Giving Patients A Giving Patients A VoiceVoice

Empowering Better HealthEmpowering Better Health

Jerry Reeves MDJerry Reeves MD

It’s All About PatientsIt’s All About Patients

Doctors adviseDoctors adviseMany advocateMany advocatePatients decidePatients decide

After 25+ years focused on doctors, hospitals, and health plans,the quality movement has not substantially eliminated quality gaps.

Care GapsCare Gaps(Rand, NCQA, Nevada Health Division)(Rand, NCQA, Nevada Health Division)

USA:USA:– Less than Less than

appropriate care:appropriate care: Angioplasty= 42%Angioplasty= 42% CABG= CABG= 9%9%

– Missing proper care:Missing proper care: CAD= CAD= 32%32% Diabetes= Diabetes= 55%55% Pneumonia=Pneumonia= 61%61% Wounds=Wounds= 59%59% Falls=Falls=

66%66% End of life=End of life= 91%91%

HEDIS Measures:HEDIS Measures:– U.S./ Nevada AveragesU.S./ Nevada Averages

Breast cancer= 75% / Breast cancer= 75% / 64%64%

Cervical ca.= 81% / 71%Cervical ca.= 81% / 71%

– U.S.: Testing & U.S.: Testing & TreatmentTreatment Diabetes-A1CDiabetes-A1C = 83%= 83% Asthma Rx= 68%Asthma Rx= 68%

Culinary FundCulinary Fund Breast cancer= 60%Breast cancer= 60% Cervical cancer= 57%Cervical cancer= 57% Diabetes-A1C= 67%Diabetes-A1C= 67% Asthma Rx= 57% Asthma Rx= 57%

physician

patient

medical record

YesterdayYesterday

physician

patient

medical record

pharmacy

consultation

other

insurance

regulators

QIhospital

lab, xray decisionsupport

FLOW OF INFORMATIONDEM:S,O:A:P:

TodayToday

patient

pharmacy

consultation

other

insurance

regulators

QIhospital

lab, xray decisionsupport

physician

online health record

FLOW OF INFORMATIONDEM:S,O:A:P:

Solution:Solution:

Patients Influence Outcomes Patients Influence Outcomes DemographicsDemographics

– Age/Sex, Race, Income, InsuranceAge/Sex, Race, Income, Insurance– Health literacy, CultureHealth literacy, Culture

ClinicalClinical– Chronic disease, ComorbiditiesChronic disease, Comorbidities– Functional status- physical, mentalFunctional status- physical, mental

Health RisksHealth Risks– Weight, fitness, diet, safetyWeight, fitness, diet, safety– Family historyFamily history

Behavior Change LikelihoodBehavior Change Likelihood– Confidence, Readiness, Confidence, Readiness,

CommitmentCommitment– ExpectationsExpectations

Cost Drivers- Doctor Cost Drivers- Doctor VisitsVisits

Emergency DepartmentEmergency Department– 6% Emergent6% Emergent– 56% Urgent56% Urgent– 38% Non Urgent38% Non Urgent

OfficeOffice– 37%37% New SymptomNew Symptom– 30%30% Chronic Problem, Routine CheckChronic Problem, Routine Check– 18%18% Non-illness CareNon-illness Care– 6%6% Chronic Problem, Flare-upChronic Problem, Flare-up– 9%9% OtherOther

Informed Decisions Are RareInformed Decisions Are Rare

1057 office visits; 3552 clinical decisions1057 office visits; 3552 clinical decisions Overall:Overall: 9% of decisions informed9% of decisions informed

– Basic:Basic: 17% of decisions informed17% of decisions informed– Complex:Complex: 0.5% of decisions informed0.5% of decisions informed

((Braddock CH. JAMA 1999; 282: 2313-20)Braddock CH. JAMA 1999; 282: 2313-20)

In one ear, out the otherIn one ear, out the other– 50% to 80% of medical information in visit is 50% to 80% of medical information in visit is

forgotten instantlyforgotten instantly– 50% of retained information is later recalled 50% of retained information is later recalled

incorrectly. incorrectly. R Kessels. J Royal Soc Med, 2003R Kessels. J Royal Soc Med, 2003

Cost Drivers- PhysiciansCost Drivers- Physicians

Patients want to make health care decisions alone or with their doctors, not with insurers, hospitals, government or employers.

Patients Want to Control Health Care Decisions

Who influences health care decisions?

Current Should BeSelf 1.9 5.4Doctor 1.8 2.4Insurer 3.3 0.7Hospital 0.7 0.6Government 1.1 0.6Employer 1.2 0.3Scores based on a 10 point allocation Source: American Hospital Association

Consumers Want ControlConsumers Want Control

Self-diagnosis and self-careSelf-diagnosis and self-care

Most people self-diagnose frequentlyMost people self-diagnose frequently 600+ prescription medications now are 600+ prescription medications now are

available over the counteravailable over the counter For up to 40% of doctor visits, self-care For up to 40% of doctor visits, self-care

turns out to be the treatment of choiceturns out to be the treatment of choice For more than 100 conditions, home For more than 100 conditions, home

remedies result in the same outcome as remedies result in the same outcome as doctor caredoctor care

70% use Internet; 78% have email70% use Internet; 78% have email

Correct “self-diagnosis” is criticalCorrect “self-diagnosis” is critical

Engaging People In Health Engaging People In Health Decisions:Decisions:

Surround With CareSurround With Care Multi-touch communicationsMulti-touch communications

– Web, phone, mail, print, media, onsiteWeb, phone, mail, print, media, onsite Behavior change incentives- SMARTBehavior change incentives- SMART

– Rules, Report Cards, Rewards, Penalties Rules, Report Cards, Rewards, Penalties Point of decision tools readily availablePoint of decision tools readily available

– Answers about benefits (15% of spend)Answers about benefits (15% of spend)– Help with health decisions (85% of spend)Help with health decisions (85% of spend)

Coaches and advocatesCoaches and advocates– Laypersons, professionals, coalitionsLaypersons, professionals, coalitions

Decision MatrixDecision Matrix

PatientPatient PreventionPrevention

– Home, Home, Work, Work, OfficeOffice

Early TreatmentEarly Treatment Late TreatmentLate Treatment

Low CostLow Cost

DoctorDoctor PreventionPrevention Early TreatmentEarly Treatment Late TreatmentLate Treatment

– HospitalHospital, ER, , ER, Office, Office, HomeHome

High CostHigh Cost

It Takes IncentivesIt Takes Incentives ProvidersProviders Bonus, Recognition, Bonus, Recognition,

Steerage, “Gold Card”Steerage, “Gold Card”– EfficiencyEfficiency– EffectivenessEffectiveness– GenericsGenerics– AccessAccess– Information TechnologyInformation Technology

Fines, Report Cards, Fines, Report Cards, P/A, TerminationP/A, Termination– DelaysDelays– SafetySafety– FraudFraud

PatientsPatients SMART- Coupons, SMART- Coupons,

Raffles, $, Points, Raffles, $, Points, Copays, DiscountsCopays, Discounts– HRA, Prevention HRA, Prevention – Steps, Weight Steps, Weight – Tests, BP, Meds, VisitsTests, BP, Meds, Visits

Penalties- Rules, Fines, Penalties- Rules, Fines, Surcharges, HiringSurcharges, Hiring– Smoking Smoking – Safety Safety – DrugsDrugs

Point of Decision ToolsPoint of Decision ToolsPersonal Evaluation System (PES)

Health Risk Appraisals (HRA) with risk reduction interventions

Online Personal Health Record – for patient and her doctors and case managers

Telephone and Interpersonal Decision Support

Hospital & Doctor Performance Comparisons

Evidence Based Treatment Assessments

Prescription Comparisons

Chronic Care Assistance and Navigation

Health Campaigns at Work

Health Decision SupportHealth Decision Support

www.culinaryhealthfund.orgwww.culinaryhealthfund.org

Online Personal Health Online Personal Health RecordRecord

Choose Your Doctor-Choose Your Doctor-Help in the Provider Help in the Provider

DirectoryDirectory NameName SpecialtySpecialty Zip CodeZip Code LanguagesLanguages Extended HoursExtended Hours Gold Star RatingGold Star Rating

Patients Desire E VisitsPatients Desire E Visits 90% of US adult Internet users want online with their doctor90% of US adult Internet users want online with their doctor 71% want online appointment scheduling and prescription refills71% want online appointment scheduling and prescription refills 70% want online test results70% want online test results 37% willing to pay for it out of pocket37% willing to pay for it out of pocket 56% say online communication access would influence their choice of 56% say online communication access would influence their choice of

doctordoctor

http://www.harrisinteractive.com/ Harris Poll April, 2002

Health Services Coalition-Health Services Coalition-LeverageLeverage

22 Large Employers and Health Trusts22 Large Employers and Health Trusts– 320,000 lives in Las Vegas (including Culinary 320,000 lives in Las Vegas (including Culinary

Fund)Fund) CollaborationsCollaborations

– Hospital Contracts- Performance ExpectationsHospital Contracts- Performance Expectations Rates, Quality, Safety, Patient SatisfactionRates, Quality, Safety, Patient Satisfaction LeapFrog/ National Quality Forum ParticipationLeapFrog/ National Quality Forum Participation

– Generics Campaign- Media, Ads, Doctor VisitsGenerics Campaign- Media, Ads, Doctor Visits– Hospitalists- 2 groups, all hospitalsHospitalists- 2 groups, all hospitals– Data Sharing- claims audits/ data warehouseData Sharing- claims audits/ data warehouse

Performance monitoringPerformance monitoring

Coalition Generics CampaignCoalition Generics Campaign

Success Determinants Success Determinants

Program promotion / employee educationProgram promotion / employee education Employer’s and support groups’ engagement Employer’s and support groups’ engagement

levellevel Intensity and types of incentive programsIntensity and types of incentive programs Behavioral/demographic characteristics of the Behavioral/demographic characteristics of the

employee population (predisposition to employee population (predisposition to change behaviors)change behaviors)

Patient’s understanding of personal diagnoses, Patient’s understanding of personal diagnoses, treatment options, and responsibility for treatment options, and responsibility for decisions under their controldecisions under their control

“First, the patient, second the patient, third the patient, fourth the patient, fifth the patient, and then maybe comes science. We first do everything for the patient.”

Bela Schick MD (1877-1967 )

(Invented the Schick Test for diphtheria; helped eradicate diphtheria.)