The California Right Care Initiative

Robert M. KaplanWasserman Distinguished Professor

UCLA Schools of Public Health and Medicine

AHRQ Conference

The Translation Problem

NIH View of Translational Research

• According to the National Institutes of Health, “in order to improve human health, scientific studies must be translated into practical applications.”

Bench research

Clinical research

Community research and application

Phase I

Phase II

Where is this going

• Cardiovascular disease is common• Risk factors have been known for 50 years• Evidence clearly shows that modifying some risk

factors reduces events• Population level modification of risk factors has been

disappointing• Several strategies show promise for risk factor

modification in group practices

Prevalence of CVD in adults age 20 and older by age and sex Prevalence of CVD in adults age 20 and older by age and sex (NHANES: 2005-2006). (NHANES: 2005-2006). Source: NCHS and NHLBI. Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension.These data include coronary heart disease, heart failure, stroke and hypertension.

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CVD deaths vs. cancer deaths by age.CVD deaths vs. cancer deaths by age.(United States: 2005). (United States: 2005). Source: NCHS and NHLBI. Source: NCHS and NHLBI.

There are more than 850,000 CVD deaths per year1/3rd before age 75, 50% higher than cancer deaths

CVD deaths vs. cancer deaths by age.

6 Year CHD Mortality by Total Serum Cholesterol 356,222 Men Screened for MRFIT, Aged 35-57 Yrs

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Clinical Event Reduction in Clinical Trials (Superko, H. R. et al. Circulation 2008;117:560-568))

Clinical Event Reduction in Clinical Trials

From Prospective Studies Collaboration:From Prospective Studies Collaboration:61 studies, 1 million Adults 61 studies, 1 million Adults

Lancet 2002, 360, 1904

Collins & Peto. Textbook of Hypertension 1994 Blackwell Scientific Publications p1159.

BP Lowering

TrialResults

Evidence Based Opinions • Most people with HTN will need 2 or 3

medications to control BP.• Diuretic/ACEI, Diuretic/ARB,

CCB/ACEI, CCB/ARB likely good first choices for combination Rx.

• Diuretic/CCB combination of uncertain effectiveness.

• Reserpine underused, but probably a good third line agent.

The Payoff is Potentially Large: Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 35-40%

Myocardial Infarction 20-25%

Heart Failure 50%

Mortality and AHA Get with the Guidelines Awards

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But, BP Control Rates Remain Disappointing

Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74

National Health and Nutrition Examination Survey

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Treatment 31% 55% 54% 59%

Control 10% 29% 27% 34%

Extent of Awareness, Treatment and Control of High Blood Extent of Awareness, Treatment and Control of High Blood Pressure by Age Pressure by Age (NHANES: 2005-2006).(NHANES: 2005-2006).Source: NCHS and NHLBI.Source: NCHS and NHLBI.

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Why Focus on Lipids and Blood Pressure Even for People with Diabetes? (Ray: Lancet 2009,

373,1765)

California Problem

Question: Question: Is health care in West LA as unusual as the people who live there?

The LA-San Diego Contrast

San DiegoLos Angeles

Figure 1. Total 2005 Medicare expenditures in Los Angeles and San Diego HSAs

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Figure 1. Total 2005 Medicare expenditures in Los Angeles and San Diego

Total Reimbursements(Part A + Part B)

Hospital Admissions During Last 6 Months of Life

California Pay for Performance:Clinical Performance Variation: Composite Clinical Score (from Williams 2008)

California Pay for Performance:A Tale of Two Regions (From Williams 2008)

Berwick's Rules for Dissemination

Seven ‘rules' for translating research into practice; require an implementer to

1) find sound innovations2) find and support innovators3) invest in early adopters4) make early adopter activity observable5) trust and enable reinvention6) create slack for change7) lead by example

Berwick, JAMA. 2003;289:1969-1975.

History of RCI

• In 2007, Governor Schwarzenegger’s health reform proposal called for healthcare quality improvement

• In response, NCQA and the California Department of Managed Health Care (DMHC) collaborated in launching a statewide effort known as the Right Care Initiative (RCI) to improve the quality of care delivered to commercial HMO members in California.

RCI Goals

• To improve clinical outcomes through enhancing the practice of evidence-based medicine and management in a collaborative, expert-based, public-private, multi-year effort

• Targets– diabetes, – heart disease, – HAIs

California’s HEDIS Scores

• California’s HEDIS rankings are surprisingly low relative to the best plans in the nation

• No California health plan other than Kaiser Permanente ranks among the top ten plans in the nation or above the 90th percentile for heart and diabetes performance measures

California Right Care Initiative:Percent of Plans Meeting HEDIS

LDL Standard 2009Cardiovascular LDL-C Level <100

California National Top 10 Kaiser - CA (Northern CA) 66.04 Humana Health LA 78.68 Blue Cross of California 65.74 PersonalCare Insurance of IL 75.89 CIGNA HealthCare of CA 64.48 PacifiCare of Texas 73.58 Health Net of California 62.84 Network Health Plan 72.85 Blue Shield of California 62.58 Gundersen Lutheran Health Plan, Inc. 72.48 Kaiser - CA (Southern CA) 62.53 CIGNA HealthCare of MA 71.78 Aetna California 61.16 Humana Health Plan of TX 71.7 Western Health Advantage 59.87 Capital Health Plan 71.29

PacifiCare of California 56.84 Group Health Coop of South Central WI 70.59

Ventura County Health Care Plan NR CIGNA HealthCare of NH 70.56 California Average 60.63 National Mean 56.61 National 90th 66.18

California Right Care Initiative:Percent of Plans Meeting HEDIS Blood Pressure Standard 2009

Controlling High Blood Pressure California National Top 10

Kaiser - CA (Southern CA) 73.97 PersonalCare 79.73 Kaiser - CA (Northern CA) 73.31 CIGNA Mid-Atlantic 75.67 CIGNA HealthCare of CA 64.23 HealthAmerica 75.23 Health Net of California 62.23 Kaiser - CA (Southern CA) 73.97 Aetna California 61.06 Kaiser - CA (Northern CA) 73.31 Western Health Advantage 60.83 Aetna Ohio 72.42 Blue Cross of California 60.04 Security Health Plan of WI 71.78 Blue Shield of California 58.60 Anthem BCBS - CT 71.75 PacifiCare of California 53.81 MVP Health Plan, Inc 71.23 Ventura County Health Care Plan NR ConnectiCare 70.80 California Average 63.40 National Mean 59.66 National 90th 68.13

Emerging web-based GIS & social networking tools will also facilitate multi-stakeholder QI efforts

Reasons to Support MTM

• Cochrane review ( 2000) The Cochrane group found pharmacist-based interventions encouraging

• Increasing evidence form controlled studies that the Ashville principles can be used to control CHD risk factors. The effect on health outcomes awaits evaluation (Carter et al 2008).

Evidence of Effectiveness for CDSMP

• 2008 (CDC) review of published studies (Gordon and Galloway 2008).

– Four studies reported lower ER visits,

– three studies demonstrated reduced hospitalizations

– four studies reported reduced number of days in the hospital,

– two studies reporting statistically significant reductions in outpatient visits.

– significant reduction in health care costs

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What is ALL?• ALL stands for

– Aspirin 81 mg, – Lisinopril 20 mg, & – Lipid lowering with simvastatin 40 mg/day– ALL is a Polypill (but delivered in 3 pills)

• Suggested that the clinical and cost effectiveness of increasing ALL use in – CAD and – diabetic (55+) populations

Evaluation of ALL (Polypill)TIPPS Trial 50 Centers in India (ACC 2009)

• Double-blind study, enrolled 2053 patients aged 45 to 80 years without cardiovascular disease but with one risk factor, type 2 diabetes, high blood pressure, smoker within past five years, increased waist-to-hip ratio, or abnormal lipids

• Pill well tolerated, but– Lower than expected reductions in

• LDL• SBP• Compliance lower than expected• No health outcome data available at this time

Steps from A to B

Get Stakeholders & Other Experts Together

Identify Evidence-Based Practices

Implement and Evaluate Intervention

Focus Attention on the Problem

Disseminate Best Practices

Right Care Proposed Strategies

• Greater use of electronic technologies

• Greater of pharmacist managed care

• Departure from reactive, appointment based care

RCI Collaborators

• Government- California Department of Managed Health Care

• Health Plans-Medical Directors -Kaiser, Blue Shield, United, Aetna….

• Academic- UC Berkeley, UCLA, UCSD, USC• Research Organizations- RAND, VA, Lumetra• Medical Groups- California Association of

Physician Groups