physician and society patientphysician population family health care structure/financing scientific...
TRANSCRIPT
Physician and SocietyPhysician and Society
Patient Physician
Population
Family
Health Care Structure/Financing
Scientific Paradigm (EBM)
Other Care Providers
Integrative Medicine
Culture
Culture of Biomedicine
Care Recipients Care Providers
CARE
Ethics LawEnd-of-Life Information Age
Community
Physician and Society
1. Patients, Providers, and Quality
2. Models of Medical Care
3. Chronically Ill, Poor, and Uninsured
4. Use of Informatics in Health Care
5. Public Health Ethics
Physician and Society
Organizational Strategies Series
Physician and Society
Disease Management
of Chronic Illness
Physician and Society
What is “Disease Management”?• Packaging of familiar and longstanding
clinical concepts centered around a condition
• Systematic, population-based approach to identify patients at risk, intervene with specific therapeutic programs, and measure clinical outcomes of interest
Physician and Society
Proactive Chronic Care (Disease Management) Model
Case Finding
Assessment
Management
Physician and Society
Proactive Chronic Care (Disease Management) Model
Case Finding
Assessment
Management
Physician and Society
Identifying High-Risk Patients
• Recognition by clinicians
Physician and Society
Identifying High-Risk Patients
• Claims data
Physician and Society
Identifying High-Risk Patients
• Surveys
Physician and Society
Proactive Chronic Care (Disease Management) Model
Case Finding
Assessment
Management
Physician and Society
Assessment of High-Risk Patients
• Performed by trained CM
• Straightforward vs multidimensional needs
• Medical and non-medical factors
Physician and Society
Proactive Chronic Care (Disease Management) Model
Case Finding
Assessment
Management
Physician and Society
Management of High-Risk Patients
• Case management
• Primary care referral
• Specialty care
• Team care
• Pharmacy
• Home care
Physician and Society
The Challenge of Chronic Diseases—the Chronic Care Model
Ed Wagner MD, MPHMacColl Institute for Healthcare Innovation
Group Health Cooperative
Improving Chronic Illness Care,a national program of The Robert Wood Johnson Foundation
Physician and Society
State of the Art in Chronic Illness Care Improvement
• Major clinical advances in most major chronic illnesses
• Growing appreciation that the patient’s (and family’s) self-management skill heavily influences outcomes
• But, patients not reaping benefits of new knowledge
Physician and Society
Current status of Chronic Illness Care in the U.S.
• 27% of hypertensives are adequately treated• 29% and 26% of diabetics have well controlled
lipid and blood pressure levels, respectively• 35% of eligible patients with atrial fibrillation
receive anticoagulation• 25% of people with depression are receiving
adequate treatment• 50 % of discharged CHF patients are
readmitted within 90 days
Physician and Society
Why are we doing so poorly?
The IOM Quality Chasm report says:
• “The current care systems cannot do the job.”
• “Trying harder will not work.”
Physician and Society
Usual Chronic Illness Care• Oriented to acute illness
• Focus on symptoms and lab results
• Patient’s role in management not emphasized
• Care dependent on provider’s memory and time
• Interaction often not productive, and frustrating for both patient and doctor
Physician and Society
What Will Improve Chronic Illness Care?
The IOM Quality Chasm report says:
• “Changing care systems will.”
Physician and Society
The Goal of System Changes to Improve Chronic Illness Care
PatientProductiveInteractions
Practice Team
a planned set of interactions
over time during which the critical clinicaland behavioral elements of care are performed reliably
Physician and Society
What characterizes an “informed, activated patient”?
Informed,ActivatedPatient
They have the motivation, information, skills, and confidence necessary to
effectively make decisions about their health and manage it
Physician and Society
What characterizes a “prepared” practice team?
PreparedPractice Team
At the time of encounters, they have the patient information, clinical expertise, team,
equipment, and time required to deliver evidence-based clinical management and
self-management support
Physician and Society
Randomized trials of system change interventions: Diabetes
Cochrane Collaborative Review• 41 studies, majority randomized trials
• Interventions classified as provider-oriented, organizational, information systems, or patient-oriented
• Patient outcomes (e.g., HbA1c, BP, LDL) only improved if patient-oriented interventions included
• All 5 studies with interventions in all four domains had positive impacts on patients
Renders et al. Diabetes Care 2001;24:1821
Physician and Society
Randomized trials of system change interventions: Heart failure
• 11 randomized trials• Most reduced hospitalization significantly• Most successful employed a nurse case
manager working with cardiology and primary care
• Care guided by protocol and strong emphasis on self-management support
• 7/8 examining costs found cost savings
McAlister et al, Am J Med 2001
Physician and Society
Does improved chronic care reduce health care costs?
• 28 randomized trials studied interventions related to the chronic care model and examined costs (diabetes, CHF, asthma)
• 17 showed either cost savings or utilization decreases
Bodenheimer et al. JAMA 2002;288:1909
Physician and Society
Interventions Supportive of Productive Interactions
• Provider-oriented
• Patient-oriented
• Practice-orientedInformation Systems
Physician and Society
The Goals of System Change Interventions to Improve Practice
• Provider-oriented—enable practice team to deliver evidence-based care to EVERY patient
• Patient-oriented—develop informed, activated patients who are competent self-managers
• Practice-oriented—design practice teams, patient encounters, and data systems that enable productive interactions
Physician and Society
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
Self-management Support
Provide effective self-management interventions
and ongoing collaborative goal-setting and
problem-solving by the team.
Physician and Society
Self-management Support
What is self-management?
“The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.”
Barlow et al, person Educ Couns 2002;48:177
Physician and Society
Effective self-management Support
• patient major role in managing her illnesses and treatment emphasized
• her knowledge, behaviors and confidence routinely assessed
• goals for improving self-management set collaboratively with practice team
• advice based on evidence and presented as information not scolding
Physician and Society
Effects of Self-management Education on Glycemic Control
• 31 RCTs evaluated effects on HbA1c• Average 6 contacts and 9 contact hours• Most often delivered by nurse-dietician-physician
team• 2/3 in groups• Reduction in HbA1c increased with contact time
(1% for every added 24 hours of contact)• Effect diminished shortly after end of class
Norris et al, Diabetes Care 2002; 25:1159
Physician and Society
Delivery System Design
• Practice team has defined roles, uses
planned visits and clinical case
management to support evidence-based
care, and assures regular follow-up and
care coordination
Physician and Society
Nurse Case Management RCT-Aubert et al.Change in Treatment and Glycemic Control
Between Baseline and 12 Months
-2.0%
-1.5%
-1.0%
-0.5%
0.0%
0.5%
1.0%
Change in HbA1c Change in % onInsulin
InterventionControl
Diabetes Cluster Visits, Sadur et al Change in Treatment and Glycemic Control Between
Baseline and 12 Months
-1.4%
-1.2%
-1.0%
-0.8%
-0.6%
-0.4%
-0.2%
0.0%
Change in HbA1c
InterventionControl
Decision Support
• Weave evidence-based guidelines into
fabric of practice: e.g., reminder and fail-
safe systems (e.g., standing orders),
specialist involvement with primary care,
problem-based learning
Physician and Society
Clinical Information System: Registry
• A database of clinically useful and timely
information on all patients provides
reminders and feedback and facilitates
care planning for individuals or
populations
Physician and Society
Health Care Organization
• Organization encourages and supports
better care through leadership, quality
improvement& incentives
Physician and Society
Community Resources and Policies
• Health care organization has linkages with
community organizations that can enhance
practice capabilities, provide key patient
services, or improve care coordination
Physician and Society
Examples of Community Linkages
• Exercise programs in local Y or gym
• Peer support programs
• Hospital nurse educator loaned to practice
• Endocrine practice nurse loaned
Physician and Society
The Quality ChasmUsual Care versus Improved Care
• Readmission rates of patients hospitalized with CHF reduced by about 50%
• Recovery rates from major depression increased 50-100%
• Children with moderately severe asthma have symptoms 14 fewer days/year
• Anticoagulated patients in safe and effective range twice as frequently
Physician and Society
Differences between Organized Programs and Usual Care of Chronic
Illness• Average HbA1c of type II diabetics will be 1%
+ lower• 1.5 - 2 times as many patients with major
depression will be recovered at six months• Readmission rates of patients hospitalized with
CHF will be cut in half• Asthmatic kids will be in school two more
weeks a year
Physician and Society
8.35
9.19
8.108.54
6
7
8
9
10
A-9
9
J-99
O-9
9
J-00
A-0
0
J-00
O-0
0
J-01
A-0
1
J-01
O-0
1
J-02
A-0
2
J-02
O-0
2
J-03
A-0
3
J-03
O-0
3
J-04
Reporting Month
DC1_Avg DC2_Avg
Goal
BPHC Diabetes Collaboratives 1and 2involving 180 Community Health Centers
and 38,000 diabetic persons
Average HbA1c Values
Physician and Society
How do you provide
care for those who
can’t afford it?
Physician and Society
Physician and Society
Structure and
Financing of Care for
the Poor and Uninsured
in America
Physician and Society
Physician and Society
Medicaid
Physician and Society
• Federal/state health insurance program
• For low-income persons
• 51 million enrollees in 2002
• 2002 Medicaid expenses: $259 billion
• 2002 Medicare expenses: $257 billion
Physician and Society
Medicaid – Medicare Similarities
Physician and Society
• Both enacted in 1965
• Both are entitlement programs
• Both are overseen by CMS
Medicaid – Medicare Differences
• Champion
– Medicare: President Johnson
– Medicaid: Congress (Wilbur Mills, D-Ark)
• Financing
– Medicare: purely federal
– Medicaid: joint federal/state
Physician and Society
Medicaid – Medicare Differences
• Beneficiaries
– Medicare: Virtually all elderly
– Medicaid: All ages
• Covered Benefits
– Medicare: set by feds, same for all enrollees
– Medicaid: set by states, different by states
Physician and Society
Medicaid – Medicare Differences
• Enrollment Criteria
– Medicare: age and/or disability only; set by feds
– Medicaid: financial and other health and social criteria; set by individual states
Physician and Society
Physician and Society
Medicaid Financing
Physician and Society
Physician and SocietyPhysician and Society
S.S. Taxes
CMS Individual Providers
Medicare + Choice Plans
$$
$$
Medicare
Physician and SocietyPhysician and Society
S.S. Taxes
CMSHealth Care
Providers
$148 billion
$259 billion
Medicaid (2002)
State Taxes
State Medical
Assistance Programs
Physician and Society Medicaid Expenses
Physician and Society Medicaid Beneficiaries
Physician and Society
Medicaid Expenses
Physician and Society
• Disproportionately to disabled
• Disproportionately to elderly
• Disproportionately to long term care
Physician and Society
Selection of Medicaid Beneficiaries
Physician and Society
• Each state sets own criteria
• Based on financial need and eligibility
Physician and Society
Selection of Medicaid Beneficiaries
Physician and Society
• Each state sets own financial criteria for:
– Families with dependent children on welfare
– Families with parent getting off of welfare
• Feds establish mandatory eligibility groups:
– Low-income pregnant women
– Low-income children
– Low-income elderly or disabled persons
Physician and SocietyPhysician and Society
MN MA Eligibility
Physician and Society
Medicaid Covered Benefits
Physician and Society
• Benefits package much more extensive than for private insurance
• Cost sharing by patients largely prohibited
• Restricting coverage to certain groups prohibited
• Caps for certain diagnoses prohibited
Physician and Society
Challenges to States
Physician and Society
• Budgetary problems
• Growth of Medicaid – projected to grow faster than national health expenditures
• Federally imposed eligibility criteria and restrictions on patient spending
• Federally imposed partial benefits package
• Matching federal funds
Physician and Society
State Medicaid Fiscal Strategies
Physician and Society
• Managed care (now 100% of MA enrollees)
• Controlling drug costs
• Decreasing physician payment rates
• Restricting eligibility (mostly financial criteria)
• Reducing benefits
• Increasing copays
Physician and SocietyPhysician and Society
S.S. Taxes
CMSMedicaid
Managed Care Plans
$148 billion
$259 billion
Medicaid (2002)
State Taxes
State Medical
Assistance Programs
Physician and Society
The Uninsured
Physician and Society
• Who are they?
• How do costs inhibit care?
• Where do they get care?
• How healthy are they?
Physician and SocietyPhysician and Society
Physician and Society
Physician and Society
Physician and Society
Physician and Society
Physician and Society
The Uninsured in
Minnesota
Physician and Society
Physician and Society
Physician and Society
How do we do it?
Physician and Society
• Employer-provided commercial insurance
• Medicaid (Medical Assistance)
• MinnesotaCare
• General Assistance Medical Care (GAMC)
Physician and Society
MinnesotaCare
Physician and Society
• 1988 -- Children’s Health Insurance Program (CHIP)
• 1992 – MinnesotaCare enacted; CHIP folded into it shortly thereafter
• Provides insurance for low income persons who do not have access
– Not on Medicaid (Medical Assistance)
– Not on commercial insurance
Physician and Society
MinnesotaCare
Physician and Society
• Covers families with children with incomes up to 275% of federal poverty guidelines
• Covers individuals/families without children up to 175% of FPG
Family Size FPG MNCare Elig.
2 $12,120 $33,000
4 $18,400 $50,000
Physician and Society
MinnesotaCare Financing
Physician and Society
• State dollars
• 1.5% tax on hospitals and health care providers
• Federal funds
• Enrollee premiums, copays, deductibles
– Average premium is $18/month
– $3 copay per Rx, $25 per pair of glasses
– $1,000 inpatient deductible
Physician and Society
General Assistance Medical Care
(GAMC)
Physician and Society
• Covers low-income persons who do not qualify for other state or federal insurance programs
– Primarily adults without dependent children
• 100% state funded
69%
13%
9%
5%3%1%
Private Insurance
Medicare
Medical Assistance
General Assistance
MinnesotaCare
No Insurance
Physician and Society Health Care Coverage in Minnesota