Business Case for Quality Recognizing Excellence in Practice

1
Business Case for QualityRecognizing Excellence
in Practice

• Presented to the Institute for Quality in
  Laboratory Medicine
• by Dr. Robert Kropp
• Aetna Health Inc.
• Atlanta, Georgia
• April 29, 2005

2
Business Case for Lab Data

• Managed cares objective is getting and keeping
  people healthy
• Our commitment is to improving the quality of
  health care and health outcomes
• Access and availability of accurate and timely
  lab data plays a key role in monitoring and
  measuring quality of care

3
Application of Lab Data

• Lab results are one of the few quantifiable
  clinical outcome measures available from easily
  accessible data (not chart review)
• Because of the sensitivity and specificity of lab
  results, they are applicable as a proxy for
  health outcomes
• Lab result data is strongly correlated with
  health outcomes and is applied in predictive
  modeling
• Provides a standardized measure of the delivery
  of quality care

4
Care Management

• Disease Management
• Case Management

5
Disease Management

• Disease management compares the care delivered to
  the care recommended
• Lab results are used to identify members with the
  target disease, and to measure health care
  outcomes

6
Case Management

• Case Managers have lab results on-line and
  available when contacting members to monitor
  their health status
• HbA1c level history showing good control and
  adequate disease management

7
Quality Improvement

• Appropriateness of Care
• Effectiveness of Care
• Patient Safety
• Improving Quality of Care

8
Operational Definitions

• Appropriateness of care
• What is being done
• The indicated lab test has not been ordered to
  monitor a known condition
• Effectiveness of care
• How effective is the treatment
• The lab test test has been ordered, but the
  result is abnormal

9
Appropriateness of Care

• Warfarin and no evidence of INR monitoring in the
  past 3 months.
• Evidence for glitazones and no evidence of liver
  function monitoring in the past 6 months.
• Member with diabetes and no evidence of screening
  for HbA1c or microalbuminuria in the past year.
• Elevated LDL cholesterol level and no evidence of
  a lipid-lowering agent.
• MedQuerySM Care Considerations

10
Effectiveness of Care

• Evidence of warfarin and lab data indicating
  persistent or recurrent sub-therapeutic INR
  values
• Evidence of diabetes and lab data indicating
  elevated glycated hemoglobin (HbA1c) level
• Evidence for diabetes and lab data indicating an
  LDL cholesterol greater than 100 mg/dl and/or HDL
  cholesterol less than 40 mg/dl

11
MedQuery

• The MedQuery program alerts physicians to
  opportunities for improved care by applying
  state-of-the-art clinical algorithms to the
  medical information derived from claims, pharmacy
  claims, laboratory results and demographic
  information.
• This technology generates specific
  recommendations applicable to a specific member
  and delivers these recommendations to the
  treating physician.

12
Patient Safety

• Lab data assists Pharmacy Management to identify
  drug-to-disease interactions
• The use of a beta blocker in a member diagnosed
  with asthma, based on a previous theophylline
  level
• Abnormal lab results are used to identify
  unintended or potentially dangerous side effects
  of prescription drugs
• Low platelet count and a drug that can cause
  thrombocytopenia

13
Patient Safety

• Elevated lab results are used to identify drug
  toxicity or drug/drug interactions
• Elevated serum level of carbamazepine and drug(s)
  that can interfere with its hepatic metabolism
• Elevated serum phenytoin level and drug(s) that
  may increase phenytoin levels
• Elevated liver transaminase and evidence of a
  drug that can cause abnormal liver function tests
  

14
Improving Quality of Care

• Pay for Performance
• Preferred Provider Networks
• Physician Performance
• HEDIS
• Member Lists
• Predictive Modeling

15
Pay for Performance

• Pay for performance programs differentiate
  payment based on clinical performance criteria
• The programs are designed to align doctors
  financial reward with improved outcomes
• Lab data plays a key role in monitoring and
  measuring clinical performance and quality of
  care

16
Preferred Provider Networks

• Preferred provider networks are selected based
  on measurable clinical outcomes and efficiency
• Lab data provides a standardized measure for
  appropriateness and effectiveness of care

17
Physician Practice Management

• Physicians have access to lists of members who
  may have treatment opportunities
• Examples
• Members with diabetes receiving an annual lipid
  screening
• Members with diabetes with at least two HbA1c
  tests annually
• Members with diabetes receiving an annual
  microalbuminuria screening

18
HEDIS

• Appropriate Testing for Children with Pharyngitis
• Group A Streptococcus tests
• Colorectal Screening
• FOBT
• Cervical Cancer Screening
• Pap smear
• Chlamydia Screening in Women
• Chlamydia trachomatis
• NCQA, HEDIS 2005 Technical Specifications

19
HEDIS

• Cholesterol Management After Acute Cardiovascular
  Event
• LDL screening and levels lt130 and lt100
• Comprehensive Diabetes Care
• HbA1c testing and level gt9
• LDL test and levels lt130 and lt100
• Micro and Macro albuminuria

20
Cholesterol Management After a Heart Attack

• 65.1 had LDL controlled below 130
• 47.6 had LDL controlled below 100
• Cholesterol control after a cardiac event can
  result in a 31 reduction of fatal and nonfatal
  reinfarction and a 21 reduction in all causes of
  mortality
• Cholesterol management can reduce the cost of
  cardiovascular disease in the U.S., estimated to
  be 368.4B in 2004, with heart disease accounting
  for 238.6B
• NCQA The State of Health Care Quality 2004

21
Diabetes

• More than 11 million Americans have been
  diagnosed with Diabetes
• About 1 million new diabetics over age 20 are
  diagnosed every year
• 32 of diabetics have HbA1c level greater than 9
• For every 1 reduction in A1c, the risk of
  developing eye, kidney and lower extremity
  amputation is reduced by 40
• NCQA The State of Health Care Quality 2004

22
Predictive Modeling

• Mathematical calculation to predict which members
  will have an acute event related to their illness
  within the next 12 months
• Lab data is integrated into the model
• The model assists case and disease managers in
  prioritizing contact with those members at
  greatest risk

23
Business Case for Lab Data

• Managed cares objective is getting and keeping
  people healthy
• Our commitment is to improve member care and
  health outcomes
• Access and availability of accurate and timely
  lab data plays a key role
• What role can IQLM play in achieving our
  commitment?