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Million Hearts
FMI WebinarMay 10, 2012
John M. O’Brien, PharmD, MPH, Senior AdvisorU.S. Department of Health & Human Services | CMS Innovation Center
Million Hearts™
National initiative co-led by CDC and CMS
Partners across federal and state agencies and private organizations
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Goal: Prevent 1 million heart attacks and strokes in 5 years
http://millionhearts.hhs.gov/pharmacies.html
Heart Disease and Strokes Leading Killers in the United States
Cause 1 of every 3 deaths Over 2 million heart attacks and strokes each
year 800,000 deaths Leading cause of preventable death in people <65 $444 B in health care costs and lost productivity Treatment costs are ~$1 for every $6 spent
Greatest contributor to racial disparities in life expectancy
Roger VL, et al. Circulation 2012;125:e2-e220Heidenriech PA, et al. Circulation 2011;123:933–4
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Status of the ABCS
AspirinPeople at increased risk of cardiovascular events who are taking aspirin
47%
Blood pressure
People with hypertension who have adequately controlled blood pressure
46%
CholesterolPeople with high cholesterol who are effectively managed
33%
SmokingPeople trying to quit smoking who get help
23%
MMWR: Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors — United States, 2011, Early Release, Vol. 60
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Key Components of Million Hearts
COMMUNITYPREVENTIONChanging the
context
CLINICALPREVENTION
Optimizing care
Focus on ABCS
Health information technology
Clinical innovations
TRANSFAT
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Community PreventionReducing the Need for Treatment: Tobacco
Comprehensive tobacco control programs work
Graphic mass media campaign Smoke-free public places and workplace policies Free or low-cost counseling and medications
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Community PreventionReducing the Need for Treatment:
Sodium
Menu labeling requirements in chain restaurants
Food purchasing policies to increase access to low sodium foods
Public and professional education about the impact of excess sodium
Publishing info on sodium consumptionAbout 90% of Americans exceed recommended sodium intake
CDC, MMWR 2011;60:1413–7
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IOM: Reduce intake as close to zero as possible
FDA in 2003: Requires labeling of trans fats content
Replacing it is feasible, does not increase cost, or change flavor or texture
Monitor and publish trans fat levels in the population
Encourage food industry to eliminate trans fats
IOM, Institute of MedicineFDA, Food and Drug Administration
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Community PreventionReducing the Need for Treatment: Trans
Fat
Have you stopped selling tobacco products? Do you offer smoking cessation assistance to
your customers, patients, and/or employees? Do you use unique labels to increase
awareness of sodium and trans fats? Do you offer wellness counseling tours or
other unique prevention services?
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Community Prevention Check-in
Clinical PreventionOptimizing Quality, Access, and Outcomes
Focus on the ABCS Fully deploy health information
technology Innovate in care delivery
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Focus on the ABCS Simple, uniform set of measures Measures with a lifelong impact Data collected or extracted in the workflow of care Link performance to incentives
Clinical PreventionOptimizing Quality, Access, and Outcomes
ABCS
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Baseline: Alignment of Clinical Quality Measures
MH CQMs PQRS MU PQRS CV Prevention Measures Group ACOs HRSA
UDS NQF
Aspirin Use PQRS #204 S1 opt NQF #0068
BP Screening
BP Control PQRS #236 S1 opt, Yes NQF #0018
Chol Control – Pop
Chol Cont – DM PQRS #2 S1 opt NQF #0064
Chol Cont – IVD PQRS #241 S1 opt NQF #0075
Smoking Cessation PQRS #226 S1 core Yes (2011) NQF #0028
Six Month Progress:Alignment of Clinical Quality Measures
MH CQMs PQRS MU PQRS CV Prevention Measures Group ACOs HRSA UDS NQF
Aspirin Use PQRS #204 S1 opt, S2 core (prop) Yes Yes Yes (2012) NQF #0068
BP Screening PQRS #317 Yes Yes
BP Control PQRS #236 S1 opt, S2 core (prop) Yes Yes Yes NQF #0018
Chol Control – Pop PQRS #316 S2 core (prop) TBD*
Chol Cont – DM PQRS #2 S1 opt, S2 opt (prop) Yes Yes NQF #0064
Chol Cont – IVD PQRS #241 S1 opt,S2 opt (prop) Yes Yes NQF #0075
Smoking Cessation PQRS #226 S1 core, S2 core (prop) Yes Yes Yes (2011) NQF #0028
Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients
When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program
50% one-sided, 60% two-sided
Medicare Shared Savings Program
Quality is defined by 33 pay-for-reporting or pay-for-performance measures, including:
Patient/caregiver experience (7 measures) Care coordination/patient safety (6 measures) Preventive health (8 measures) At-risk population: Diabetes, Hypertension,
Ischemic Vascular Disease, Heart Failure, Coronary Artery Disease
Expenditures are defined as Part A & B spending
Medicare Shared Savings Program
The Pioneer ACO Model
Designed for more advanced organizationsAlternative payment models possible (5/50,
10/60, 15/75, population-based payments possible in years 3-5)
32 sites listed at innovations.cms.gov
ACOs & Part D
ACOs & Part D sponsors have expressed an interest in working together
CMS has an interest in PDPs playing a greater role in managing the care of FFS beneficiaries and having greater accountability for overall health outcomes
CMS encourages these entities to form appropriate business arrangements that support improve pharmacy care coordination
Incentives Under the ACO Rule
ACOs in good standing and their suppliers may provide items for free or at less than market value if:There is a reasonable connection between the items or
services and the medical care of the beneficiary.The items or services are in-kind and either are
preventive care items or services or advance one or more of the following clinical goals: adherence to a treatment regime; adherence to a drug regime; adherence to a follow-up care plan; or management of a chronic disease or condition.
Fully deploy health information technology (HIT) Registries for population management Point-of-care tools for assessment of risk for CVD Timely and smart clinical decision support Reminders and other health-reinforcing messages
Coming Soon? ONC smartphone app challenge
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Clinical PreventionOptimizing Quality, Access, and Outcomes
Innovate in care delivery Embed ABCS and incentives in new models
Health Homes, Accountable Care Organizations, bundled payments
Interventions that lead to healthy behaviors Mobilize a full complement of effective team members
Pharmacists, cardiac rehabilitation teams Health coaches, lay workers, peer wellness specialists
Coming soon: Team Up. Pressure Down: The Pharmacy Outreach Projects
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Clinical PreventionOptimizing Quality, Access, and Outcomes
Do you have a store clinic? Do you offer blood pressure & lipid testing? Do you measure or report data back to other
providers? Do you enter into collaborative practice
agreements or practice team-based care with other other professionals?
Are you reimbursed by any insurers for MTM or other pharmacist services?
Do you provide these benefits for your employees & their dependents?
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Clinical Prevention Check-in
Public-Sector Support
Administration on Aging Agency for Healthcare Research and Quality Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services Food and Drug Administration Health Resources and Services Administration Indian Health Service National Heart, Lung, and Blood Institute National Prevention Strategy National Quality Strategy Office of the Assistant Secretary for Health Substance Abuse and Mental Health Services
Administration U.S. Department of Veterans Affairs
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Academy of Nutrition and Dietetics
Alliance for Patient Medication Safety
America’s Health Insurance Plans
American College of Cardiology American Heart Association American Medical Association American Nurses Association American Pharmacists’
Association American Pharmacists
Association Foundation Association of Black
Cardiologists CVS/Pharmacy Georgetown University School of
Medicine Kaiser Permanente Medstar Health System
Private-Sector Support
National Alliance of State Pharmacy Associations
National Committee for Quality Assurance
National Community Pharmacists Association
National Consumers League Samford McWhorter School of
Pharmacy SUPERVALU The Ohio State University UnitedHealthcare University of Maryland School of
Pharmacy Walgreens WomenHeart YMCA of America Maryland Dept of Health and Mental
Hygiene New York State Dept of Health23
Med, Pharmacy, Nursing Students Raise Awareness via Events, Contests, & Social Media
Med, Pharmacy, Nursing Academy develops team-based care (TBC) QI module, teaches TBC
Med, Pharmacy, Nursing post-grads practice TBC, measure and improve quality
Care & reimbursement models, state law support TBC, reward ABCS outcomes
Partners Support Progress With Action
A Network of Networks
State Activity
Existing HDSP, CTG, etc work Nebraska ABCS Advisory Group
CIMRO and Nebraska HDSP meeting regularly to discuss collaboration on initiatives in an ABCS Advisory Group
Purpose: To bring together partners, programs, policies, and campaigns to create a positive impact across the spectrum of prevention utilizing the ABCS of clinical prevention to prevent heart attack and stroke.
First Meeting – January 25th
Approximately 25 partners in attendance
Maryland and New York Alignment Efforts
A Network of Networks
State Medical, Pharmacy,
Nursing, etc Associations
Schools of Medicine
Pharmacy,Nursing, Public Health, etc
Patient & Science Advocacy Groups
(WomenHeart, AHA)
Employers & Insurers
Action-Oriented and Results-Focused State Nodes: Harvesting, Spreading, and Providing Technical Assistance on Quality Improvement in the ABCS
Corporate Partners
SMDs SHOs
What Improvement Could Look Like
A State Department of Public Health, QIO, School of Pharmacy, and other partners align efforts to reduce health disparities in hypertension in a county of 11,000 people.
• Other schools/counties in their state test their approach in other locations.
• A nearby statewide initiative is launched. • A national partner achieves results in a
HTN primary care learning collaborative.• An IPA in another state launches a QI
initiative in 14 practices
Tools and “lessons learned” are harvested by QIO & HDSP coordinating centers from leading locations and those
involved in testing change.
• Technical assistance is deployed by the coordinating centers to EACH state node.
• QIOs, HDSPs, RECs, and other partners support learning via LANs and webinars.
• Local knowledge combines with national experience
What Improvement Could Look Like
Measuring Progress
Measurement & Reporting• Short-term, Intermediate, and Long-term metrics reported by the field• Awareness > Activity > Improvements > Outcomes
Results Drive Technical Assistance• High performers analyzed to identify best practices• Low performers investigated to discover barriers to success
Technical Assistance Refines Local Improvement Strategy• Best practices become change practices others may use• High performers mentor others using their tools and methods• Barriers to success overcome with assistance by those who’ve faced similar
challenges
Metrics Across the 5 Year Million Hearts Initiative
Metrics of engagement and involvement of
partners are needed to build MH levers and
activities
Metrics of the levers and activities are needed to
measure short and intermediate outcomes
Metrics of short and intermediate outcomes
are needed to reach our goal of preventing a
million heart attacks and strokes by 2017
2012-2017 2012-2017 2013-2017
Intervention Baseline Target Clinical target
Aspirin for those at high risk 47% 65% 70%
Blood pressure control 46% 65% 70%
Cholesterol management 33% 65% 70%
Smoking cessation 23% 65% 70%
Sodium reduction ~ 3.5 g/day 20% reduction
Trans fat reduction ~ 1% of calories 50% reduction
Getting to Goal
Unpublished estimates from Prevention Impacts Simulation Model (PRISM)
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Million Hearts in May
Kicking off the initiative’s early focus on BP Highlight high performers’ use of Million Hearts
pillars Team-based care HIT to enable PI, medication adherence, disparity reduction Focus on and incenting of ABCS Reductions in sodium, trans-fat, tobacco use
QI module for interdisciplinary care Video Challenge to “Beat Down High Blood Pressure” Ignite partners across country to control BP
37 of 65 Million Americans with Hypertension Are Un-Controlled
Small SBP Reductions Can Save Many Lives
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National Health and Nutrition Examination Survey (NHANES), 2005-2008 Whelton, PK, et al. JAMA 2002;288:1882Stamler R, et al, Hypertension 1991:17:I-16
The Future State
Lower sodium foods are abundant and inexpensive BP monitoring starts at home and ends with control Data flows seamlessly between settings Professional advice when, where, how, and from
whom it is most effective No or low co-pays for medications High performance on BP control is rewarded
Green BB, et al. JAMA 2008;299:2857-67
Adding web-based pharmacist care to home blood pressure monitoring
increases control by >50%
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How Can You Support Million Hearts?
Sign the pledge at: http://millionhearts.hhs.gov Be deputized ambassadors of Million Hearts and speak
to: Reducing disparities Increasing the use of team-based care Support behavior change and medication adherence
Engage with the Million Hearts network and state nodes Participate in the app challenge and Team Up Pressure
Down! Encourage the improvement model to your colleagues
working in heart health Share with us what you’re working on, what works, and
what you’ve learned
