Evidence-Based Guidelines Affecting Policy, Practice and Stakeholders (E-GAPPS)December 10, 2012 New York, NY

Joanne Schottinger , MDAssistant Medical Director, Quality & Clinical AnalysisKaiser PermanenteSouthern California Permanente Medical Group

How can health care networks develop policy autonomy within an environment shaped by external mandates?

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Statement of Disclosure

I have no commercial or academic conflicts of interest Employed by the Southern California Permanente Medical Group

(SCPMG), which contracts exclusively with the Kaiser Foundation Health Plan in the U.S.

Affiliations/Positions: • Assistant Medical Director for Quality & Clinical Analysis

• Responsible for Medical Technology Assessment and Clinical Practice Guidelines Programs for KPSC

• National Kaiser Permanente Clinical Lead for Cancer Care Programs

• Practicing internist, specializing in oncology

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About Kaiser Permanente (KP)

Description:

• Largest nonprofit health plan in the U.S. (founded 1945)

• Prepaid integrated health care delivery system

• 9 million members (3.5 million in So. California Region)

• 16,000+ physicians• 173,000+ employees• 37 hospitals and med centers• 600+ medical offices

• Active National Guideline Program (Care Management Institute)

8 regions serving 9 statesand the District of Columbia

Kaiser Foundation Hospitals

PermanenteMedicalGroup

KaiserFoundationHealth Plan

+ +

Kaiser Permanente

KP Southern California (KPSC) Region

200 medical offices 5,700 physicians 19,500 nurses 60,000 employees

3.5+ million members 140+ languages spoken 8 counties 13 service areas 14 medical centers

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KP’s National Guideline Program (NGP)

NGP identifies, develops and maintains a core set of 17 evidence-based clinical practice guidelines• Preventive care: Immunizations, cancer screening (breast, cervical, colorectal,

prostate), screening/counseling for HIV/STIs• Chronic conditions: Asthma, ADHD, depression, CVD risk reduction, heart

failure, osteoporosis

National Guideline Directors (NGD)• Oversee all NGP efforts – at least one representative from each of 8 KP regions• Sponsored by KP’s Care Management Institute, funded by regions

Guideline Development • Goal is to provide best available, systematically derived clinical guidance to

improve care delivery and optimize the health of KP members

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External Influences on Guideline Development

Regulatory• California Department of Managed Health Care

Accreditation• National Committee on Quality Assurance (NCQA)• The Joint Commission

Government• Health care reform (PPACA)• Medicare/Medicaid

Legal• California State Senate and Assembly• Medical lawsuits

Case Example:Accreditation Organizations

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Issue: NCQA HEDIS performance measures that lag behind or are inconsistent with current evidence

• Breast Cancer Screening: Mammogram every 2 years for women aged 40-49– Evidence suggests balance of benefit/harms of breast cancer screening

uncertain in women 40-49 (USPSTF)– Increases unnecessary biopsies, overdiagnosis and anxiety due to false

positive tests– Raises health system costs for potentially unnecessary/harmful

procedures

Cervical Cancer Screening: Pap test every 3 years for women aged 21-64– Evidence suggests change in screening interval for women 30-64 to

Pap + HPV testing every 5 years (USPSTF, ACS, ASCCP, ACOG)– HEDIS measure will not change in 2013, delaying implementation and

cost savings for patients and health systems

Case Example:Accreditation Organizations (cont.)

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KPSC Response:• Breast Cancer Screening: Discuss benefits and harms of

mammography, offer screening every 2 years• Cervical Cancer Screening: Change Pap + HPV screening interval

to every 5 years

Implications: • Risk/harms of overdiagnosis and unnecessary/ineffective treatments• Lowers nationally reported performance rates; organizations appear

to be “underperforming”• Influences large purchaser and consumer perceptions of health

system performance• Potential loss of patients and small/large group purchasers• Increases cost to patient and health system

Case Example:Legislative & Regulatory Requirements

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Issue: Medical practice by legislation, later incorporated into state regulatory requirements

• CA Senate Bill 1538 – Breast Density Legislation:– Requires “…a health facility at which a mammography examination is

performed to include in the summary of the written report that is sent to the patient a prescribed notice on breast density.”

• CA Senate Bill 946 – Autism Legislation– Requires behavioral health treatment for patients with autism or

pervasive developmental disorder, including applied behavioral analysis (ABA).

• CA Senate Bill 1 (Section 2248) – Prostate Cancer Screening Legislation– Requires that physicians conducting prostate examinations must

provide information to the patient about the availability of appropriate diagnostic tests, including but not limited to PSA.

Case Example:Legislative/Regulatory (cont.)

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KPSC Response:

• Breast Density: – Conducted repeat evidence search and technology assessment on

automated breast ultrasound system (ABUS)– Required specific language added to letters to patients– Developed FAQ for primary care and educational materials for women

• Autism:– Required creation of developmental specialist teams in each medical

center to coordinate evaluation and treatment– Extensive external contracts initiated to provide services

• Prostate Cancer Screening:– Required development of educational materials on benefits/harms of

prostate-specific antigen testing and shared decision making– Emphasized not doing harm with PSA test in patients aged 75+

Case Example:Legislative/Regulatory (cont.)

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Implications: • Large increase in costs to health system, leading to potential

increases in health care dues for patients

• Focuses resources and funding on interventions that may result in no benefit to patient or harm

• Risk/harms of overdiagnosis and unnecessary/ineffective treatments

• Limits research for more effective treatments

Conclusion/Comments

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Guidelines reflect the evidence, but implementation also impacted by external influences

Regulations are a hard stop

NCQA/accreditation has room to finesse – more systematic interventions to achieve high rates where evidence supports doing so