applying evidence-based medicine and best practices to improve healthcare outcomes and control costs...

Applying Evidence-based Medicine and Best Practicesto Improve Healthcare Outcomes and Control Costs

July 17, 2005

Presented by:

Reed V. Tuckson, M.D.SVP Consumer Health and Medical Care Advancement

We’re All In This Together

• It’s not about who pays

– Private Employers

– Individuals

– Federal Government

– State Government

• It is about making healthcare work better

“The system falls short in translating knowledge into practice and applying technology safely in a manner that decreases waste.”

Institute of Medicine

• 45% didn’t receive recommended treatment

• 11% received care that wasn’t recommended or was harmful

• 35% of hypertensives not diagnosed or correctly treated

• 55% of diabetics not adequately monitored for glucose control

Suboptimal Healthcare Delivery

30% of direct health care costs result from poor quality Poor quality care costs approximately $2,000 per covered employee year

Overuse of Antibiotics

35-60% of antibiotics are prescribed inappropriately

$ Billions Total Use

AppropriateUse

Suboptimal Care: Overuse of Interventions

$0

$2

$4

$6

$8 Over $2.5 Billion potential savings

Under Use of Antihypertensives

Medical cost per person to treat MI, Unstable Angina, Stroke avg $10,500 leads to potential cost of approx $15B

Total

Diagnosed

0

10

20

30

40

50

60 30% of people with hypertension are

undiagnosed

Suboptimal Care: Under Use of Interventions

Inappropriate Use of Cox-2s

Optimally the population at risk for bleeding should use Cox-2s

$ BillionsTotal NSAID & Cox-2

AppropriateUse of Cox-2

0

2

4

6

8

10$ 6 Billion potential

savings

48,000 to 98,000 preventable medical errors

Suboptimal Care: Misuse of Interventions

1. New Knowledge, Drugs and Technology

Dual Chamber

ICDSignificant New Challenges Lie Ahead

2. Consumptive Society: Everybody Wants Everything

• Pharma marketing expenditures increased

14.1% annually since 1999

• DTC $4B in 2004

Patient’s requests for clinical services are persuasive and influential: successful 45% of time

Significant New Challenges Lie Ahead

Significant New Challenges Lie Ahead

3. New Public Health Threats

O B E S I T Y

Significant New Challenges Lie Ahead

4. Aging and Chronic Disease

• Fragmented Care Delivery System

• People with 5 or more chronic

conditions account for 2/3 of medical care costs

Best Data and Information Infrastructures

Best Evidence for Clinical Practice and Medical Decisions

Best Clinical Expertise for Product and Policy Development

Discounted, Broad and Deep Networks of Hospitals and Physicians

Integrated Care Management Teams

Improve Physician and Hospital Performance

Facilitate Access to Best Hospitals and Physicians

Improve Coordination of Care

Performance Evaluation and Elimination of Variation

Effective Cost Management and Purchasing

Inform Patient Decision-Making

Consumer Decision Support Infrastructures

Improving Quality, Accessibility, Usability, and Affordability, that Meet the Needs of Consumers/Patients and Private/Public Purchasers

Interconnected Chain of Tools and Supports: Right Care to the Right Person at the Right Time From the Right

Professional and the Right Facility

Best Data and Information Infrastructures

Best Evidence for Clinical Practice and Medical Decisions

Best Clinical Expertise for Product and Policy Development

Discounted, Broad and Deep Networks of Hospitals and Physicians

Integrated Care Management Teams

Improve Physician and Hospital Performance

Facilitate Access to Best Hospitals and Physicians

Improve Coordination of Care

Performance Evaluation and Elimination of Variation

Effective Cost Management and Purchasing

Inform Patient Decision-Making

Consumer Decision Support Infrastructures

Applying Best Evidence and Expertise to Improve Physician and Hospital Performance

Supported by UnitedHealth Foundation

Advocacy for Clinical

Evidence

Evidence-based Medicine: “…the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Sackett,et al

The Keys to Making a Difference

• 635K physician user sites• 59% user penetration• 287M transaction run rate

Best Data and Information Infrastructures

Best Evidence for Clinical Practice and Medical Decisions

Best Clinical Expertise for Product and Policy Development

Discounted, Broad and Deep Networks of Hospitals and Physicians

Integrated Care Management Teams

Improve Physician and Hospital Performance

Facilitate Access to Best Hospitals and Physicians

Improve Coordination of Care

Performance Evaluation and Elimination of Variation

Effective Cost Management and Purchasing

Inform Patient Decision-Making

Consumer Decision Support Infrastructures

Applying Data and Information Infrastructures

to Assess and Improve Quality and Cost Effective Care

Medical Claims Pharmacy Personal Health Risk Assessment

Data Warehoused and Aggregated into Clinically Relevant Groups (280 discrete ETG’s)

Laboratory

Sophisticated Analytics

Risk Adjusters

Evidence-based

Guidelines

Other Databases

(NCDR, STS, MEDPAR)

Administrativeand Costs

AssessQuality

and

Use of Resources

The Keys to Making a Difference

Network Differentiation to Meet the Needs of the Individual

National Network

Premium Performance

Primary Care Physicians

Musculoskeletal Care

Cardiac Care

Cancer Care

Hospital-based Specialists

Ambulatory Specialists

such as Diabetes,

Respiratory, Neurology,

KidneyCongenital

Heart Surgery

Transplantation

Radiology Services

90 days Pre-event 360 Days Post-event

“Anchor” Cardiac Procedure Performed

Analyze all of the tests, interventions, complications and outcomes that occurred

after the procedure

Longitudinal tracking of total episode of care risk-adjusted data

Analyze all of the diagnostic tests used

before the intervention

RestudiesInitial Diagnostic Studies

Example: Assessing the Quality and Efficiency of Cardiac Care to Identify Best Performers and Most Efficient Care Delivery Settings

Rework

40

37

55

17

9

23

-150.00%

-100.00%

-50.00%

0.00%

50.00%

100.00%

150.00%$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000 $20,000

Ov

era

ll C

om

pli

ca

tio

n R

ate

Co

mp

are

d t

o E

xp

ec

ted

Complication Rate vs. Cost Per Admission for a Percutaneous Cardiovascular Procedure Over 12 Months

Expensive &poorer quality

Less expensive &lesser quality

Less expensive &better quality

Expensive &better quality

Differentiation by Quality and EfficiencyFacilitates Patient Choice, Physician Referral, Network

Contracting, and Continuous Quality Improvement

The Complete Picture: Hospital-based Physician Quality Plus Hospital Efficiency Analysis

Overall Complication Rate by Physician vs. Hospital Cost/Admission

13

21

14

1314

35

9085 79

59

43

26

-5.00%

0.00%

5.00%

10.00%

15.00%

20.00%

$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000

Cost Per Admit

Co

mp

lic

atio

n R

ate

(# C

om

pli

cat

ion

s/C

ases

)

COSTS

Best Data and Information Infrastructures

Best Evidence for Clinical Practice and Medical Decisions

Best Clinical Expertise for Product and Policy Development

Discounted, Broad and Deep Networks of Hospitals and Physicians

Integrated Care Management Teams

Improve Physician and Hospital Performance

Facilitate Access to Best Hospitals and Physicians

Improve Coordination of Care

Performance Evaluation and Elimination of Variation

Effective Cost Management and Purchasing

Inform Patient Decision-Making

Consumer Decision Support Infrastructures

Coordinating Care Across Diseases and Care Settings: Right Care to the Right Person at the Right Time From the Right

Professional and the Right Facility

Care Coordination Nurse

The Keys to Making a Difference: Combining Data and Decision Support/Care Coordination

Clinical Information Systems Facilitate Efficient andSeamless Coordinated Comprehensive Health Teams

CareOne

Coordinating Care for the Vulnerable Elderly

Care Management Model

evidence-based

Individual

Comprehensive

Care PlanCare One

Behavioral

Medical

Social

ADL

Home and CommunityBased Services

• Home Health• Meals• Attendant Care• Rehabilitation Services• Transportation

Out Patient Care

• Physician Services• Behavioral Health• Urgent/Emergency Services

In Patient Care

• Acute Hospital Care• Long Term Care• Hospice

COORDINATIONC

are

coor

dina

tion

and

on-s

ite

mon

itorin

g

Integrating Medicaid and Medicare to Meet Individual Needs

• Integration of medical, behavioral, and long term care

• Coordination of funding

• Individual care plan

• Constant monitoring and evaluation of care plan status

• Incentives for quality and focus on prevention

• Increase community services and providers

• Consumer direction and involvement

• Rely on aging network and community partnerships

• Strong state oversight and high standards for organizations (quality, financial, clinical)

Medicaid OnlyCovered

MedicareCovered

Adult Day HealthCare

Attendant Care /Personal Care

Home Meals

Nursing Home

Non-Emergent /Urgent

TransportOutpatient Services

Urgent/EmergencyServices

Hospice

Physician Services

Acute CareHospital

Post-Acute / Rehab

DME / Supplies

Home Health

Home Mods

Assisted Living

Behavioral Health

Pharmacy

Care One

+

• Flexibility in Medicaid & MedicareProgram Requirements

• State Flexibility in SupportingHome and Community-based Care

• Incentives for Cost EffectiveQuality Care Organization

• Financial Support for CareManagement

MostRestrictive

LeastRestrictive

AssistedLiving/

ResidentialCare

AdultFosterCare

Home

AdultCare

HomeHome or

Apartment

SpecialtyUnit

within a NursingFacility

SkilledNursingFacility

Hospital Setting

The bottom line has been significant savings to State Government budgets.

• Arizona reduced the percentage of its Medicaid long-term care population living in nursing homes from 95% to 40%.

• For every person Florida’s Medicaid diversion program maintains in a community setting, the State saves roughly $10,000-$15,000 each year.

• Expansion of the program recently approved.

• Implementation of the STAR+PLUS program in one county in Texas saved approximately $123 million over two years.

• Statewide expansion recently approved.

The Model Works: Proven Results

Best Data and Information Infrastructures

Best Evidence for Clinical Practice and Medical Decisions

Best Clinical Expertise for Product and Policy Development

Discounted, Broad and Deep Networks of Hospitals and Physicians

Integrated Care Management Teams

Improve Physician and Hospital Performance

Facilitate Access to Best Hospitals and Physicians

Improve Coordination of Care

Performance Evaluation and Elimination of Variation

Effective Cost Management and Purchasing

Inform Patient Decision-Making

Consumer Decision Support Infrastructures

Supporting the “Activated” Patient: Helping People Make the Right Choices

• Influence their own health• Participate in the selection and delivery of health services• Maximize value • Share the consequences of their choices and actions

Activating the Individual to Take Informed Action

Benefit, TransactionCapabilities

(How much do I have in my PBA or FSA?)

Evidence-basedCondition/Procedure

Management(What do I have/need?

What are my alternatives?)

Facility Selection(Which hospital hasthe best quality for

my condition?)

Physician Selection(Who’s performanceis best to treat me?)

Cost Estimation Tools

(What are my alternatives likely to cost?)

Health Risk Assessment

(What am I at risk for?How can I intervene early?)

Integrating Data and Information to Support Consumer and Patient Decisions

Facilitation of besthealth care decisions

Data and Technology Infrastructures:Helping People Make Better Decisions

Eligibility and payment cards are merging into one card that will include access to a pre-populated

“Personal Health Record”

“Activating” Behavior Through Timely and Relevant Outreach

The right information at the right time saves money and improves therapeutic compliance

Explanation of Benefits StatementExplanation of Benefits Statement

Multiple touch points reinforce “activation” campaign messages

“Activating” Behavior Through Timely and Relevant Outreach

Integrating All “Touch-points” to Maximize Appropriate Choices for “Influenceable” Events

Employers

Employer-Provided InformationNurselineNurseline

Health RiskAssessment

High Risk Patients

Health RiskAssessment

High Risk Patients

DecisionSupport

By Phone

DecisionSupport

By Phone

Member ServicesMember Services

Care Coordination

Care Coordination

Physician PortalPhysician Portal

ClinicalOperations

ClinicalOperations

UnitedHealthcare

Education & Steerage

Welcome Kit

Mailings and Call-outs

Premium NetworkSM InfoCardiac Care Clinical

Content E-mails to users

“Health Coach” Inbound Calls

Mailings

Premium NetworkSM InfoTargeted

Communications

THE KEY: Getting the right person, the right care, at the right time, from the right place, from the right health professional!

“Best”Physicians

Premium

Hospital

HealthiestBehavior

Consumers/Patients

THERESULT

The Results of Our Strategy and Execution Are Clear

Best Data and Information Infrastructures

Best Evidence for Clinical Practice and Medical Decisions

Best Clinical Expertise for Product and Policy Development

Discounted, Broad and Deep Networks of Hospitals and Physicians

Integrated Care Management Teams

Improve Physician and Hospital Performance

Facilitate Access to Best Hospitals and Physicians

Improve Coordination of Care Performance Evaluation and Elimination of Variation

Effective Cost Management and Purchasing

Industry Leading Medical Cost Control and Improved Quality Outcomes:

• Medical Trend of 8% for commercially insured services

• Pharmacy Trend of 4% for 2004

Inform Patient Decision-Making

Consumer Decision Support Infrastructures