Prevention and Management of Chronic Illness in Vermont. Don Dickey Joint Fiscal Office January 16, 2007

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1 1 Prevention and Management of Chronic Illness in Vermont Don Dickey Joint Fiscal Office January 16, 2007

2 2 Outline of Presentation Why the focus on chronic illness? Making health care more responsive to needs of people with chronic conditions Reducing the prevalence of chronic disease (reduces need for health care) Act 191 chronic care strategies / Blueprint for Health Challenges facing Act 191 / Blueprint

3 3 Why Chronic Illness? Chronic conditions are the leading cause of illness, disability, and death in Vermont Common chronic conditions in adults: diabetes hypertension (high blood pressure) asthma arthritis cancer cardiovascular disease respiratory diseases depression and other mental health disorders substance dependence

4 4 75% of Health Care Spending Over 50% of all Vermont adults have one or more chronic conditions 75-80% of the $3.7 billion spent on health care in VT this year Vermont can lower demand for medical services and overall cost if: Prevent/manage chronic conditions through more effective health care Reduce the prevalence of chronic illness

5 5 More Effective Health Care Only 55% of chronically ill Vermonters patients receive the right care at the right time Health care system not designed to make sure the many things that need to happen are happening System evolved to provide care for people with short-term, acute, and episodic health needs (e.g., injury, infectious disease)

6 6 Health Care Redesign Needed Patients with chronic conditions need many things to ensure a good outcome Frequent blood tests Adequate medication intensification Education so that they can manage aspects of their conditions themselves Prevention/management of chronic disease requires proactive, planned care and ongoing, productive relationship between the individual and provider team

7 7 What Change Is Required? New model of health care delivery and payment more responsive to chronic illness needs Based on the Chronic Care Model (Ed Wagner, MD, MPH) The essential elements of a health care system that supports high-quality chronic disease care

8 8 Key Elements of Chronic Care 1. Evidence-based guidelines 2. Clinical information systems (IT) 3. Payment incentives aligned with quality goals 4. Self management 5. Chronic care management 6. Health system change

9 9 1. Evidence-Based Care Evidence-based guidelines = scientific studies/consensus on quality care Right care at the right time for managing chronic illness Current system has insufficient tools and incentives to promote rapid adoption of best practices Key tools and incentives: IT systems and payment incentives

10 10 2. Information Technology Proactive tool to track and plan care and provide timely reminders about needed services Real time information when and where it s needed (where action can be taken) Must be easy-to-use in day-to-day practice Complete medical history (feeds from all providers), with ability to sort or analyze Interface with clinical guidelines/protocols

11 11 3. Aligning Payment Practices Payments encourage providers to deliver high quality care wisely and efficiently Provide incentives to use IT and consult evidence-based guidelines Current system offers few incentives to avoid overuse, underuse, or misuse of care, and does not reward efficiency Pay for performance is among many strategies in this highly complex area

12 12 4. Self Management Portfolio of tools and techniques, primarily education and skill development programs offered in the community People with chronic conditions make dayto-day decisions about their illnesses, but see physician only 15 minutes twice a year Individual s behavior and self-care are most important in slowing the onset and progression

13 13 5. Chronic Care Management Any systematic approach to improve both cost effectiveness and outcomes Identify individuals with one or more chronic conditions (using claims data) Conduct health risk assessments (HRAs) for all beneficiaries identified Stratify the population into high, middle, low risk groups Conduct care management interventions for each risk group (differing intensity)

14 14 6. Health System Change Shift system toward chronic care model Several different major payers, each with their own payment and delivery rules Medicaid State Employees (CIGNA) Blue Cross Blue Shield Medicare MVP Health Care Self-Insured Plans Other Payers

15 15 Not Just About Health Care! Chronic disease prevention/management is broader than health care alone Health care plays an important role in preventing chronic illness (child well-care) But many factors influence individual and population health, often more profoundly than health care Public health - use information to develop methods to prevent disease occurrence

16 16 Reducing the Prevalence of Chronic Disease Paramount long-term strategy to improve health and reduce costs of care Ounce of prevention is preferable to medically managing widespread chronic disease Important role of Public Health Community Health Improvement

17 17 Public Health Policies/Systems Traditional public health Immunizations, nutritional needs, food safety, infectious diseases, and (now) terrorism Coordination with clinical prevention services (e.g., immunizations and breast cancer screening) New role: Population-level health improvement, addressing multiple determinants of health (e.g., genetic, behavioral, social, and environmental)

18 18 Community Resources/Policies Mobilize community partnerships (businesses, schools, health providers, etc.) to identify and solve health problems Local level initiatives to address physical activity, nutrition, and other behaviors Must be effective in reaching members at risk and getting them to participate

19 19 Act 191: Chronic Care Strategies Blueprint for Health Chronic Care Management Program for Medicaid Align other state programs with Blueprint State employee health benefits plan Catamount Health Plans

20 20 Blueprint for Health Launched in 2004; Endorsed by Act 191 in 2006 Statewide system of care to improve the lives of individuals with and at risk for chronic conditions Preventing/managing chronic illness will reduce demand for high-cost medical services, moderating the rise in costs

21 Blueprint Care and Prevention Model Public Health Policies, Systems, Environment Community Resources and Policies Self- Management Support Delivery System Design Health System Health Care Organization Decision Support Clinical Information Systems Supportive Environment Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Adapted from the chronic care model which is used by permission of Effective Clinical Practice. Improved Outcomes-Healthier People 21

22 22 Blueprint Key Components Public Health Community Activation (for health improvement) Patient Self-Management Evidence-Based Standards Information Systems Payment for Quality (e.g., pay for performance, financing for patient self-education) Health System Change

23 23 Core Goals of Blueprint Utilize the Chronic Care Model as the framework for system change Utilize a public-private partnership to facilitate and assure sustainability of the new system of care Facilitate alignment of Blueprint priorities and projects with other statewide health care reform initiatives

24 24 Blueprint - Organizational Structure Program of the Vermont Department of Health Public-private partnership to develop and implement strategy for cross-systems change Blueprint Executive Committee has advisory role (representation from state, providers, health plans) Stakeholder Workgroups - Self-Management - Community - Provider Practice - Information Technology - Health Systems - Evaluation

25 25 Strategic Plan Jan Provides implementation objectives, milestones, and timelines for next 5 years Many specifics remain to be fleshed out ( living document) Blueprint is a work in progress Blueprint funding in FY07 - $5 million Important oversight role for legislative committees

26 26 Six Communities Participating First two communities ( ) St. Johnsbury (Northeastern Vermont Regional Hospital) Bennington (Southwestern Vermont Medical Center) Four additional communities (July 2006) Windsor (Mt. Ascutney Hospital and Health Center) Springfield (Springfield Hospital) Berlin (Central Vermont Physician Hospital Organization) Burlington (Fletcher Allen Health Care)

27 27 Community Implementation Each community has work plan Practice redesign Information systems Self management Community health initiatives

28 28 Blueprint and State CCM Programs Act 191: Blueprint mandates standards for chronic care management in state programs: Medicaid chronic care management program State employee health benefit program Catamount Health Plans

29 29 Chronic Care Management in Medicaid Two related initiatives developed in consultation with the legislature Care Coordination initiative - begun in early 2006 Chronic Care Management Program - slated to begin July 1, 2007 Building staff capacity for CCM at OVHA

30 30 State Employees Health Benefits Summer 2006: contract rebid process for State s self-insured health care plan for employees Include chronic care management aligned with Blueprint CIGNA medical director added to Blueprint leadership committees New contract begins January 2007

31 31 Catamount Health Insurance carriers offering Catamount Health Plans Required to have chronic care management aligned with Blueprint Cost-sharing will be waived for enrollees who are actively participating March 7: Plans for CCM programs must be filed with BISHCA

32 32 Key Challenges for Blueprint 1. Challenge of building a chronic care system in a fragmented fee-for-service environment with multiple payers Payers operate in many other states Payers are market competitors Payers and providers often diverge on policy Medicare does its own thing

33 33 Key Challenges for Blueprint 2. Getting in front of ongoing chronic care delivery and payment initiatives and leading the change process 3. Reducing the prevalence of chronic disease Public health dollars in federal payment silos with strings attached Developing effective strategies at the level of public health and community

34 34 Key Challenges for Blueprint 4. Sustaining the investments needed Change will take time to implement Investments now, payoff later 5. Gaining investments from other stakeholders to accomplish Blueprint goals

35 35 Summary VT making progress on making health care more responsive to the needs of people with chronic conditions (right care at right time) Long term strategy for reducing the prevalence of chronic disease is vital, & deserves attention Blueprint / Act 191 must meet early implementation challenges to sustain energy and momentum QUESTIONS?

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