is consumer directed health care the magic bullet? leveraging the convergence of disease management...
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Is Consumer Directed Health Care the Magic Bullet? Leveraging the Convergence of Disease Management and Consumer Directed HealthPaul Wallace MDPermanente FederationKaiser [email protected]
The Disease Management ColloquiumMay 11, 2006Philadelphia
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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
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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
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Healthcares Middle Space Population Based Care* Chronic Condition Care* Care and Disease Management* Health and Wellness Interventions
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Population-based care: Managing the whole populationin Sickness and in HealthHealth + WellnessDisease MgmtPhysician Care
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The Blueprint From Improving Chronic Illness CareEd Wagner, MD, Group Health Cooperative of Puget Sound
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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
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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
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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
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Sample Plan Design Benchmark Deductible HMO (DHMO) PlanNon-Preventive ServicesPremiumPreventive ServicesDeductible20%copayPharmacycopay
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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
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Linking Plan Design to Clinical Relevance
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Sample Plan Design Benchmark DHMO Plan
Non-Preventive Services
Premium
Preventive Services
Deductible
20%
copay
Pharmacy
copay
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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
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What would you imagine is the dose response for skin in the game yielding health?Skin in the GameImproved Health
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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
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The Patient at the Center of Care
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How many hours a year does a personwith diabetes spend:In the health care system?At work?At Home? (At Pats?)
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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
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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
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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
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Direct to the Patient: Opportunities to Support and Integrate CareAsthma Featured Health Topic from the pull-down menuAnnouncement about asthma
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Asthma Featured Health Topic: Connecting to InformationInformacin en espaolLinks to evidence-based content, and Health Encyclopedia
Reviewed by subject matter experts
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Tools To Support Spanish Speaking Users
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Managing Your Asthma:Connecting to Appropriate ActionsLink to Asthma Triggers toolPhysicianFollow-upLink toasthma action planSelfManagement
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Managing Your Asthma:Connecting to Appropriate ActionsLink to Asthma Triggers toolPhysicianFollow-upLink toasthma action planSelfManagement
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Managing Your Asthma:Connecting to Appropriate ActionsLink to Asthma Triggers toolPhysicianFollow-upLink toasthma action planSelfManagement
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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
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Healthy Lifestyles: Tools to Improve Health
Online Health Assessments and Interventions Balance, Relax, Breathe, Nourish, Succeed
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UnderstandingHealthMedia Nourish tailored nutrition program for each individual
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participants set goals includingcalorie intake fat consumptionphysical activityselect the frequency they will report their progressSupporting Change : Goal Setting
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participants report their progressa graph shows their reported progress against their set goalsmore participants achieve their weight management goalsSupporting Change : Goal Setting
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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.*)
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Easy Access to the PatientsHealth and Medical Record
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Office visit summariesPaper copyhanded to the patient or family at the end of every visit and also available in the online health record
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ValueAffordabilityCareExperienceClinicalQualityPurchaserPerspective
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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
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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