Enhanced Personal Health Care. A collaboration between Anthem and Cedars-Sinai Medical Care Foundation. Cynthia Litt, VP Medical Network Development

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1 Enhanced Personal Health Care A collaboration between Anthem and Cedars-Sinai Medical Care Foundation Cynthia Litt, VP Medical Network Development Scott Weingarten, MD, Sr VP and Chief Clinical Transformation Officer

2 Cedars Sinai Health System Cedars Sinai Medical Center Medical Delivery Network Education and Research

3 Why was Cedars-Sinai interested? PPO is dominant in our community Longstanding, valued relationship with Anthem Ability to leverage HMO experience Insight into total costs via full claims Binds community physicians together in clinically integrated network Consistent with the Cedars-Sinai strategic plan and leadership goals Cedars-Sinai Medicine initiative launched more than 2 years ago Improves our ability to compete in the marketplace and new benefit models 3

4 The Cedars-Sinai Model Contract is with Cedars-Sinai Medical Care Foundation (CSMCF) Started with 43 PCPs 30 employed by Cedars-Sinai Medical Group 13 private attending doctors in our Clinically Integrated network Care Management infrastructure provided by CSMCF in collaboration with Anthem Receiving claims and monthly reports from Anthem 4

5 The Number Breakdown Population N Baseline PMPM CSMCF Attributed Patients 5108 (8% are Peds) $x CSMCF Chronic 2 s 1619 (32% of total) $2x 5

6 Strong Track Record on Quality Measure Rate Anthem Benchmark CHD cholesterol management HEDIS PQP 93.22% 85.38% Diabetes annual HbA1c HEDIS PQP 84.69% 88.12% Diabetes annual LDL HEDIS PQP 80.09% 81.98% Diabetes proteinuria HEDIS PQP 86.22% 79.42% Lower back pain imaging HEDIS PQP 79.17% 79.25% ACEI or ARB needs K and SCr HEDIS PQP 86.75% 77.77% Digoxin K and SCr 12 months HEDIS PQP % 79.37% Diuretics K and SCr 12 months HEDIS PQP 87.27% 76.18% Pharyngitis appropriate testing HEDIS PQP 87.50% 73.09% URI appropriate med HEDIS PQP % 90.78% Breast cancer screen HEDIS PQP 70.90% 67.02% Chlamydia screen HEDIS PQP 47.69% 38.20% DTaP, HiB, MMR & VZV vaccine HEDIS PQP 83.33% 81.82% Bronchitis acute adults avoid antibiotics HEDI 53.85% 25.44% 6

7 Important Discoveries: The original process was to send an engagement letter to all patients with 2+ chronic illness to engage them in care management Quickly learned that patients with sinusitis don t want or need a care manager! Patients with 2+ Chronic Illness 1619 Patients with 2+ Chronic Illness and DxCG Risk Score % (712) 56% Patients with 2+ Chronic Illnesses but lower risk score Patients with <2 Chronic Illness and DxCG Risk Score 2.5 Additional 200 patients identified via risk score 2 nd important discovery: Obstetrics is large driver of cost but not considered a chronic illness! 7

8 Strategies for Reducing Cost Putting a cocoon around the highest risk patients Ambulatory Care Manager serving as navigator; every patient sent engagement letter Standardizing care processes to personalize the care Assessments Telephonic interventions House calls PCP visits Enrollment in Disease Management Programs 24/7 Hotline Creating a system for the full continuum of care Inpatient Care Managers assigned to every adult patient Hospitalists used by >50% of the PCPs NPs in SNFS NPs making housecalls Inpatient and Ambulatory Palliative Care 8

9 Strategies for Reducing Cost Transparent Data Sharing with PCPs Specialty-specific initiatives Tackling the prevalent Oncology Behavioral Health Joint Diseases Tackling the uncommon - Rheumatoid Arthritis Leveraging Clinical Decision Support in the EMR 9

10 Oncology Drugs: Anti-emetic Guideline Compliance Baseline: Retrospective review of Cycle 1 anti-emetic regimens for SOCCI patients scheduled 5/20 and 5/23, 2013* (N=54) Compliance with new anti-emetic guidelines: 26/54 (48 %) Post- Implementation: 2 week (9/16-9/27) evaluation of all Chemo orders for Cycle 1 regimens at SOCCI and THO. Compliance with new anti-emetic guidelines: 78/93* (83 %) * 4 patients excluded due to previous Chemo treatment and N/V profile 10

11 Oncology Drugs: Anti-Emetic Expenditure Trends Medication Cost Oncology Site Aprepitant (Emend PO) Fosaprepitant (Emend IV) Palonosetron (Aloxi IV) Ondansetron (Zofran PO) Ondansetron (Zofran IV) $$$$ $$$$ $$$$ $ $ Granisetron PO $ Granisetron IV $ Pre: Nov 12- Mar 13; Post: June 13-Aug 13 Pre Implementation Post Implementation Monthly Avg. Monthly Avg. %Change SOCCI THO 0 0 SOCCI THO SOCCI THO SOCCI THO 0 0 SOCCI THO SOCCI THO 0 0 SOCCI THO

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13 Integration of ECOG Scores into Chemotherapy Ordering Process ASCO Choosing Wisely: Cancer Therapy during the last 14 days of life Process: Methodology: Utilization of ECOG score to determine functional status and need for continued chemotherapy or patient on IV and oral chemotherapy ECOG score field added to paper chemotherapy ordersets and incorporated into CS-Link for inpatient oral chemotherapy orders Next steps: For patients with ECOG score > 2, recommend implementation of physician to physician discussion to determine if chemotherapy should be continued

14 Reducing Spine Surgery Pre Pilot During Pilot Patients visiting Spine Clinic Patients referred directly to another spine Surgeon Number of Referrals Surgeries performed 41 (18%) 4 A (8%) 2 A 2 additional patients who had been seen in clinic were referred to surgeon by the another physician.

15 Rheumatology Drugs Enbrel and Humira Medication Use Evaluation January 2013 March Tried/failed MTX Did not tried/failed MTX Tried/failed 1 DMARD Tried/Failed 2+ DMARD Did not try any DMARDs Poor prognostic factors (Rh factor +/ANA+/small joints) 1 N=16 2 N=14 3 N=

16 Time Period: 09/30/ /30/2011 Urologist Service Category Number of Services Services per Episode Network Services per Episode Total Cost Cost per Service Network Cost per Service A Ultrasound - Abdominal or Pelvic $6,443 $84 $83 B Ultrasound - Abdominal or Pelvic $96 $96 $83 C Ultrasound - Abdominal or Pelvic $276 $46 $83 D Ultrasound - Abdominal or Pelvic $407 $102 $83

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18 Accident Avoidance Systems 18 Lowered accident claims Mercedes 16% Acura 15%

19 Clinical Decision Support

20 Clinical decision support

21 Education Patient encounter Clinical Decision Support Review Physician Data 21

22 Benefits of reducing inappropriate utilization* Up to 19-times greater false-positive rate than true-positive rate No improvement in patient worry, anxiety, symptoms CT may increase incidence of cancer by 24% Elimination of 5 of 90 Choosing Wisely -type tests would reduce costs by $5 billion per year** *JAMA Intern Med. Published online February 25, doi: /jamainternmed **Arch Intern Med. 2011;171(20): JAMA Intern Med. 2013;173(6): BMJ 2013; 346 doi: (Published 21 May 2013) Cite this as: BMJ 2013;346:f

23 Don t do imaging studies for chronic isolated headache Kaiser Permanente Woodland Hills 1990, 100,800 adults 15 to 27 month follow-up period No CT scans for chronic isolated headache yielded new and important information CT brain radiation exposure may cause 4,000 additional cases of cancer per year in US Model based on National Research Council s Biological Effects of Ionizing Radiation False positives, one led to unnecessary brain biopsy.»weingarten, et al. Archives of Internal Medicine 1992;152(12): Arch Intern Med Dec 14;169(22):

24 Benzodiazepines in the Elderly Increased risk of falls (57% for benzos, 97% for Valium) Increased risk of MVAs Increased risk of hip fractures 24 Arch Intern Med. 2009;169(21): J Am Geriatr Soc 59: , 2011.

25 Results Whenever Mother s Day Rolls Around, I Regret Having Eaten My Young

26 Prescriptions of benzodiazepines to elderly patients Change in number of prescriptions from baseline with active alert* Age >=65 years Age <65 years Pilot MD offices 20.9% 3.6% Control MD offices 10.6% 3.5% Difference 31.5% +0.1% *Comparison periods 7/13/13 to 8/6/13 and 8/7/13 to 8/31/13

27 Benzodiazepine Prescriptions for Patients >= 65 Years Old (Early Data) 27

28 Potential impact Reduction in benzodiazepine use 31.5% Projected reductions over 3 months Fall related injures 5.6 ED visits 3.2 Hospitalizations 0.8 Deaths from falls 0.5 Woolcott et al. JAGS 2009, CDC. MMWR Weekly 2008, Schiller et al., Adv Data No. 392 (CDC) 2007, Pariente et al, Drugs Aging

29 Clinically Meaningful

30 Lessons Learned Need to customize the patient engagement strategy much different than a high risk senior population More emphasis on long term disease prevention and management Attribution challenges patient receiving majority of services elsewhere removed from attribution Found that many patients were attributed to PCPs but followed by non-cedars-sinai specialists Very difficult to drill down into claims data for clinical purposes Private physicians concerns about alienating fee for service patients and many are non-par with Anthem Bottom line. Difficult to move from fee for service to fee for value when doctors still being paid FFS, and patients not selecting to participate in coordinated system Yet, this collaboration offers great opportunity within current structure 30