Blue Cross to raise awareness of programs and support tobacco tax
State Health IndexExample: California
Opportunities – Smoking
Slide 19
SHI Example: Georgia
HealthMPowers is a unique, coordinated initiative designed to build the supportive environment necessary for students to choose health-enhancing behaviors by working in collaboration with students, school staff and families.
March of Dimes – Centering Pregnancy program: A significant number of women (estimated at 11.3%) continue to receive inadequate or no prenatal care. African-American women are nearly three times as likely as non-Hispanic whites to receive late or no prenatal care. This program will improve health outcomes for all women and their children, but also has the greatest potential to reduce racial disparities in poor birth outcomes.
Safe, fun, highly-supportive coaching process at the YMCA. Participants learn to start and stick to an exercise regimen, reduce health risks associated with obesity (Class II) and improve energy levels. Participants are supported by a personal wellness coach who will teach them how to exercise, eat for results and achieve long-term weight loss.
Slide 20
The Call to Address Health Inequalities
“Of all the forms of inequality, injustice in
health care is the most shocking and inhumane”
Dr. Martin Luther King, Jr.
Slide 21
Reducing Health Disparities:WellPoint’s Multi-Faceted Approach
Associates Physicians Employers Members
Coordinated Strategies
Culturally-tailored approaches produce increased patient knowledge and understanding for self-care, decrease barriers to access, and improve multiple
areas of cultural competence for health care providers.
Slide 22
Connecting with Physicians to Improve Community Health
Geographic Information System and decision support tools enable identification of quality and disparity “Hotspots”
• Racial / Ethnicity demographic data linked to quality data to examine performance of different communities
• Target high performing and low performing medical groups to evaluate and analyze success factors and gaps in care
• Provide medical groups with population and patient-specific information to improve screening and outcomes
Slide 23
Mapping Highlights Health Disparities and Opportunities for Interventions
Slide 24
Analysis of MHI Health Disparities and Unscreened Members by Volume
Unscreened Mammography Commercial Members & Testing RatesSept. 1, 2007 -Aug. 31, 2008
57.1
%
54.5
%
56.5
%
60.1
%
57.5
%
59.4
%
60.7
%
55.3
%
64.8
%
56.4
%
53.3
%
60.2
%
61.3
%
55.1
%
62.3
%
54.2
%
52.8
%
55.2
%
60.7
%57.0
%
58.7
%
66.1
%
61.6
%
64.5
%
0
50,000
100,000
150,000
200,000
250,000
300,000
CA NY VA OH IN GA
Asian African American Latino White / OtherIndicates significant difference vs. White rate at a 95% confidence level
Hatched marks indicate number of members screened.
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Physician Strategies:Provider Portal Disparities Resource Center
On-Line Resource for On-Line Resource for Network PhysiciansNetwork Physicians
• Health disparities facts and myths
• Cultural and linguistic CME seminar and conferences
• Health promotion and disease specific tools
• Asthma• Diabetes• Breast / Cervical Cancer• Immunizations• Arthritis• Obesity• Heart Health
Slide 26
Collaborative Partnership:Alliance for a Healthier Generation
• Three-year pilot to address prevention, assessment, and treatment of childhood obesity in clinical settings
100 pediatric physicians in California and Georgia
3,000 children ages 2-18 at or above the 85th percentile for BMI
• Focus on early identification, intervention, and support
AMA Guideless for Assessment, Prevention, and Treatment of Child Obesity
WLP reimbursed wellness, weight management, and dietician visits
Regular communications to patients and physicians
• Empower children and families to make healthy lifestyle choices
• Third party evaluation of program success
Slide 27
Employer based awareness, education and support for lifestyle and behavioral change
Community based awareness and education
HealthCore Health
Economics and
Outcomes Research
Study
Novartis Hypertension Alliance
Slide 28
Collaborative Diabetes Program:Taking Action Together
• Diabetes education and community health improvement program in CA “Inland Empire” where diabetes rates are 2nd highest in the state
• Focus on awareness, prevention, management, and community support
English/Spanish educational outreach calls made to 11,000 members
Free community-based diabetes education and support sessions
Educational information sent to select providers
Mobile health screening busses to participating Anthem employer groups
• Services available to all, regardless of membership
Slide 29
Physician Quality/Safety:Specialty Society Partnerships
Society of Thoracic Surgeons (STS)
• STS Database: most sophisticated, risk adjusted surgical database in the world
• Data used for surgeon and hospital improvement, recognition, and reward programs
American College of Cardiology (ACC)
• Collaboration to develop criteria for Blue Distinction Cardiac Network
• Development of the Quality-In-Sights Hospital Incentive Program (Q-HIPSM) and Coronary Services Centers Program
• Focus on evidence-based clinical indicators and published guidelines to improve quality outcomes
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Q-P3SM Cardiology Program Components
JC AMI Section
• Aspirin at arrival
• Aspiring prescribed at discharge
• ACEI/ARB for LVSD
• Beta blocker at arrival
• Beta blocker at discharge
• Smoking cessation advice
JC HF Section
• LVF assessment
• ACEI/ARB for LVSD
• Discharge Instructions
• Smoking cessation advice
ACC-NCDR Section
• Rate of serious complications – diagnostic caths
• Door to balloon time for primary PCI <=90 min
• Door to balloon time for primary PCI <=120 min
• % of patients receiving Thienopyridine
• % of patients receiving statin or substitute at discharge
• Rate of serious complications – PCI
• Risk-adjusted mortality rate - PCI
Bonus Section
• Generic Dispensing - Statins
Slide 31
429 Blue Distinction Centers for Cardiac Care®
278 Blue DistinctionCenters for Bariatric Surgery®
84 Blue Distinction Centers for Transplants®
90 Blue Distinction Centers for Complex and Rare CancersSM
WA
OR
CA
AKHI
TX
NMAZ
UTNV
ID
MT ND
SD
NE
WY
COKS
OKAR
LA
MSAL GA
FL
SC
NCTN
KYMO
IL
IA
MN
WIMI
INOH
WV VA
PA
NY
MEVT
NH
RIMA
CTNJDEMD
PR
Centers of Excellence
Blue Distinction Centers are developed in partnership with the Blue Cross Blue Shield Association and participating Blue Plans
Slide 32
Advancing Cardiac Quality:Blue Distinction Centers of Excellence
Qualified facilities demonstrate $6K - $8K lower costs per event
$5,000
$15,000
$25,000
$35,000
$45,000
CABG+PCICABGAMI
Median Cost Per DRG Event• Collaborate with Medical Community
Identify areas for clinical improvement
Establish evidence-based selection criteria
• Evaluation Process
Facilities compete via formal RFI process
Selection based on structures, processes and outcomes
Claims and cost not a selection factor
• Award Designation Status
Designations awarded and published
Work with denied facilities to improve scores and potentially re-apply
• Ongoing Quality Assurance
Re-evaluated every 18-24 months 0%
4%
8%
12%
16%
20%
OP PCI Readmissions CABG Complications
Readmissions/Complications
Non-Blue Distinction
Slide 33
Prevention Case Study: Childhood Obesity
• Multi-faceted initiatives; providers, members, communities
• Scientific evaluation and dissemination of best practices
• Public-private collaboration on education, outreach, and improvement
Percent
Years
~31% of U.S. children are either overweight or obese 16
7
4 4
11
19
1717
11
56
5
0
2
4
6
8
10
12
14
16
18
20
1963-70 1971-74 1976-80 1988-94 1999-02 2003-04
6-11 years
12-19 years
6-11 years 12-19 years
• Core Obesity Interventions
• Physician CME and tools
• Clinical BMI Program
• Member Resources
• Community Outreach
• Collaborative Partnerships
Source: National Health and Nutrition Examination Survey (NHANES) - 1963-65 through 2003-04.
Slide 34
Physician Training and Tools
National AAFP Childhood Obesity CME
• CME bulletin in partnership with AAFP
• AAFP members/residents; all WellPoint primary care physicians
Childhood Obesity Physician Toolkit
• Mailed to all network PCPs since 2005
Anthem Clinical Body Mass Index Program
• Promotes standard BMI screening; tailored to clinical staff
• 63 workshops; 2400 clinical staff, health educators, and school nurses trained
• BMI Quality measures:
• NCQA pilot performance measures in child/adolescent obesity
• 2009 adult and childhood HEDIS measures
• BMI Program Recognition
• “Best of Blue” marketing and communication
• NCQA Quality Profiles™
Slide 35
Member Programs and Resources
Educational Materials
• Get Up and Get Moving! Family Workbook; available in 5 languages
• Healthy Habits for Healthy Kids
• BMI Parent Brochure
Weight Management
• Weight Watchers; TOPS/KOPS
• OnetoWon! Nutritional and Physical Activity Counseling
• High Touch Customized Case Management Pilot
Simple Steps:
Choose Better Health
• Customized wellness program
• Stress management, physical activity, healthy eating
KICK – Kids in Charge of Kalories
• Outreach through smart voice technology, KICK website, and educational materials
• Customized for Medicaid members
Slide 36
Community Outreach
Fruit and Vegetable Bar Study
• Partnered with UCLA and Los Angeles Unified School District
• Disseminate findings through NIHCM
RAND Adolescent Study
• Partnership to examine access/utilization of well-adolescent care
• “Texting” pilot to improve care
Healthy Hoosiers
• Partnership with Eli Lilly, JDRF, ADA, IHIE, IN Dept. of Health
• Website, physician and patient tools, “Nutrition in the Fast Lane”
Georgia HealthMPowers
• Give students information, skills, and motivation to manage their own health
ealthyoosiersHHealthyoosiersHH
Questions?