The Role of the Citizen Voice
in Reducing Overuse
May 19, 2016, 11 am – 12 pm, PST
Our Work
Our work creates credible, actionable information that enables sustainable improvement in California
health care systems through multi-stakeholder collaboration, and is organized around projects that
generate insights, improve accountability, and accelerate solutions.
Insights
Accountability
Acceleration
Regional Variation: HEDIS by
Geography & Cost & Quality Atlas
Value Based P4P
Encounter Data
Medicare Advantage Stars
Digital Health
Statewide Workgroup on Reducing
Overuse
Medi-Cal
Regional Data Collaborative
Transforming Clinical Practices
Promoting ABIM Foundation’s
Choosing Wisely®
Accountable Care Organizations
Maternity Care
Cancer Care Quality
Bundled Payment
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Statewide WG on Reducing Overuse
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•
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Multi-stakeholder work group co-chaired
by Covered California, CalPERS, and
DHCS
Purpose: To develop, initiate, monitor,
and evaluate approaches to reducing
the overuse of selected unnecessary
and wasteful medical services
Targeting overuse in three focus areas:
• Cesarean section for low-risk, first-time
birth
• Imaging for low back pain without red
flags
• Opioid dependence
© 2016 Integrated Healthcare Association. All rights reserved.
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Decreasing Inappropriate Care in California
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•
IHA-led team is one of 7 across the
country participating in ABIM
Foundation-led effort
Targeting 20% reductions in specific
tests/treatments:
• Antibiotics for acute bronchitis
• Imaging for low back pain, headache without
red flags
• Inpatient -- preoperative stress testing,
“repeating” orders for blood work
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Project Partners:
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•
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•
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Sutter Health
Sharp Rees-Stealy Medical Group
American College of Physicians
Center for Healthcare Decisions
Blue Shield of California
© 2016 Integrated Healthcare Association. All rights reserved.
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Today’s Presenters
•
Jill Yegian, PhD, Senior Vice President, Programs and Policy,
Integrated Healthcare Association
•
Beccah Rothschild, MPA, Senior Outreach Leader, Health Impact
Team, Consumer Reports
•
Marge Ginsburg, MPH, Executive Director, Center for Healthcare
Decisions
•
Julia Logan, MD, MPH, Chief Quality Officer, California Department
of Health Care Services
•
Lance Lang, MD, Chief Medical Officer, Covered California
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Beccah Rothschild, Consumer Reports
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The Roles of the Public in Healthcare
Type of engagement
Type of decision
Direct care
Personal: Which
treatment is best for
me?
Patient/
Consumer
Programmatic: How
can the service
improve?
Policy: To decrease
patient harm,
should some
treatment options
be restricted?
Organizational
Policy making
governance
Health Plan
Member
Citizen
Based on K. Carman et al, Exhibit 1 in Patient And Family Engagement: A Framework For Understanding The
Elements And Developing Interventions And Policies. Health Affairs, February 2013
Addressing overuse may require
trade-offs among societal values, such as:
•
•
•
•
•
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The autonomy of individual doctors;
The variety of choices that patients have;
The authority of patients to decide what has personal
value;
Trust in their personal doctor to deliver high quality
care;
Trust that their medical care does not jeopardize the
health of others; and
Effective use of shared resources.
Focus Groups vs. Public Deliberation
Focus Group: What do you like? What do you want?
What has been your experience?
Public Deliberation: How would you solve this problem
based on competing viewpoints?
Marge Ginsburg, Center for Healthcare Decisions
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Report released in April
Today briefly describe:
• Sessions conducted
• Process used
• Results
• Recommendations
Funding: California Health Care
Foundation; Kaiser Permanente Nat’l
Community Benefit Fund
DWW sessions/participants
Ten half-day sessions, 9-12 people each,
117 total
• Five sessions with Medi-Cal members
(two in Spanish)
• Four sessions with CoveredCA
members
• One session with CalPERS members
Low-to-moderate income, ages 30-60, diverse health
plans, not working in healthcare
• Introduction
• Educational information
• Antibiotics for adult bronchitis
• C-sections for normal births
• Meal break
• MRIs for acute LBP
• Costly cancer drug
• Final discussion / post survey
Case scenarios’ emphasis on harms
Greater risk to the individual. Antibiotics can have harmful side effects, ones that are
sometimes dangerous for patients. Also, if a patient has antibiotics often, she or he may
be more likely to get sick from resistant bacteria. This puts the patient in greater danger
of having an infection that cannot be controlled.
Puts others at risk. When antibiotics are over-used, super-resistant bacteria (a “superbug”) may develop that no antibiotic can kill. This means that patients everywhere may
risk an infection that cannot be treated. These super-bugs now sicken 2 million
Americans each year and kill 23,000 people.
Greater cost to society. Although many antibiotics are not expensive, treating patients
who are extremely ill with an uncontrolled infection adds to the cost of health insurance
for everyone. For example, patients in the hospital with resistant bacteria must stay in
the hospital twice as long as patients who do not have infections.
Types of actions considered
Provider-facing: greater oversight
• MDs that overuse need approval from expert
• Monitoring/discipline
• Stricter rules
Provider-facing: compensation related
Patient-facing: incentives or disincentives
No action: continue to leave it to doctor/patient
Initial voting before discussion
Participant Demographics (N = 117)
Insurer
Gender
Ethnicity
Medi-Cal
51 %
30 – 40
36 %
Covered CA
38
41 – 50
38
CalPERS
10
51 – 60
26
Male
36 %
H.S. or less
35 %
Female
64
Some College/AA
37
College Grad or
more
29
Excellent
21 %
Good
51
Fair
23
Poor
5
0 – 3 times
38 %
4 – 8 times
30
9 or more times
32
White/Anglo
41 %
Latin/Hispanic
40
Black/African
10
Asian/Pacific
Islander
5
Other
3
Age Ranges
Education
In general which
best describes your
current health?
In the past year,
how often have you
used your medical
services?
Results
Types of actions considered: preferences
Provider-facing: greater oversight 57%
• MDs that overuse need approval from expert
• Monitoring/discipline
• Stricter rules
Provider-facing: compensation related 13%
Patient-facing: incentives or disincentives 21%
No action: continue to leave it to doctor/patient 9%
Principles: cornerstones for actions
1. Physicians must be held accountable.
2. Actions should be effective, efficient and credible.
3. Not wasting resources is a valid reason for reducing
unnecessary care.
4. Respect for patient choice must be balanced by
ethical practices.
5. Patients have responsibility to be better informed.
PRE/POST
If my doctor and I agree on the best treatment for my problem,
my health plan should pay for it, no matter what the research
shows. (N = 117)
Pre-survey
responses
Post-survey
responses
Agree Strongly
26%
28%
Agree
50
Not Sure
16
19
Disagree
5
15
Strongly Disagree
2
2
76%
37
65%
PRE/POST
Health plans should pay for any treatments that doctors
recommend, even if research shows that a treatment does not
work well for patients.
Agree Strongly
Pre-survey
responses (N=117)
Post-survey
responses (n = 115)
19%
12%
55%
27%
Agree
36
15
Not Sure
25
22
Disagree
19
44
Strongly Disagree
2
7
Post discussion question
Doing What Works discussion was to learn the views of health
plans members like you and to share those views with health
care leaders. Which statement is closest to your view? (n = 116)
It is very important that health care leaders
understand the views of people like me.
91 %
It is somewhat important that health care leaders
understand the views of people like me.
9%
It is not important that health care leaders
understand the views of people like me.
0%
Post discussion question
Do you think your opinion matters to California health care
leaders, such as those who make policy or funding decisions?
(n=116)
Yes, I think health care leaders care about my
opinion.
42 %
I’m not sure if health care leaders care about my
opinion.
48 %
No, I don’t think health care leaders care about my
opinion.
10 %
Julia Logan, Department of Health Care Services
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Statewide Workgroup on
Reducing Overuse
2015 Charter
Research and report
the priorities and values of
public and private sector health plan members.
Propose approaches
to reducing overuse that take into
consideration consumers’ views and values.
Why this task – engaging the public – was
included in the State Workgroup charter.
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Notable findings
•
•
•
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A “big picture” problem
A problem of physicians, not of patients
Willing to set boundaries despite MD trust
Patients’ choice is important – but others
should not pay for ineffective care
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Informing our health policy work
1. The public takes the problem of overuse
seriously – and wants action.
2. Our obligation to “the public” is as
important as our obligation to patients.
3. Assure sufficient checks and balances in
strategies we promote.
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Informing our health policy work
4. Assure methods are effective and
efficient.
5. Is there a role for value-based costsharing?
6. We need to communicate to the public at
large what the problem is.
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Lance Lang, Covered California
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Take-aways from DWW
• Overuse must be viewed from a societal viewpoint:
reduces resources for evidence-based care.
• The public counts on clinicians to be professionals,
to lead efforts toward appropriate use.
• Wearing their public hats, people understand that
overuse can lead to harm.
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How these findings
can lead to improvement
• Provide Feedback to Clinicians.
• Teach clinical leaders to convene, evaluate
performance and plan improvement.
• Implement practice redesign with team-based
approach to support shared decision making.
• Implement payment that supports better care.
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Questions and comments
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