The California Right Care Initiative (Text Version)

On September 16, 2009, Robert Kaplan made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (189 KB).

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Slide 1

The California Right Care Initiative

Robert M. Kaplan
Wasserman Distinguished Professor
UCLA Schools of Public Health and Medicine
AHRQ Conference

Slide 2

The Translation Problem

Slide 3

NIH View of Translational Research

Image of a flowchart showing the research process:

Bench research - Phase I - Clinical research - Phase II - Community research and application, and then back to Bench research

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

Slide 4

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

Slide 5

More than one in three adults have prevalent CVD

Percentage of population between 20-39:

• Men: 15.9
• Women: 7.8

Percentage of population between 40-59:

• Men: 37.9
• Women: 38.5

Percentage of population between 60-79:

• Men: 73.3
• Women: 72.6

Percentage of population between 80+:

• Men: 79.3
• Women: 85.9

Prevalence of CVD in adults age 20 and older by age and sex (NHANES: 2005-2006). Source: NCHS and NHLBI.

These data include coronary heart disease, heart failure, stroke and hypertension.

Slide 6

There are more than 850,000 CVD deaths per year 1/3rd before age 75, 50% higher than cancer deaths

Percentage of Deaths in Thousands < 45:

• CVD: 26
• Cancer: 21

Percentage of Deaths in Thousands 45-54:

• CVD: 48
• Cancer: 50

Percentage of Deaths in Thousands 55-64:

• CVD: 81
• Cancer: 99

Percentage of Deaths in Thousands 65-74:

• CVD: 125
• Cancer: 138

Percentage of Deaths in Thousands 75-84:

• CVD: 258
• Cancer: 166

Percentage of Deaths in Thousands 85+:

• CVD: 327
• Cancer: 83

Percentage of Deaths in Thousands Total:

• CVD: 864
• Cancer: 559

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

Slide 7

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

Chart of Age Adjustment CHD Death Rate/1,000 Men Vs. Serum Cholesterol (mg/dL)

Slide 8

LDL-C Lowering With Statins Reduced CHD Events

Chart of Primary Prevention and Secondary Prevention
Events vs. LDL Cholesterol (mg/dL)

Slide 9

Clinical Event Reduction in Clinical Trials

Chart of Control and Treatment of Clinical Events broken down by percentage.
(Superko, H. R. et al. Circulation 2008;117:560-568))

Slide 10

From Prospective Studies Collaboration: 61 studies, 1 million Adults

Graph of two charts broken down by age, one is Systolic Blood Pressure, the other is Diastolic Blood Pressure.

Lancet 2002, 360, 1904

Slide 11

BP Lowering Trial Results

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

Slide 12

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.

Slide 13

The Payoff is Potentially Large: Benefits of Lowering BP

Average Percent Reduction

• Stroke incidence 35-40%
• Myocardial infarction 20-25%
• Heart Failure 50%

Slide 14

Mortality and AHA Get with the Guidelines Awards

Award Hospital Effect
30-day Mortality Rate (%)

Heart Failure Mortality

• Adjusted for case mix: -.2
• Above plus hospital characteristics: -.1
• Above plus Surgical and Pneumonia Measures: -.1
• Above Plus HF and AMI measures: -.1

Acute MI Mortality

• Adjusted for case mix: -.3
• Above plus hospital characteristics: -.2
• Above plus Surgical and Pneumonia Measures: -.2
• Above Plus HF and AMI measures: -.1

Heidenreich, AHJ (In Press)

Slide 15

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

	II 1976-80	III (phase 1) 1988-91	III (phase 2) 1991-94	IV 1999-2000
Awareness	51%	73%	68%	70%
Treatment	31%	55%	54%	59%
Control	10%	29%	27%	34%

Slide 16

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

Awareness

• Percentage of Population with Hypertension between the ages of 20-39: 53.8%
• Percentage of Population with Hypertension between the ages of 40-59: 79.9%
• Percentage of Population with Hypertension between the ages of 60+: 82.4%

Treatment

• Percentage of Population with Hypertension between the ages of 20-39: 33.1%
• Percentage of Population with Hypertension between the ages of 40-59: 67.2%
• Percentage of Population with Hypertension between the ages of 60+: 77.2%

Controlled

• Percentage of Population with Hypertension between the ages of 20-39: 27.9%
• Percentage of Population with Hypertension between the ages of 40-59: 48.8%
• Percentage of Population with Hypertension between the ages of 60+: 45.9%

Source: NCHS and NHLBI.

Slide 17

Why Focus on Lipids and Blood Pressure Even for People with Diabetes? (Ray: Lancet 2009, 373,1765)

Chart of Intensive treatment vs. standard treatment

Slide 18

California Problem

Slide 19

The LA-San Diego Contrast

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

Image of Los Angeles
Image of San Diego

Slide 20

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

Slide 21

Total Medicare Reimbursements per enrollee (Part A + Part B)

Figure of LA vs. SD
Los Angeles is between 8,000 and 14,000
San Diego is between 7,000 and 8,500

Slide 22

Hospital Admissions During Last 6 Months of Life

Figure of LA vs. SD
Los Angeles is between 1,400 and 1,900
San Diego is between 1,100 and 1,300

Slide 23

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

• Inland Empire:: 65
• Los Angeles: 67
• Central Cost: 69
• Central Valley: 70
• San Diego: 71
• Orange County: 74
• Bay Area: 76
• Sacramento/North: 77
• Statewide: 70

Slide 24

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

Inland Empire

• All Groups: 66
• Top Performing Groups: 85

Bay Area

• All Groups: 79
• Top Performing Groups: 85

Slide 25

Berwick's Rules for Dissemination

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

1. Find sound innovations
2. Find and support innovators
3. Invest in early adopters
4. Make early adopter activity observable
5. Trust and enable reinvention
6. Create slack for change
7. Lead by example

Berwick, JAMA.2003;289:1969-1975.

Slide 26

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.

Slide 27

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

Slide 28

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

Slide 29

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

Cardiovascular 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

Slide 30

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

Slide 31

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

Slide 32

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).

Slide 33

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

Slide 34

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

Slide 35

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

Slide 36

Steps from A to B

Disseminate Best Practices
Implement and Evaluate Intervention
Identify Evidence-Based Practices
Get Stakeholders & Other Experts Together
Focus Attention on the Problem
 

Slide 37

Right Care Proposed Strategies

• Greater use of electronic technologies. Greater of pharmacist managed care Departure from reactive, appointment based care

Slide 38

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