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


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  • Patient-Centered Care: What Difference Does it Make? Measuring and Improving Patient Care Experiences: From Research to Practice to National Quality Priority
  • There soon followed a slew of reports on the quality and safety of health care. <click> In 1998, the Institute of Medicine ’s National Roundtable issued a report called “the Urgent Need to Improve Quality.” <click> That same year, a Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry was formed (?). <click> In 2000, the IOM published its landmark study “To Err is Human.” <click> A year later, the IOM published “Crossing the Quality Chasm” suggesting how to fix American Health Care. <click> Then in 2003, the RAND Corporation weighed in with an article in the New England Journal of Medicine called “The Quality of Health Care Delivered to Adults in the United States” which found that just over half of Americans get the recommended care. <<next slide>>
  • Before I describe the details of the Alternative Quality Contract model, I ’d like to give you some context. We have all heard that the health care industry is facing a crisis of increasing costs along with significant issues related to quality and safety of care. Many of these issues are unintended consequences of the dominant reimbursement model, fee-for-service, which rewards doctors and hospitals for the quantity and complexity of services provided instead of rewarding the quality and outcomes of care. To do our part as a health plan to move toward solutions, Blue Cross evaluated how our payment methodology could be changed to better support high-value health care.
  • Since 2009, Blue Cross Blue Shield of Massachusetts has engaged physicians and hospitals in a voluntary global payment model called the Alternative Quality Contract (AQC). The AQC is designed to decrease participating provider groups ’ spending trend at least in half by the end of five years, while producing significant, measurable improvements in quality. The AQC links financial incentives to clinical quality, patient outcomes, and overall resource use. Hospitals and physicians that choose to adopt the AQC agree to take responsibility for the full continuum of care received by their patients—including the cost and quality of that care—regardless of where the care is provided. The contract model combines a global budget for a patient population with significant performance incentives based on nationally endorsed quality measures (Figure 1).
  • MassTLC healthcare seminar, Patient Engagement and the Role of Technology to Improve Outcomes and Lower Costs

    1. 1. Realizing the Promise ofPatient-Centered Care: WhatWill It Take? Dana Gelb Safran, ScD Senior Vice President Performance Measurement & ImprovementMassachusetts Healthcare Technology Leadership CouncilWaltham, MA8 June 2012
    2. 2. US Health Care Spending As a Percent of GDP Highest Among Economically Developed Nations Total Health Expenditures as a % of GDP, U.S. and Selected Countries (2003) 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, Cross Blue Shield of Massachusetts 2
    3. 3. 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, 1980-2003Blue Cross Blue Shield of Massachusetts 3
    4. 4. Despite Highest Per Capita Spending in the World,US Health Lags Substantially Per Capita Health Expenditures vs. Life ExpectancyBlue Cross Blue Shield of Massachusetts 4
    5. 5. Seeds of the Quality Imperative IOM: Scoping the extent of medical errors and system- related harm 2000 2001 2003 RAND: Percent of US population IOM: Six receiving Pillars of appropriate High Quality preventive and Health Care chronic careBlue Cross Blue Shield of Massachusetts 5
    6. 6. Twin Goals of Improving Quality & Outcomes While Significantly Slowing Spending GrowthIn 2007, leaders at BCBSMA challenged the company to develop anew contract model that would improve quality and outcomes whilesignificantly slowing the rate of growth in health care spending. 18.0% MA health reform law (2006) 16.0% 15.9% 13.1% 13.3% caused a bright light to shine 14.0% 12.0% 13.8% 12.8% 12.1% on the issue of unrelenting 10.0% 8.0% double-digit increases in 6.0% 8.2% health care spending growth 4.0% 2.0% (“Health Care Reform II). 0.0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 BCBSMA Workers’ Earnings Medical Trend Overall Inflation Sources: BCBSMA, Bureau of Labor StatisticsBlue Cross Blue Shield of Massachusetts 6
    7. 7. Components of the AQC Model AQC Providers are Accountable for Quality and Cost Performance Incentives Financial Structure Promote Promotes Affordability and Quality, Safety and Efficiency Patient-Centered Care Providers receive upside Providers share risk on a health payments for performance on a status adjusted Total Medical broad set of quality and patient Expense Budget experience measuresBlue Cross Blue Shield of Massachusetts 7
    8. 8. AQC Measure Set for Performance Incentives AMBULATORY HOSPITALPROCESS • Preventive screenings • Evidence-based care elements for: • Acute care management • Heart attack (AMI) • Heart failure (CHF) • Chronic care management • Pneumonia • Depression • Surgical infection prevention • Diabetes • Cardiovascular diseaseOUTCOME • Control of chronic conditions • Post-operative complications • Diabetes • Hospital-acquired infections • Cardiovascular disease • Obstetrical injury • Hypertension • Mortality (condition –specific) • ***Triple weighted***PATIENT • Access, Integration • Discharge quality, StaffEXPERIENCE • Communication, Whole-person responsiveness care • Communication (MDs, RNs)DEVELOPMENTAL Up to 3 measures on priority topics for which measures lackingBlue Cross Blue Shield of Massachusetts 8
    9. 9. AQC Improving Preventive and Chronic CareThe 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 oftheir contract (2009 vs. 2010). Preventive Screenings Chronic Care Management 5 2009 AQC 2010 AQC 2009 AQC 2010 AQC Non-AQC Non-AQC Cohort Cohort Cohort Cohort 3.9 4 3.6Optimal Care 3.3 3.3 3 2.7 2.5 2.6 2.7 2.5 2.3 2.2 2 2.1 1.9 2 1.8 1.7 1.8 1.7 1.7 1.2 1.1 1.1 0.9 1 0.5 0 2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010 Blue Cross Blue Shield of Massachusetts 9
    10. 10. Barriers to Adherence Cognitive Financial Logistical MotivationalBlue Cross Blue Shield of Massachusetts 10
    11. 11. Essential Attributes of Primary Care Measured by the Ambulatory Care Experiences Survey (ACES) Access  financial 14 2/7 %  organizational Trust 14 2/7 % Continuity 14longitudinal 2/7 %  visit based Interpersonal Primary 14 2/7 % Treatment Care Comprehensiveness  knowledge of patient % 14 2/7  preventive Clinical Interaction 14 2/7 % counseling  communication  physical exams 14 2/7 % IntegrationSource: Safran DG et al. JGIM 2006; 21(1):13-21.Blue Cross Blue Shield of Massachusetts 11
    12. 12. Clinical Relationship Quality Is A LeadingPredictor of Outcomes Business Outcomes Loyalty to the practice (voluntary disenrollment) Malpractice Risk Recommending the practice Health Outcomes Adherence to Clinical Advice Symptom Resolution Improved Clinical IndicatorsBlue Cross Blue Shield of Massachusetts 12
    13. 13. Patient Trust as a Predictor of Adherence: Successful Behavior Change 1996 Trust (percentile) 95th 32.9% 75th 31.7% 50th 29.9% 25th 28.0% 5th 24.3% 0 20 25 30 35 % Successful ChangeSource: Safran et al. JGIM 2000; 15 (supp):116. Blue Cross Blue Shield of Massachusetts 13
    14. 14. Patient Preference for Active Involvement in Medical Decision-Making: Effect of Patient Intervention 30 25 24.3* Experimental Group Control Group 19.4 19.2 20 18.7 15 10 5 0 Pre-Intervention Post-InterventionSource: Greenfield, S., et al. Annals of Internal Medicine, 1985; 102:520-528 * Blue Cross Blue Shield of Massachusetts p<0.001 14
    15. 15. Effect of a Patient Involvement on Clinical Outcomes: Diabetes Control 14 12 10.59 10.61 10.26 10 9.06* 8 Experimental Group Control Group 6 4 2 0 Glycosylated HbA1 (%) Glycosylated HbA1 (%) Pre-Intervention Post-InterventionSource: Greenfield, S., et al. J Gen Intern Med, 1988; 3:448-457 * Blue Cross Blue Shield of Massachusetts p<0.001 15
    16. 16. Patient Reported Outcome Measures (PROMs)• Measures of a patients 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 Blue Cross Blue Shield of Massachusetts 16
    17. 17. 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 PROMs Payers/Purchasers • Tools to promote focus on health and Clinicians/Systems health outcomes • Monitor patient progress • Improved evidence base on efficacy • Data to guide treatment decisions and basis for informed decision making • Improved evidence-base for care • Ability to measure and improve • Compete on evidence of better results outcomes Blue Cross Blue Shield of Massachusetts 17
    18. 18. 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 solutionsBlue Cross Blue Shield of Massachusetts 18
    19. 19. Questions and Comments dana.safran@bcbsma.comBlue Cross Blue Shield of Massachusetts 19
    20. 20. 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 HealthcareBlue Cross Blue Shield of Massachusetts 20