Overuse in Clinical Care: Too Much of a Good Thing? Wendy Everett, - PowerPoint PPT Presentation

Overuse in Clinical Care: Too Much of a Good Thing? Wendy Everett, ScD President, NEHI National Quality Forum March 26, 2009

Fostering Innovation Through Collaboration

Strong Reputation as a Trusted Source Reputation as a Trusted Source Cross Cutting Issues Disease HIT Medical Waste & Prevention & Innovation Innovation Inefficiency Wellness Indicators Report II

Fostering Innovation Through Policy Action Fostering Innovation Through Policy Action

Waste: Where & How Much? Waste: Where & How Much? 50%? 30%?

Demand for Data Is Everywhere Demand for Data Is Everywhere

The Call to Action 1. We must find the evidence and understand root causes to solve the problem. 2. We must create a roadmap for progress. 3. We must pull the right policy levers to enable the health care system to reduce waste.

Major Phases of the Policy Process Major Phases of the Policy Process What/Where? Why? How? Definition, Policy Action Identification of Identification, and Plan Policy Issues Quantification • What is Waste? • Why does it • How can we exist? reduce it? • Where is it? • Who wins • How do we • How much is and loses? reallocate the there? savings? Phase I Phase II Phase III

Waste Across the System Focus on Clinical Care Focus on Clinical Care Prototype Approval, Marketing Basic Preclinical Clinical Development Design/ Scale-up, and and Research Development Development Discovery Manufacturing Evaluation Acute Care Chronic Care End of Life Clinical Care Prevention Screening Diagnosis Care Treatment Treatment Price / Fee Claims Utilization / Disease Payment & Enrollment Setting Processing Management Finance

Piecing Together the Puzzle of Waste Piecing Together the Puzzle of Waste 3,000 Studies 1,500 Studies 460 Studies NEHI Goal: Select 3 – 5 areas for policy action

NEHI’s Evidence: Quantifying the Problem Compendium Overview of of Evidence Findings 2008 2008

Waste Evidence – – in a Few Clicks in a Few Clicks Waste Evidence Searchable by: 1. Type of Waste (overuse, underuse, misuse) 2. Service type 3. Diagnostic category 4. Condition 5. Region www.nehi.net

The $700 Billion Health Care Wasteland = Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving Potential Opportunities $600 b Unexplained Variation $100 b Adverse Events Cost Saving Non Urgent ED Use $10 b Antihypertensive CABG/PTCA Misuse Overuse Asthma Medication Underuse $1 b Antibiotic Back Imaging Back Surgery Overuse Overuse Overuse $100 m Antidepressant Beta Blocker DM Underuse Underuse Underuse Strength of 0 Evidence Low High Statin Underuse Cost Effective Colon & Breast Cancer (But Not Screening Underuse Cost Saving) Antihypertensive Underuse Cervical Cancer Screening Underuse

$682 Billion Opportunity $682 Billion Opportunity Unexplained variation: $500 Billion Adverse events: $ 52 Billion Non-urgent ED use: $ 32 Billion

Top Three Contenders Top Three Contenders Unexplained variation Adverse events Non-urgent ED use

NEHI and NQF: NPP Intersections NEHI and NQF: NPP Intersections NEHI NQF Opportunities Opportunities Antibiotic Overuse Adverse Events Harmful preventive services with no benefit Asthma Medication Non Urgent ED Use Underuse Maternity care interventions Practice Variation: Antihypertensive Misuse Diagnostic Procedures CABG/PTCA Overuse Back Imaging Inappropriate Overuse non-palliative services at Back Surgery end of life Overuse Lab tests

The $700 Billion Health Care Wasteland = Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving Potential Opportunities $600 b Unexplained Variation $100 b Adverse Events Cost Saving Non Urgent ED Use $10 b Antihypertensive CABG/PTCA Misuse Overuse Asthma Medication Underuse $1 b Antibiotic Back Imaging Back Surgery Overuse Overuse Overuse $100 m Antidepressant Beta Blocker DM Underuse Underuse Underuse Strength of 0 Evidence Low High Statin Underuse Cost Effective Colon & Breast Cancer (But Not Screening Underuse Cost Saving) Antihypertensive Underuse Cervical Cancer Screening Underuse

Practice Variation: Key Driver of Waste Practice Variation: Key Driver of Waste • The largest source of wasteful spending is unexplained practice variation in patterns of care that are not associated with differences in clinical outcomes. • This variation represents a potential cost savings of up to $500 billion annually. • Overuse of three procedures contribute significantly to overall practice variation: – Back surgery – Coronary artery bypass grafts (CABG) – Percutaneous coronary interventions (PCI)

Root Causes and Strategies for Change

Reducing Overuse/Practice Variation What can we do? � Reform guideline development process and use � Encourage IT innovations to advance clinical decision support � Train physicians on guideline use and IT � Pay for performance and adherence

Money Matters Money Matters Likelihood of Compliance with Guidelines by Bonus Level 19% 51% 32% Somewhat or much 81% more likely to comply 36% 49% 15% 13% 4% 2% 9% 20% Bonus Bonus Bonus

The $700 Billion Health Care Wasteland = Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving Potential Opportunities $600 b Unexplained Variation $100 b Adverse Events Cost Saving Non Urgent ED Use $10 b Antihypertensive CABG/PTCA Misuse Overuse Asthma Medication Underuse $1 b Antibiotic Back Imaging Back Surgery Overuse Overuse Overuse $100 m Antidepressant Beta Blocker DM Underuse Underuse Underuse Strength of 0 Evidence Low High Statin Underuse Cost Effective Colon & Breast Cancer (But Not Screening Underuse Cost Saving) Antihypertensive Underuse Cervical Cancer Screening Underuse

Combined Preventable Adverse Drug Events: 10.4% of All Admissions Preventable Adverse Drug Events 8.8% of total adult admissions Preventable Renal Dosing Errors 1.6% of all admissions with renal ADE

Adverse Events: Medication Errors Adverse Events: Medication Errors With CPOE: 55,000 medication errors eliminated annually $170 million in annual savings to hospitals and payers

Adverse Events: Policy Change Adverse Events: Policy Change SECTION 36 – Health Reform Bill, August 2008: “…the department of public health shall adopt regulations requiring hospitals and community health centers, as a standard of eligibility for February 2008: Massachusetts original licensure and payers to require hospitals to renewal of licensure , to adopt CPOE by 2012 for implement computerized participation in quality incentive physician order entry programs systems….”

The $700 Billion Health Care Wasteland = Process/System Issues = Early Targets = Cost-Effective, But Not Cost Saving Potential Opportunities $600 b Unexplained Variation $100 b Adverse Events Cost Saving Non Urgent ED Use $10 b Antihypertensive CABG/PTCA Misuse Overuse Asthma Medication Underuse $1 b Antibiotic Back Imaging Back Surgery Overuse Overuse Overuse $100 m Antidepressant Beta Blocker DM Underuse Underuse Underuse Strength of 0 Evidence Low High Statin Underuse Cost Effective Colon & Breast Cancer (But Not Screening Underuse Cost Saving) Antihypertensive Underuse Cervical Cancer Screening Underuse

ED Overuse: a $32 Billion Problem 16% 13.9% 14% 13% 12% 10.7% 12.5% 9.7% 10% Non-urgent 10% ED Visits as 9% 9% 8% 9.1% Percent of Overall Visits 6% 4% 2% 0% 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year Source: CDC 40% of all ED visits could be treated or avoided with could be treated or avoided with 40% of all ED visits timely primary care. timely primary care.

Who Overuses EDs EDs? ? Who Overuses A new mother cannot get her baby to stop crying - her doctor’s office is closed and the ED is the best place to get immediate reassurance. A college student thinks she has strep throat and decides that a few hours at the ED on a Sunday is better than waiting until the student health clinic re-opens on Monday. An elderly nursing home patient is taken to the ED with dehydration as his facility did not have a physician on site at the time.

It’ ’s Not Just the Uninsured s Not Just the Uninsured It Estimated Non-urgent and Preventable/Avoidable ED Visits in 2006 25,000,000 Preventable/Avoidable 20,000,000 Total Number of ED Visits Non-urgent 15,000,000 10,000,000 5,000,000 0 Private Medicaid Uninsured Medicare Source: CDC and MADHCFP

Reducing Emergency Department Overuse Root Causes Solutions Limited Access to Primary Telemedicine Care Improved Chronic Disease Management Worksite Wellness Programs Convenience of the ED Co-location of Urgent Care at the ED Perceived True Emergency Online Access to Healthwise After hours Telephone Triage

Innovations to Reduce Overuse Innovations to Reduce Overuse

Reducing Emergency Department Overuse Root Causes Solutions Limited Access to Primary Telemedicine Care Improved Chronic Disease Management Worksite Wellness Programs Convenience of the ED Co-location of Urgent Care at the ED Perceived True Emergency Online Access to Healthwise After hours Telephone Triage