Is Consumer Directed Health Care the Magic Bullet? Leveraging the Convergence of Disease Management and Consumer Directed HealthPaul Wallace MDPermanente FederationKaiser PermanentePaul.Wallace@kp.org

The Disease Management ColloquiumMay 11, 2006Philadelphia

About Kaiser Permanente Integrated health care delivery system 8 Regions Serving 9 States and the District of Columbia

8.6 + million members~ $35 Billion annual Budget

Largest US nonprofit health plan Founded 1945 Over 12,000 Physicians and Over 130,000 Employees 31 Hospitals and Medical Centers, and 431+ Medical Offices Large investments in Research and Information Technology All employees and their families are KP members

KP Priority ConditionsClinical AreaKP Memberswith this Condition Asthma 155,000 (2.7% of members)Coronary Artery Disease216,000 (3.4%)Depression448,000 (7.1%)Diabetes604,000 (9.3%)Heart Failure103,000 (1.4%)Cancer>25,000 new cases/yrChronic Pain 285,000 (5.1%)Elder Care 869,000 (11.3%)Obesity (BMI > 29)~ 30% of adultsSelf Care & Shared Decision Making8.6 MM

Healthcares Middle Space Population Based Care* Chronic Condition Care* Care and Disease Management* Health and Wellness Interventions

Population-based care: Managing the whole populationin Sickness and in HealthHealth + WellnessDisease MgmtPhysician Care

The Blueprint From Improving Chronic Illness CareEd Wagner, MD, Group Health Cooperative of Puget Sound

Primary Care Physicians and How They Manage Their Patient Panel

Chart3

2500010000

Office visits

Group visits

"Fast Track"'s

Annual health goals

Phone contacts

Email contacts

Mail-merge

US mail contacts

# of "Contacts" per doc per day

Before Panel Management

Graphics

Advanced Panel Management

Kaiser Permanente Hawaii Region

Graphics

320.010.010.010.010.010.010.01

Office visits

Group visits

"Fast Track"'s

Annual health goals

Phone contacts

Email contacts

Mail-merge

US mail contacts

No. of "Contacts"

Before Panel Management

Calculations spreadsheet

1061010105710

Office visits

Group visits

"Fast Track"'s

Annual health goals

Phone contacts

Email contacts

Mail-merge

US mail contacts

No of "Contacts"

Goal With Panel Management

Advanced Panel Management

Kaiser Permanente Hawaii Region

2/14/05

Before Panel ManagementGoal with Panel Mangement

Interaction Methods(AKA "Touches")Avg Daily VolTime per interaction, minutesDaily Total, minutesAvg Daily VolTime per interaction, minutesDaily Total, minutes

Seeing patients in office visits32154801020200

Seeing patients in group visits0006212

"Fast Track"'s0001010100

Annual health goals reviews00010110

Phone contacts00010440

Email contacts0005420

mailmerge70.53.5

US mail contacts00010330

Panel management00065

total3248068415.5

Before Panel MangementGoal with Panel Mangement

Office visits32Office visits25

Group visits0.01Group visits0

"Fast Track"'s0.01"Fast Track"'s0

Annual health goals0.01Annual health goals0

Phone contacts0.01Phone contacts10

Email contacts0.01Email contacts0

Mail-merge0.01Mail-merge0

US mail contacts0.01US mail contacts0

Panel managementPanel management

Before Panel Management (i.e. using the standard model), all interactions were using the standard 15 minute office visit. Only 32 daily contacts were possible under this model in an eight hour day.

Under Panel Management, the day's activities are distributed around other more flexible and time efficient methods of interacting with the patient. Under this model, about 68 daily "contacts" are possible.

By utilizing multiple methods to interact with the patient, and using the same amount of time spent in the day (about 480), the number of contacts per day can increase significantly (32 to 68). This supports the panel management goals

Average Daily "Touches" With Total Panel Care Doubles to 60+010203040506070801No. of Daily ContactsUS mail contactsRN and HCT contactsEmail contactsPhone contactsAnnual health goals "Fast Track"'sGroup visitsOffice visitsMass-personalizing care: Tools for determining how to best touch membersDr G. Livaudais, Maui Lani Clinic, Hawaii, Gerard.F.Livaudais @KP.ORGDynamic Cross ConditionPatient Registries

How do we get the consumers attention?Rules of the Game modelManaged Care Case management for high risk participants Skin in the game modelTiered co-paysCoinsuranceHigh Deductible Health PlansTiered networks: hospitals, specialists, PCPsConsumer Directed Plans

Sample Plan Design Benchmark Deductible HMO (DHMO) PlanNon-Preventive ServicesPremiumPreventive ServicesDeductible20%copayPharmacycopay

In health care, geography is destiny -- our roots are in understanding and addressing unwarranted variation in careUnwarranted variation accounts for up to 30% of healthcare costs

Effective Care: Proven effectiveness, no significant trade-offs (e.g. chronic conditions management)

Effective Care Beta Blocker Use Among Patients Post Heart AttackVaries from 5% - 92%, when it should be ~100%Preference-Sensitive Care - Herniated Disk: In Southern California, a patient is 6 times more likely to have back surgery than in New York City. Preference-Sensitive Care: Involves trade-offs, (at least) two valid alternative treatments are availableClinical Relevance

Linking Plan Design to Clinical Relevance

Sample Plan Design Benchmark DHMO Plan

Non-Preventive Services

Premium

Preventive Services

Deductible

20%

copay

Pharmacy

copay

Sample Plan Design Clinically-Driven Plan

Chronic ConditionEvidence-based Care

All Other Care

Premium

Preventive Services

Deductible

Preference-Sensitive Care: Incentives for using Shared Decision Making

Pharmacy

Pre-Natal/Well-Baby

What would you imagine is the dose response for skin in the game yielding health?Skin in the GameImproved Health

How do we get the consumers attention?Rules of the Game modelManaged Care Case management for high risk participants Skin in the game modelTiered co-paysCoinsuranceHigh Deductible Health PlansTiered networks: hospitals, specialists, PCPsConsumer Directed PlansBrain in the game modelHealthy lifestyles, wellness activitiesDisease Management through Health Coaching to support effective self-management Self management for acute and chronic conditionsShared decision makingWeb-based decision support tools

The Patient at the Center of Care

How many hours a year does a personwith diabetes spend:In the health care system?At work?At Home? (At Pats?)

Targeted communications to reach and engage membersAll members are invited to participatePosterMailerPayroll StufferVideo library~ 25% receive targeted,needs-specificcommunicationsHealth coach interventionOnline informationE-mailDecision supportTargeted mailings

Personal health coaches educate and support members24/7 health coaching includes:Wellness information and general informationUrgent need supportDecision supportChronic condition/disease management

Health coaches:Specially trained professionals, including:NursesRespiratory therapistsSmoking cessation expertsDietitians/nutritionistsWeight loss expertsAverage between 15-20 years of experienceCertified in collaborative decision-making methodology

Key components of the personal health coaching modelIntegrated whole person approachPrimary coach model -- 85% of interactions are with a members personal coachCall frequency and duration is dictated by the opportunity for impact, not call quotas or targeted call lengthsReinforces patient-provider relationshipFocused on building self-reliance, not dependenceBased on evidence-based clinical standards and sensitive to culturally-competent care and health literacy issuesPowerful, yet easy to use, support tools

Direct to the Patient: Opportunities to Support and Integrate CareAsthma Featured Health Topic from the pull-down menuAnnouncement about asthma

Asthma Featured Health Topic: Connecting to InformationInformacin en espaolLinks to evidence-based content, and Health Encyclopedia

Reviewed by subject matter experts

Tools To Support Spanish Speaking Users

Managing Your Asthma:Connecting to Appropriate ActionsLink to Asthma Triggers toolPhysicianFollow-upLink toasthma action planSelfManagement

Managing Your Asthma:Connecting to Appropriate ActionsLink to Asthma Triggers toolPhysicianFollow-upLink toasthma action planSelfManagement

Managing Your Asthma:Connecting to Appropriate ActionsLink to Asthma Triggers toolPhysicianFollow-upLink toasthma action planSelfManagement

Peer Support... like other animals we tend to isolate ourselves when we hurt. We forget the value of... positive support ... It helps so much to reach out and share our lives and it works both ways. -- Arthritis message boardI've noticed that since I've been going to the gym I have more energy than before. I just feel better.-- Exercise & fitness message board

Healthy Lifestyles: Tools to Improve Health

Online Health Assessments and Interventions Balance, Relax, Breathe, Nourish, Succeed

UnderstandingHealthMedia Nourish tailored nutrition program for each individual

participants set goals includingcalorie intake fat consumptionphysical activityselect the frequency they will report their progressSupporting Change : Goal Setting

participants report their progressa graph shows their reported progress against their set goalsmore participants achieve their weight management goalsSupporting Change : Goal Setting

Healthy Lifestyles: Having a big impact Over 100,000 KP members have completed a program since August 04~ 50,000 weight management/physical fitness program.~ 15,000 nutrition program.~ 10,000 stress reduction program.~ 5,000 smoking cessation program.> 25,000 total health assessment in the first three months 86% of responders were satisfied with the programs.

Findings of the weight management/physical fitness program (180 day outcomes / n=3,258*):51% lost weight by following the recommendations provided in their Healthy Lifestyles report.Average weight loss was 3.6 lbs.43% reduced their BMI by at least 1 BMI unit (e.g. 30 to 29).12% dropped an entire BMI stratification level (e.g. from very obese to obese).Those who lost weight had 0.6 fewer office visits per year.

(Note: A study of non-survey responders showed that non-responders had similar outcomes to responders.*)

Easy Access to the PatientsHealth and Medical Record

Office visit summariesPaper copyhanded to the patient or family at the end of every visit and also available in the online health record

ValueAffordabilityCareExperienceClinicalQualityPurchaserPerspective

Is Consumer Directed Healthcare the Magic Bullet?

Only if it is combined with support for active and informed participation by consumers in their care

Effective Disease Management is an essential feature to enable and support Consumer Directed Health Care

We are a large system that offers many benefits to our members, especially in terms of convenience and economies of scale.

Busy- complex projectCC care model as standard- leveraging social science to understand how to better deliver healthcareThis is a new field of research in healthcareMore flexibility - give the right patients the right care at the right timeMore coverage of the entire panelMore efficientIn a year, a PCP will presently see 60% of the panel (ranging from 50-75%); 100% will be touched under Total Panel CareAdd weight management message boards screen grab