Leading Edge Opportunities in Health Care and Medicine:

Using Data to Increase Value

Bob Gluckman, MD, FACPCMO- Providence Health Plan

January 25, 2013

Exhibit 1. International Comparison of Spending on Health, 1980–2010

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

USSWIZNETHCANGERFRAUSUKJPN

Average spending on healthper capita ($US PPP)

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

0

2

4

6

8

10

12

14

16

18

USNETHFRGERCANSWIZUKJPNAUS

Total health expenditures aspercent of GDP

Notes: PPP = purchasing power parity; GDP = gross domestic product.Source: Commonwealth Fund, based on OECD Health Data 2012.

2

20012003

20052007

20092011

20132015

20172019

20210

5

10

15

20

25

30

35

1213

1517

18 18 18 18 1920

22 23 24 25 26 26 27 28 29 30 31

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

0

25

50

75

100

125

150

175

200 Health insurance premiumsWorkers' contribution to premiumsWorkers' earningsOverall inflation

Exhibit 3. Premiums Rising Faster Than Inflation and Wages

Sources: (left) Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits Annual Surveys, 1999–2012; (right) authors’ estimates based on CPS ASEC 2001–12, Kaiser/HRET 2001–12, CMS OACT 2012–21.

Projected average family premium as a percentage of median family income,

2013–2021

Cumulative changes in insurance premiums and workers’ earnings,

1999–2012

Percent Percent

180%

47%

38%

Projected

172%

200101

200106

200111

200204

200209

200302

200307

200312

200405

200410

200503

200508

200601

200606

200611

200704

200709

200802

200807

200812

200905

200910

201003

201008

201101

2011060.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Member Cost Sharing

Member Cost Sharing

Deductible

Incurred Month

Mem

ber

Port

ion

of A

llow

ed A

mou

nt

2006 2007 2008 2009 2010 Jan-Dec 11$0.00

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

PHP All Commercial InsuredPer Member Per Month Expenses

(Portland Service Area Only)

PCP Spec Hosp RX Admin

PMPM

Case and Disease ManagementHealth Care Cost Continuum - Why We Focus on Specific members

Source: Milliman USA Health Cost Guidelines—2001 Claim Probability Distributions.

% of People

1% of People

30% Total Cost

10% Total Cost

70% of People

0% Total Cost

20% of People

6

JAMA 2012;307:1513-1516

Exhibit 7. Synergistic Strategy: Cumulative Savings, 2013–2023

Payment reforms to accelerate delivery system innovation ($1,333 billion)

• Pay for value: replace the SGR with provider payment incentives to improve care• Strengthen patient-centered primary care and support care teams• Bundle hospital payments to focus on total cost and outcomes• Align payment incentives across public and private payers

Policies to expand and encourage high-value choices ($189 billion)• Offer new Medicare Essential plan with integrated benefits through Medicare, offering positive

incentives for use of high-value care and care systems

• Provide positive incentives to seek care from patient-centered medical homes, care teams, and accountable care networks (Medicare, Medicaid, private plans)

• Enhance clinical information to inform choice

Systemwide actions to improve how health care markets function ($481 billion)• Simplify and unify administrative policies and procedures• Reform malpractice policy and link to payment*• Target total public and private payment (combined) to grow at rate no greater than GDP

per capita**

Notes: SGR = sustainable growth rate formula; GDP = gross domestic product.* Malpractice policy savings included with provider payment policies.** Target policy was not scored.

Seven Megatrends That Will Influence the Healthcare Industry

• Demanding demographics– Aging, obesity, income inequality

• Strategic globalization– Competitive global economy, medical tourism

• Unconstrained connectivity– Personal health records, smartphone apps

• Accelerated consolidation– ? Impact on cost

www.medcitynews.com/?s=keckley

Seven Megatrends That Will Influence the Healthcare Industry

• Constrained resources– Limited public budget, inability to shift costs

• Consumer discontent– Cost sharing, mistrust of government, payers,

providers• Big data

– Ability to aggregate data to demonstrate quality and cost variation

Integrating Claims and Clinical Data to Improve Quality and Lower Cost

Cardiology

Appropriateness of Diagnostic Angiography

Retrospective analysis of 565,504 patients without previous MI or revascularization from 2005-2008 undergoing elective

coronary angiography

JACC 2011;58:801-809

Cardiology- Practice Variation

Cardiac Procedure Rates by Top 6 Regions (Jan 2010-Sep 2011)

Data from Large Employer

CAD Presentation in Patients Receiving Diagnostic Coronary Angiography

A B C D E F0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

22.4% 25.9%32.3%

19.0%27.8%

5.7%

8.4%11.5% 3.4%

5.6%

22.2%

10.8%

27.2%

31.3% 40.1%

45.7%

31.2%

56.8%

42.0%31.4%

24.3% 29.8%18.9%

26.7%

No Symptoms and Symptoms Unlikely to be Angina Stable Angina Unstable Angina Non-STEMI and STEMI

CAD Presentation in Patients Receiving PCI

A B C D E F0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3.1% 5.1%11.0%

2.9%12.7%

5.9%3.1%

10.1% 1.6%2.4%

21.6%

10.4%

30.4%

36.8% 36.8%44.1%

34.3%

56.3%

63.5%

48.6% 50.6% 50.6%

31.4% 27.4%

No Symptoms and Symptoms Unlikely to be Angina Stable Angina Unstable Angina Non-STEMI and STEMI

Two or More Anti-Anginal Meds in PCI Patients without ACS

A B C D E F0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%38.5%

19.8%

36.2%

11.4%

23.4%

31.8%

Note: 100% Agreement on Class I and Class III Guidelines

CardiologyI = Inappropriate U = Uncertain A = Appropriate

Large Statewide Employer Caths/1,000 in a High Use Community

Large Statewide Employer Stents/10,000 in a High Use Community

Large Statewide Employer CABGs/10,000 in a High Use Community

PEBB Cardiac Procedure Rates by Top 6 Regions (Jan 2010 - Dec 2011)

Cardiac Caths/1,000 Cardiac Stents/10,000 CABG/10,0000

3

6

9

12

15

2.0

4.4

2.62.7

7.5

2.3

5.6

13.4

6.1

3.1

10.7

1.7

3.3

8.5

4.7

2.4

7.1

2.7

Large Statewide Employer Cardiac Procedure Rates by Top 6 Regions (Jan 2012 – Sep 2012)

Cardiac Caths/1,000 Cardiac Stents/10,000 CABG/10,0000

3

6

9

12

15

2.2

7.6

1.91.7

7.3

3.64.1

10.0

4.8

2.43.0

6.0

2.5

4.9

3.7

2.3

9.8

6.8

CAD Presentation in Patients Receiving PCI

1--37

2--53

3--101

4--36

5--247

6--254

7--824

8--127

9--321

10--46

11--44

12--329

13--184

14--69

15--143

16--24

17--36

18--46

19--394

20--48

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

22%32% 34%

44% 45% 46% 47% 47% 47% 52% 55% 58% 59% 59% 62% 63% 64%70% 70% 75%

68%53%

43%31% 25%

13%

29% 30%

8%

20% 18% 15%18%

23%

3%13%

28% 13%3%

6%

0% 8%

3% 8%24%

36%12%

17%

39%13% 14%

19% 13%9%

27% 8%

3%

7% 23% 2%

11% 8%

21% 17%6% 5%

12%6% 5%

15% 14%8% 10% 9% 8%

17%6%

11%4%

17%

Distribution of Stress Testing w/ High Tech Imaging

Stress w/ SPECT only, 52.5% Stress w/ ECHO only, 19.5%Stress w/ SPECT and ECHO, 19.2% Stress only, 8.8%

Provider Group-count of total Stress tests(% below represent averages across all groups)

% o

f tot

al co

unt o

f Str

ess T

ests

Test performed by cardiologist within 30 days of cardiologist office visit25

Integrating Patient Outcome Data to Improve Care

Orthopedics and Neurosurgery

Total Joint Replacement and Spine Surgery

• Add pre-operative and 6 month post-op standardized assessment of pain and functional status– WOMAC- TJR– OSWESTRY- LS Surgery– NDI- cervical spine surgery

Using Data to Target Care to the Right Patients

GI-Colonoscopy

Cumulative Mortality from Colorectal Cancer in the General Population, as Compared with the Adenoma and Nonadenoma Cohorts.

Zauber AG et al. N Engl J Med 2012;366:687-696

Colonoscopy vs. Fecal Immunochemical Testing in Colorectal Cancer Screening

Colonoscopy FIT

Cancer 0.5% 0.3%

Advanced adenoma 9.7% 2.4%

Non-advanced adenoma 22.1% 1.1%

Rate of high grade dysplasia or cancer with 5 year surveillance colonoscopy

Baseline colonoscopy findings Rate per 1000 patient years

No neoplasia 0.7

Adenoma < 10 mm 1.5

Large tubular or any villous adenoma

6.4

High grade dysplasia 26.0

Cancer 74.8

Complication rate requiring surgery approximately 1 per thousand proceduresGastroenterology 2007; 133; 1077-85

PHP Diagnosis Associated with Colonoscopy: 2011-12

Other33%

Polyp18%Scree

ning30%

Sur-veil-lance20%

Colonoscopy Dx.(Age 75-79)

Other52%

Polyp15%

Screen-ing19%

Surveil-lance14%

Colonoscopy Dx. (Age 80+)

Is this a shared decision making opportunity?

• A collaborative process between patients and physicians

• Uses best scientific evidence• Considers patient values and preferences

Final Thoughts

• Data can inform physicians on current practice and opportunities to improve value

• Transparency needed to better inform patients and physicians on how practice variation impacts the value of care

• Payment reform required to create better value• Improving value essential to pay for new

treatment