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

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


1
The Ins and Outs of the Clinical Assessment
ProgramProgram Directors Workshop
  • Breakout 3
  • Richard Snow DO, MPH
  • March 24th 2006

2
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

3
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

4
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

5
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

6
Newest reform Consumerism ?
ERA of Managed Care
DRGs Introduced
Patient Bill of Rights
7
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.

8
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
9
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
10
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
11
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

12
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?

13
CAP Results compared to STENO Abstract
14
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

15
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

16
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

17
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

18
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

19
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.

20
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

21
Discussion
  • Questions about the environment?
  • Similar dissimilar assessments?

22
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

23
Academic Years 2003-2005
24
Academic Years 2003-2005
25
Academic Years 2003-2005
26
Academic Years 2003-2005
27
Academic Years 2003-2005
28
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

29
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

30
AOA- CAP Low Back Pain Module
31
AOA- CAP Low Back Pain Module
32
AOA- CAP Low Back Pain Module
33
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

34
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

35
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

36
AOA CAP for Residencies
  • Focus shifting to improvement from measurement
  • What to we know regarding the science of
    improvement?
  • Identifying barriers
  • Developing solutions

37
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?

38
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

39
(No Transcript)
40
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?

41
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

42
Response Distributions
43
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

44
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
45
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

46
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  312-202-8363 asattler_at_osteopathic.org
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