quality in laboratory medicine conference business case for quality recognizing excellence in...
TRANSCRIPT
Quality in Laboratory Medicine Conference
Business Case for QualityRecognizing Excellence in Practice
Presented to the Institute for Quality in Laboratory Medicine
by Dr. Robert Kropp
Aetna Health Inc.
Atlanta, Georgia
April 29, 2005
Business Case For Quality Business Case for Lab Data
Managed care’s objective is getting and keeping people healthy
Our commitment is to improving the quality of health care and health outcomes
Access and availability of accurate and timely lab data plays a key role in monitoring and measuring quality of care
Business Case For Quality Application of Lab Data
Lab results are one of the few quantifiable clinical outcome measures available from easily accessible data (not chart review)
Because of the sensitivity and specificity of lab results, they are applicable as a proxy for health outcomes
Lab result data is strongly correlated with health outcomes and is applied in predictive modeling
Provides a standardized measure of the delivery of quality care
Business Case For Quality Care Management
Disease Management
Case Management
Business Case For Quality Disease Management
Disease management compares the care delivered to the care recommended
Lab results are used to identify members with the target disease, and to measure health care outcomes
Business Case For Quality Case Management
Case Managers have lab results on-line and available when contacting members to monitor their health status
– HbA1c level history showing good control and adequate disease management
Business Case For Quality Quality Improvement
Appropriateness of Care
Effectiveness of Care
Patient Safety
Improving Quality of Care
Business Case For Quality Operational Definitions
Appropriateness of care – “What is being done”
– The indicated lab test has not been ordered to monitor a known condition
Effectiveness of care– “How” effective is the treatment
– The lab test test has been ordered, but the result is abnormal
Business Case For Quality Appropriateness of Care
Warfarin and no evidence of INR monitoring in the past 3 months.
Evidence for glitazones and no evidence of liver function monitoring in the past 6 months.
Member with diabetes and no evidence of screening for HbA1c or microalbuminuria in the past year.
Elevated LDL cholesterol level and no evidence of a lipid-lowering agent.
MedQuerySM Care Considerations
Business Case For Quality Effectiveness of Care
Evidence of warfarin and lab data indicating persistent or recurrent sub-therapeutic INR values
Evidence of diabetes and lab data indicating elevated glycated hemoglobin (HbA1c) level
Evidence for diabetes and lab data indicating an LDL cholesterol greater than 100 mg/dl and/or HDL cholesterol less than 40 mg/dl
Business Case For Quality MedQuery
The MedQuery program alerts physicians to opportunities for improved care by applying state-of-the-art clinical algorithms to the medical information derived from claims, pharmacy claims, laboratory results and demographic information.
This technology generates specific recommendations applicable to a specific member and delivers these recommendations to the treating physician.
Business Case For Quality Patient Safety
Lab data assists Pharmacy Management to identify drug-to-disease interactions
– The use of a beta blocker in a member diagnosed with asthma, based on a previous theophylline level
Abnormal lab results are used to identify unintended or potentially dangerous side effects of prescription drugs
– Low platelet count and a drug that can cause thrombocytopenia
Business Case For Quality Patient Safety
Elevated lab results are used to identify drug toxicity or drug/drug interactions
– Elevated serum level of carbamazepine and drug(s) that can interfere with its hepatic metabolism
– Elevated serum phenytoin level and drug(s) that may increase phenytoin levels
– Elevated liver transaminase and evidence of a drug that can cause abnormal liver function tests
Business Case For Quality Improving Quality of Care
Pay for Performance
Preferred Provider Networks
Physician Performance
HEDIS
Member Lists
Predictive Modeling
Business Case For Quality Pay for Performance
Pay for performance programs differentiate payment based on clinical performance criteria
The programs are designed to align doctor’s financial reward with improved outcomes
Lab data plays a key role in monitoring and measuring clinical performance and quality of care
Business Case For Quality Preferred Provider Networks
Preferred provider networks are selected based on measurable clinical outcomes and efficiency
Lab data provides a standardized measure for appropriateness and effectiveness of care
Business Case For Quality
Physician Practice Management
Physicians have access to lists of members who may have treatment opportunities
Examples– Members with diabetes receiving an
annual lipid screening
– Members with diabetes with at least two HbA1c tests annually
– Members with diabetes receiving an annual microalbuminuria screening
Business Case For Quality HEDIS
Appropriate Testing for Children with Pharyngitis
– Group A Streptococcus tests
Colorectal Screening– FOBT
Cervical Cancer Screening– Pap smear
Chlamydia Screening in Women– Chlamydia trachomatis
NCQA, HEDIS 2005 Technical Specifications
Business Case For Quality HEDIS
Cholesterol Management After Acute Cardiovascular Event
– LDL screening and levels <130 and <100
Comprehensive Diabetes Care– HbA1c testing and level >9
– LDL test and levels <130 and <100
– Micro and Macro albuminuria
Business Case For Quality
Cholesterol Management After a Heart Attack
65.1% had LDL controlled below 130
47.6% had LDL controlled below 100
Cholesterol control after a cardiac event can result in a 31% reduction of fatal and nonfatal reinfarction and a 21% reduction in all causes of mortality
Cholesterol management can reduce the cost of cardiovascular disease in the U.S., estimated to be $368.4B in 2004, with heart disease accounting for $238.6B
NCQA: The State of Health Care Quality 2004
Business Case For Quality Diabetes
More than 11 million Americans have been diagnosed with Diabetes
About 1 million new diabetics over age 20 are diagnosed every year
32% of diabetics have HbA1c level greater than 9
For every 1% reduction in A1c, the risk of developing eye, kidney and lower extremity amputation is reduced by 40%
NCQA: The State of Health Care Quality 2004
Business Case For Quality Predictive Modeling
Mathematical calculation to predict which members will have an acute event related to their illness within the next 12 months
Lab data is integrated into the model
The model assists case and disease managers in prioritizing contact with those members at greatest risk
Business Case For Quality Business Case for Lab Data
Managed care’s objective is getting and keeping people healthy
Our commitment is to improve member care and health outcomes
Access and availability of accurate and timely lab data plays a key role
What role can IQLM play in achieving our commitment?