Reforming Health Care in America Union Delegates Conference

Reforming Health Care in America Union Delegates Conference George C. Halvorson Chairman and CEO, Kaiser Permanente March 26, 2011 1

Care Delivery Requirements and Agendas from the Affordable Care Act 2

Health Care Reform Bill – Over a Thousand “Shalls” 3

75 % of the “Shalls” Deal with Care (Less than 25 % deal with insurance) 4

Focus on -- Chronic Care -- Team Care -- Connected Care -- Safer Care -- Continuously Improving Care -- Becoming a Culture of Learning For Care 5

The new law requires a first time ever care improvement plan for America. 6

National Strategy for Quality Improvement in Health Care March 2011 http: //www. healthcare. gov/center/reports 7

Agenda One -- Making Care Safer http: //www. healthcare. gov/center/reports 8

Agenda Two -- Ensuring Person and Family Centered Care http: //www. healthcare. gov/center/reports 9

Agenda Three -- Promoting Effective Communication and Coordination of Care http: //www. healthcare. gov/center/reports 10

Agenda Four -- Promoting the Most Effective Prevention and Treatment of the Leading Causes of Mortality Starting with Cardiovascular Disease http: //www. healthcare. gov/center/reports 11

Agenda Five -- Working with Communities to Promote Wide Use of Best Practices to Enable Healthy Living 12

Agenda Six -- Making Quality Care More Affordable http: //www. healthcare. gov/center/reports 13

The bill is rich in care improvement provisions. (most invisible to the general public) 14

ACA PROVISION REGARDING CARE Requires HHS Secretary to develop a National Strategy to Improve Health Care Quality to improve health outcomes and efficiency, identify areas for improvement, address gaps in comparative effectiveness information and data gathering, and improve research and dissemination of best practices. National strategy must be updated annually. 15

ACA PROVISION REGARDING CARE Requires AHRQ, and CMS to develop quality measures conforming to National Strategy; requires HHS Secretary to develop, periodically update provider-level outcome measures for hospitals and physicians, including 10 outcome measurements for acute and chronic diseases by March 2012 and 10 outcome measurements for primary and preventive care by March 2013. 16

ACA PROVISION REGARDING CARE Establishes Medicaid Quality Measurement Program, requiring state Medicaid plans to report on state-specific health quality measures, as determined by the HHS Secretary; requires HHS Secretary to test, validate, and develop the quality measures. 17

ACA PROVISION REGARDING CARE Creates a quality measures reporting system for long-term care hospitals, inpatient rehabilitation facilities, cancer hospitals, and hospice programs. 18

ACA PROVISION REGARDING CARE Creates an Interagency Working Group on Health Care Quality to coordinate quality activities across 23 federal departments. 19

ACA PROVISION REGARDING CARE Care Continuity Establishes the Community-Based Care Transitions Program to improve home-based chronic care management for Medicare beneficiaries with multiple chronic conditions. 20

ACA PROVISION REGARDING CARE Establishes interdisciplinary community health teams, created by grants and contracts to eligible organizations from the HHS Secretary, to facilitate collaboration between primary care providers and community-based prevention, patient education, and other resources. 21

ACA PROVISION REGARDING CARE Condition-Specific Care Improvement Creates a National Congenital Heart Disease Surveillance System to track epidemiological data on heart disease and identify areas for prevention and outreach. 22

ACA PROVISION REGARDING CARE Establishes Centers of Excellence for Depression - a network of organizations developing, implementing evidence-based treatment and prevention standards; foster communication with stakeholders; leverage community resources; and promote use of electronic health records to coordinate and manage treatment of depressive disorders. 23

ACA PROVISION REGARDING CARE Creates National Diabetes Report Card: biennial, publicallyavailable report of aggregate prevention, quality of care, risk factors, and outcomes data for diabetic patients. 24

ACA PROVISION REGARDING CARE Modifies the Medicare physician fee schedule to incorporate payments that vary based on the quality of care provided. The modifier will be applicable to specific physicians and physician groups, as determined by HHS, beginning January 1, 2015, and will apply to all physicians and physician groups starting January 1, 2017. 25

ACA PROVISION REGARDING CARE Modifies the Medicare physician fee schedule to incorporate payments that vary based on the quality of care provided. The modifier will be applicable to specific physicians and physician groups, as determined by HHS, beginning January 1, 2015, and will apply to all physicians and physician groups starting January 1, 2017. 26

ACA PROVISION REGARDING CARE Rating System - The Secretary shall develop a rating system that would rate qualified health plans offered through an Exchange in each benefits level on the basis of the relative quality and price. The Exchange shall include the quality rating in the information provided to individuals and employers through a required Internet portal. 27

Medicare Advantage Quality Stars CMS rates Medicare Advantage plans on a scale of one to five stars. Health plans achieving four or more stars receive additional quality payments. § Five Stars = Excellent Performance § Four Stars = Above Average Performance § Three Stars = Average Performance § Two Stars = Below Average Performance § One Star = Poor Performance 28

Medicare Advantage Quality Requirements Quality scores for Medicare Advantage plans are based on 36 standard performance measures that are derived from four sources: § Healthcare Effectiveness Data and Information Set (HEDIS) § Consumer Assessment of Healthcare Providers and Systems (CAHPS) § Health Outcomes Survey (HOS) § CMS administrative data, including information about member satisfaction, plans’ appeals processes, audit results, and customer service 29

Hospital Value-Based Purchasing Program § Designed to provide incentive payments to hospitals that meet set performance standards for certain quality measures. § Program will reward hospitals for improving patients’ experiences of care, while making care safer by reducing medical mistakes. § Significant departure from current system, which rewards hospitals for reporting quality data through the Hospital Inpatient Quality Reporting Program. 30

ACA PROVISION REGARDING CARE Safe hospitals are a priority – ACA reduces Medicare payments to hospitals for hospital-acquired conditions and preventable readmissions; imposes monetary penalty on hospitals with the worst rates of hospital-acquired conditions. 31

ACA PROVISION REGARDING CARE Allows Accountable Care Organizations (ACOs), groups of Medicare providers that voluntarily meet quality thresholds, to share in cost savings; ACO regulations are being developed now. 32

ACA PROVISION REGARDING CARE Establishes an Office of Women’s Health 33

ACA PROVISION REGARDING CARE Establishes an Office of Minority Health 34

ACA PROVISION REGARDING CARE Awards grants to states for programs that incentivize Medicaid beneficiary participation in tobacco cessation, weight control, and other health promotion programs to help prevent or manage chronic disease. 35

ACA PROVISION REGARDING CARE Creates a Medicaid demonstration program requiring states to reimburse qualified mental health care institutions for services to stabilize Medicaid beneficiaries experiencing an emergency psychiatric condition. 36

ACA PROVISION REGARDING CARE Promotes employer-based wellness programs through assessment, technical support on implementation, and grants to small employers. 37

ACA PROVISION REGARDING CARE Increases funding for the National Health Service Corps, community health centers, school-based health centers, and nurse-managed clinics. 38

ACA PROVISION REGARDING CARE Creates an evidence-based national education campaign to increase awareness about breast cancer. 39

ACA PROVISION REGARDING CARE Cross-Cutting - Innovation Creates a new Center for Medicare and Medicaid Innovation (CMMI) within CMS to test and evaluate payment and service delivery models that reduce costs and maintain or improve quality of care. 40

Aligned Elements of the Recovery Package 41

Health Care IT §To promote adoption and improve the performance of the health care system, the HITECH Act was signed into law in 2009. §The Act addresses obstacles to the adoption of EHRs and provides substantial financial incentives for the adoption and meaningful use of certified EHR technology. 42

Meaningful Use § Meaningful use criteria include quality measurements that will be built on over the next several years. §The goal is to build a system that supports clinical practice, research, public health, and the health of individual patients. 43

The entire agenda includes Seventeen Billion Dollars to fund Health Care IT. (with meaningful use requirements needed to receive the money) 44

So What About Kaiser Permanente? How do we fit the new care agenda? 45

-- Team Care -- Data Supported Care -- Focus on Patients with Chronic Care Needs -- Connected Care -- Consistently Improving Care -- Safe Care 46

-- Sepsis -- Pressure Ulcers -- Central Line Infections -- HAI’s 47

We are the proof point that care can be much safer. 48

Sepsis -- #1 cause of death in California hospitals -- 24% of seniors who die in hospitals die of sepsis -- Triple the percentage who die in hospitals from cancer Sources: California Office of Statewide Health Planning and Development (OSHPD) 49

Up to a third of sepsis patients die from the disease. Sources: California Office of Statewide Health Planning and Development (OSHPD) 50

We are on a path of continuous improvement and team care for sepsis 51

Sepsis Death Rate Sources: California Office of Statewide Health Planning and Development (OSHPD) 52

Sepsis Death Rate Sources: California Office of Statewide Health Planning and Development (OSHPD) 53

Sepsis Death Rate Sources: California Office of Statewide Health Planning and Development (OSHPD) 54

Sepsis Death Rate Sources: California Office of Statewide Health Planning and Development (OSHPD) 55

Sepsis Death Rate Sources: California Office of Statewide Health Planning and Development (OSHPD) 56

Why? -- Team Care -- Rapid Reponse Times and Teams 57

Kaiser Permanente Value Compass 58

Team care gives us 21 HEDIS First Place Scores 59

Our data base supports Team Care. 60

Our data base also supports great research. 61

Other Research (without EMR) -- A few hundred patients -- A couple of years -- Truncated research with no follow up -- hugely expensive ( We have electronic data for ten million patients. ) 62

We can sort through data and learn important things 63

Alzheimer's High cholesterol in 30’s – 360% higher Alzheimer’s in 60’s Source: KP Division of Research Study 64

Special Data Combinations 65

Question -When mothers have an amniotic fluid infection during pregnancy, are their kids more likely to have asthma? 66

The Answer? We used our database to find mothers with that infection and then track their kids for a couple of years after they were born -- YES 67

What did we learn? African-American kids: 98% higher rate of childhood asthma 68

What did we learn? African-American kids: 98% higher rate of childhood asthma Hispanic kids: 70% higher rate of childhood asthma 69

What did we learn? African-American kids: 98% higher rate of childhood asthma Hispanic kids: 70% higher rate of childhood asthma Caucasian kids: 60% higher rate of childhood asthma 70

What did we learn? African-American kids: 98% higher rate of childhood asthma Hispanic kids: 70% higher rate of childhood asthma Caucasian kids: 60% higher rate of childhood Asthma -- What about Asian-American kids? 71

What did we learn? Asian-American kids – zero (There was no increase in the childhood asthma rate for Asian-American kids whose mothers had that very same infection) 72

Zero and 90 are very different numbers -- Same caregivers -- Same care settings -- Same care -- Different results 73

Next step – 500, 000 DNA samples (being collected now) DNA will open doors that will save many lives – and it will be particularly useful at Kaiser Permanente because we are a total care team with accountability for each patient’s total care needs and we have the ability to make data use real. 74

We are on the edge of a Golden Age of Medical Research that only Kaiser Permanente can do. 75

People’s lives will be better everywhere because of the care improvement we model and the medical research we do. 76

Chronic Care vs. Acute Care Chronic Care 75% Acute Care 25% 77

Population health is the next big challenge. 78

-- We can make care better. -- We also need to help people stay healthier. 79

HEAL is our total package Healthy Eating Active Living 80

Multiple Eating Programs -- Farmers Market -- Live Well Be Well -- Locally sourced food in Kaiser Permanente hospitals 81

Multiple eating programs 82

New Focus -WALKING 83

Walking Works 84

Walking improves health 85

Walking 30 minutes a day five days a week cuts the likelihood of becoming diabetic by half – and the likelihood of stroke, heart disease and a couple of cancers by over a third. 86

-- Dieting is hard (people don’t get addicted to diets) -- Walking can be extremely pleasant (people do become “addicted” to walking) 87

The Best News Is -The thirty minutes a day can be done in two fifteen minute chunks. 88

Two fifteens are a lot easier to accommodate and schedule then one thirty. 89

Diabetes is a Disease of Urbanization. 90

The United Nations is holding a world summit this Fall on Chronic Conditions. 91

World Epidemic of Chronic Disease 92

Walking needs to be part of the answer everywhere. 93

WHO cited the Kaiser Permanente Walking Campaign in Davos as a direction the world needs to study. 94

We Need -- Patient focused care -- Best Care -- Safest Care -- Active and useful programs to support health 95

-- We can model the right direction for the world. -- We need to do it all together. 96

Be Well 97