metrics progress on right care initiative targets for blood …rci/blog/wp-content/... ·...

Metrics Progress on Right Care Initiative Targets for Blood Pressure, Lipids and Blood Sugar Control

Stephen M. Shortell, PhD, MPH, MBA

Professor of Health Policy and Management & Dean Emeritus

UC Berkeley, School of Public Health

October 28, 2013

Preventable Cerebrovascular Deaths in the U.S., 2001-2010

Promising Interventions to Reach HEDIS Control Targets for Heart Attack and Stroke Prevention

Intensive Ambulatory Care

Medical HomeTeam-Based

Web SupportedHigh-Tech Enabled

Continuous Care—Not Episodic

Patient Centered Practice Redesign

Patient ActivationMotivate stress reduction, nutritious eating, physical activity, smoking cessation & medication adherence

Evidence-based patient education (e.g., Project DULCE; Stanford Patient Self-Management)Motivational interviewing and evidence-based media messaging

Clinical Pharmacistson Care TeamHRSA.gov/patientsafety The Asheville Project

Medication ProtocolsNationally endorsed

guidelines (AHA, ADA) European Union

guidelines ALL/PHASE (Kaiser)

Right Care Initiative Current Activities

Rotating Right Care University of Best Practices in three metro-areas to catalyze uptake of evidence-based interventions for preventing heart attacks, strokes, and complications from diabetes (e.g., amputations, blindness, kidney failure). Practical presentations from benchmark performers are geared toward medical, pharmacy and quality improvement directors, coupled with Continuing Medical Education in Sacramento and Los Angeles, to spur achievement of national “A-grade” performance.

Annual leadership summit to highlight newly released HEDIS & P4P performance data, award top performers and those with the best improvement, and spread strategies from leading edge Triple Aim performers.

Right Care Resources

Project Briefs The Power of Home Blood Pressure Monitoring

Cardio-Protective Medication Bundle Protocol

The Proactive Patient Improves Clinical Outcomes

Pharmacists on the Care Team

White Paper Ivey S, Hanley H, Knox M, Hirsch J, Shortell S, Rodriguez H,

Mangione C, Dudl J, Halpin H. ”Right Care Initiative’s Quality Improvement Efforts in Prevention of Heart Attack and Stroke in High Risk Managed Care Patients: A White Paper.” Technical Report for California Office of the Patient Advocate, July 2012.

Key Right Care Initiative Control Measure Trends

CA’s average improvement far outpaced the national average for the key Right Care control measures (below):

Key Control Measures

2008-2012 Trends

CA Avg. National Avg.

High Blood Pressure Control (<140/90) +5.3% -0.3%

Lipid Control: Heart Care (LCL-C<100) +4.3% +0.2%

Lipid Control: Diabetic Care (LDL-C<100) +5.4% +2.9%

Blood Sugar Control: Diabetic Care (HbA1c<9) +4.4% -0.1%

Blood Pressure Control: Diabetic Care (<130/80) Not avail. Not avail.

CA Achievement of National 90th percentile of performance for at least one

Right Care control measure:

22/199 managed health plan-contracted medical groups reporting Pay for Performance data

(source: Integrated Health Care Association, CA Pay for Performance Program)

3/of 10 CA health plans that report data to NCQA

(source: National Committee for Quality Assurance)

Percent Patients with Hypertension Controlled (<140/90)

50%

55%

60%

65%

70%

75%

80%

85%

90%

2006 2007 2008 2009 2010 2011 2012

Aetna Health of California (HMO/POS)

Blue Cross (HMO/POS)

Blue Shield of California (HMO/POS)

Chinese Community Health Plan (HMO)

Cigna Health Care (HMO/POS)

Health Net of California, Inc. (HMO/POS)

Kaiser Permanente-North

Kaiser Permanente-South

Sharp Health Plan (HMO)

United Healthcare (HMO)

Western Health Advantage (HMO)

National 90th Percentile

Blood Pressure Controlled (<140/90) of Previously-Diagnosed Hypertensive Patients Among CA Health Plans

2006 2007 2008 2009 2010 2011 2012 Change

National 90th Percentile 71.61% 72.68% 74.09% 76.16% 74.94% 3.33%

California Average 63.64% 69.44% 70.30% 70.81% 68.93% 5.29%

National Average 63.37% 64.09% 63.43% 65.36% 63.04% -0.33%

Percent Heart Patients with Lipids Controlled (LDL-C<100)

45%

50%

55%

60%

65%

70%

75%

80%

2006 2007 2008 2009 2010 2011 2012













Lipid Control (LDL-C<100) of Heart Patients Among CA Health Plans

2006 2007 2008 2009 2010 2011 2012 Change



National Average 59.72% 59.16% 59.89% 59.84% 59.87% 0.15%

Percent Patients with Diabetes with Lipids Controlled (LDL-C<100)

Lipid Control (LDL-C<100) of Heart Patients Among CA Health Plans

2006 2007 2008 2009 2010 2011 2012 Change



National Average 59.72% 59.16% 59.89% 59.84% 59.87% 0.15%

35%

40%

45%

50%

55%

60%

65%

70%

2006 2007 2008 2009 2010 2011 2012













Percent Patients with Diabetes with Blood Sugar HbA1c<9

60%

65%

70%

75%

80%

85%

90%

2006 2007 2008 2009 2010 2011 2012













Blood Sugar HbA1c<9 of Diabetic Patients Among CA Health Plans

2006 2007 2008 2009 2010 2011 2012 Change



National Average 71.64% 71.79% 72.68% 71.11% 71.53% -0.11%

Patients with Hypertension Controlled (<140/90)74.94 = National 90th Percentile for 2012 Performance Year

California

2006 2012

Chinese Community Health Plan* - 86.86

Kaiser Foundation Health Plan, Inc. -

Northern California73.31 85.71

Kaiser Foundation Health Plan Inc. -

Southern California73.97 85.64

Western Health Advantage 60.83 70.80

Sharp Health Plan - 67.78

Health Net of California, Inc. 62.23 65.03

UnitedHealthcare of California 53.81 64.10

Blue Shield of California 58.60 60.50

Blue Cross of California dba Anthem Blue

Cross60.04 60.16

Aetna Health of California, Inc. 61.06 59.43

Cigna HealthCare of California, Inc. 64.23 52.22

National Top 10 (2012)

Kaiser -Ohio, Colorado, Hawaii, Northern

California, Southern California, Northwest,

Georgia, Mid-Atlantic States

88.32-

81.02

Chinese Community Health Plan (CA)* 86.86

Gundersen Health Plan, Inc. (WI) 82.24

Medical Associates Health Plan, Inc.- Accred (IA) 81.27

Tufts Associated HMO, Inc. (MA) 80.74

HealthAmerica Pennsylvania, Inc. (PA) 80.38

Health Partners, Inc. (MN) 79.63

Saint Mary's HealthFirst (NV) 79.08

Health New England, Inc. (MA) 78.92

Harvard Pilgrim Health Care, Inc. (MA, NH, ME) 77.88

Heart Patients with LDL Controlled (<100)73.06 = National 90th Percentile for 2012 Performance Year

California

2006 2012











Cross65.74 64.66




National Top 10 (2012)

Coventry Health Care of Illinois, Inc. (IL) 86.89

Kaiser- Hawaii, Northern California, Southern

California, Colorado, Mid-Atlantic States, Georgia

82.16-

73.21


Network Health Plan (WI) 77.80

Harvard Pilgrim Health Care of New England

(NH)76.61

MercyCare HMO, Inc d/b/a MercyCare Health

Plans (WI)75.83


Health Partners, Inc. (MN) 73.78

Medical Associates Health Plan, Inc.- Accred. (IA) 73.58

Dean Health Plan, Inc. (WI) 73.23

Diabetes Care: Blood Sugar Controlled (HbA1c<8)71.43 = National 90th Percentile for 2012 Performance Year

Note: Trend data not available for HbA1c<8 since only “Poor Diabetes Control” (HbA1c>9) was tracked prior to performance year 2011.

California (2012)

Chinese Community Health Plan* 74.21

Sharp Health Plan 73.48

Western Health Advantage 68.07

Kaiser Foundation Health Plan Inc. - Southern

California66.59

UnitedHealthcare of California 64.44

Cigna HealthCare of California, Inc. 63.26

Kaiser Foundation Health Plan, Inc. - Northern

California63.14

Health Net of California, Inc. 62.44

Blue Cross of California dba Anthem Blue Cross 62.33

Blue Shield of California 61.45

Aetna Health of California, Inc. 52.13

National Top 10


Johns Hopkins US Family Health Plan

(MD,DC,PA,VA,DE,WV)77.13

Medical Associates Health Plan, Inc.- Accred

(IA)76.46

Security Health Plan of Wisconsin, Inc. (WI) 75.00


Chinese Community Health Plan (CA)* 74.21

Capital Health Plan, Inc. (FL) 73.97

Sharp Health Plan (CA) 73.48


Rocky Mountain Health Maintenance

Organization, Inc. (CO)72.68

Diabetes Care: LDL-C Controlled (<100)59.12 = National 90th Percentile for 2012 Performance Year

California

2006 2012








Blue Cross of California dba Anthem

Blue Cross42.17 51.00






National Top 10

Coventry Health Care of Illinois (IL) 77.13

Optima Health Plan (VA) 73.89


Kaiser- Northern California, Hawaii, Colorado,

Mid-Atlantic States, Southern California

68.72-

63.61

HealthPartners, Inc. (MN) 62.41

Cigna HealthCare of Colorado (CO) 61.98




Dean Health Plan, Inc.(WI) 61.09

Security Health Plan of Wisconsin, Inc. (WI) 60.40

Diabetes Care: Blood Pressure Controlled (<140/80)58.39 = National 90th Percentile for 2012 Performance Year

Note: Trend data not available since Diabetes Care: Hypertension Control was a new measure for Performance Year 2011

California (2011)

Kaiser Foundation Health Plan Inc. - Southern

California67.64

Kaiser Foundation Health Plan, Inc. - Northern

California64.78

Western Health Advantage 51.09

Sharp Health Plan 48.42


Cross48.33

Chinese Community Health Plan* 47.45

UnitedHealthcare of California 44.22

Blue Shield of California 44.00

Health Net of California, Inc. 43.05

Cigna HealthCare of California, Inc. 41.36

Aetna Health of California, Inc. 40.86

National Top 10

Kaiser- Georgia, Mid-Atlantic States, Southern

California, Hawaii, Northern California,

Northwest, Colorado, Ohio

74.12-

60.34

Dean Health Plan, Inc. (WI) 69.22

Health Tradition Health Plan (WI) 65.21

Medical Associates Health Plan, Inc- Accred (IA) 63.32

HealthPartners, Inc.(MN) 62.96

Conventry Health Care of Iowa, Inc. (IA) 60.00


Geisinger Health Plan (PA) 59.31

Medica (MN) 59.31

Coventry Health Care if Illinois, Inc. (IL) 58.88

Diabetes Care: Poor HbA1c Control (>9%)18.18= National 90th Percentile for 2012 Performance Year

(Lower Score Indicates Better Performance)

California

2006 2012













Cross30.12 28.00


National Top 10



Medical Associates Health Plan, Inc. - Accred (IA) 11.86



Security Health Plan of Wisconsin, Inc. (W) 14.96



Tufts Associated Health Maintenance

Organization, Inc. (MA)15.57

UnitedHealthcare of Wisconsin, Inc. (WI) 15.84

Harvard Pilgrim Health Care of New England

(NH)16.30

Observations

Among the top performing health plans, those with more exclusive contractual relationships with primary care physicians tend to be able to more effectively galvanize improvement for their patients.

Among physician organizations, most top performers serve relatively affluent patient populations (compared to other physician organizations in CA). Major exceptions to the affluent area pattern are integrated medical groups that have implemented robust chronic care management strategies (team-based care; registries; reminders and point of care prompts; medication protocols).

Data indicates that the CA delegated Independent Practice Association model has particular challenges that require innovation and substantial effort to improve health outcomes.

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