Strategic Planning Retreat

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The HMO Alliance

• Strategic Planning Retreat

September 11-12, 2000
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Guiding Principles Going Forward

• Marcus Welby isnt just dead he never lived in
  the first place
• Everyday medical practice should be anchored to
  the greatest extent possible in science (over 50
  of medical care has never been validated by
  clinical trial)
• Information technology needs to be firmly
  anchored in health care
• Spending our limited resources only on care that
  is appropriate and effective is more than
  economic necessity it is also an ethical
  obligation

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Consider

• When Marcus Welby, M.D. premiered, 90 of
  Americans were covered by public or private
  insurance
• FFS reimbursement
• UR did not exist

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However

• Public dissatisfaction was pervasive
• 1967, Surgeon General Openly calls U.S. Medical
  Care Often of Low Quality, Fragmented and
  Impersonal
• House of Delegates of the AMA urged doctors to
  show more restraint in how much they charged

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1969

• White House Press Conference, President Nixon
  spoke of a Massive Crisis in American medicine
  and called for Revolutionary Change

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1970

• Fortune Magazine Editorial, Much of U.S. Medical
  Care, particularly the everyday business of
  preventing and treating routine illnesses....
  is inferior in quality, wastefully dispensed
  and inequitably financed.

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The Result

• Health Maintenance Organization Act of 1973
• Gave government support to the establishment of
  HMOs
• Supported by the American Medical Association

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1974

• The AMA gave Robert Young and James Brolin an
  award for promoting the positive image of doctors
• A House Subcommittee held the first public
  hearings on inappropriate care
• Children dying of complications from unnecessary
  tonsillectomies
• Studies published around unneeded hysterectomies

Meanwhile
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1982

• Presidents Commission for the study of ethical
  problems in Medical, Biological and Behavioral
  research concluded that as much as 35 of some
  high-tech hospital care was unnecessary

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1993

• National Health Reform
• AMA study
• 70 of population losing faith in its doctors
• 69 thought doctors too interested in

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1996-2000

• Managed care backlash in full force
• What have we been doing wrong for 30 years and
  why cant we fix it?

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The Care Management Business

• Random Physician Survey 1/5 to 1/2 physicians
  failed to make use of clinical advances in
  treating diabetes, Asthma, CHF and three other
  common conditions
• The Failure Well-intentioned and competent
  physicians to carefully examine what works best
  and integrate those findings into routine use

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Opportunities in Care Management
Example One
Heart Disease

• 1 Case of Death
• 150 Billion Annually
• Harvard Univ. Researchers Found
• 25 of bypasses, angioplasties and
  catheterizations performed on elderly heart
  attack victims have no effect on patient survival
• Study examined Medicare records in New Jersey
  found that 1/5 of eligible heart attack victims
  received Beta Blocker Therapy that could have
  increased their chance of survival by 20-40

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Opportunities in Care Management
Example One (continued)
Heart Disease

• Medicare studied MI victims in four states. 1/5
  patients never received indicated Thrombolytic
  therapy
• 1/3 of those patients never given instruction to
  take one aspirin a day
• 1/3 of the 1,023 U.S. hospitals performing open
  heart surgery performed fewer than 200 cases per
  year

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Opportunities in Care Management
Urinary Track Infections (UTI)
Example Two

• Family Practitioner Study re Simple UTIs, 82
  physicians responded with 137 different strategies

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Opportunities in Care Management
Example Three
Breast Cancer

• Dartmouth Center for the Evaluative Clinical
  Sciences 35-fold variation in the rate of
  Mastectomies versus Breast -- conserving surgery
  given Medicare beneficiaries across the country.
• Also true of back pain, prostate disease and
  others
• Geography is Destiny

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Opportunities in Care Management
Example Four
Maternity and Childbirth

• Publication Effective Care in Pregnancy and
  Childbirth, ECPC
• Most comprehensive review of all clinical trials
  in the world related to childbirth
• Conclusions
• 1/5 interventions did more harm than good
• Many others unproven
• Publication ignored by ACOG as Foreign

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Opportunities in Care Management
Example Four (continued)
Maternity and Childbirth

• American Journal of Obstetrics and Gynecology
• Routine Episiotomies are often unjustified (based
  on five randomized controlled trials)
• Clear evidence regarding harm Poorer future
  sexual capability

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The Opportunity for Health Plans

• Disease Management
• Harvard Pilgrim Health Care Childhood Asthma
• Data on Rx, audits, ER analyzed
• Outreach program developed
• Admits by 86
• ER visits by 79

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Kaiser Permanente Southern California
Pap Smears

• Analyzed membership and found 6/10 women eligible
  were receiving it
• Stretched out low risk women to 2-3 years
• Outreach to fill appointment voids
• New Policy doubled the number of women found with
  precancerous cells

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Defining Disease State Management
Integrated system of interventions, measurements
and refinements of health care delivery designed
to optimize clinical and economic outcomes within
a specific population
Key Elements

• Aggressive prevention of complications
• Effective treatment of chronic disease
• Interventions at critical points
• Systems approach, not component approach

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Benefits of Disease Management

• Provides for a systematic approach to manage high
  cost diseases
• Prevents exacerbation of disease and use of
  expensive resources
• Improves health outcomes
• Reduces costs
• Targets interventions on the group that has the
  greatest chance of affecting healthcare costs
• Fits the evolving healthcare system focusing on
  the measurement of outcomes, prevention, health
  promotion and cost containment
• Provides data to forecast how future high cost
  cases should be managed

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Complex Case Management

• This is not just about car wrecks and
  transplants
• 1.3 of members driving 34 of cost
• Do you know the names, addresses, phone numbers
  and attending physicians for your top 3 of
  members and are they in case management
• Many dont hit the hospital anymore
• Better have pharmacy data
• This is not about opening cases, monitoring and
  closing
• This is about blocking and tackling, long term
  compliance and intervention

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YOUR DASHBOARD LIGHTS

• LOS, days/1000, admits/1000 less important these
  days
• Top ten DRGs
• Top 3 members case management reports
• Top 20 physicians by dollars paid
• Top 3 hospitals by dollars paid
• Top 10 outpatient procedures
• Top 10 outpatient diagnostic tests
• PMPM for top 10 specialties