Giving Patients A Giving Patients A Voice Voice Empowering Better Health Empowering Better Health Jerry Reeves MD Jerry Reeves MD
Jan 13, 2016
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.)