The Ins and Outs of the Clinical Assessment Program Program Directors Workshop

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The Ins and Outs of the Clinical Assessment
ProgramProgram Directors Workshop

• Breakout 3
• Richard Snow DO, MPH
• March 24th 2006

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AOA-CAP Residency Program

• The Environment
• Teaching points from the CAP
• Getting our residents ahead of the curve in
  population management, evidence based medicine
  and contract negotiations (P4P)
• Research database
• Getting residents engaged on a research agenda
  around CAP data
• Resources

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AOA-CAP Residency Program

• The Results
• Where is AOA-CAP for residents now?
• Additional modules
• Low Back Pain
• Module with more meaning
• Measures of efficacy
• Results from the first 2 years
• Program participation rates

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AOA-CAP Residency Program

• Where do we go from here?
• How does this help prepare residents for their
  future?
• Process improvement
• Early results from successive years of
  contributing programs
• Model for improvement used in the industry
• Institute for Healthcare Improvement
• If we build it will they come
• Research agenda
• Presently a fully operational population based
  registry
• Value in an environment with a lack of knowledge

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Macroeconomic Forces Shaping Practice Environment

• The President's Reform Agenda Can Make The Health
  Care System More Efficient While Continuing To
  Lead The World In Cutting Edge Medicine.
  Americans should be able to choose their health
  care based on individual needs and preferences
  and easily obtain understandable information
  about the price and quality of the care they
  receive. Insurance should be portable and
  affordable. The President proposes to improve
  health care through initiatives to provide
  increased stability and peace of mind for working
  families across the country. The President's
  health care agenda includes
• Expanding Health Savings Accounts (HSAs)
• Making Health Insurance More Portable
• Improving Information On Price And Quality To
  Make Health Care More Transparent
• Leveling The Playing Field For Individuals And
  Small Business Employees
• Passing Medical Liability Reform
• Improving Access To Health Information Technology
  
• Assisting Vulnerable Americans

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Newest reform Consumerism ?
ERA of Managed Care
DRGs Introduced
Patient Bill of Rights
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What is behind Pay for Performance Movement?
(Remember DRGs)

• The payment reduction shows the need for more
  effective ways to pay physicians that help them
  improve quality and avoid unnecessary costs,
  said CMS Administrator Mark B. McClellan, M.D.,
  Ph.D.  CMS is working with members of Congress,
  physician organizations, and other healthcare
  stakeholders on ways to improve physician payment
  without adding to overall Medicare costs, if at
  all possible.  These collaborations build on
  Medicares performance-based payment
  demonstrations, value-based payment reforms
  implemented in the private sector, and especially
  promising measures and reform ideas from leading
  physician organizations.

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Why this can workExample of the STENO study

• 80 Type 2 diabetic patients with microalbuminuria
  randomized to
• Control
• Regular care
• Intensive intervention
• Step-wise introduction of lifestyle and
  pharmacological interventions aimed at keeping
• glycated hemoglobin lt6.5
• blood pressure lt130/80mmHg
• total cholesterol lt175mg/dl
• and triglycerides lt150mg/dl.
• reduction in intake dietary fat regular exercise
  and smoking cessation.

N Engl J Med 348383-393,2003
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Results of the STENO study

• Intermediate Outcomes

• Event Rate
• End Points
• death from CVD, nonfatal MI, nonfatal stroke,
  revascularization, and amputation.

N Engl J Med 348383-393,2003
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Results of the STENO studyThe business case and
The right thing to do

• Endpoints after 7.8 years of follow-up
• 44 of patients in the conventional care arm had
  events
• 24 of patients in the intensive treatment arm
  had events (significantly lower)
• In addition to the 53 reduction in CVD events
  the intensive treatment group had a reduction of
  nephropathy, retinopathy, and autonomic
  neuropathy by 61, 58, and 63 respectively

N Engl J Med 348383-393,2003
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Return on Investment

• For every 100 patients treated aggressively
• Achieving the numbers in this study
• There are 19 less events over 7.8 years
• 2.4 less events per year
• Estimate costs of events
• Conservative at 10,000
• Savings in this highly managed population of
  24,000/year

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What does this mean for CAP?

• Of the 3,149 diabetic patients in the CAP
  registry 2,176 had screening for albuminuria
  (69) and 831had albuminuria (38)
• Who do we look compared to the STENO population?

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CAP Results compared to STENO Abstract
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What does this mean to future practicing
physicians?

• Shift in payment from services to product.
• Issues with locus of control.
• Shift in focus from seeing patients and doing
  procedures to evidenced based medicine and
  managing populations
• Rewards for
• Tools to identify chronic disease populations
• Implementation of consistent (electronic) methods
  of assuring laboratory and preventive medicine
  follow-up
• Increased capacity to connect with and educate
  patients over time
• Use of evidenced based medicine

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What does this mean to future practicing
physicians?

• Key ingredients
• Population Perspective
• We teach patient care very well, how well do we
  teach physicians the population perspective and
  systems of care
• Evolving but opportunities exist to define
  osteopathic training in this venue
• Improving resident interest in programs
• Managing systems of care
• Increasing efficiency and improving outcomes
  using community or local resources
• Group patient teaching
• Developing disease management capabilities locally

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What does this mean to future practicing
physicians?

• Key ingredients
• Registry
• Ability to track populations is a key component
  in managing a practice from a population
  perspective
• Key component of most P4P programs executed
  recently
• Identify populations and trends of interest
• As a function of EMR
• Moving from a passive to active approach to
  Electronic Medical Record
• CAP as a training tool in this venue

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What does this mean to future practicing
physicians?

• Key ingredients
• Support to break through barriers or understand
  why we can not effect the outcome
• Physician
• Perspective and culture
• Patient
• Taught and incentivised
• System
• What resources do we need to systematically
  achieve good to excellent outcomes

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Population management

• What payers, employers and patients want.
• NCQA Practice Connections
• CMS Demonstration Project
• Medicare 646
• Realigning health care by changing financial
  incentives
• United Health Care
• Discussions

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Research Agenda

• Results from the STENO study and interest
  expressed by Medicare to develop a budget
  neutral approach to realigning incentives
  suggest that there are opportunities to fill in
  the knowledge gaps in applied health services
  research.
• This is a fertile ground for research dollars and
  publications.

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Opportunity

• Teaching our osteopathic residents to be part of
  the problem or part of the solution?
• Practicing osteopathic physicians should welcome
  objective measures of the care we deliver and the
  ability to compete on a level playing field.
• The foundation of what consumers, employers, and
  payers want is what primary care can provide
  Co-ordinated cognitive care

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Discussion

• Questions about the environment?
• Similar dissimilar assessments?

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AOA-CAP Residency Program

• Summary of the first 2 academic years
• Changes for 2005-2007
• Continuous abstraction
• Monthly report generation
• Need for clarifying end data
• Expanded measures
• Pulmonary (COPD and Asthma)
• Low Back Pain
• Measures of Efficacy
• Adding Internal Medicine Programs
• Shifting from measurement to improvement
• Model for implementation?
• Incentive

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Academic Years 2003-2005
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Academic Years 2003-2005
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Academic Years 2003-2005
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Academic Years 2003-2005
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Academic Years 2003-2005
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Academic Years 2003-2005

• Residency requirement to complete the Diabetes
  Mellitus and Low Back Pain Modules during the 2
  academic years
• Diabetes Module completed by 75 programs
• Low Back Pain Module completed by 57 programs
• Programs fulfilling requirement of both Low back
  Pain and Diabetes Mellitus Abstraction 47

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AOA- CAP Low Back Pain Module

• History of measure set
• Elements collected
• Value
• Evidence base in OMM
• Guideline development using the CAP as an
  observational study
• Development of efficacy measures
• Evaluate variation in low back pain treatment and
  associations with resource utilization

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AOA- CAP Low Back Pain Module
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AOA- CAP Low Back Pain Module
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AOA- CAP Low Back Pain Module
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Low Back Pain2005-2007

• Background
• Observational Study regarding OMT
• Pilot project demonstrates variance in use of OMT
  during low back pain treatment
• Use this natural variation to evaluate patient
  response to OMT
• Need to control for presenting symptoms
• Development of efficacy study for low back pain
• Meetings with CMS
• Direction of the Ambulatory Quality Association
• Insurance industry
• Additional Elements to evaluate patients response
  to treatment and use of resources
• Split into two projects
• Following information is where we are now in
  terms of data collection

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AOA CAP Low Back Pain2005- 2007

• Timeline
• Final module launched December 05
• Negotiation on elements
• Residencies populating fields presently
• Anticipate early analysis by May June time
  frame.
• Feedback from participants
• To the BOCER

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Discussions

• Operational issues with the first 2 years
• Continuous data entry
• Operational issues with the years 2005-2007
• Clinical modules in place
• Low Back Pain

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AOA CAP for Residencies

• Focus shifting to improvement from measurement
• What to we know regarding the science of
  improvement?
• Identifying barriers
• Developing solutions

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Trended Data

• Moving into the new academic year provided
  adequate time for motivated programs to deploy
  interventions to effect process and outcomes of
  care.
• Educational feedback?
• Tickler systems?

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Early Results from the Diabetes Module

• Based on 6 programs contributing data from
  2003-2005 (Wave 1 and Wave 5) and 2005-2007
• Comparisons
• All CAP submission for 2003-2005
• HEDIS
• Commercial population

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Engaged Programs

• These 6 programs are the first to re-measure and
  have demonstrated improvement.
• Can we learn from things they are doing within
  their programs?
• Models for process sharing
• Institute for Healthcare Improvement
• Should we have a recognition program within this
  group?

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Resident Response

• Part of the new DM module (2005-2007) collects
  information regarding actions documented in the
  medical record to elevated HgbA1c and LDL
• HgbA1c gt 7
• LDL gt 100 mg/dl
• Compared new participants to repeat participants

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Response Distributions
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DiscussionWhere do we go from here?

• Process comparison between programs
• Model of IHI
• Interest
• User group interested in research
• Academic programs as partners
• External funding
• AHRQ
• Model

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Factors affecting diabetic control in CAP
Residency ProgramsAn example why risk adjustment
/ stratification is important at the physician
level
AHA Outcomes Conference April 2005 Wash DC
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DiscussionWhere do we go from here?

• Research ingredients
• Study population
• Study design
• Academic partners
• Funding
• Research resource within specific programs
• Nurse coordinator
• What is the breaking even point?
• IRB approval

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AOA-CAP Contact

• Arlene R. Sattler, MS, RHIA, CPHQ
• Manager, Quality Programs
• American Osteopathic Association
• 142 E. Ontario St. Chicago,IL
• 312-202-8063
• 1-800-621-1773, ext. 8063
• Fax  [phone] asattler_at_osteopathic.org