Giving Patients A Voice Empowering Better Health Jerry

Giving Patients A Voice Empowering Better Health Jerry Reeves MD

It’s All About Patients n Doctors advise n Many advocate n Patients decide After 25+ years focused on doctors, hospitals, and health plans, the quality movement has not substantially eliminated quality gaps.

Care Gaps (Rand, NCQA, Nevada Health Division) n USA: n – Less than appropriate care: – U. S. / Nevada Averages § Breast cancer= 75% / 64% § Cervical ca. = 81% / 71% § Angioplasty= 42% § CABG= 9% – U. S. : Testing & Treatment § Diabetes-A 1 C = § Asthma Rx= – Missing proper care: § § § CAD= Diabetes= Pneumonia= Wounds= Falls= End of life= 32% 55% 61% 59% 66% 91% HEDIS Measures: n 83% 68% Culinary Fund § § Breast cancer= Cervical cancer= Diabetes-A 1 C= Asthma Rx= 60% 57% 67% 57%

Yesterday patient physician medical record

Today patient pharmacy insurance consultation regulators hospital physician lab, xray QI decision support other medical record FLOW OF INFORMATION DEM: S, O: A: P:

Solution: patient pharmacy insurance consultation regulators hospital online health record lab, xray QI decision support other physician FLOW OF INFORMATION DEM: S, O: A: P:

Patients Influence Outcomes n Demographics – Age/Sex, Race, Income, Insurance – Health literacy, Culture n Clinical – Chronic disease, Comorbidities – Functional status- physical, mental n Health Risks – Weight, fitness, diet, safety – Family history n Behavior Change Likelihood – Confidence, Readiness, Commitment – Expectations

Cost Drivers- Doctor Visits n Emergency Department – – – n 6% 56% 38% Emergent Urgent Non Urgent Office – – – 37% 30% 18% 6% 9% New Symptom Chronic Problem, Routine Check Non-illness Care Chronic Problem, Flare-up Other

Informed Decisions Are Rare 1057 office visits; 3552 clinical decisions n Overall: 9% of decisions informed n – Basic: 17% of decisions informed – Complex: 0. 5% of decisions informed (Braddock CH. JAMA 1999; 282: 2313 -20) n In one ear, out the other – 50% to 80% of medical information in visit is forgotten instantly – 50% of retained information is later recalled incorrectly. R Kessels. J Royal Soc Med, 2003

Cost Drivers- Physicians

Consumers Want Control Patients Want to Control Health Care Decisions Who influences health care decisions? Current Should Be Self 1. 9 5. 4 Doctor 1. 8 2. 4 Insurer 3. 3 0. 7 Hospital 0. 7 0. 6 Government 1. 1 0. 6 Employer 1. 2 0. 3 Scores based on a 10 point allocation Source: American Hospital Association Patients want to make health care decisions alone or with their doctors, not with insurers, hospitals, government or employers.

Self-diagnosis and self-care n n n Most people self-diagnose frequently 600+ prescription medications now are available over the counter For up to 40% of doctor visits, self-care turns out to be the treatment of choice For more than 100 conditions, home remedies result in the same outcome as doctor care 70% use Internet; 78% have email Correct “self-diagnosis” is critical

Engaging People In Health Decisions: Surround With Care n Multi-touch communications – Web, phone, mail, print, media, onsite n Behavior change incentives- SMART – Rules, Report Cards, Rewards, Penalties n Point of decision tools readily available – Answers about benefits – Help with health decisions n Coaches (15% of spend) (85% of spend) and advocates – Laypersons, professionals, coalitions

Decision Matrix n Patient n Doctor n Prevention n Early Treatment n Late Treatment – Hospital, ER, Office, Home – Home, Work, Office n Early Treatment n Late Treatment n Low Cost n High Cost

It Takes Incentives n n Providers Bonus, Recognition, Steerage, “Gold Card” – – – n Efficiency Effectiveness Generics Access Information Technology Fines, Report Cards, P/A, Termination – Delays – Safety – Fraud n n Patients SMART- Coupons, Raffles, $, Points, Copays, Discounts – HRA, Prevention – Steps, Weight – Tests, BP, Meds, Visits n Penalties- Rules, Fines, Surcharges, Hiring – Smoking – Safety – Drugs

Point of Decision Tools Personal Evaluation System (PES) Health Risk Appraisals interventions (HRA) with risk reduction 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 Support www. culinaryhealthfund. org

Online Personal Health Record

Choose Your Doctor. Help in the Provider Directory n Name n Specialty n Zip Code n Languages n Extended Hours n Gold Star Rating

Patients Desire E Visits n 90% of US adult Internet users want online with their doctor n 71% want online appointment scheduling and prescription refills n 70% want online test results n 37% willing to pay for it out of pocket n 56% say online communication access would influence their choice of doctor http: //www. harrisinteractive. com/ Harris Poll April, 2002

Health Services Coalition. Leverage n 22 Large Employers and Health Trusts – 320, 000 lives in Las Vegas (including Culinary Fund) n Collaborations – Hospital Contracts- Performance Expectations § Rates, Quality, Safety, Patient Satisfaction § Leap. Frog/ National Quality Forum Participation – – – Generics Campaign- Media, Ads, Doctor Visits Hospitalists- 2 groups, all hospitals Data Sharing- claims audits/ data warehouse § Performance monitoring

Coalition Generics Campaign

Success Determinants n n n Program promotion / employee education Employer’s and support groups’ engagement level Intensity and types of incentive programs Behavioral/demographic characteristics of the employee population (predisposition to change behaviors) Patient’s understanding of personal diagnoses, treatment options, and responsibility for decisions 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. )