Methods for Fostering the Widespread Implementation of Shared Decision Making

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Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
May 24, 2013

Jeff Thompson, Washington State Health Care Authority
David Downs, Engaged Public
David Swieskowski, Mercy ACO Mercy Clinics, Inc.
Lisa Weiss, High Value Healthcare Collaborative
Kate Chenok, Pacific Business Group on Health

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  • EP,
  • Updating this with the full list of hospitals
  • PERA, BVSD
  • Methods for Fostering the Widespread Implementation of Shared Decision Making

    1. 1. M e t h o d s f o r F o s t e r i n g t h e W i d e s p r e a d I m p l e m e n t a t i o n o f S h a r e d D e c i s i o n M a k i n g Aligning Incentives for Patient Engagement May 24, 2013
    2. 2. Using Shared Decision and Supply Side Management Thursday, May 23, 2013 Jeff Thompson MD MPH Principal Seattle
    3. 3.  Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
    4. 4. Shared Decision Making Adding Value to Mercy ACO David Swieskowski, MD, MBA CEO – Mercy ACO Senior VP & Chief Accountable Care Officer Mercy Medical Center, Des Moines, IA
    5. 5. Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making Washington D.C. May 24, 2013
    6. 6. Purchaser Perspectives on Shared Decision Making Kate Eresian Chenok Director, New Initiatives
    7. 7. ©PBGH 2013 7 PBGH Members
    8. 8. ©PBGH 2013 8 PBGH 2015 Vision A health care system transparent about the quality, cost and outcomes of care, where consumers are motivated to seek the right care at the right price and providers are incented to offer better quality, more affordable care.
    9. 9. ©PBGH 2013 9 What purchasers are looking for:  Affordability  Appropriate use  Reward for efficient providers  Accountability  Patient engagement  Collaboration across specialties  Evidence based practice  Delivery System Innovation  Payment redesign  Health IT  Continual learning
    10. 10. ©PBGH 2013 10 Case study: purchasers are concerned about trends in births Delivery Trends Caesarian delivery rates have now risen to over 32% in the U.S. (up from less than 20% in 1996) with no evidence of better outcomes. Payment Trends  Caesarian delivery reimbursement averages 33% more than that for spontaneous vaginal birth.  Births are in the top 10 high cost episodes for PBGH members (both HMO and PPO)
    11. 11. ©PBGH 2013 11 Case study: purchasers are concerned about trends in births (continued) Consumer Experience(1) 63% of mothers with primary cesareans indicated the doctor was the decision maker. Appx.1% of mothers with a primary cesarean reported that they themselves had made the decision to have a cesarean in advance of labor and there had been no medical reason for the cesarean. Women reported holding back from asking questions because their care provider might view them as difficult, they wanted maternity care that differed from what their provider wanted, or their care provider seemed rushed. (1) Listening to Mothers III
    12. 12. ©PBGH 2013 12 What are PBGH members doing? Planning to support SDM in maternity care with CBC and IMDF Promoting SDM in orthopaedics Communicating with health plans about importance of patient engagement and informed decision making Here is the current landscape for PBGH members…
    13. 13. ©PBGH 2013 13 Purchasers have a wide range of definitions of Shared Decision Making One quarter offer formal SDM programs In addition, most offer:  Online decision support  Telephonic nurse support  Case management  Online cost calculators and comparison tools  Online and in person wellness programs  Educational materials Some offer onsite clinics which provide direct care Source: December 2012 survey of PBGH members
    14. 14. ©PBGH 2013 14 Believe Shared Decision Making results in: 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Improved decision quality Appropriate treatment choice Potential for reduction in variation Potential for reduction in expensive procedures More productive employees Bottom line cost savings How would you define value for Decision Aids and Communications Aids? (check all that apply) Source: December 2012 survey of PBGH members
    15. 15. ©PBGH 2013 15 Purchasers evaluate programs they offer according to: Employee engagement Health improvement Cost
    16. 16. ©PBGH 2013 16 Who should promote SDM?  Expect it from providers as part of appropriate care  Expect health plans to support and provide additional channel for patient engagement  Employers can play a supporting role
    17. 17. ©PBGH 2013 17 Shared Decision Making – links to purchaser goals:  Affordability  Appropriate use  Reward for efficient providers  Accountability  Patient engagement  Collaboration across specialties  Evidence based practice  Delivery System Innovation  Payment redesign  Health IT  Continual learning
    18. 18. • What HVHC is doing to advance shared decision making (SDM) between clinicians and patients • Why HVHC sees shared decision making as important • Steps to make shared decision making a sustainable part of day-to-day health care Confidential - Internal Use Only 18 Topics
    19. 19. HVHC 21 members and growing 31 states; patients in every state
    20. 20. CMMI award* The goals of this initiative are to: 1. Improve quality, outcomes, and cost of care by advancing best practice care models for patients considering hip, knee, or spine surgery and patients with diabetes, congestive heart failure, or sepsis 2. Improve patient experience and reduce utilization and total cost by implementing: a. Shared decision making (SDM) interventions for preference-based decisions (hips, knees, spine surgery) b. Patient engagement interventions (e.g., decision tools, motivational interviewing, patient management) for complex patients with diabetes or CHF * The project described was supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. 20
    21. 21. • What HVHC is doing to advance shared decision making between clinicians and patients • Why HVHC sees shared decision making as important • Steps to make shared decision making a sustainable part of day-to-day health care Confidential - Internal Use Only 21 Topics
    22. 22. Addressing Unwarranted Variation in Health Care: Can Better Care Cost Less? Cost = (cost / episode) x (# episodes)
    23. 23. 23 Knee Replacement Rate by PHN Adj.KneeReplacementRateper1000Beneficiaries
    24. 24. • What HVHC is doing to advance shared decision making between clinicians and patients • Why HVHC sees shared decision making as important • Steps to make shared decision making a sustainable part of day-to-day health care Confidential - Internal Use Only 24 Topics
    25. 25. • Transfer SDM into patient time and home • Integrate SDM tools into clinical care workflow • Measure and communicate patient experience • Provide multi-professional training and incentives Confidential - Internal Use Only 25 Making SDM Part of Day-to-Day Health Care
    26. 26. Transfer SDM into patient time and home
    27. 27. Transfer SDM into patient time and home
    28. 28. Integrate SDM tools into clinical care workflow
    29. 29. 29 Measure and communicate patient experience
    30. 30. CMMI Award Improvement Targets • Improve care: >50% eligible patients referred to SDM and >50% of referred patients/families participate in SDM intervention • Improve health: Improve health status measures (function, pain) for > 50% of patients considering hip, knee, and spine surgery at one year • Reduce cost*: Reduce rates of hip & knee surgeries and episode costs resulting in 5% total cost reduction (aggregate relative rate); for complex patients with diabetes or CHF: reduce aggregate relative hospitalizations by 10% and reduce aggregate cost of annual episodes by 2% (aggregate relative rates); Total cost savings = $64M 30
    31. 31. • Owned by Catholic Health Initiatives • 627 beds • Medical Staff - 1,045 • Employed physicians & Mid-levels - 545 • Total Acute Admissions - 31,592 • Visits to All Mercy Clinics - 1.4 M • Payroll/ Net Revenues - $492M/ $901M Mercy – Des Moines Mercy ACO • LLC wholly owned by CHI Iowa – formed in Feb 2012 • 657 Provider participants – Employed – 470, Independent – 187 – Primary Care – 289, Specialists – 368 • 26 adult primary care clinics & 6 pediatric clinics • 62,000 lives in shared savings contracts
    32. 32. Mercy Steps to Advance Shared Decision Making Between Clinicians and Patients • Physician Engagement – Support from quality & governance committees – Champions identified – Academic detailing • Utilize ACO resources and Health Coaches – ACO distributes Decision Aid to practices – Sponsoring CME events – Specific initiatives launched • Advanced directives • Colon cancer screening – Embed decision aids in our care management software – ACO Health Coaches promote shared decision making
    33. 33. Health Coaches Key delivery system redesign • Located in each primary care clinic • Self-Management Support – Motivational interviewing for Health Behavior change – Connection to community resources • Coordination of care – Track patients through transitions in care • Quality Improvement – Point person for introduction of new care processes – Meet every two weeks to share best practices • Shared decision making – Trained to use Decision Aids and assist patients with decisions – Identify patients, distribute decision aids, and f/U – Coaches are champions in each clinic
    34. 34. SDM Aligns With ACO Goals • Fully informed patients will have better outcomes  More engaged and adherent to treatment plans  Will choose the best options for themselves • Lower total cost of care – Better outcomes will lead to lower overall cost of care – Patient choices will often be less costly than physician choices • SDM reduces the ethical dilemma when there is an incentive to reduce cost • Patient centered • Increase patient satisfaction • Distinguish us in the marketplace
    35. 35. Steps needed to make shared decision making a sustainable part of day-to-day health care • Make the quality case • Make the value proposition – Clearly identify where there is a financial gain • Recipient of the gain needs to finance SDM • Do not increase the work of the physicians – Build a physician support system that uses DAs
    36. 36. Engaged Benefit Design  Vision  Coloradoans will be the wisest consumers of health care in the country  Developed by Engaged Public  Public policy development firm  Facilitation  Public engagement  Policy development and analysis  Leadership development
    37. 37. Why Engaged Benefit Design?  Most incentives for quality and value aimed at providers  P4P  PCMH  ACO  Bundled payment  Incentives to patients indiscriminately aimed at cost  High deductible  Across the board increase in cost-share  Reduce utilization of effective care
    38. 38. Engaged Benefit Design  Value Based Insurance Design  Identify Specific high-value, effective services and eliminate cost sharing  Prevention, screening, chronic disease management, ….  Identify specific high cost, preference sensitive services and raise cost sharing  Coronary stenting, large joint replacement, back surgery, hysterectomy, BPH surgery, ….  Borrowed heavily from Oregon Health Leadership Council  Multiple sources for best evidence and comparative effectiveness  Vetted through physician leaders, insurance experts, business and consumers over 18 months
    39. 39. Engaged Benefit Design  Provide incentives to consumers to utilize Patient Decision Aids and engage in Shared Decision- Making with their providers  $50 check in current pilot  Waive increased co-payments in upcoming implementation  Consider “wellness points” to reduce deductible  Others  Assess experience with PDA using decision quality measurement tools to authorize incentives
    40. 40. Engaged Benefit Design  Current pilot  Funded through HRSA and RWJF grants  1/1/2012 - 12/31/2013  San Luis Valley Regional Medical Center  725 enrolled (kitchen staff to CEO)  Well received by employees, providers, employer and administering health plan
    41. 41. Engaged Benefit Design  Lessons we are learning  This is about culture change  Outreach to consumers and providers is critical  Patient incentives help  Once using PDAs, providers want to use them with all patients  Dedicated resource center is key to making things work
    42. 42. Engaged Benefit Design  Next steps  New grant from The Colorado Health Foundation  Identify and assist more employers/groups  Assist Medicaid Accountable Care Collaboratives implement SDM  Create a regional SDM resource center  Community wide implementation  Colorado Health Insurance Cooperative  Benefit design  Community engagement around a medical commons
    43. 43. MERCER 43July 11, 2013
    44. 44. MERCER 44July 11, 2013 Priorities in Demand & Supply Controls: How does shared decision making apply? Two Populations - Different Issues 5% 95% Chronic Care Worried Well Two Populations - Different Expenditures 50%50% Chronic Care Worried Well Chronic Care: •Cardiovascular •Cancer •Orthopedics •Mental Health •Obstetrics Worried Well: •Cholesterol •Glucose •Blood pressure •Weight
    45. 45. MERCER 45July 11, 2013 Where does a Patient Decision Aid fit in Supply Controls? Two Populations - Different Issues 5% 95% Chronic Care Worried Well Two Populations - Different Expenditures 50%50% Chronic Care Worried Well Wellness: • Immunizations • Smoking • Substance abuse Chronic Care: •Shared Decision making •Care/Case Management •Informed consent •Second Opinions •Variation Control •Centers of Excellence
    46. 46. MERCER 46July 11, 2013 Patient Decision Aids (PDAs) • Patient Decision Aids provide unbiased, evidence-based information about the available options and possible benefits and risks so the patient is better equipped to make an informed decision that is aligned with their preferences. PDA are about one service vs. another service •What is treatment A and B •What are likely benefits of treatment A and B •What are the likely harms of treatment A and B Example: Spine Surgery: • You have a 50% chance of success with surgery or physical therapy • Smokers who have spine surgery have a 40% failure rates vs.10% for non-smokers
    47. 47. MERCER 47July 11, 2013 Informed Consent Tools Informed consent tools give patients more information after they have chosen a procedure or treatment. They can help to educate the patient on what to expect and reduce surprises. Example: Spine Surgery: •Excellent pictures and descriptions •Recommendations like Do not smoke before surgery Informed is about a particular service: •What is treatment B •What should I do before and after treatment B
    48. 48. MERCER 48July 11, 2013 Second Opinions Second Opinion services can give a member information following a treatment or when there is a need for an expert to offer another opinion. Spine Surgery: • You should not have a fusion while smoking. May I help you stop smoking with a transfer to Free and Clear Second opinions can help with questions: •They told me treatment B would work – it did not work! •They want me to have treatment B – I am concerned! •They can not tell me what’s wrong - I need help!
    49. 49. MERCER 49July 11, 2013 Centers of Excellence and variation control Center of Excellence services have proven outcomes that are better than peers with predictable costs (e.g. warrantees). Spine Surgery: • This center only operate where there is evidence of effectiveness! • They can not operate when you smoke! • If you go to hospital B your co-payment will be less due to better outcomes! Centers of Excellence is about where to have a particular service: • Here are differ outcomes for venue A and B
    50. 50. MERCER 50July 11, 2013http://qualitysafety.bmj.com/content/early/2013/03/27/bmjqs-2012-001550.abstract
    51. 51. MERCER 51July 11, 2013 WA Legislation Washington State Legislature Health Care bill includes decision aids (SB 5930 and RCW 7.70.060 and WAC 182- 60-005) • This statute changes the level of proof in a malpractice case from preponderance (>50%) to clear and convincing (>75%) suggesting a value proposition for providers to reduce their liability risks. • This code identifies items for certification based on International Patient Decision Aid Standards (IPDAS).

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