How can health care networks develop
policy autonomy within an environment
shaped by external mandates?
Evidence-Based Guidelines Affecting Policy, Practice and
Stakeholders (E-GAPPS)
December 10, 2012
New York, NY
Joanne Schottinger , MD
Assistant Medical Director, Quality & Clinical Analysis
Kaiser Permanente
Southern California Permanente Medical Group
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)
Kaiser Permanente
Kaiser
Foundation
Health Plan
+
Kaiser
Foundation
Hospitals
+
Permanente
Medical
Group
8 regions serving 9 states
and the District of Columbia
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)
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KP Southern California (KPSC) Region
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3.5+ million members
140+ languages spoken
8 counties
13 service areas
14 medical centers

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200 medical offices
5,700 physicians
19,500 nurses
60,000 employees
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
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Case Example:
Accreditation Organizations
 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
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Case Example:
Accreditation Organizations (cont.)
 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
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Case Example:
Legislative & Regulatory Requirements
 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.
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Case Example:
Legislative/Regulatory (cont.)
 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+
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Case Example:
Legislative/Regulatory (cont.)
 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
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Conclusion/Comments
 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
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