Health Plan Strategies to Improve Public Health

CDC Heart Disease and Stroke Prevention Annual MeetingSeptember 15, 2009

Lisa M. Latts, MD, MSPH, FACPVP, Programs in Clinical Excellence

Slide 2

Agenda

• Introduction to WellPoint

• Challenges to Improving Health

• Member Health Index

• State Health Index

• Health Disparities

• Local/National Partnerships to Improve Health

• Physician Partnerships to Improve Cardiovascular Health

• Childhood Obesity – A Case Study

Slide 3

Blue Cross or Blue Cross Blue Shield

UniCare >100K members

34 Million Members Across the United States,34 Million Members Across the United States,1 in every 9 Americans covered by WellPoint Plans1 in every 9 Americans covered by WellPoint Plans

WellPoint, Inc.

Slide 4

The State of U.S. Population Health

Obesity

PhysicalActivity

Smoking

Stress

66% obese or overweight

28% inactive

23% smokers

36% high stress

Key Drivers of Health Status

Aging 22% > 55 years, aging population

Driver Prevalence

Population health status continues to deteriorate

Schroeder S. N Engl J Med 2007;357:1221-1228

Proportional Contribution to Premature Death

Genetic predisposition

30%

Social circumstances

15%

Environmental exposure

5%

Health care10%

Behavioral patterns

40%

Slide 5

Prevalence of Chronic Illnesses

More than 130 million Americans suffer from chronic conditions

100

105

110

115

120

125

130

135

140

145

1995 2000 2005 2010

42

43

44

45

46

47

48

Chronic Conditions % of Population

Po

pu

lati

on

in

Mil

lio

ns

% o

f P

op

ula

tio

n

Chronic Condition

Prevalence in America

Annual Cost

Diabetes 16 million

• $105 billion in health expenses

• 11 million lost work days

Heart Disease 60 million

• $300 billion in health expenses

• 1 million deaths

Asthma 14 million

• $5.1 billion in medical expenses

• 2.1 million missed work days

Depression 17 million • $43 billion

Slide 6

Patients do not receive care in

accordance with best practices

Patients receive care in

accordance with best practices

45% 55%64.7% Hypertension

63.9% Congestive Heart Failure

53.9% Colorectal Cancer

53.5% Asthma

45.4% Diabetes

39.0% Pneumonia

22.8% Hip Fracture

% of Recommended Care Received

Source: Elizabeth McGlynn et al, RAND, 2003

Nearly one-half of physician care not based on established best practices

Inconsistent Quality in Care Delivery

Slide 7

1

10

100

1,000

10,000

100,000

1,000,000

Defectsper

million

level (% defects)

U.S. IndustryBest-in-Class

Anesthesia-relatedfatality rate

Airline baggage handling

Outpatient ABX for colds

Post-MIb-blockers

Breast cancerscreening (65-69)

Detection &treatment ofdepression

Adverse drugevents

Hospital acquired infections

Hospitalized patientsinjured through negligence

1(69%)

2(31%)

3(7%)

4(.6%)

5(.002%)

6(.00003%)

Source: modified from C. Buck, GE

Overall Health Care in U.S. (RAND)

Health Care Quality Defects Occur at Alarming Rates

Slide 8

Measuring Health Improvement:WellPoint Health Indices

MissionMission Health Health IndicesIndices

DomainsDomains

Maternity and Prenatal CareMaternity and Prenatal Care

LifestyleLifestyle

Mortality and MorbidityMortality and Morbidity

Clinical OutcomesClinical Outcomes

Care ManagementCare Management

Patient SafetyPatient Safety

Preventive CarePreventive Care

Prevention and ScreeningPrevention and Screening

Member Health Index

Member Health Index

State Health Index

State Health Index

Improve the lives of the people we

serveand

the health of our

communities

Improve the lives of the people we

serveand

the health of our

communities

Slide 9

WellPoint Member Health Index: Improving Population Health

Screening and PreventionScreening and Prevention

• Diabetes ER visits

• Congestive heart failure ER visits

• Asthma ER visits

• Select hospital admissions

• Select 30-day readmissions

• Diabetes compliance

• Hypertension compliance

• Behavioral health follow-up

• Controller medications for asthma

• Appropriate treatment for upper respiratory infection

• Participation in disease management programs

Patient SafetyPatient SafetyClinical OutcomesClinical Outcomes

Care ManagementCare Management

• Breast cancer screening

• Cervical cancer screening

• Colorectal cancer screening

• High cholesterol screening

• Childhood immunizations

• Patient safety hospital structural index

• Patient safety outcome index

• Persistent medication monitoring

4 Domains of health care services covering 20 Clinical Areas; comprised of 40 Measures4 Domains of health care services covering 20 Clinical Areas; comprised of 40 Measures

Slide 10

Screening and Prevention: Why these measures?

• Preventive screenings decrease cancer and heart disease mortality

• Early diagnosis of breast, cervical and colorectal cancer significantly decrease treatment costs

• Timely colorectal cancer screening can prevent colorectal cancer

• High cholesterol is major risk factor for cardiovascular disease

• Childhood immunization is the most important intervention to prevent childhood illness and reduce costs

Breast cancer screening

% getting mammography

Cervical cancer screening

% getting pap smear

Colorectal cancer screening

% getting screening

High cholesterol screening

% getting cholesterol test

Childhood immunizations

% getting full series for six immunizations

Slide 11

• 40% - 50% of health care costs attributed to five chronic diseases

Diabetes, asthma, congestive heart failure, hypertension, and coronary artery disease

• Clinical guidelines are not consistently followed 45% of the time (RAND)

• Chronic illnesses prevalence increasing More prevalent in African Americans and

Latinos

• Established methods for measuring results

• DM programs are designed to improve care guideline compliance

Care Management: Why these measures?

Diabetes compliance

A1c lab testing

Cholesterol lab testing

Eye exams

Kidney disease monitoring

Hypertension compliance

% on antihypertensive drugs

% getting cholesterol tests

Behavioral health follow up

% getting follow up care

Controller meds for asthmatics

% getting controller meds

Appropriate treatment for URI

% getting antibiotics

HMC participation

% high intensity participating

HMC Blood Pressure control

% that know their BP

% that have a controlled BP

Slide 12

• Immediate results from better management of chronic illnessesCommon, expensive, manageable

• Improving compliance with evidence-based clinical guidelines results in:Better outpatient management of chronic

diseases

Decreases ER visits and inpatient stays

• Care management of specific diseases after acute hospitalization reduces unnecessary readmissionsCoordinated care

Pharmaceutical compliance

Follow-up visits

Clinical Outcomes: Why these measures?

Diabetes ER visits ER visits/1000 for diabetes

complicationsCHF ER visits ER visits/1000 for congestive

heart failure complicationsAsthma ER visits ER visits/1000 for asthma

complicationsSelect hospital admits Acute myocardial infarction Stroke TIA (mini-stroke)Select 30-day readmits Congestive heart failure Diabetes Asthma

Slide 13

• Serious patient safety events increase

1.18 million to 1.24 million of 40 million Medicare hospitalizations

Cost to Medicare $8.6 billion 2003-2005

• Computerized order entry and e-prescribing reduce errors

• Adequate ICU physician staffing reduces risk of death by 40%

• Certain medications require monitoring of side-effects and toxicity

Over-use can cause death

Under-use is ineffective and wasteful

Patient Safety: Why these measures?

Patient Safety Hospital Index% publicly reporting to and meeting LeapFrog

• Critical care physicians in ICU• Required electronic ordering tests and

treatments

Patient Safety Outcome index% hospital improvement 3 AHRQ measures

• Post operative infection• Post operative DVT/PE• Acquired infections

Persistent Meds Monitoring% patients getting recommended lab tests

• Seizure, digoxin for heart failure, diuretics for heart failure, ACE/ARB for diabetes and kidney disease

Slide 14

The Member Health Index

45

50

55

60

2006 2007 2008 2009 2010

5.6% Reduction

1.9% Reduction

Goal: 5% Reduction

Goal: 5% Reduction

The MHI was created to demonstrate WellPoint’s commitment to health improvement and care management and to measure

our success

2005-2006

MHI concept developed and implemented Initial baseline determined

2007• First year of enterprise-wide measurement• MHI/HEDIS workgroups identify and

implement improvement projects

2008• 2007 results announced • 770 million total impressions

2009 • Streamlined Reporting methodology (EDL)

2010• Enhance MHI with focus on new WellPoint

programs

Reduction in Quality GapMHI Timeline

Slide 15

WellPoint Health Status Rankings

WellPoint Health Status and State Health Index

• Diabetes in adult population• 5-year trend in diabetes in adult population• Diabetes death rate• Cancer death rate• Heart disease death rate• Obstructive pulmonary disease death rate

Morbidity and Mortality

• Self-reported poor mental health• Persistent poor mental health• Suicide rate

Behavioral Health

• Meet recommended levels of physical activity• Overweight/obesity• Cigarette smoking• Sexually transmitted diseases

Lifestyle

• Childhood immunizations• Adult influenza immunization• Adult pneumococcal immunization• Breast cancer screening• Cervical cancer screening• Prostate cancer screening

Preventive Care

• Prenatal care in the first trimester• Cesarean delivery rate• Low/very low birth weight• Newborn mortality rate

Maternity and Prenatal Care

• Diabetes in adult population• 5-year trend in diabetes in adult population• Diabetes death rate• Cancer death rate• Heart disease death rate• Obstructive pulmonary disease death rate

Morbidity and Mortality

• Self-reported poor mental health• Persistent poor mental health• Suicide rate

Behavioral Health

• Meet recommended levels of physical activity• Overweight/obesity• Cigarette smoking• Sexually transmitted diseases

Lifestyle

• Childhood immunizations• Adult influenza immunization• Adult pneumococcal immunization• Breast cancer screening• Cervical cancer screening• Prostate cancer screening

Preventive Care

• Prenatal care in the first trimester• Cesarean delivery rate• Low/very low birth weight• Newborn mortality rate

Maternity and Prenatal Care

1 to 10

21 to 30

31 to 40

41 to 51

WellPoint Health Status Ranking

11 to 20

1 is Best, 51 is Worst

Current Performance for the composite State Health Index is 77.6 (out of 100 points).

Red Italicized Measures = SHI measures

Slide 16

Slide 17

State Health Index:Local Health Improvement Collaboration

• Analyze state-specific results

• Identify improvement opportunities with government and community leaders

• Develop state-specific improvement plans

• Deploy collaborative programs

“Anthem shares our commitment to improving public health… We’ll have the greatest impact on public health when the private, public and non-profit sectors work together.” – Judy Monroe, M.D., Commissioner of the Indiana State Department of Health.

“It is important that we continue to see faster and safer access to flu and pneumococcal vaccines for Georgians...The donation of these vaccines will aid in the overall wellness of the citizens of our state.” – Georgia Lt. Governor Casey Cagle.

Legislative Initiatives

Local Initiatives and Health

Departments

Clinical & Health

Services Research

Community Partnerships

Improvement in State Health

Collaborative, Multi-Faceted Approach:

Slide 18

• Team with the American Lung Association of California

• Targeting smokers for quit smoking programs

• Advocating for an increased state tobacco tax to enhance funding for prevention

• Blue Cross to raise awareness of programs and support tobacco tax

State Health IndexExample: California

Opportunities – Smoking

Slide 19

SHI Example: Georgia

HealthMPowers is a unique, coordinated initiative designed to build the supportive environment necessary for students to choose health-enhancing behaviors by working in collaboration with students, school staff and families.

March of Dimes – Centering Pregnancy program: A significant number of women (estimated at 11.3%) continue to receive inadequate or no prenatal care. African-American women are nearly three times as likely as non-Hispanic whites to receive late or no prenatal care. This program will improve health outcomes for all women and their children, but also has the greatest potential to reduce racial disparities in poor birth outcomes.

Safe, fun, highly-supportive coaching process at the YMCA. Participants learn to start and stick to an exercise regimen, reduce health risks associated with obesity (Class II) and improve energy levels. Participants are supported by a personal wellness coach who will teach them how to exercise, eat for results and achieve long-term weight loss.

Slide 20

The Call to Address Health Inequalities

“Of all the forms of inequality, injustice in

health care is the most shocking and inhumane”

Dr. Martin Luther King, Jr.

Slide 21

Reducing Health Disparities:WellPoint’s Multi-Faceted Approach

Associates Physicians Employers Members

Coordinated Strategies

Culturally-tailored approaches produce increased patient knowledge and understanding for self-care, decrease barriers to access, and improve multiple

areas of cultural competence for health care providers.

Slide 22

Connecting with Physicians to Improve Community Health

Geographic Information System and decision support tools enable identification of quality and disparity “Hotspots”

• Racial / Ethnicity demographic data linked to quality data to examine performance of different communities

• Target high performing and low performing medical groups to evaluate and analyze success factors and gaps in care

• Provide medical groups with population and patient-specific information to improve screening and outcomes

Slide 23

Mapping Highlights Health Disparities and Opportunities for Interventions

Slide 24

Analysis of MHI Health Disparities and Unscreened Members by Volume

Unscreened Mammography Commercial Members & Testing RatesSept. 1, 2007 -Aug. 31, 2008

57.1

%

54.5

%

56.5

%

60.1

%

57.5

%

59.4

%

60.7

%

55.3

%

64.8

%

56.4

%

53.3

%

60.2

%

61.3

%

55.1

%

62.3

%

54.2

%

52.8

%

55.2

%

60.7

%57.0

%

58.7

%

66.1

%

61.6

%

64.5

%

0

50,000

100,000

150,000

200,000

250,000

300,000

CA NY VA OH IN GA

Asian African American Latino White / OtherIndicates significant difference vs. White rate at a 95% confidence level

Hatched marks indicate number of members screened.

Slide 25

Physician Strategies:Provider Portal Disparities Resource Center

On-Line Resource for On-Line Resource for Network PhysiciansNetwork Physicians

• Health disparities facts and myths

• Cultural and linguistic CME seminar and conferences

• Health promotion and disease specific tools

• Asthma• Diabetes• Breast / Cervical Cancer• Immunizations• Arthritis• Obesity• Heart Health

Slide 26

Collaborative Partnership:Alliance for a Healthier Generation

• Three-year pilot to address prevention, assessment, and treatment of childhood obesity in clinical settings

100 pediatric physicians in California and Georgia

3,000 children ages 2-18 at or above the 85th percentile for BMI

• Focus on early identification, intervention, and support

AMA Guideless for Assessment, Prevention, and Treatment of Child Obesity

WLP reimbursed wellness, weight management, and dietician visits

Regular communications to patients and physicians

• Empower children and families to make healthy lifestyle choices

• Third party evaluation of program success

Slide 27

Employer based awareness, education and support for lifestyle and behavioral change

Community based awareness and education

HealthCore Health

Economics and

Outcomes Research

Study

Novartis Hypertension Alliance

Slide 28

Collaborative Diabetes Program:Taking Action Together

• Diabetes education and community health improvement program in CA “Inland Empire” where diabetes rates are 2nd highest in the state

• Focus on awareness, prevention, management, and community support

English/Spanish educational outreach calls made to 11,000 members

Free community-based diabetes education and support sessions

Educational information sent to select providers

Mobile health screening busses to participating Anthem employer groups

• Services available to all, regardless of membership

Slide 29

Physician Quality/Safety:Specialty Society Partnerships

Society of Thoracic Surgeons (STS)

• STS Database: most sophisticated, risk adjusted surgical database in the world

• Data used for surgeon and hospital improvement, recognition, and reward programs

American College of Cardiology (ACC)

• Collaboration to develop criteria for Blue Distinction Cardiac Network

• Development of the Quality-In-Sights Hospital Incentive Program (Q-HIPSM) and Coronary Services Centers Program

• Focus on evidence-based clinical indicators and published guidelines to improve quality outcomes

Slide 30

Q-P3SM Cardiology Program Components

JC AMI Section

• Aspirin at arrival

• Aspiring prescribed at discharge

• ACEI/ARB for LVSD

• Beta blocker at arrival

• Beta blocker at discharge

• Smoking cessation advice

JC HF Section

• LVF assessment

• ACEI/ARB for LVSD

• Discharge Instructions

• Smoking cessation advice

ACC-NCDR Section

• Rate of serious complications – diagnostic caths

• Door to balloon time for primary PCI <=90 min

• Door to balloon time for primary PCI <=120 min

• % of patients receiving Thienopyridine

• % of patients receiving statin or substitute at discharge

• Rate of serious complications – PCI

• Risk-adjusted mortality rate - PCI

Bonus Section

• Generic Dispensing - Statins

Slide 31

429 Blue Distinction Centers for Cardiac Care®

278 Blue DistinctionCenters for Bariatric Surgery®

84 Blue Distinction Centers for Transplants®

90 Blue Distinction Centers for Complex and Rare CancersSM

WA

OR

CA

AKHI

TX

NMAZ

UTNV

ID

MT ND

SD

NE

WY

COKS

OKAR

LA

MSAL GA

FL

SC

NCTN

KYMO

IL

IA

MN

WIMI

INOH

WV VA

PA

NY

MEVT

NH

RIMA

CTNJDEMD

PR

Centers of Excellence

Blue Distinction Centers are developed in partnership with the Blue Cross Blue Shield Association and participating Blue Plans

Slide 32

Advancing Cardiac Quality:Blue Distinction Centers of Excellence

Qualified facilities demonstrate $6K - $8K lower costs per event

$5,000

$15,000

$25,000

$35,000

$45,000

CABG+PCICABGAMI

Median Cost Per DRG Event• Collaborate with Medical Community

Identify areas for clinical improvement

Establish evidence-based selection criteria

• Evaluation Process

Facilities compete via formal RFI process

Selection based on structures, processes and outcomes

Claims and cost not a selection factor

• Award Designation Status

Designations awarded and published

Work with denied facilities to improve scores and potentially re-apply

• Ongoing Quality Assurance

Re-evaluated every 18-24 months 0%

4%

8%

12%

16%

20%

OP PCI Readmissions CABG Complications

Readmissions/Complications

Non-Blue Distinction

Slide 33

Prevention Case Study: Childhood Obesity

• Multi-faceted initiatives; providers, members, communities

• Scientific evaluation and dissemination of best practices

• Public-private collaboration on education, outreach, and improvement

Percent

Years

~31% of U.S. children are either overweight or obese 16

7

4 4

11

19

1717

11

56

5

0

2

4

6

8

10

12

14

16

18

20

1963-70 1971-74 1976-80 1988-94 1999-02 2003-04

6-11 years

12-19 years

6-11 years 12-19 years

• Core Obesity Interventions

• Physician CME and tools

• Clinical BMI Program

• Member Resources

• Community Outreach

• Collaborative Partnerships

Source: National Health and Nutrition Examination Survey (NHANES) - 1963-65 through 2003-04.

Slide 34

Physician Training and Tools

National AAFP Childhood Obesity CME

• CME bulletin in partnership with AAFP

• AAFP members/residents; all WellPoint primary care physicians

Childhood Obesity Physician Toolkit

• Mailed to all network PCPs since 2005

Anthem Clinical Body Mass Index Program

• Promotes standard BMI screening; tailored to clinical staff

• 63 workshops; 2400 clinical staff, health educators, and school nurses trained

• BMI Quality measures:

• NCQA pilot performance measures in child/adolescent obesity

• 2009 adult and childhood HEDIS measures

• BMI Program Recognition

• “Best of Blue” marketing and communication

• NCQA Quality Profiles™

Slide 35

Member Programs and Resources

Educational Materials

• Get Up and Get Moving! Family Workbook; available in 5 languages

• Healthy Habits for Healthy Kids

• BMI Parent Brochure

Weight Management

• Weight Watchers; TOPS/KOPS

• OnetoWon! Nutritional and Physical Activity Counseling

• High Touch Customized Case Management Pilot

Simple Steps:

Choose Better Health

• Customized wellness program

• Stress management, physical activity, healthy eating

KICK – Kids in Charge of Kalories

• Outreach through smart voice technology, KICK website, and educational materials

• Customized for Medicaid members

Slide 36

Community Outreach

Fruit and Vegetable Bar Study

• Partnered with UCLA and Los Angeles Unified School District

• Disseminate findings through NIHCM

RAND Adolescent Study

• Partnership to examine access/utilization of well-adolescent care

• “Texting” pilot to improve care

Healthy Hoosiers

• Partnership with Eli Lilly, JDRF, ADA, IHIE, IN Dept. of Health

• Website, physician and patient tools, “Nutrition in the Fast Lane”

Georgia HealthMPowers

• Give students information, skills, and motivation to manage their own health

ealthyoosiersHHealthyoosiersHH

Questions?