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Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive Medicine 2011 Eduardo Sanchez, MD,MPH,FAAFP Vice President and Chief Medical Officer BlueCross and BlueShield of Texas February 19, 2011

Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

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Page 1: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Preventive Medicine and ACA:Back to the Future – Or is it?

Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts

Preventive Medicine 2011

Eduardo Sanchez, MD,MPH,FAAFPVice President and Chief Medical Officer

BlueCross and BlueShield of TexasFebruary 19, 2011

Page 2: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

DisclosureStatement

Employed asVice President and Chief Medical Officer

BlueCross and BlueShield of Texas,

Page 3: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Ancient History: 1995

• Prevention and Managed Care: Opportunities for Managed Care Organizations, Purchasers of Health Care, and Public Health Agencies (MMWR, 44(RR14);1-12, November 17, 1995)

• Public health agencies bring valuable skills and experience to partnerships with MCOs and purchasers (e.g., experience with surveillance and information systems, epidemiologic and laboratory skills, health promotion skills, experience in developing and implementing prioritized prevention strategies, experience in using policy and legislation to promote the public's health, and experience in case management and providing enabling services to promote access to health services for vulnerable populations).

Page 4: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and Managed Care: Opportunities for Managed Care Organizations, Purchasers of Health Care, and Public Health Agencies

• Because HMOs offer the capacity to both characterize and influence the services delivered to and the health status of enrolled populations, these HMOs are held accountable by purchasers, consumers, and regulators for delivering services and improving health status. This accountability is an inherent advantage of managed care.

• Access to needed preventive services depends on more than insurance; it also depends on provision of enabling services, such as transportation and reduction of language barriers.

• Staff of public health agencies need more practical knowledge about managed care and how it works.

• In a highly competitive health-care market, performance measurement will be important to assure that the MCOs' need to contain costs does not displace quality of care as a priority.

(MMWR, 44(RR14);1-12, November 17, 1995)

Page 5: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and Managed Care: Opportunities for Managed Care Organizations, Purchasers of Health Care, and Public Health Agencies

• The greatest potential for improving the health status of populations results from community-based action (e.g., reduction of risk behaviors such as tobacco use).

• Because of their clinical orientation, MCOs are more likely to be active participants in the delivery of clinical preventive services than in the delivery of nonclinical preventive services. However, MCOs can be powerful partners in nonclinical preventive service areas (e.g., education, laws, and regulations to prevent the initiation of tobacco use and to ensure environmental intervention for children with high blood-lead levels).

(MMWR, 44(RR14);1-12, November 17, 1995)

Page 6: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and Managed Care: Opportunities for Managed Care Organizations, Purchasers of Health Care, and Public Health Agencies

• MCOs have found that maintaining the health of their populations is an important way to improve their cost effectiveness.

• As MCOs have become the primary provider of health care to large segments of a community, they have become more involved with the health of the community as a whole.

• Many preventive services, even though they may be highly cost effective and may contribute to the quality of life, cost more to implement than they save. Therefore, particularly in capitated systems, additional incentives that favor investments in prevention are needed (e.g., performance measures that are prevention oriented).

(MMWR, 44(RR14);1-12, November 17, 1995)

Page 7: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and Managed Care: Opportunities for Managed Care Organizations, Purchasers of Health Care, and Public Health Agencies

• Recommended High Priority Activities

• Work with MCOs, purchasers, and state and local health departments in key areas of prevention effectiveness, including

• using information to determine the prevalence, incidence, and burden of disease, and the availability, efficacy, acceptability, effectiveness, and cost-effectiveness of interventions to specify highest-priority health problems for prevention;

• assessing, through original research or review of the scientific literature, the effectiveness and cost-effectiveness of population-based and clinical strategies for prevention;

• and developing, disseminating, and evaluating a "Guide to Community Preventive Health Services," science-based recommendations for choosing and implementing community-based preventive services.

(MMWR, 44(RR14);1-12, November 17, 1995)

Page 8: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

1998: The Changing Managed Care-Public Health Interface

• “Changes in health care markets and regulatory environments threaten some managed care-public health collaborations…” related to clinical services.

• Opportunities for “new relationships to support population-based, patient-focused health interventions that provide health education, information dissemination, and outreach”.

(JAMA, Vol. 280, No.20, November 25, 1998)

Page 9: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

2000: Managed Care and Public Health

• Two Questions1 How can public health influence managed care by

integrating public health principles into the workings of managed care?

2 How must public health adapt to compete [add value?] in a managed care environment, collaborate with a changed health care delivery system, or both?

(AJPH, Vol. 90, No. 12, December 2000)

Page 10: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Causes of Death, United States 2005

Source: cdc.gov

1.4%

1.8%

2.9%

3.1%

4.8%

5.3%

5.9%

22.8%

26.6%

0% 9% 18% 27% 36%

Septicemia

Influenza and pneumonia

Alzheimer’s disease

Diabetes mellitus

Unintentional injuries

Chronic lower respiratory disease

Stroke

All cancers

Diseases of the heart

Page 11: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

The Preventable Causes of Death in the United States:Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors (Danaei,2009)

Deaths attributable to individual risk (thousands) in both sexesDeaths attributable to individual risk (thousands) in both sexes

Page 12: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

“an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited microsystems each performing in ways that too often lead to suboptimal performance”

(Halvorson, 2007)

Our Health Care System?

Page 13: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

The future ain’t

what it used

to be- Yogi Berra

Page 14: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

The health reform debate

Access: High numbers and percentages of uninsured

Cost: High cost of medical care

Quality: Suboptimal care delivery

Page 15: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Affordable Care Act of 2010

• No Preexisting conditions exclusions

• No lifetime limits

• Adult dependents can stay on parents health plans until age 26

• Maintains state regulation for insured business, under federal framework of rules

• Largely maintains employer-based system

• ERISA protections maintained

• Makes far-reaching changes in health care coverage and financing• Expands Medicaid (up to 133% FPL)

• Establishes state-based exchanges (133% - 400% FPL)

Page 16: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and Public Health Fund• Expands and sustains national investment in prevention and

public health programs

• Grows from $500m to $2b annually

• Goal is to improve health and help restrain the rate of growth in private and public sector health care costs

• Prevention, wellness, and public health activities including prevention research

• Health screenings

• Immunization(From Rein, Berger; CDC)

Page 17: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention/Wellness

National strategy Establish the National Prevention, Health Promotion and Public Health Council to coordinate federal prevention, wellness, and public health activities. Develop a national strategy to improve the nation’s health. (Strategy due one year following enactment) Create a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs including prevention research and health screenings, the Education and Outreach Campaign for preventive benefits, and immunization programs. . (Initial appropriation in fiscal year 2010) Create task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services. (Effective upon enactment)Establish a grant program to support the delivery of evidence-based and community-base prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas. (Funds appropriated for five years beginning in FY 2010)

Kff.org

Page 18: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Improving Quality/Health System Performance

National quality strategyDevelop a national quality improvement strategy that includes: • priorities to improve the delivery of healthcare services,

• patient health outcomes, and

• population health.

Create processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs. (National strategy due to Congress by January 1, 2011)

Kff.org

Page 19: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Improving Quality/Health System Performance

Disparities

Require enhanced collection and reporting of data on race, ethnicity, sex, primary language, disability status, and for underserved rural and frontier populations.

Also require collection of access and treatment data for people with disabilities.

Require the Secretary to analyze the data to monitor trends in disparities. (Effective two years following enactment)

Kff.org

Page 20: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Work Force

Improve workforce training and development:Establish a multi-stakeholder Workforce Advisory Committee to develop a national workforce strategy. (Appointments made by September 30, 2010)Increase the number of Graduate Medical Education (GME) training positions by redistributing currently unused slots, with priorities given to primary care and general surgery and to states with the lowest resident physician-to-population ratios (effective July 1, 2011) Increase workforce supply and support training of health professionals through scholarships and loans; … establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals. (Effective dates vary) Support the development of interdisciplinary mental and behavioral health training programs (effective fiscal year 2010) and establish a training program for oral health professionals. (Funds appropriated for six years beginning in fiscal year 2010)

Kff.org

Page 21: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Challenges to ACA 2010

Age

Obesity

Demographix

Page 22: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Indicator 1 – Number of Older Americans

Page 23: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Source: Behavioral Risk Factor Surveillance System, CDC.

1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2009

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2009

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Page 24: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Cost of childhood obesity

The Biggest Reason Why Young Americans Cannot Join the Military:

The Biggest Reason Why Young Americans Cannot Join the Military:

Physically unfit: 27 percent of young Americans are too overweight to join the military.

Physically unfit: 27 percent of young Americans are too overweight to join the military.

Ready, Willing, And Unable To Serve (Mission: Readiness)

Page 25: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Projected Population (census.gov)

2000 2010 2020 2030 2040 2050

Total Pop 282 M 309 M 336 M 364 M 392 M 420 M

White 69.4% 65.1% 61.3% 57.5% 53.7% 50.1%

Hispanic 12.6% 15.5% 17.8% 20.1% 22.3% 24.4%

Black 12.7% 13.1% 13.5% 13.9% 14.3% 14.6%

Asian 3.8% 4.6% 5.4% 6.2% 7.1% 8.0%

Page 26: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

The Frame: Triple Aim

Coined by the Institute for Healthcare Improvement (IHI) which believes that new designs can and must be developed to simultaneously accomplish three critical objectives

• Improve the health of the population; 

• Enhance the patient experience of care (including quality, access, and reliability); and 

• Reduce, or at least control, the per capita cost of care.

Page 27: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

27

ACA Alternative Payment Legislation

Title III, Subtitle A, Part III

• Improving the Quality and Efficiency of Health Care

• Transforming the Health Care Delivery System

• Encouraging Development of New Patient Care Models

§3022 – Medicare Shared Savings Program - ACOs

§3023 – National Pilot Program on Payment Bundling

Page 28: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

28

Align Reimbursement & Incentives for Desired Outcomes

• Provider infrastructure and appetite for risk

• Patient condition

• Benefit design

Fee-for-Service Pay-for-Performance

Episodic Bundling

Global Payment

Full Risk / % of Premium

Episodic Cost Total Cost

Provider Accountability

Continuum of Payment Models

Patient Centered Medical Home Accountable Care Organization

Variables to consider:

Page 29: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Patient Centered Medical Home Model

Redesigning the Way Primary Care is Delivered and Financed

Patient Personal Physician*

Trusted personal physician Physician who provides, manages and facilitates care Care is coordinated or integrated across healthcare system More accessible practice with increased hours and easier

scheduling

Payment mechanisms that recognize the added value of delivering care through the PCMH model

Assistance to practices seeking transformation Support to practices adopting HIT for QI

Specialist Care Pharmacist Care

Hospital Care

Imaging Services

* Includes Non Physician Professionals

Lab Services

Page 30: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Accountable Care Organizations (ACOs)

Defined as a set of providers associated with a defined set of patients, accountable for the quality and cost of care for that population.

The providers could include a hospital, a group of primary care providers, specialists, and other health professionals who share responsibility for the quality and cost of care provided to patients.

Hospitals are not a necessary part of ACOs, but seem to be taking the lead.

An ACO is responsible for a patient wherever he or she elects to get care.

ACO members receive a financial bonus for meeting certain prescribed targets.

(AcademyHealth, 2009)

Page 31: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

The future ain’t

what it used

to be- Yogi Berra

Page 32: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Accountable Practice Model

Primary Care/Medical Home focus – in a POS/PPO environment

Standard practice evaluation criteria based on NCQA must pass elements

Standard set of quality metrics (primarily NCQA based)

Shared Savings model

• Historical population trend performance

• Year 1 Target Trend = historical 3 year average trend less trend reduction percentage

• Year 2 – Year 3 Target trend – movement toward floor of general CPI

• Savings only shared if quality metric performance is attained

Care coordination payment

• Software, Outreach services, Mailers, Increased time with physician, IT support

Data sharingCollaborative chronic condition, case and trend management

Performance measurement

Page 33: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Accountable Health Organizations (AHOs)

Defined as a set of social services, health, and medical providers associated with a defined population, accountable for the health status and outcomes for that population.

The providers could include a local health department, health plans, employers, primary care providers, specialists, and other health professionals who share responsibility for the quality and cost of care provided to patients in addition to the health of all.

Local health departments and health plans (public and private) should be taking the lead.

Preventive medicine physicians are uniquely qualified to lead and manage AHOs.

AHOs are rewarded for optimizing health.

(adapted from AcademyHealth, 2009)

Page 34: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

34

Metabolic Syndrome Program Down Under

• 10 Australian Aborigines

– Overweight

– With diabetes

– Living a western lifestyle

• Returned to traditional homeland for seven weeks

– Average weight loss of 18 pounds

– Blood pressure reduction

– Normal triglycerides

Page 35: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

35

Diabetes Prevention Program (DPP)

The DPP Research Group, NEJM 346:393-403, 2002

Placebo Metformin Lifestyle

Incidence of diabetes (percent per year)

11.0% 7.8% 4.8%

Reduction in incidence compared with placebo

– 31% 58%

Number needed to treat to prevent 1 case in 3 years

– 13.9 6.9

Page 36: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

5 Healthy behaviors to lower cardiovascular risk

physical activity,

not smoking,

higher healthy eating index,

moderate alcohol intake (1-2 drinks per week), and

maintaining weight or trying to lose weight in the past 12 months.

DMN, 11/30/2010, AHA scientific conferences

Page 37: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

The Community Guide - Obesity

Interventions in Community Settings• Interventions to Reduce Screen Time

• Behavioral interventions to reduce screen time R

• Mass Media interventions to reduce screen time I

• Technology-supported interventions (computer/web applications)

• Multi-component counseling/coaching to effect weight loss R

• Multi-component counseling/coaching to effect weight loss R

Interventions in Specific Settings• Worksite programs to control overweight and obesity R

• Worksite programs to control overweight and obesity I

(AHRQ)

Page 38: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Opportunities

Evidenced-based health

• The Community GuideAHO – Accountable Health Organizations

• Be at the tableHealth plans

• CMO, CEO, wellness and disease management Conversion foundations

Opportunity in the business community

• Business groups on health

• Large employers

Page 39: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Fast forward: 2011

Prevention and ACOs:Preventive medicine physicians can bring valuable skills and experience to ACOs (e.g., experience with surveillance and information systems, epidemiologic and laboratory skills, health promotion skills; experience in developing and implementing prioritized prevention strategies; experience in using policy and legislation to promote the public's health, and experience providing enabling services to promote access to and utilization of health services for vulnerable populations).

Page 40: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and ACOs

Because health plans offer the capacity to both characterize and influence the services delivered to and the health status of enrolled populations, health plans should continue to be held accountable by purchasers, consumers, and regulators for delivering services and improving health status.

Access to needed preventive services depends on more than insurance; it also depends on a system of care that enables utilization.

Preventive medicine needs more practical knowledge about how the health plan world works.

In a highly competitive health-care market, performance measurement should include health outcomes and keep quality of care ahead of cost containment .

Page 41: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and ACOs

The greatest potential for improving the health status of populations results from community-based action (e.g., reduction of risk behaviors such as tobacco use and sedentary living).

Because of their clinical orientation, health plans are more likely to be active participants in the delivery of clinical preventive services than in the delivery of nonclinical preventive services. However, they can be powerful partners in nonclinical preventive service areas (e.g., education, laws, and regulations to prevent the initiation of tobacco use and to ensure environmental intervention for children with high blood-lead levels).

Page 42: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and ACOs

Health plans have found that maintaining the health of their populations is an important way to improve their cost effectiveness.

As health plans become the primary provider of health care to large segments of a community, they should be more involved with the health of the community as a whole.

Many preventive services, even though they may be highly cost effective and may contribute to the quality of life, cost more to implement than they save. Therefore, particularly in capitated systems, additional incentives that favor investments in prevention are needed (e.g., performance measures that are prevention or workplace oriented).

Page 43: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Prevention and ACOs

Recommended High Priority Activities

Work with health plans, purchasers, and state and local health departments in key areas of health promotion and prevention effectiveness, including

• using information to determine the prevalence, incidence, and burden of disease, and the availability, efficacy, acceptability, effectiveness, and cost-effectiveness of interventions to specify highest-priority health problems for prevention;

• assessing, through original research or review of the scientific literature, the effectiveness and cost-effectiveness of population-based and clinical strategies for prevention;

• and developing, disseminating, and evaluating a "Guide to Community Preventive Health Services," science-based recommendations for choosing and implementing community-based preventive services.

Page 44: Preventive Medicine and ACA: Back to the Future – Or is it? Growing & Strengthening Preventive Medicine and Medical Quality in Multiple Contexts Preventive

Concluding remarks