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AMGA All Rights Reserved
Plank 3: Blood Pressures
Addressed During Every Visit
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Achieving Breakthrough
Chronic Disease Outcomes
Bob Matthews
MediSync / PriMed Physicians
2
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About MediSync
• Manage (don’t own) multiple medical groups
– Assist them to achieve “breakthrough”
performance financially and clinically
• Use Six Sigma and Lean to innovate
medical group performance and operations
• Innovated management processes to 120+
medical groups nationwide
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About PriMed Physicians
• Community based, physician owned and
governed
• Greater Dayton, OH
• PCP Based Multi-specialty Medical Group
– Family Practice, Internal Medicine, Pediatrics
+ Cardiology, Electrophysiology, Neurology &
Endo
• 55 physicians; ~100,000 patients
• Started prepping for value agreements in 2004
• Nov 1, 2012 almost all value contracts
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What Doctors Do
1. Acute care
2. Chronic disease management
3. WRAP – Wellness, Risk Assessments &
Preventive care
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Cost of Chronic Disease
“Seventy-five percent of the (monies)
spent on health care in the U.S. is for
treatment of the chronically ill.”
- The Commonwealth Fund
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“Big” Chronic Diseases
HTN
Diabetes
Lipids (CAD & Vascular Diseases)
Asthma
Heart Failure
COPD
Depression
Osteoporosis
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“Normal” Quality/Cost Improvement
In Virtually All Medical Groups
1. Remind physicians about evidence based
standards, goals, pathways, etc.
–Put quality “pop ups” in EHR
–Generate a registry with lists of patients
2. Generate metrics and publish – (un)blinded
3. Hire additional staff to support the effort, remind
the patients, remind the doctors (i.e. PCMH)
4. Link outcomes to pay
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WHAT DO THE NORMAL METHODS
GAIN IN IMPROVEMENT?
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Medical Quality Goal:
Move One Variable (i.e. BP) G
roup M
ean P
erc
ent
to G
oal
10
70
60
50
40
30
20
80
90
100
Time in Months
1st 3rd 2nd 5th 4th 6th 8th 7th 9th 10th 11th 12th 13th 14th 15th 16th
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The IHI and “All or None” Goals
Wisconsin Diabetes
1. BP ≤129/79
2. A1c <7
3. LDL <100
Minnesota D5
1. BP ≤139/89
2. A1c <7
3. LDL <100
4. On Aspirin or Anti-thrombotic Tx
5. Non-smoker
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Three Goals @ 60% Each
»1st Goal 60%
»2nd Goal 36%
»3rd Goal 21.6%
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2010 Diabetes Outcomes (Using Wisconsin Measures)
0 5 10 15 20 25 30 35
Aurora Advanced
Aurora Medical Group
Aurora UW Medical
Bellin Medical
Columbia St. Mary's
Dean Clinic
Froedtert/West Bend
Gundersen Clinic
Marshfield Clinic
Mayo/Franciscan
Mayo/Eau Claire
Medical College
Mercy Health
Monroe Clinic
Prevea Health
ProHealth Care
ThedaCare
UW Health
Wheaton Franciscan
Percentage
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The “All or None” Hurdle
1 goal @ 90% / 60% each 90% 60%
2 goals @ 90% / 60% each 81% 36%
3 goals @ 90% / 60% each 72.9% 21%
4 goals @ 90% / 60% each 65.6% 12%
5 goals @ 90% / 60% each 59% 7.5%
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“Normal” Quality/Cost Improvement
In Virtually All Medical Groups
1. Remind physicians about evidence based
standards, goals, pathways, etc.
–Put quality “pop ups” in EHR
–Generate a registry with lists of patients
2. Generate metrics and publish – (un)blinded
3. Hire additional staff to support the effort,
remind the patients, remind the doctors (i.e.
PCMH, care coordinators, etc.
4. Link outcomes to pay
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About Quality Theory & Tools
• Used in virtually all other economic sectors
• Sophisticated ways to help make quality
improvements and cut costs
• Examples from every day life
• Examples: Six Sigma, Lean, TQI, etc.
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What Six Sigma & Lean Taught Us
1. Process, process, process
2. If you can’t measure it, you can’t improve it
3. Process, process, process
NB -- A process is a defined set of steps
designed to achieve a very specific goal
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First Medical Quality Project:
Create HTN Process
1. Use Six Sigma
2. Establish baseline performance – 42%
3. Start with an “Ishikawa” or “Fishbone”
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HTN %
TO GOAL
STAFF (POLICIES/PROCEDURES)
PROCESSES
INTERNAL ENVIRONMENT –SYSTEMS -OFFICE, EQUIPMENT, MATERIALS,
SUPPLIES, HARDWARE/SOFTWARE,
ETC.
HEALTHCARE ENVIRONMENT
(EXTERNAL) – INSUR. CO., GOV’T.
AGENCIES, SPEC., HOSPITAL, PHARM., ETC.
PATIENTS PHYSICIANS
Compliance
B.P. Tech.
√ Knowledge of HTN
Access. of Office for Pt.
Measurements Reported
No Shows
Policy/Comm. between Cardio., Spec.-
Renal (Role Clarity) Phys., & PCP’s
√ Algorithm
Following “visits” not “Pts.”
Home Monitor
Paying bills (invoice) Process
“Little Old Lady”
Resistance to SBP
Pt. provide full disclosure of meds.
Pt. Population (defining)
Process to f/u with Pt. √
Coverage – ICG Test
ICG
Delay of data
results (over a month)
BP Cuff
Efficiency of
Office
Role Clarification – PCP, Cardio, Renal
Review of Meds.
(med. list)
Algorithm
White Coat Synd.
√ Inter-phys. variation
√ Knowledge of HTN
Compliance
√ Time
Reluctance to treat
No shows
Money
Dialysis of Pts.
√ Knowledge of HTN
Planning (med refill)
Socio. / Econ./ √
Demographics / Ethnicity
√ Compliance
Motivation
(lack of)
Definition of Pt.
White Coat Synd.
√ Cost
“Little Old Lady”
Full disclosure of meds.
Employer (perception)
Pharmacy
Ambul. BP monitoring
Insurance
Media
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Creating the HTN Process - 1
1. Use Six Sigma
2. Establish baseline performance
3. Start with an “Ishikawa” or “Fishbone”
4. Create a true process that
• Addresses every HTN patient, every visit
• Includes Impedance Cardiography
• Guides drug selection and dosing
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Creating the HTN Process - 1
1. Use Six Sigma
2. Establish baseline performance
3. Start with an “Ishikawa” or “Fishbone”
4. Create a true process that
• Addresses every HTN patient, every visit
• Includes Impedance Cardiography
• Guides drug selection and dosing
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Creating the HTN Process
1. Use Six Sigma
2. Establish baseline performance
3. Start with an “Ishikawa” or “Fishbone”
4. Create a true process that
• Addresses every HTN patient, every visit
• Includes Impedance Cardiography
• Guides drug selection and dosing
5. Solve controversy with statistics
Example: ICG
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Inside Expert’s DOE Analysis
Usefulness of ICG
Y-hat Model
BP@Goal Factor Name Low High Exper
Factor Name Coeff P(2 Tail) Tol Activ
e
Const 0.47645 0.0000 A StatusCoded -1 1 0
C A StatusCoded -0.00136 0.7305 0.8938 X B AlgFollow edCoded -1 1 0
C B AlgFollow edCoded -0.00487 0.1671 0.9781 X C ICG_RightCoded -1 1 0
C C ICG_RightCoded 0.47597 0.0000 0.8767 X
R20.8710 Multiple Response Prediction
Adj R2 0.8709
Std Error 0.1742 99% Confidence Interval
F 6205.1690 Y-hat S-hat Lower Bound Upper Bound
Sig F 0.0000 BP@Goal 0.4765 0.1742 -0.046 0.999
FLOF 2.5130
Sig FLOF 0.0398
Source SS df MS
Regression 564.8 3 188.3
Error 83.7 2757 0.0
ErrorPure 83.4 2753 0.0
ErrorLOF 0.3 4 0.1
Total 648.5 2760
Effect Actual Coded
Constant 0.47645172 0.4765
A 0 0 -0.0013569 0
B 0 0 -0.0048689 0
C 0 0 0.4759703 0
0.4765
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Inside Expert’s DOE Analysis
Usefulness of ICG PriMed
Y bar Marginal Means
SBP &DBP Combined at BP Goal
Dec 05
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
-1 1 -1 1 -1 1
Effect Levels
StatusCoded
AlgFollowedCoded
ICG_RightCoded
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Creating the HTN Process
5. Measure use of HTN Process and outcomes
6. Unblinded publication of data
• What do you do with docs who do not use
HTN Process?
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Dr. A Dr. B Dr. C Dr. D Dr. E Dr. F Dr. G Dr. H Dr. I Dr. J
PriMed % HTN to Goal vs. % Copy of Algorithm vs. % Algorithm Followed
August 2005
% BP at Goal
% Copy of Algorithm
% Algorithm Followed
Average:
% HTN to Goal = 83%
% Algorithm Followed = 66%
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Dr. K Dr. L Dr. M Dr. N Dr. O Dr. P Dr. Q Dr. R Dr. S Dr. T
PriMed % HTN to Goal vs. % Copy of Algorithm vs. % Algorithm Followed
August 2005
% BP at Goal
% Copy of Algorithm
% Algorithm Followed
Average:
% HTN to Goal = 70%
% Algorithm Followed = 49%
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PriMed % HTN to Goal vs. % Copy of Algorithm vs. % Algorithm Followed
August 2005
% BP at Goal
% Copy of Algorithm
% Algorithm Followed
Average:
% HTN to Goal = 61%
% Algorithm Followed = 66%
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PriMed % HTN to Goal vs. % Copy of Algorithm vs. % Algorithm Followed
August 2005
% BP at Goal
% Copy of Algorithm
% Algorithm Followed
Average:
% HTN to Goal=49%
% Algorithm Followed=37%
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Creating the HTN Process
5. Measure: HTN Process use and outcomes
6. Publish results
• What do you do with docs who do not use HTN Process?
7. Link HTN Process compliance to physician compensation
• NOT based upon outcomes, based upon participation in the process
9. Constant work on “group culture”
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100% 100% 100% 100% 100% 100% 100%98% 98% 98% 98% 98%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% BP@Goal PriMed
Quartile 1September 2009
% BP @ Goal
%Protocol Followed
Averages:% BP@Goal = 99%% Protocol Followed = 100%
Dr. A Dr. B Dr. C Dr. D Dr. E Dr. F Dr. G Dr. H Dr. I Dr. J Dr. L Dr. K
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96% 96% 96% 96%94%
92% 92% 92% 92% 92% 92% 92% 92% 92%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% BP@Goal PriMed
Quartile 2 September 2009
% BP @ Goal
%Protocol Followed
Averages:% BP@Goal = 93%% Protocol Followed = 100%
Dr. M Dr. N Dr. O Dr. P Dr. Q Dr. R Dr. S Dr. T Dr. U Dr. V Dr. X Dr. W Dr. Z Dr. Y
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91%
90% 90% 90%
88%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
AHMAD SHAH WELLER ADIB PORTER
% BP@Goal PriMed
Quartile 3 September 2009
% BP @ Goal
%Protocol Followed
Averages:% BP@Goal = 90%% Protocol Followed = 99%
Dr. AB Dr. AA Dr. AD Dr. AC Dr. AE
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88% 88% 88%86% 86%
84% 83% 82%
75% 74% 73% 73%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% BP@Goal PriMed
Quartile 4 September 2009
% BP @ Goal
%Protocol Followed
Averages:%BP@Goal = 82%% Protocol Followed = 96%
Dr. AG Dr. AF Dr. AI Dr. AH Dr. AJ Dr. AL Dr. AK Dr. AN Dr. AM Dr. AO Dr. AP Dr. AQ
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Elite Medical Groups Post Intervention
Average US Performance
Percent of Patients Reaching JNC-7 BP Goal HTN Outcomes With or Without Co-Morbidities
MediSync Groups
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HTN vs Comorbid
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Nov-0
4
Jan-0
5
Mar-
05
May-0
5
Jul-05
Sep-0
5
Nov-0
5
Jan-0
6
Mar-
06
May-0
6
Jul-06
Sep-0
6
Nov-0
6
Jan-0
7
Mar-
07
May-0
7
Jul-07
Sep-0
7
Nov-0
7
Jan-0
8
Mar-
08
May-0
8
Jul-08
Sep-0
8
Nov-0
8
Jan-0
9
Mar-
09
May-0
9
Jul-09
Sep-0
9
% A
t G
oal
HTN Only
Comorbid
All
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2010 Diabetes Outcomes (Using Wisconsin Measures)
0 5 10 15 20 25 30 35
Aurora Advanced
Aurora Medical Group
Aurora UW Medical
Bellin Medical
Columbia St. Mary's
Dean Clinic
Froedtert/West Bend
Gundersen Clinic
Marshfield Clinic
Mayo/Franciscan
Mayo/Eau Claire
Medical College
Mercy Health
Monroe Clinic
Prevea Health
ProHealth Care
ThedaCare
UW Health
Wheaton Franciscan
Percentage
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2010 Diabetes Outcomes (Using Wisconsin Measures)
0 5 10 15 20 25 30 35 40
PriMed Physicians
Aurora Advanced
Aurora Medical Group
Aurora UW Medical
Bellin Medical
Columbia St. Mary's
Dean Clinic
Froedtert/West Bend
Gundersen Clinic
Marshfield Clinic
Mayo/Franciscan
Mayo/Eau Claire
Medical College
Mercy Health
Monroe Clinic
Prevea Health
ProHealth Care
ThedaCare
UW Health
Wheaton Franciscan
Percentage
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PriMed Physicians 2012 D5 Results by Office
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What Makes PriMed Different?
• It is NOT that:
– Dayton patients are
more eager to make
lifestyle change or
adhere to Rx
therapies
– PriMed doctors are
better educated