Targeting Prevention to Evidence Based, High Impact

Interventions in MedicareGeorge Isham, M.D., M.S.

Chief Health Officer

AHRQ Annual ConferenceBethesda, MD.

September 14, 2009

Is There Enough Time for Is There Enough Time for Prevention?Prevention?

• 54.9% of Adults are receiving recommended preventive care*

• To fully satisfy all services recommended by the USPSTF, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive care services by primary care physicians **

*McGlynn, et al, NEJM, 348:26. June 26, 2003** Yarnall KSH, et al, AJPH. Vol. 93. No.4., April, 2003

National Priorities National Priorities PartnershipPartnership

28 multi-stakeholder organizations• Consumers

• Purchasers

• Quality alliances

• Health professionals/providers

• Public sector: CMS, NGA, CDC, AHRQ, NIH

• Accreditation/certification groups

• Health plans

Co-Chairs:– Donald Berwick

– Institute for Healthcare Improvement– Margaret O'Kane

National Committee for Quality Assurance

© National Priorities Partnership

Selecting the Priorities: Selecting the Priorities: CriteriaCriteria

© National Priorities Partnership

RemoveWaste

EradicateDisparities

EliminateHarm

Reduce Disease Burden

High Impact Areas

National PrioritiesNational Priorities

• Patient and family engagement• Population health • Safety• Care coordination• Palliative care• Overuse

© National Priorities Partnership

NATIONAL PRIORITYNATIONAL PRIORITY

Population healthPopulation health

• Improve the health of the population

• 3 Areas of focus:– Preventive care– Healthy lifestyle

behaviors– Community index to

assess health status

© National Priorities Partnership

Underuse of Preventive Underuse of Preventive Services is a Big ProblemServices is a Big Problem

• The first of the NPP Population Health Goals is that all Americans will receive the most effective preventive services recommended by the USPSTF

A Strategy for Promoting the Most A Strategy for Promoting the Most Effective Preventive ServicesEffective Preventive Services

– Stratify the USPSTF A & B recommendations by Clinical Preventive Burden and Cost Effectiveness *

– Develop a Clinical Practice Guideline that incorporates those most impactful recommendations. ** (must do, nice to do, discuss, don’t do.

– Develop systems (decision support, standardized work flows, team assignments, etc) to support the implementation of the guideline

Maciosek, M.V., et. al., 2006. Priorities Among Effective Clinical Preventive Services, AJPM; (31): 52-61.

Institute for Clinical Systems ImprovementAdult Preventive Services Guideline accessed at icsi.org

A Strategy for Promoting the Most A Strategy for Promoting the Most Effective Preventive ServicesEffective Preventive Services

– Deploy an “all or none” measure that measures preventive services up to date by age and gender to monitor performance against the guideline*

– Deploy educational materials for patients designed to reinforce the prevention expectations of patients that are consistent with the most impactful recommendations by age and gender.

*Nolan T. and Berwick DM, JAMA. 295:10. March 2006.

2006 Prevention PrioritiesShort Name CPB CE Total

Aspirin Chemoprophylaxis – ‘high risk’ 5 5 10 Childhood Vaccination Series 5 5 10

Tobacco Cessation Counseling 5 5 10

Colorectal Cancer Screening 4 4 8

Hypertension Screening 5 3 8

Influenza Immunization - adults 4 4 8

Pneumococcal Immunization - adults 3 5 8

Problem Drinking Screening & Brief Counseling 4 4 8

Vision Screening - adults 3 5 8

Cervical Cancer Screening 4 3 7 Cholesterol Screening 5 2 7

Breast Cancer Screening 4 2 6

Maciosek, M.V., et. al., 2006. Priorities Among Effective

Clinical Preventive Services, AJPM; (31): 52-61.

ICSI Adult Preventive Services ICSI Adult Preventive Services Guideline - 2005Guideline - 2005

11

Institute for Clinical Systems Improvement, Bloomington, MN, 2005. icsi.org

ICSI Adult ICSI Adult Preventive Services Preventive Services

Guideline - 2005Guideline - 2005

12

Institute for Clinical Systems Improvement, Bloomington, MN, 2005. icsi.org

Examples of Measures Examples of Measures Currently in the Field: Currently in the Field: HealthPartnersHealthPartners• Adults - % members in sample who received all

preventive screening appropriate to age & gender– Cholesterol– Colon cancer screening– Breast cancer screening– Cervical cancer screening– Chlamydia screening– Pneumococcal vaccine– Blood pressure– Vision screening

• Member up to date rate = 78.7%

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HealthPartners, Inc. 2008. Clinical Indicators Report.

Our Inability to Address Key Our Inability to Address Key Health Behaviors Leads to Health Behaviors Leads to

Premature MortalityPremature Mortality• For example, for middle aged Americans, optimal

evidence based treatment at the time of an acute cardiac event would prevent or postpone only 8% of deaths. By comparison, 47% of deaths in this group could be prevented or postponed if everyone met dietary and activity guidelines and did not smoke *

• Therefore, the second of the NPP population health goals is that all Americans will adopt the most important healthy lifestyle behaviors known to promote health. (nutrition, activity, tobacco use, healthy alcohol use)

* Kottke T, et al, AJPM. 2009; 36(1): 82-8

Actual Causes of Death: Actual Causes of Death: 1990 and 20001990 and 2000

0 5 10 15 20

Illicit Drug use

Sexual behavior

Firearms

Motor vehicle

Toxic agents

Microbial agents

Alcohol

Poor diet and physical inactivity

Tobacco

%

20001990

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. JAMA. Mar 10 2004;291(10):1238-1245.

We Have no Standard Metric to We Have no Standard Metric to help our Communities be help our Communities be

HealthierHealthier• What gets measured gets done • 10 most important determinants of health do not include

access to health care – Marmot• “The nations heavy investment in the personal health

system is a limited future strategy for promoting health” IOM Future of the Public’s Health

• “The pathways to better health do not generally depend on better health care” – Schroeder, NEJM

• Therefore, the third of the NPP population health goals is that The health of American communities will be improved according to a national index of health

Strategies for Improving Strategies for Improving Community HealthCommunity Health

• We will develop a national health index that addresses not only the contribution of healthcare to good health, but also the health behaviors of individuals and the socioeconomic and physical environment factors that affect health.

• We will calculate and report the index for all counties in the United States

Examples of Types of Examples of Types of Overuse (Waste)Overuse (Waste)

• An preventive service could be harmful or ineffective – USPSTF D list.

• The American Public is being defrauded and doesn’t know it.

• An effective intervention could be deployed inefficiently in the target population. (Cervical Cancer Screening Example – Next Slide)

An effective intervention could be An effective intervention could be deployed inefficiently in the target deployed inefficiently in the target

population.population.

0

10000

20000

30000

40000

50000

60000

No Pap >=2 PAP/ 3 yrs >=65 yrs 1 pap in 3 yrs

# of Women # of Paps

Under Use ($1.9m)

Overuse - $8.8m

Appropriate Use

Some Questions -Some Questions -

• Is a single preventive visit the most effective strategy to address preventive services in Medicare?

• How will it integrate with our sophisticated IT strategies?

• Is addressing waste and overuse in preventive services in Medicare an opportunity to contribute to a more affordable Medicare benefit?

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ConclusionsConclusions

• New policies for Medicare based on A and B recommendations of the USPSTF move in the right direction.

• There remain significant opportunities to encourage the adoption of state of the art approaches to maximize the value and impact of preventive services for Medicare Beneficiaries.