Targeting Prevention to Evidence Based, High Impact Interventions in Medicare (Text Version)

On September 14, 2009, George Isham made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (615 KB).

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Slide 1

Targeting Prevention to Evidence Based, High Impact Interventions in Medicare

George Isham, M.D., M.S.
Chief Health Officer

AHRQ Annual Conference
Bethesda, MD.
September 14, 2009

Slide 2

Is There Enough Time for Prevention?

• 54.9% of Adults are receiving recommended preventive care*

• To fully satisfy all services recommended by the USPSTF, 1773 hours of a physician's annual time, or 7.4 hours per working day, is needed for the provision of preventive care services by primary care physicians **

  *McGlynn, et al, NEJM, 348:26. June 26, 2003 ** Yarnall KSH, et al, AJPH. Vol. 93. No.4., April, 2003

Slide 3

National Priorities Partnership

28 multi-stakeholder organizations

• Consumers
• Purchasers
• Quality alliances
• Health professionals/providers
• Public sector: CMS, NGA, CDC, AHRQ, NIH
• Accreditation/certification groups
• Health plans

Co-Chairs:

• Donald Berwick
  Institute for Healthcare Improvement
• Margaret O'Kane National Committee for Quality Assurance
  National Priorities Partnership

Slide 4

Selecting the Priorities: Criteria

High Impact Areas

• Reduce Disease Burden
• Eliminate Harm
• Remove Waste
• Eradicate Disparities

Slide 5

National Priorities

High Impact Areas

• Patient and family engagement
• Population health
• Safety
• Care coordination
• Palliative care
• Overuse

Slide 6

NATIONAL PRIORITY Population health

• Improve the health of the population
• 3 Areas of focus:
  • Preventive care
  • Healthy lifestyle behaviors
  • Community index to assess health status

Slide 7

Underuse of Preventive Services is a Big Problem

• The first of the NPP Population Health Goals is that all Americans will receive the most effective preventive services recommended by the USPSTF

Slide 8

A Strategy for Promoting the Most Effective Preventive Services

• Stratify the USPSTF A & B recommendations by Clinical Preventive Burden and Cost Effectiveness *

  Maciosek, M.V., et. al., 2006. Priorities Among Effective Clinical Preventive Services, AJPM; (31): 52-61.

• Develop a Clinical Practice Guideline that incorporates those most impactful recommendations. ** (must do, nice to do, discuss, don't do.

  Institute for Clinical Systems Improvement Adult Preventive Services Guideline accessed at icsi.org

• Develop systems (decision support, standardized work flows, team assignments, etc) to support the implementation of the guideline

Slide 9

A Strategy for Promoting the Most Effective Preventive Services

• Deploy an "all or none" measure that measures preventive services up to date by age and gender to monitor performance against the guideline*

• Deploy educational materials for patients designed to reinforce the prevention expectations of patients that are consistent with the most impactful recommendations by age and gender.

  *Nolan T. and Berwick DM, JAMA. 295:10. March 2006.

Slide 10

2006 Prevention Priorities

Short Name	CPB	CE	Total
Aspirin Chemoprophylaxis— 'high risk'	5	5	10
Childhood Vaccination Series	5	5	10
Tobacco Cessation Counseling	5	5	10
Colorectal Cancer Screening	4	4	8
Hypertension Screening	5	3	8
Influenza Immunization - adults	4	4	8
Pneumococcal Immunization - adults	3	5	8
Problem Drinking Screening & Brief Counseling	4	4	8
Vision Screening - adults	3	5	8
Cervical Cancer Screening	4	3	7
Cholesterol Screening	5	2	7
Breast Cancer Screening	4	2	6

Slide 11

ICSI Adult Preventive Services Guideline - 2005

Two images are shown one is Level I, Preventive services that providers and care systems must deliver (based on best evidence). The second, Level II, Preventive services that providers and care systems should deliver (based on goof evidence).

Institute for Clinical Systems Improvement, Bloomington, MN, 2005. icsi.org

Slide 12

ICSI Adult Preventive Services Guideline - 2005

Two images are shown one is Level III, Preventive Services for which the evidence is currently incomplete, therefore left to the judgement of individual medical groups, clinicians and their patients. The second image is Level IV, Screening maneuvers that are not supported by evidence.

Institute for Clinical Systems Improvement, Bloomington, MN, 2005. icsi.org

Slide 13

Examples of Measures Currently in the Field: HealthPartners

• Adults - % members in sample who received all preventive screening appropriate to age & gender
  • Cholesterol
  • Colon cancer screening
  • Breast cancer screening
  • Cervical cancer screening
  • Chlamydia screening
  • Pneumococcal vaccine
  • Blood pressure
  • Vision screening

• Member up to date rate = 78.7%

  HealthPartners, Inc. 2008. Clinical Indicators Report.

Slide 14

Our Inability to Address Key Health Behaviors Leads to Premature Mortality

• For example, for middle aged Americans, optimal evidence based treatment at the time of an acute cardiac event would prevent or postpone only 8% of deaths. By comparison, 47% of deaths in this group could be prevented or postponed if everyone met dietary and activity guidelines and did not smoke *

• Therefore, the second of the NPP population health goals is that all Americans will adopt the most important healthy lifestyle behaviors known to promote health. (nutrition, activity, tobacco use, healthy alcohol use)

  * Kottke T, et al, AJPM. 2009; 36(1): 82-8

Slide 15

Actual Causes of Death: 1990 and 2000

	Illicit Drug use	Sexual behavior	Firearms	Motor vehicle	Toxic agents	Microbial agents	Alcohol	Poor diet and physical inactivity	Tobacco
1990	1	1	2	1	3	4	5	14	19
2000	0.7	0.8	1.2	1.8	2.3	3.1	3.5	16.6	18.1

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. JAMA. Mar 10 2004;291(10):1238-1245.

Slide 16

We Have no Standard Metric to help our Communities be Healthier

• What gets measured gets done
• 10 most important determinants of health do not include access to health care - Marmot
• "The nations heavy investment in the personal health system is a limited future strategy for promoting health" IOM Future of the Public's Health
• "The pathways to better health do not generally depend on better health care" - Schroeder, NEJM
• Therefore, the third of the NPP population health goals is that The health of American communities will be improved according to a national index of health

Slide 17

Strategies for Improving Community Health

• We will develop a national health index that addresses not only the contribution of healthcare to good health, but also the health behaviors of individuals and the socioeconomic and physical environment factors that affect health.
• We will calculate and report the index for all counties in the United States

Slide 18

Examples of Types of Overuse (Waste)

• An preventive service could be harmful or ineffective - USPSTF D list.
• The American Public is being defrauded and doesn't know it.
• An effective intervention could be deployed inefficiently in the target population. (Cervical Cancer Screening Example - Next Slide)

Slide 19

An effective intervention could be deployed inefficiently in the target population.

	No Pap	>=2 PAP/3 yrs	>=65 yrs	1 pap in 3 yrs
# of Women	8552	22549	13333	10616
# of Paps	0	56138	5112	10616

Slide 20

Some Questions -

• Is a single preventive visit the most effective strategy to address preventive services in Medicare?
• How will it integrate with our sophisticated IT strategies?
• Is addressing waste and overuse in preventive services in Medicare an opportunity to contribute to a more affordable Medicare benefit?

Slide 21

Conclusions

• New policies for Medicare based on A and B recommendations of the USPSTF move in the right direction.
• There remain significant opportunities to encourage the adoption of state of the art approaches to maximize the value and impact of preventive services for Medicare Beneficiaries.