Reforming Health Care in America
Union Delegates Conference
George C. Halvorson
Chairman and CEO, Kaiser Permanente
March 26, 2011
1
Care Delivery Requirements
and Agendas from the
Affordable Care Act
2
Health Care Reform Bill –
Over a Thousand
“Shalls”
3
75 % of the “Shalls”
Deal with Care
(Less than 25 % deal with insurance)
4
Focus on
-- Chronic Care
-- Team Care
-- Connected Care
-- Safer Care
-- Continuously Improving Care
-- Becoming a Culture of Learning For Care
5
The new law requires a
first time ever
care improvement plan
for America.
6
National Strategy for
Quality Improvement in
Health Care
March 2011
http://www.healthcare.gov/center/reports
7
Agenda One --
Making Care Safer
http://www.healthcare.gov/center/reports
8
Agenda Two --
Ensuring Person and
Family Centered Care
http://www.healthcare.gov/center/reports
9
Agenda Three --
Promoting Effective
Communication and
Coordination of Care
http://www.healthcare.gov/center/reports
10
Agenda Four --
Promoting the Most Effective
Prevention and Treatment
of the Leading Causes
of Mortality Starting with
Cardiovascular Disease
http://www.healthcare.gov/center/reports
11
Agenda Five --
Working with Communities
to Promote Wide Use of
Best Practices to Enable
Healthy Living
12
Agenda Six --
Making Quality Care
More Affordable
http://www.healthcare.gov/center/reports
13
The bill is rich in care
improvement provisions.
(most invisible to the general public)
14
ACA PROVISION REGARDING CARE
Requires HHS Secretary to develop a National Strategy to
Improve Health Care Quality to improve health outcomes
and efficiency, identify areas for improvement, address
gaps in comparative effectiveness information and data
gathering, and improve research and dissemination of best
practices. National strategy must be updated annually.
15
ACA PROVISION REGARDING CARE
Requires AHRQ, and CMS to develop quality
measures conforming to National Strategy; requires HHS
Secretary to develop, periodically update provider-level
outcome measures for hospitals and physicians, including
10 outcome measurements for acute and chronic diseases
by March 2012 and 10 outcome measurements for primary
and preventive care by March 2013.
16
ACA PROVISION REGARDING CARE
Establishes Medicaid Quality Measurement Program,
requiring state Medicaid plans to report on state-specific
health quality measures, as determined by the HHS
Secretary; requires HHS Secretary to test, validate, and
develop the quality measures.
17
ACA PROVISION REGARDING CARE
Creates a quality measures reporting system for long-term
care hospitals, inpatient rehabilitation facilities, cancer
hospitals, and hospice programs.
18
ACA PROVISION REGARDING CARE
Creates an Interagency Working Group on Health Care
Quality to coordinate quality activities across 23 federal
departments.
19
ACA PROVISION REGARDING CARE
Care Continuity
Establishes the Community-Based Care Transitions Program
to improve home-based chronic care management for
Medicare beneficiaries with multiple chronic conditions.
20
ACA PROVISION REGARDING CARE
Establishes interdisciplinary community health teams,
created by grants and contracts to eligible organizations
from the HHS Secretary, to facilitate collaboration between
primary care providers and community-based prevention,
patient education, and other resources.
21
ACA PROVISION REGARDING CARE
Condition-Specific Care Improvement
Creates a National Congenital Heart Disease Surveillance
System to track epidemiological data on heart disease and
identify areas for prevention and outreach.
22
ACA PROVISION REGARDING CARE
Establishes Centers of Excellence for Depression - a
network of organizations developing, implementing
evidence-based treatment and prevention standards; foster
communication with stakeholders; leverage community
resources; and promote use of electronic health records to
coordinate and manage treatment of depressive disorders.
23
ACA PROVISION REGARDING CARE
Creates National Diabetes Report Card: biennial, publicallyavailable report of aggregate prevention, quality of care, risk
factors, and outcomes data for diabetic patients.
24
ACA PROVISION REGARDING CARE
Modifies the Medicare physician fee schedule to incorporate
payments that vary based on the quality of care provided.
The modifier will be applicable to specific physicians and
physician groups, as determined by HHS, beginning January
1, 2015, and will apply to all physicians and physician groups
starting January 1, 2017.
25
ACA PROVISION REGARDING CARE
Modifies the Medicare physician fee schedule to incorporate
payments that vary based on the quality of care provided.
The modifier will be applicable to specific physicians and
physician groups, as determined by HHS, beginning January
1, 2015, and will apply to all physicians and physician groups
starting January 1, 2017.
26
ACA PROVISION REGARDING CARE
Rating System - The Secretary shall develop a rating
system that would rate qualified health plans offered through
an Exchange in each benefits level on the basis of the relative
quality and price. The Exchange shall include the quality rating
in the information provided to individuals and employers
through a required Internet portal.
27
Medicare Advantage Quality Stars
CMS rates Medicare Advantage plans on a scale of
one to five stars. Health plans achieving four or more
stars receive additional quality payments.
 Five Stars = Excellent Performance
 Four Stars = Above Average Performance
 Three Stars = Average Performance
 Two Stars = Below Average Performance
 One Star = Poor Performance
28
Medicare Advantage Quality Requirements
Quality scores for Medicare Advantage plans are based on 36
standard performance measures that are derived from four
sources:
 Healthcare Effectiveness Data and Information Set (HEDIS)
 Consumer Assessment of Healthcare Providers and Systems
(CAHPS)
 Health Outcomes Survey (HOS)
 CMS administrative data, including information about
member satisfaction, plans’ appeals processes, audit results,
and customer service
29
Hospital Value-Based Purchasing Program
 Designed to provide incentive payments to hospitals that
meet set performance standards for certain quality measures.
 Program will reward hospitals for improving patients’
experiences of care, while making care safer by reducing
medical mistakes.
 Significant departure from current system, which rewards
hospitals for reporting quality data through the Hospital
Inpatient Quality Reporting Program.
30
ACA PROVISION REGARDING CARE
Safe hospitals are a priority – ACA reduces Medicare
payments to hospitals for hospital-acquired conditions and
preventable readmissions; imposes monetary penalty on
hospitals with the worst rates of hospital-acquired
conditions.
31
ACA PROVISION REGARDING CARE
Allows Accountable Care Organizations (ACOs), groups of
Medicare providers that voluntarily meet quality thresholds,
to share in cost savings; ACO regulations are being
developed now.
32
ACA PROVISION REGARDING CARE
Establishes an Office of Women’s Health
33
ACA PROVISION REGARDING CARE
Establishes an Office of Minority Health
34
ACA PROVISION REGARDING CARE
Awards grants to states for programs that incentivize
Medicaid beneficiary participation in tobacco cessation,
weight control, and other health promotion programs to
help prevent or manage chronic disease.
35
ACA PROVISION REGARDING CARE
Creates a Medicaid demonstration program requiring states
to reimburse qualified mental health care institutions for
services to stabilize Medicaid beneficiaries experiencing an
emergency psychiatric condition.
36
ACA PROVISION REGARDING CARE
Promotes employer-based wellness programs through
assessment, technical support on implementation, and
grants to small employers.
37
ACA PROVISION REGARDING CARE
Increases funding for the National Health Service Corps,
community health centers, school-based health centers, and
nurse-managed clinics.
38
ACA PROVISION REGARDING CARE
Creates an evidence-based national education campaign to
increase awareness about breast cancer.
39
ACA PROVISION REGARDING CARE
Cross-Cutting - Innovation
Creates a new Center for Medicare and Medicaid Innovation
(CMMI) within CMS to test and evaluate payment and service
delivery models that reduce costs and maintain or improve
quality of care.
40
Aligned Elements of the
Recovery Package
41
Health Care IT
To promote adoption and improve the performance of
the health care system, the HITECH Act was signed
into law in 2009.
The Act addresses obstacles to the adoption of EHRs
and provides substantial financial incentives for the
adoption and meaningful use of certified EHR
technology.
42
Meaningful Use
 Meaningful use criteria include quality measurements
that will be built on over the next several years.
The goal is to build a system that supports clinical
practice, research, public health, and the health of
individual patients.
43
The entire agenda includes
Seventeen Billion Dollars to fund
Health Care IT.
(with meaningful use requirements
needed to receive the money)
44
So What About Kaiser Permanente?
How do we fit the new
care agenda?
45
-- Team Care
-- Data Supported Care
-- Focus on Patients with Chronic Care Needs
-- Connected Care
-- Consistently Improving Care
-- Safe Care
46
-- Sepsis
-- Pressure Ulcers
-- Central Line Infections
-- HAI’s
47
We are the proof point
that care can be much
safer.
48
Sepsis
-- #1 cause of death in California hospitals
-- 24% of seniors who die in hospitals die
of sepsis
-- Triple the percentage who die in
hospitals from cancer
Sources: California Office of Statewide Health Planning and Development (OSHPD)
49
Up to a third of sepsis
patients die from the
disease.
Sources: California Office of Statewide Health Planning and Development (OSHPD)
50
We are on a path of
continuous improvement
and team care for sepsis
51
Sepsis Death Rate
35%
30%
30%
25%
20%
15%
10%
5%
0%
Sources: California Office of Statewide Health Planning and Development (OSHPD)
52
Sepsis Death Rate
35%
30%
30%
25%
24%
20%
15%
10%
5%
0%
Sources: California Office of Statewide Health Planning and Development (OSHPD)
53
Sepsis Death Rate
35%
30%
30%
25%
20%
24%
18%
15%
10%
5%
0%
Sources: California Office of Statewide Health Planning and Development (OSHPD)
54
Sepsis Death Rate
35%
30%
30%
25%
20%
15%
24%
18%
12%
10%
5%
0%
Sources: California Office of Statewide Health Planning and Development (OSHPD)
55
Sepsis Death Rate
35%
30%
30%
25%
20%
15%
24%
18%
12%
10%
10%
5%
0%
Sources: California Office of Statewide Health Planning and Development (OSHPD)
56
Why?
-- Team Care
-- Rapid Reponse Times and Teams
57
Kaiser Permanente Value Compass
58
Team care gives us
21 HEDIS First Place Scores
59
Our data base supports
Team Care.
60
Our data base
also supports
great research.
61
Other Research (without EMR)
-- A few hundred patients
-- A couple of years
-- Truncated research with no follow up
-- hugely expensive
( We have electronic data for ten million patients.)
62
We can sort through data
and learn important things
63
Alzheimer's
High cholesterol in 30’s –
360% higher Alzheimer’s in 60’s
Source: KP Division of Research Study
64
Special Data Combinations
65
Question -When mothers have an amniotic
fluid infection during pregnancy,
are their kids more likely to have
asthma?
66
The Answer?
We used our database to find
mothers with that infection and
then track their kids for a couple of
years after they were born
-- YES
67
What did we learn?
African-American kids: 98% higher rate of childhood asthma
68
What did we learn?
African-American kids: 98% higher rate of childhood asthma
Hispanic kids:
70% higher rate of childhood asthma
69
What did we learn?
African-American kids: 98% higher rate of childhood asthma
Hispanic kids:70% higher rate of childhood asthma
Caucasian kids:
60% higher rate of childhood asthma
70
What did we learn?
African-American kids: 98% higher rate of childhood asthma
Hispanic kids:70% higher rate of childhood asthma
Caucasian kids: 60% higher rate of childhood Asthma
-- What about Asian-American kids?
71
What did we learn?
Asian-American kids –
zero
(There was no increase in the childhood asthma rate for
Asian-American kids whose mothers had that very same
infection)
72
Zero and 90 are very
different numbers
-- Same caregivers
-- Same care settings
-- Same care
-- Different results
73
Next step –
500,000 DNA samples
(being collected now)
DNA will open doors that will save many lives – and it will be
particularly useful at Kaiser Permanente because we are a total
care team with accountability for each patient’s total care needs
and we have the ability to make data use real.
74
We are on the edge of a
Golden Age of
Medical Research that only
Kaiser Permanente can do.
75
People’s lives will be better
everywhere because of the care
improvement we model and the
medical research we do.
76
Chronic Care vs. Acute Care
Chronic Care
75%
Acute
Care
25%
77
Population health is the
next big challenge.
78
-- We can make care better.
-- We also need to help
people stay healthier.
79
HEAL is our total package
Healthy Eating Active Living
80
Multiple Eating Programs
-- Farmers Market
-- Live Well Be Well
-- Locally sourced food in Kaiser Permanente
hospitals
81
Multiple eating programs
82
New Focus -WALKING
83
Walking Works
84
Walking improves health
85
Walking 30 minutes a day five days a
week cuts the likelihood of becoming
diabetic by half – and the likelihood of
stroke, heart disease and a couple of
cancers by over a third.
86
-- Dieting is hard
(people don’t get addicted to diets)
-- Walking can be extremely pleasant
(people do become “addicted” to walking)
87
The Best News Is -The thirty minutes a day can be
done in two fifteen minute chunks.
88
Two fifteens are a lot easier to
accommodate and schedule
then one thirty.
89
Diabetes is a
Disease of Urbanization.
90
The United Nations is
holding a world summit this
Fall on Chronic Conditions.
91
World Epidemic of
Chronic Disease
92
Walking needs to be
part of the answer
everywhere.
93
WHO cited the
Kaiser Permanente Walking Campaign
in Davos as a direction the world
needs to study.
94
We Need
-- Patient focused care
-- Best Care
-- Safest Care
-- Active and useful programs to support
health
95
-- We can model the right
direction for the world.
-- We need to do it all together.
96
Be Well
97