ADHD in Children

1
ADHD in Children
Avg children 4.24
Detroit 2.09 Alpena 2.28 Alma 2.29
Kalamazoo 6.05 Grosse Pointe 7.08 Grand Haven 7.11
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Antibiotic Use

• Michigan and regional activities
• MARR
• Flint Health Coalition
• Capital Area Health Coalition
• Muskegon County Health Coalition
• Why so many
• Emergence of Community-Acquired
  Methicillin-Resistant Staphylococcus aureus as
  the Predominant Cause of Skin and Soft-Tissue
  Infections
• Ann Intern Med 2006144 309-317
• And others

3
Antibiotic Use in Adults
Avg adults 46.16
Marquette 34.00 Munising 34.01 Ishpeming 36.50
Jackson 52.19 Pontiac 52.19 Flint 53.00
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Antibiotic Use Within 7 Days of URI in Adults and
Children
Avg adults child 49.73
Sault Ste Marie 34.89 Chelsea 38.09 Muskegon 39.26
Gladwin 61.90 Lakeview 61.92 Ontonagon 64.08
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Antibiotic Use in Children
Avg children 50.56
Detroit 33.19 Southfield 35.79 Munising 39.93
Lanse 60.42 Jackson 60.97 Monroe 61.37
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So Why Do We Care?

• Appropriate use saves lives
• Appropriate use improves quality of life
• Appropriate use improves health expenditure model
• And inappropriate use costs
• Lives
• Quality of life
• More resources of all kinds

7
Programs and Patient Safety
The person who takes medicine must recover
twice, once from the disease and once from the
medicine. - William Osler, M.D.
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Medication Use in the United States

• Very high proportion of adults in the U.S. take
  at least one medication in any given week.
• The highest medication use is in males and
  females gt/ 65 years of age.
• Kaufman DW, Kelly JP, Rosenberg L, Anderson TE,
  Mitchell AA. Recent Patterns of Medication Use
  in the Ambulatory Adult
• Population of the United States. The Slone
  Survey. JAMA. 2002287(3)337-344.

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The Value of Pharmaceuticals

• What is the value of pharmaceuticals?
• ? The answer is complex
• Direct Value
• gt reduction in morbidity or mortality
• gt symptom relief
• gt prevention of disease
• Indirect Value
• gt improvement in quality of life
• gt improved productivity at work
• gt reduction in absenteeism at work

Source The Value of Pharmaceuticals and Managed
Pharmaceutical Care. Foundation for Managed Care
Pharmacy. 2001. www.amcp.org
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The Value of Pharmaceuticals

• When does risk outweigh value?
• gt Vioxx (rofecoxib)
• gt Bextra (valdecoxib)
• gt Palladone (hydromorphone extended release)
• FDA under heavy scrutiny for safety reviews
• Are there other drugs in the pipeline or on the
  market already that may pose unnecessary risk to
  patients?

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Quality of Health Care

• Survey of more than 10,000
• adults in the U.S.
• Follow-up chart review on
• almost 7,000 of those adults
• surveyed
• Used nationally-accepted
• quality indicators
• Participants received 54.9
• percent of recommended
• care
• No significant differences in
• quality of care for preventive,
• acute care, or chronic care

McGlynn EA, et.al. The Quality of Health Care
Delivered to Adults in the United States. NEJM.
June 26, 200334826. 2635-2645.
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Focus on Delivery of Care

• Society spends billions of dollars on development
  of new drugs and technology but relatively little
  on improving systems to ensure the delivery of
  care to all of those in need.1
• We need markets that encourage integrated
  delivery systems, with incentives for teams of
  professionals to provide coordinated, efficient,
  evidence-based care, supported by
  state-of-the-art information technology.2

• Woolf SH, Johnson RE. The Break-Even Point
  When Medical Advances are Less Important than
  Improving the
• Fidelity with Which They are Delivered. Ann Fam
  Med 20053545-552.
• Enthoven AC, Tollen LA. Competition in Health
  Care It Takes Systems to Pursue Quality and
  Efficiency.
• Ann Fam Med 20053(6)420-434.

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BCBSM Pay-for-Performance

• 2000 BCBSM Physician Prescribing Pilot
• 2004 Design physician group incentive program
  in collaboration with physician groups and
  medical societies
• 2005 Implement physician group incentive
  program
• 2006 Design and implement physician
  organization gain-sharing incentive
  program

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Partnering for ValueProgram Goals

• Physician Group Incentive Program (PGIP)
• Support and facilitate significant performance
  improvement by physician groups through financial
  incentives
• Improve care of all-payer patients with
  diabetes mellitus, persistent asthma, coronary
  heart disease and congestive heart failure
• Increase generic prescribing for BCBSM members
• Increase use of shared decision-making for BCBSM
  members
• Gain-sharing program

• Physician Organization Gain-Sharing Incentive
  Program (POGS)
• Achieve measurable savings
• Pharmacy costs
• Laboratory costs
• Diagnostic imaging
• In-network referrals
• Strengthen the performance improvement
  infrastructure available to clinicians
• Share savings achieved from improved practices
  with physicians

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Evaluation and Reward Process

• PGIP
• Medical groups collaborate on focused committees
  and report progress to BCBSM describing progress
  and performance
• BCBSM evaluates each groups performance and
  provides written feedback
• Share of incentive pool for each group based on
  BCBSM members served and performance in meeting
  program goals
• Fourth quarter 2005 incentive based on pharmacy
  measure (generic prescribing)

• POGS
• Physician organizations selected receive defined
  payments derived from incentive component of
  TRUST fee update. Payment made semi-annually
  based on size of BCBSM membership served by PO.
• Share at least 50 percent of overall program
  savings with participating physicians through
  higher fees on Evaluation and Management services
  during follow-up payment period

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Participating Physician Groups
Physician Group Incentive Program
(PGIP) Advantage Health Physicians, Grand
Rapids Genesys Integrated Group Physicians,
Flint Henry Ford Medical Group, Detroit
(1Q06) Huron Valley Physicians Association, Ann
Arbor Integrated Health Associates, Ann
Arbor McLaren Medical Management, Flint Medical
Network I, Rochester Michigan Medical, P.C.,
Grand Rapids ProMed Healthcare,
Kalamazoo Regional Delivery Network of West
Michigan Sparrow Family Medical Services,
Lansing St. John Health, Medical Resource Group,
Detroit United Oakwood Physicians, Dearborn
(1Q06) United Physicians, Bingham Farms
(4Q05) University of Mich. Health System Faculty
Group Practice, Ann Arbor Upper Peninsula Health
Plan, Marquette (4Q05)

• Physician Organization Gain-Sharing Incentive
  Program (POGS)
• Contract with selected physician organizations
• Criteria
• Physician organizations with 30 or more TRUST
  physicians with primary care focus
• A partnership, association, corporation,
  individual practice association or other group
  that distributes income from the practice among
  members
• Organizations will coordinate and facilitate
  practice improvements and program administration
  on behalf of their physicians
• Physicians limited to participation with only one
  physician organization for purposes of gain
  sharing program
• PGIP groups automatically eligible to participate

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2006 Performance Measures

• PGIP / POGS will have identical measures
• Generic dispensing rate
• Improvement over baseline
• One percentage point over control group
• PMPM
• PPIs (Proton Pump Inhibitors)
• NSAs (Non sedating antihistamines)
• NSAIDs (Non-steroidal anti-inflammatory drugs)

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Summary

• Variation in pharmaceutical use and prescribing
  is common across all drug categories, some more
  than others
• The Atlas is a tool to measure how we are doing
  and where we can focus attention for quality of
  care and patient safety
• Improving quality and safety is a collaborative
  effort among all stakeholders in health care

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Discussion

• Thoughts about the data?
• Thoughts about how unwarranted variation applies
  to pharmaceuticals?
• Thoughts about using this data to promote patient
  safety?
• Upcoming meetings/forums that would be interested
  in learning about the atlas?

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Contact Us
Huda Fadel, MPH, Ph.D. Manager, Health Services Research [phone] hfadel_at_bcbsm.com
Atheer Kaddis, Pharm.D. Director, Clinical Program Development 248-448-5956 akaddis_at_bcbsm.com
Richard Cook, Pharm.D. Manager, Clinical and Quality Programs 616-285-3072 rcook1_at_bcbsm.com