David Wennberg, MD, MPH, describes a recent randomized trial he was involved with that studied the potential of shared decision making to reduce costs among preference-sensitive conditions. David also explains the vision of the 20-member High Value Healthcare Collaborative. This presentation was part of the Shared Decision Making Month webinar "Turning Shared Decision Making Policy into a Reality."

1. NNEACC
REDUCING COSTS
COLLABORATIVE
NORTHERN NEW ENGLAND
ACCOUNTABLE CARE
USING SHARED
DECISION MAKING
FIMDM
March 19, 2013
David Wennberg, MD, MPH
Chief Executive Of ficer
NNEACC

2. PREVIOUSLY PUBLISHED STUDY
NNEACC
Largest study of population care management to date
 Collaboration between Health Dialog and two clients
 Randomized study of 174,120 individuals
 Compared medical costs and utilization of two different care
support strategies
 Overall results:
 Total costs reduced by over 3.6%
 Total population admissions reduced by 10.1%

3. STUDY DESIGN
NNEACC
 Random assignment by predicted costs using an ‘every
other individual’ method.
 Predictive models and real time data were used to assess
the likelihood of using or needing health care services
 Rank-order lists of individuals likely to have support needs
were used to generate
 Outbound mail
 Interactive voice response calls
 Calls by health coaches

4. ENHANCED SUPPORT VERSUS
USUAL SUPPORT
NNEACC
 Difference driven by WHO was targeted for engagement
Health Continuum
Preference
Sensitive Other
Chronic Care High Risk Healthy
High
Risk
Usual Support
Enhanced Support
Enhanced Support
Focus on Preference
Sensitive Conditions
N = 60,185
Low Risk

5. PREFERENCE SENSITIVE FOCUS
NNEACC
 Based on original randomize trial
 60,185 identified as potential candidates for Shared Decision
Making
Usual Support Enhanced Support
Number 30,240 29,945
Costs
Total medical costs (PMPM) $371.92 $371.73
Inpatient costs (per 1,000/yr) $106.77 $106.05
Resource Use
Inpatient admissions (per 1,000/yr) 131 129
Emergency department (per 1,000/yr) 377 379
Surgeries for PSC (per 1,000/yr) 32 30
Advanced imaging studies (per 1,000/yr) 372 382
Standard imaging studies (per 1,000/yr) 1,396 1,394
Northern New England Accountable Care Collaborative 5

6. OUTREACH ACTIVITY
NNEACC
1000 Coach Contacts Usual
800 Enhanced
600
400
200
0
Any PSC Heart Condition
Benign Uterine Cond Prostatic Cond Hip Pain
Benign Knee Pain Back Pain
70 Videos Sent Usual
60
Enhanced
50
40
30
20
10
0
Any PSC Heart Condition
Benign Uterine Cond Prostatic Cond Hip Pain
Benign Knee Pain Back Pain
Northern New England Accountable Care Collaborative 6

7. COST AND UTILIZATION
NNEACC
Usual Enhanced Relative Absolute
Support Support diff (%) diff
Number 30,240 29,945
Costs
Total medical costs (PMPM) $436.05 $412.78 (5.3%) ($23.27)
Total
Medical Costs were $23.27
Inpatient costs (per 1,000/yr) $132.73 $116.20 (12.5%) ($16.53)
per member per$96.91 lower
month $92.49 (4.6%) ($4.42)
Resource Use (per 1,000/yr) in Enhanced Support Group
Inpatient admissions (per 1,000/yr) 155 135 (12.5%) (20)
• Reduced inpatient costs - $16.53 PMPM
Emergency department (per 1,000/yr) outpatient 409 - $4.42 PMPM
• Reduced hospital costs 399 (2.6%) (10)
Surgeries for PSC (per 1,000/yr) 32 29 (9.9%) (3)
Advanced imaging studies (per 1,000/yr) 400 393 (1.9%) (7)
Standard imaging studies (per 1,000/yr) 1,488 1,458 (2.0%) (30)
Northern New England Accountable Care Collaborative 7

8. Achieving Patient Engagement through
Shared Decision Making
March 15, 2012

9. High Value Healthcare Collaborative – 20 Members
9

10. Goals of the CMMI Innovation Grant
• Enhance value by engaging patients to improve
care experience, outcomes and costs:
– Total Medicare costs = cost per episode x # of episodes
• Process improvement within care episodes to
improve outcomes and reduce costs
• Reduce number of episodes and improve patient
experience through informed choice

11. Cost = cost per episode x # of episodes
Variation in cost per episode: Variation in # of episodes:
Cost of TKRs across HVHC sites # of TKRs across HVHC sites
$20#
Part# Prof#
B#
$18#
($Thousands)%
Home#
$16# Health#
$14# LTCH#
Reimbursement%
$12# IP#
rehab#
$10#
SNF#
$8#
OP#
Care%
$6#
IP#
Acute%
$4#
Post%
$2#
$0#
4#
7#
0#
C#
A#
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12. Timing of shared decision making (SDM)
Referral for service
Primary care MD Orthopedic surgeon
• 2000 Medicare patients • 450 cases each year
• 0.5% hip, 0.5%, 10% spine referrals • 1/3 each: TKA, THA, spine surgery
Timing of referral for SDM
Primary Care Specialist
Earlier in decision process Later in decision process
Common SDM pathways across conditions Density and focus
No financial/professional incentives? Financial/professional incentives?
Consensus slowly building for primary care SDM, but still point of debate

13. SUMMING IT UP
NNEACC
 Growing evidence that shared decision making can both
lead to
 Effective patient engagement
 Change the care patients get based on their preferences
 Improve the experience of care
 Reduce utilization and costs
 Next big questions are related to scale…..
Northern New England Accountable Care Collaborative 13