Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making May 24, 2013 Jeff Thompson, Washington State Health Care Authority David Downs, Engaged Public David Swieskowski, Mercy ACO Mercy Clinics, Inc. Lisa Weiss, High Value Healthcare Collaborative Kate Chenok, Pacific Business Group on Health

1. M e t h o d s f o r F o s t e r i n g t h e W i d e s p r e a d I m p l e m e n t a t i o n
o f S h a r e d D e c i s i o n M a k i n g
Aligning Incentives for Patient
Engagement
May 24, 2013

2. Using Shared Decision and Supply Side
Management
Thursday, May 23, 2013
Jeff Thompson MD MPH
Principal
Seattle

3. 
Aligning Incentives for Patient Engagement:
Enabling Widespread Implementation of Shared Decision Making

4. Shared Decision Making
Adding Value to Mercy ACO
David Swieskowski, MD, MBA
CEO – Mercy ACO
Senior VP & Chief Accountable Care Officer
Mercy Medical Center, Des Moines, IA

5. Aligning Incentives for Patient Engagement:
Enabling Widespread Implementation of
Shared Decision Making
Washington D.C.
May 24, 2013

6. Purchaser Perspectives on
Shared Decision Making
Kate Eresian Chenok
Director, New Initiatives

7. ©PBGH 2013 7
PBGH Members

8. ©PBGH 2013 8
PBGH 2015 Vision
A health care system transparent about the quality, cost
and outcomes of care, where consumers are motivated
to seek the right care at the right price and providers are
incented to offer better quality, more affordable care.

9. ©PBGH 2013 9
What purchasers are looking for:
 Affordability
 Appropriate use
 Reward for efficient providers
 Accountability
 Patient engagement
 Collaboration across specialties
 Evidence based practice
 Delivery System Innovation
 Payment redesign
 Health IT
 Continual learning

10. ©PBGH 2013 10
Case study: purchasers are concerned about trends
in births
Delivery Trends
Caesarian delivery rates have now risen to over 32% in
the U.S. (up from less than 20% in 1996) with no
evidence of better outcomes.
Payment Trends
 Caesarian delivery reimbursement averages 33%
more than that for spontaneous vaginal birth.
 Births are in the top 10 high cost episodes for PBGH
members (both HMO and PPO)

11. ©PBGH 2013 11
Case study: purchasers are concerned about trends
in births (continued)
Consumer Experience(1)
63% of mothers with primary cesareans indicated the doctor
was the decision maker.
Appx.1% of mothers with a primary cesarean reported that they
themselves had made the decision to have a cesarean in
advance of labor and there had been no medical reason for the
cesarean.
Women reported holding back from asking questions because
their care provider might view them as difficult, they wanted
maternity care that differed from what their provider
wanted, or their care provider seemed rushed.
(1) Listening to Mothers III

12. ©PBGH 2013 12
What are PBGH members doing?
Planning to support SDM in maternity care with CBC and IMDF
Promoting SDM in orthopaedics
Communicating with health plans about importance of patient
engagement and informed decision making
Here is the current landscape for PBGH members…

13. ©PBGH 2013 13
Purchasers have a wide range of definitions of
Shared Decision Making
One quarter offer formal SDM programs
In addition, most offer:
 Online decision support
 Telephonic nurse support
 Case management
 Online cost calculators and comparison tools
 Online and in person wellness programs
 Educational materials
Some offer onsite clinics which provide direct care
Source: December 2012 survey of PBGH members

14. ©PBGH 2013 14
Believe Shared Decision Making results in:
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Improved decision
quality
Appropriate treatment
choice
Potential for reduction
in variation
Potential for reduction
in expensive
procedures
More productive
employees
Bottom line cost
savings
How would you define value for Decision Aids and Communications Aids? (check all that apply)
Source: December 2012 survey of PBGH members

15. ©PBGH 2013 15
Purchasers evaluate programs they offer according
to:
Employee engagement
Health improvement
Cost

16. ©PBGH 2013 16
Who should promote SDM?
 Expect it from providers as part of appropriate care
 Expect health plans to support and provide additional
channel for patient engagement
 Employers can play a supporting role

17. ©PBGH 2013 17
Shared Decision Making – links to purchaser goals:
 Affordability
 Appropriate use
 Reward for efficient providers
 Accountability
 Patient engagement
 Collaboration across specialties
 Evidence based practice
 Delivery System Innovation
 Payment redesign
 Health IT
 Continual learning

18. • What HVHC is doing to advance shared decision
making (SDM) between clinicians and patients
• Why HVHC sees shared decision making as
important
• Steps to make shared decision making a
sustainable part of day-to-day health care
Confidential - Internal Use Only 18
Topics

19. HVHC 21 members and growing
31 states; patients in every state

20. CMMI award*
The goals of this initiative are to:
1. Improve quality, outcomes, and cost of care by advancing best
practice care models for patients considering hip, knee, or spine
surgery and patients with diabetes, congestive heart failure, or
sepsis
2. Improve patient experience and reduce utilization and total cost
by implementing:
a. Shared decision making (SDM) interventions for preference-based
decisions (hips, knees, spine surgery)
b. Patient engagement interventions (e.g., decision tools, motivational
interviewing, patient management) for complex patients with
diabetes or CHF
* The project described was supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid
Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily
represent the official views of HHS or any of its agencies.
20

21. • What HVHC is doing to advance shared decision
making between clinicians and patients
• Why HVHC sees shared decision making as
important
• Steps to make shared decision making a
sustainable part of day-to-day health care
Confidential - Internal Use Only 21
Topics

22. Addressing Unwarranted Variation in Health Care: Can Better Care Cost Less?
Cost = (cost / episode) x (# episodes)

23. 23
Knee Replacement Rate by PHN
Adj.KneeReplacementRateper1000Beneficiaries

24. • What HVHC is doing to advance shared decision
making between clinicians and patients
• Why HVHC sees shared decision making as
important
• Steps to make shared decision making a
sustainable part of day-to-day health care
Confidential - Internal Use Only 24
Topics

25. • Transfer SDM into patient time and home
• Integrate SDM tools into clinical care workflow
• Measure and communicate patient experience
• Provide multi-professional training and incentives
Confidential - Internal Use Only 25
Making SDM Part of Day-to-Day Health Care

26. Transfer SDM into patient time and home

27. Transfer SDM into patient time and home

28. Integrate SDM tools into clinical care workflow

29. 29
Measure and communicate patient experience

30. CMMI Award Improvement Targets
• Improve care: >50% eligible patients referred to SDM and
>50% of referred patients/families participate in SDM
intervention
• Improve health: Improve health status measures
(function, pain) for > 50% of patients considering
hip, knee, and spine surgery at one year
• Reduce cost*: Reduce rates of hip & knee surgeries and
episode costs resulting in 5% total cost reduction
(aggregate relative rate); for complex patients with diabetes
or CHF: reduce aggregate relative hospitalizations by 10%
and reduce aggregate cost of annual episodes by 2%
(aggregate relative rates); Total cost savings = $64M
30

31. • Owned by Catholic Health Initiatives
• 627 beds
• Medical Staff - 1,045
• Employed physicians & Mid-levels - 545
• Total Acute Admissions - 31,592
• Visits to All Mercy Clinics - 1.4 M
• Payroll/ Net Revenues - $492M/ $901M
Mercy – Des Moines
Mercy ACO
• LLC wholly owned by CHI Iowa – formed in Feb 2012
• 657 Provider participants
– Employed – 470, Independent – 187
– Primary Care – 289, Specialists – 368
• 26 adult primary care clinics & 6 pediatric clinics
• 62,000 lives in shared savings contracts

32. Mercy Steps to Advance Shared Decision Making
Between Clinicians and Patients
• Physician Engagement
– Support from quality & governance committees
– Champions identified
– Academic detailing
• Utilize ACO resources and Health Coaches
– ACO distributes Decision Aid to practices
– Sponsoring CME events
– Specific initiatives launched
• Advanced directives
• Colon cancer screening
– Embed decision aids in our care management software
– ACO Health Coaches promote shared decision making

33. Health Coaches
Key delivery system redesign
• Located in each primary care clinic
• Self-Management Support
– Motivational interviewing for Health Behavior change
– Connection to community resources
• Coordination of care
– Track patients through transitions in care
• Quality Improvement
– Point person for introduction of new care processes
– Meet every two weeks to share best practices
• Shared decision making
– Trained to use Decision Aids and assist patients with decisions
– Identify patients, distribute decision aids, and f/U
– Coaches are champions in each clinic

34. SDM Aligns With ACO Goals
• Fully informed patients will have better outcomes
 More engaged and adherent to treatment plans
 Will choose the best options for themselves
• Lower total cost of care
– Better outcomes will lead to lower overall cost of care
– Patient choices will often be less costly than physician
choices
• SDM reduces the ethical dilemma when there is an
incentive to reduce cost
• Patient centered
• Increase patient satisfaction
• Distinguish us in the marketplace

35. Steps needed to make shared decision making a
sustainable part of day-to-day health care
• Make the quality case
• Make the value proposition
– Clearly identify where there is a financial gain
• Recipient of the gain needs to finance SDM
• Do not increase the work of the physicians
– Build a physician support system that uses DAs

36. Engaged Benefit Design
 Vision
 Coloradoans will be the wisest consumers of health
care in the country
 Developed by Engaged Public
 Public policy development firm
 Facilitation
 Public engagement
 Policy development and analysis
 Leadership development

37. Why Engaged Benefit Design?
 Most incentives for quality and value aimed at
providers
 P4P
 PCMH
 ACO
 Bundled payment
 Incentives to patients indiscriminately aimed at cost
 High deductible
 Across the board increase in cost-share
 Reduce utilization of effective care

38. Engaged Benefit Design
 Value Based Insurance Design
 Identify Specific high-value, effective services and eliminate cost
sharing
 Prevention, screening, chronic disease management, ….
 Identify specific high cost, preference sensitive services and raise
cost sharing
 Coronary stenting, large joint replacement, back
surgery, hysterectomy, BPH surgery, ….
 Borrowed heavily from Oregon Health Leadership Council
 Multiple sources for best evidence and comparative effectiveness
 Vetted through physician leaders, insurance experts, business and
consumers over 18 months

39. Engaged Benefit Design
 Provide incentives to consumers to utilize Patient
Decision Aids and engage in Shared Decision-
Making with their providers
 $50 check in current pilot
 Waive increased co-payments in upcoming
implementation
 Consider “wellness points” to reduce deductible
 Others
 Assess experience with PDA using decision quality
measurement tools to authorize incentives

40. Engaged Benefit Design
 Current pilot
 Funded through HRSA and RWJF grants
 1/1/2012 - 12/31/2013
 San Luis Valley Regional Medical Center
 725 enrolled (kitchen staff to CEO)
 Well received by employees, providers, employer
and administering health plan

41. Engaged Benefit Design
 Lessons we are learning
 This is about culture change
 Outreach to consumers and providers is critical
 Patient incentives help
 Once using PDAs, providers want to use them with
all patients
 Dedicated resource center is key to making things
work

42. Engaged Benefit Design
 Next steps
 New grant from The Colorado Health Foundation
 Identify and assist more employers/groups
 Assist Medicaid Accountable Care Collaboratives
implement SDM
 Create a regional SDM resource center
 Community wide implementation
 Colorado Health Insurance Cooperative
 Benefit design
 Community engagement around a medical commons

43. MERCER 43July 11, 2013

44. MERCER 44July 11, 2013
Priorities in Demand & Supply Controls: How
does shared decision making apply?
Two Populations - Different Issues
5%
95%
Chronic Care Worried Well
Two Populations - Different
Expenditures
50%50%
Chronic Care Worried Well
Chronic Care:
•Cardiovascular
•Cancer
•Orthopedics
•Mental Health
•Obstetrics
Worried Well:
•Cholesterol
•Glucose
•Blood pressure
•Weight

45. MERCER 45July 11, 2013
Where does a Patient Decision Aid fit in
Supply Controls?
Two Populations - Different Issues
5%
95%
Chronic Care Worried Well
Two Populations - Different
Expenditures
50%50%
Chronic Care Worried Well
Wellness:
• Immunizations
• Smoking
• Substance abuse
Chronic Care:
•Shared Decision making
•Care/Case Management
•Informed consent
•Second Opinions
•Variation Control
•Centers of Excellence

46. MERCER 46July 11, 2013
Patient Decision Aids (PDAs)
• Patient Decision Aids provide unbiased, evidence-based
information about the available options and possible
benefits and risks so the patient is better equipped to make
an informed decision that is aligned with their preferences.
PDA are about one service vs. another service
•What is treatment A and B
•What are likely benefits of treatment A and B
•What are the likely harms of treatment A and
B
Example: Spine Surgery:
• You have a 50% chance of success with
surgery or physical therapy
• Smokers who have spine surgery have a
40% failure rates vs.10% for non-smokers

47. MERCER 47July 11, 2013
Informed Consent Tools
Informed consent tools give patients more information
after they have chosen a procedure or treatment. They can
help to educate the patient on what to expect and reduce
surprises.
Example: Spine Surgery:
•Excellent pictures and
descriptions
•Recommendations like Do not
smoke before surgery
Informed is about a particular service:
•What is treatment B
•What should I do before and after treatment B

48. MERCER 48July 11, 2013
Second Opinions
Second Opinion services can give a member information
following a treatment or when there is a need for an expert
to offer another opinion.
Spine Surgery:
• You should not have a fusion while smoking.
May I help you stop smoking with a transfer to
Free and Clear
Second opinions can help with questions:
•They told me treatment B would work – it did
not work!
•They want me to have treatment B – I am
concerned!
•They can not tell me what’s wrong - I need
help!

49. MERCER 49July 11, 2013
Centers of Excellence and variation control
Center of Excellence services have proven outcomes that
are better than peers with predictable costs (e.g.
warrantees).
Spine Surgery:
• This center only operate where there is
evidence of effectiveness!
• They can not operate when you smoke!
• If you go to hospital B your co-payment will
be less due to better outcomes!
Centers of Excellence is about where to have a
particular service:
• Here are differ outcomes for venue A and B

50. MERCER 50July 11, 2013http://qualitysafety.bmj.com/content/early/2013/03/27/bmjqs-2012-001550.abstract

51. MERCER 51July 11, 2013
WA Legislation
Washington State Legislature Health Care bill includes
decision aids (SB 5930 and RCW 7.70.060 and WAC 182-
60-005)
• This statute changes the level of proof in a malpractice
case from preponderance (>50%) to clear and
convincing (>75%) suggesting a value proposition for
providers to reduce their liability risks.
• This code identifies items for certification based on
International Patient Decision Aid Standards (IPDAS).