Meeting November 18 th , 2015 | Seattle Public Library Agenda Chair - - PowerPoint PPT Presentation
Bree Collaborative Meeting November 18 th , 2015 | Seattle Public Library Agenda Chair Report Action Item : Approve September 16 th Meeting Minutes Final Adoption : Prostate Cancer Screening Report and Recommendations Action Item
November 18th, 2015 | Seattle Public Library
Chair Report Action Item: Approve September 16th Meeting Minutes Final Adoption: Prostate Cancer Screening Report and Recommendations Action Item: Adopt Prostate Cancer Screening Report and Recommendations Current Topic Update: Oncology Care Membership Spotlight: Amerigroup New Topics Selection
Action Item: Select two new topics
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September 16th Meeting Minutes
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Update: Psychotropic Drug Use in Children
Chair: Bree Member Paula Lozano, MD, MPH, Group Health Cooperative Robert Hilt, MD, Director of Partnership Access Line, Seattle Children's Robert Penfold, PhD, Co-investigator, Mental Health Research Network, Group Health Research Institute Donna Sullivan, PharmD, MS, Special Assistant to the Chief Medical Officer, Washington Health Care Authority Currently reaching out to other members:
Parent advocate from Seattle Children's Health Plan representative Washington State Medical Association
Plan first meeting for January
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Update: AMDG Opioid Prescribing Guideline Implementation
Convened group for preliminary conversations:
Gary Franklin, Dan Lessler, Kathy Lofy, Jaymie Mai, Hugh Straley, Mark Stephens, Michael Von Korff Alignment with other state efforts
Expand group, regular meetings, charter
Dental Health Plans
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Update: Implementation Bree Implementation Team Healthier Washington
Accountable Care Programs Practice Transformation HUB
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Rick Ludwig, MD, Chief Medical Officer, Accountable Care Organization, Providence Health & Services Chair, PSA workgroup
November 18th, 2015
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Providers
Rick Ludwig, MD (Chair), Accountable Care Organization, Providence Health & Services Eric Wall, MD, MPH, UnitedHealthcare Shawn West, MD, Edmonds Family Medicine Bruce Montgomery, MD, Seattle Cancer Care Alliance
Urology
John Gore, MD, MS, University of Washington Medicine Jonathan Wright, MD, MS, FACS, University of Washington/Fred Hutchinson Cancer Research Center
Patient Advocates
Steve Lovell, Patient and Family Advisory Council
State Agencies
Leah Hole-Marshall, JD, Department of Labor & Industries
Insurers
Matt Handley, MD, Group Health Cooperative
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….differ on whether health care providers should initiate a discussion about PSA testing with all men in the appropriate age range and risk category or only discuss screening if the patient initiates the discussion.
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58 comments total
47 through online survey 11 through email
25 submitted by self-identified patients
“Yes: the breadth of clinical opinion internationally, accurately captured in the Work Group's thorough research, should be a component of the shared decision making model, so that patients are fully informed.” “Early detection is fundamental for best treatment outcomes. Continue more PSA testing.” “Everyone is different. But a biopsy won't kill you.” “I'm concerned patients will be denied testing (and/or doctors sanctioned for doing it). Not a few of the patients I see are high risk and don't know it.” “The best means of limiting harm is to tackle the issue of
the ability of patients to have access to screening.”
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Add overdiagnosis to executive summary and clearer language that shared decision making is a process not a document. Add “Although the cost of the PSA test itself is low, the potential for downstream complications due to follow-up tests and potentially unnecessary treatment is high.” “associated with” changed to “can cause” Add “Not included in the “Not Screened” figure are the men who would be diagnosed with prostate cancer without the PSA test.” Add “The workgroup also discussed the psychological benefit of a negative PSA test to reassure patients of health status. However, the inaccuracy of the PSA test and the psychological harms from a false positive PSA test must also be taken into consideration.”
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Add “The Bree Collaborative acknowledges the importance of the physician-patient relationship and the importance of physicians meeting individual patient needs.” Edited language to read “If patient decision aids are used to assist in the discussion, aids should strive to be those certified by Washington State when available. Patient decision aids should not be used alone without a comprehensive, patient-centered discussion.” To Employers add “Do not include PSA testing for prostate cancer screening in employee health fairs or incentivize PSA testing in a wellness program (e.g., granting points towards a reduction in deductible for those self-reporting a PSA test).”
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Stakeholder Recommendations
Primary Care (and others who screen for prostate cancer)
The Bree Collaborative recommends against routine screening with PSA testing for men:
At average risk 70 years and older, At average risk under 55 years old, Who have significant co-morbid conditions, or with a life expectancy less than 10 years.
The Bree Collaborative acknowledges the importance of the physician- patient relationship and the importance of physicians meeting individual patient needs. Primary care clinicians should review evidence regarding PSA testing for prostate cancer screening. The shared decision making process should be formalized and documented in the patient’s medical record. If patient decision aids are used to assist in the discussion, aids should strive to be those certified by Washington State when available. Patient decision aids should not be used alone without a comprehensive, patient-centered
pathways depending on the physician’s interpretation of the evidence:
Clinicians who believe there is overall benefit from screening with PSA testing should engage in a formal and documented shared decision-making process prior to ordering this test for average risk men between 55-69 years old. Clinicians who believe there is overall harm from screening with PSA testing should not initiate testing but should engage average-risk men aged 55-69 in a formal and documented shared decision making process prior to testing if the patient requests a PSA test. Only men who express a definite preference for screening after discussing the advantages, disadvantages, and scientific uncertainty should have screening with PSA testing.
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Stakeholder Recommendations
Primary Care (and others who screen for prostate cancer)
Men who are at higher risk of prostate cancer because of African American descent, a family history or first degree male relative diagnosed with prostate cancer prior to age 65, Agent Orange exposure, or having a known or suspected familial genetic predisposition to breast, ovarian cancer, or prostate cancer (e.g. BRCA1, BRCA2) should be given the opportunity to discuss the harms, benefits, and scientific uncertainty about PSA testing using a formal and documented shared decision-making process including conversations about increased risk. This conversation can begin earlier than age 55. Only men who express a definite preference for screening should have PSA testing. Medical facilities should train clinicians on the shared decision- making process, make available patient decision aids, and allow for tracking of the shared decision-making process within the patient’s medical record.
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Stakeholder Recommendations Others
Hospitals
Support communication and education of patients that accurately reflects the most recent medical knowledge on PSA testing for prostate cancer screening. Encourage discussions between clinicians and patients about the potential harms, benefits, and conflicting evidence for PSA testing for prostate cancer screening. Only men who express a definite preference for screening should have PSA testing.
Health Plans
Reimburse clinicians for engaging patients in a formal and documented shared decision-making process (using a Washington State-approved patient decision aid when available) about prostate specific antigen testing for prostate cancer screening.
Employers/Health Care Purchasers
Contract with health plans that reimburse clinicians for engaging patients in a formal and documented shared decision-making process (using a Washington State-approved patient decision aid when available) about prostate specific antigen testing for prostate cancer screening. Do not include PSA testing for prostate cancer screening in employee health fairs
reduction in deductible for those self-reporting a PSA test).
Washington State Health Care Authority
Prioritize certification of a PSA testing for prostate cancer screening patient decision aid. Include use of the shared decision making process in contractual requirements (e.g., in Accountable Care Organization contracts).
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Adopt Prostate Cancer Screening Report and Recommendations
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November 18th, 2015
Oncologists
Hugh Straley, MD, Bree Collaborative Rick McGee, MD, FACP, FASCO, Washington State Medical Oncology Society Patricia Dawson, MD, Swedish Breast Cancer Center Gary Lyman, MD, MPH, Hutchinson Institute for Cancer Outcomes Research Keith Eaton, MD, PhD, Seattle Cancer Care Alliance Bruce Cutter, MD, Medical Oncology Associates Jennie Crews, MD, PeaceHealth St. Joseph Cancer Center John Rieke, MD, FACR, MultiCare Regional Cancer Center
Providers
Christopher Kodama, MD, MBA, MultiCare Health System
Patient Advocates
Janet Freeman-Daily
Health Plans
Richard W. Whitten, MD, MBA, FACP, Noridian Healthcare Solutions
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Advanced Imaging Barriers v Countermeasures
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Barriers Countermeasures Patient
Wanting to receive advanced imaging for low-risk disease Evidence-informed decision-making process including discussion about harms and benefits
Clinician
Being unaware of the guidelines Education through organizational partners Believing guidelines are not evidence-based
Education on research base; sharing patient stories; sharing site and clinician-specific data on advanced imaging use relative to other oncology care centers Uncertainty about staging and what constitutes cancer at low risk for metastasis Education Decision support tools at point of care Concern about legal repercussions Additional legal protections granted through use of a Washington State-certified patient decision aid Being uncomfortable providing what feels like less care Education, connection with peers
Institutional
Care team or organization protocols conflict with the guidelines Leadership engagement with recommendations Reimbursement incentivizes overuse of imaging Compensation model reform (e.g., bundled payment,
inappropriate advanced imaging or self-referred advanced imaging)
ASCO Integration of Palliative Care into Active Oncology Care
Source: Ferris FD, Bruera E, Cherny N, Cummings C, Currow D, Dudgeon D, Janjan N, Strasser F, von Gunten CF, Von Roenn JH. Palliative cancer care a decade later: accomplishments, the need, next steps -- from the American Society of Clinical
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Von Roenn JH, Voltz R, Serrie A. Barriers and approaches to the successful integration of palliative care and
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Barriers Countermeasures Patient and Clinician
Perception of palliative care as end-of- life care or as “giving up” Use of term supportive care rather than palliative care Education about definition and scope of palliative care services (e.g., to relieve pain, to connect patients with supports)
Clinician
Concern that palliative care referral would alarm patients and families Shared decision making tools Patient education Uncertainty of when to initiate palliative care Clear referral pathways and protocols (e.g., green flags such as initiation of palliative care for patients with stage IV melanoma)19 Relationship-building between oncology and palliative care centers or palliative care skills building within oncology practice Multidisciplinary care team Uncertainty of who to refer to palliative care Implementation of valid and reliable screening tools showing individualized palliative care need (e.g., distress screening) Concern that pain will not be properly treated outside of active care Education of proper pain management at all stages of care
Institutional
Care team or organization protocols conflict with the guidelines Leadership engagement with recommendations Lack of palliative care financial incentives Compensation model reform (e.g., bundled payment,
Inability to pay for concurrent active Revising hospice reimbursement exclusions to allow for
HICOR IQ Intuitional definition Communication Oncology point-person Identifying need Health Plan support
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Cost of care Further details for addressing barriers Hospice and home care Aim for final draft to be presented January 20th
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An introduction to the Amerigroup Washington Apple Health plan
Getting to know Amerigroup Washington, Inc.
benefits coverage in the state since July 2012. We deliver meaningful value through provider collaborations and engagement with physicians; enhanced affordability and cost of care and care management capabilities; and a superior breadth of solutions that deliver a better, more personalized health care experience.
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Our State Medicaid Programs
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We serve approximately 5.8 million members in 19 states
delivered to our members. We voluntarily submit to evaluation by the largest health plan accreditation
rigorous review of consumer protection and quality improvement systems, but also requires health plans to submit audited data on key clinical and service measures.
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Disease sease Management nagement Program
Accreditat creditation ion
by NCQA since 2006:
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LCSW staff – Medical/Behavioral Complex Case Management
– Stabilization- CM activities post acute/SNF inpatient care – Care Coordination-short term CM services to assist with access or coordination of care for member – DMCCU-Disease management care management team
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A closer look at Amerigroup Washington
members at fun, educational events
improve our members’ health and well-being
– The Boys & Girls Clubs in Washington, which works to improve the health and wellness of over 30,000 youth – The Tree Program, which offers learning experiences through the
– The Safe Kids Coalition, which teaches safety for kids – Wheels on the River, a summer bicycle safety program – Community baby showers and peer breastfeeding groups
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Who we serve. Washington Apple Health.
care for over 142,000 Amerigroup members through: – Temporary Assistance for Needy Families (TANF) – Expansion population – Children’s Health Insurance Program (CHIP) – Supplemental Security Income and Aged, Blind and Disabled (SSI/ABD)
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– 3,600 primary care locations – 13,000 specialty care locations – 100 hospitals
programs, including: asthma, diabetes, HIV and AIDS, major depressive disorders and schizophrenia
Washington: 1,800
Washington: 10,200
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We are proud of our Amerigroup Foundation
throughout Washington. Here are a few of the organizations and programs we funded in 2015
– Pierce County Project Access – Interpretive services – Orcas Family Connection – Transportation for cancer patients – Washington Low Income Housing Alliance – Emerging advocates program – Inland Baby – Adoption and foster care awareness – American Red Cross – Wenatchee and Chelan fires – Gilda’s Club – Cancer education for teens
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November 18th, 2015| Seattle Public Library
“…identify health care services for which there are substantial variation in practice patterns or high utilization trends in Washington state, without producing better care outcomes for patients, that are indicators of poor quality and potential waste in the health care system. On an annual basis, the collaborative shall identify up to three health care services it will address.”
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Available: http://www.eiu.com/ public/topical_report .aspx?campaignid=H ealthoutcome2014
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Source:
Spenders in Healthcare. Available: https://www.me digo.com/blog/a bout-us/smart- spenders-in- healthcare/
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USA = 33rd
Substantial variation in practice patterns
High utilization/cost growth trends in WA State Source of waste and inefficiency in care delivery
Patient safety issues or poor health outcomes Significant direct and indirect costs Proven means or strategies exist to address topic
Implement-ability
The Bree is uniquely positioned State input/focus (e.g., Healthier Washington, HTA) Choosing Wisely Shared-decision making
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Obstetrics Cardiology
Elective Total Knee and Total Hip Replacement Bundle and Warranty
Elective Lumbar Fusion Bundle and Warranty
Coronary Artery Bypass Surgery Bundle and Warranty
Low Back Pain and Spine SCOAP Hospital Readmissions End-of-Life Care
Addiction and Dependence Treatment AMDG Opiate Prescribing Guidelines
Topics
Bariatric Surgery Bundled Payment Model Mental Health Integration: Depression Screening Diabetes Care Bundled Payment Model Health Services Coordination
Specifically identify common elements of best practice health care coordination that can be applied to multiple diagnoses (e.g., falls)
Hysterectomy
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Implementation Likelihood Potential for Harm Reduction Degree of Bree fit Likelihood of reducing costs Can we measure impact? Is data available? Y/N Rating: High (3) – Medium (2) – Low (1)
Bariatric
2.05 2.36 2.9 2.5 Y: 9 N: 1
Depression
2.05 2.2 2.45 1.56 Y: 5 Ish: 2 N: 1
Diabetes
1.73 2.36 2.45 1.77 Y: 9 Ish: 1 N: 0
Health Services
1.44 2.6 2.17 2.06 Y: 3 N: 5
Hysterectomy
2.67 2.38 2.54 2.5 Y: 9 N: 0
Mental Health
1.75 2.45 2.3 2.38 Y: 5 N: 1
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Bariatric Surgery Bundled Payment Model
Focus:
Build off previous bundled payment models Best practices for bariatric surgery including outcome metrics
In Washington State, 2168 bariatric surgery cases (CHARS data 2013)
Maximum # in hospital = 416 (only 6 hospitals >100 cases annually)
Health Technology Assessment Program: Bariatric Surgery for patients aged 18 and older is a covered benefit with conditions SCOAP bariatric surgery data National work
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Bariatric Surgery Bundled Payment Model Implementation Likelihood = MEDIUM Potential for Harm Reduction = MEDIUM Degree of Bree fit = HIGHEST Likelihood of reducing costs =HIGHEST (tie) Data = YES
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Focus:
Identify best practice elements of depression screening within primary care Mental health integration
Lifetime prevalence of 23% Low rates of depression screening Many comorbidities Opportunity to align with Healthier Washington Could be part of ongoing behavioral health integration workgroup
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Depression Screening
Implementation Likelihood = LOW Potential for Harm Reduction = HIGHEST Degree of Bree fit = MEDIUM Likelihood of reducing costs = MEDIUM Data = NONE
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Mental Health Integration
Core part of Healthier Washington Different levels of integration across the state Untreated anxiety and depression associated with many comorbidities Good guidelines as to how to integrate nationally and within our state (e.g., AIMS center)
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Mental Health Integration
Too close to Depression Screening Implementation Likelihood = LOW Potential for Harm Reduction = MEDIUM Degree of Bree fit = MEDIUM Likelihood of reducing costs = MEDIUM Data = DIFFICULT BUT POSSIBLE
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Diabetes Care Bundled Payment Model
Focus:
Build off previous bundled payment models Best practices for year of diabetes care including outcome metrics
9% of Washingtonians have diabetes “The greatest opportunity to reduce avoidable complications and generate savings is with chronic medical condition bundles, and not procedure bundles.” Many comorbid conditions Many examples of best practices and implementation of those practices Core Measure Set Large body of patient decision aids
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Source: Health Care Incentives Improvement Institute. Bundled Payment Across the US Today: Status of Implementations and Operational Findings. Issue Brief. April 2012. Available: http://www.hci3.org/sites/default/files/files/HCI-IssueBrief-4-2012.pdf. Accessed: August 2015. Abt Associates Inc., Medicare Cataract Surgery Alternate Payment Demonstration: Final Evaluation Report, Cambridge, MA 1997.
Diabetes Care Bundled Payment Model A challenge/opportunity, but very difficult Implementation Likelihood = LOW Potential for Harm Reduction = MEDIUM Degree of Bree fit = MEDIUM Likelihood of reducing costs = MEDIUM Data = YES
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Health Services Coordination
Focus:
Identify common elements of best practice health care coordination that can be applied to multiple diagnoses (e.g., falls)
Care fragmentation leads to poor outcomes and is very underutilized Lack of coordination is high cost Many organizations have done work in this area Work with Accountable Communities of Health
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Health Services Coordination
Needs better definition Implementation Likelihood = LOW Potential for Harm Reduction = HIGHEST Degree of Bree fit = MEDIUM Likelihood of reducing costs = MEDIUM Data = NONE
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Hysterectomy
Focus:
Standardize indications and adherence to indications for hysterectomy
One of most frequently performed surgical procedures in nation Side effects from surgery include excessive bleeding, anesthesia complications, incontinence, bowel dysfunction, sexual dysfunction Washington Health Alliance has seen wide variations in number of hysterectomies Patient decision aids exist
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Hysterectomy
Implementation Likelihood = HIGHEST Potential for Harm Reduction = MEDIUM Degree of Bree fit = HIGH Likelihood of reducing costs = HIGH Data = YES (highest rated)
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Steering Committee Recommendation
Highly Consider
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Next Meeting
January 20th, 2016 | 12:30-4:30 Seattle Central Library Level 4, Room 2 | 1000 Fourth Ave. | Seattle, WA 98104
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