BETHESDA, MD—Due to its ability to track patient health data within its system and to orchestrate initiatives inside what is essentially a unified healthcare program, VA has played a pioneering role in showing how chronic disease treatment, such as for cardiovascular disease, can be improved over large swathes of a patient population.
Could that same success be replicated in the private sector across multiple care systems? That is the question that researchers in California are attempting to answer with the California Right Care Initiative. The project is being overseen by the National Heart, Lung and Blood Institute (NHLBI)-funded California Comparative Effectiveness and Outcomes Improvement (CEOI) Center, which has the long-term goal of improving cardiovascular prevention and care for more than 15 million people enrolled in California managed care plans. Along with the CEOI Center, the State of California, three campuses of the University of California, the RAND Corp., and most of the major health plans serving California, are joining together in this community-wide initiative to prevent heart attacks and stroke.
The initiative is still in its early stages, but Robert Kaplan, PhD, who was the principal investigator on the project before moving across the country to work at NIH in January, gave a recent progress update to an audience of federal researchers. The Department of Health and Human Services strategic plan emphasizes evidence-based primary care and preventive care and lowering costs through higher quality evidence-based practices. And it also stresses dissemination of evidence-based practices into community practice,” Kaplan said. “That’s a lot of what we’re attempting to do.”
The inspiration for the project came from California’s Healthcare Effectiveness Data and Information Set (HEDIS) scores, the standard set ofperformance measures used in the managed care industry. For a state with a population that prides itself on its healthy lifestyle, those scores are surprisingly low, Kaplan said. “No California plan other than Kaiser Permanente scored higher than the 90th percentile nationally.”
Researchers thought that, if progress could be made in creating a healthier population statewide, then cardiovascular (CV) disease was the logical target. It remains the predominant cause of death in the U.S.—850,000 deaths per year—and the risk factors are well understood. Many of these risk factors, which include tobacco smoking, high blood pressure, high serum cholesterol, and diabetes, have been known and understood since 1961.
“We’ve known for a very long time that intervening with those risk factors lowers the chance of death,” Kaplan said. “We feel that quality of care for CV disease can be improved and measured.”
According to the 2004 National Health and Nutrition Examination Survey, between 75% and 80% of the U.S. population has high blood pressure and are unaware of it. Among those, fewer than 70% get treated. And, among those, only 35% to 50% get adequate control. “This means that only 28% of people with high blood pressure are being successfully treated,” Kaplan said. “We consider this a very significant problem, because we know that (blood pressure) can be controlled in almost anyone. It may take three drugs to get there, but we know it can be achieved.”
The key, he said, was improving health care delivery through greater reliance on best practices.
“We know that patients who receive evidence-based care have a higher probability of achieving better outcomes. But when we look at the probably that patients get this evidence-based care, we see that they only get it in about half the cases,” Kaplan said. “In trying to move California to this next level, we wanted to see if, on a statewide basis, could we make a dent in this and get evidence-based care to people a higher proportion of the time.”
Making San Diego the Heart-Healthiest Place in America?
Kaplan and his colleagues narrowed the focus down even further, specifically targeting diabetes as a risk factor for CV disease. Diabetes has a significant impact on CV disease, and the data set for diabetes care in California was much more complete than for other risk factors.
“It’s remarkable how inadequate the data are, even though we’re working with the State Department of Managed Health Care, who can, by law, actually request data,” Kaplan said.
Then the researchers narrowed the focus geographically. Working with software developers at RAND, they performed hot-spot analyses, identifying populations at a higher risk for poor diabetes management. They found that the hot-spots were focused in areas with a high Latino population, such as San Diego, which is close to the Mexican border. That city also has a managed care system that operates on the high end of the performance spectrum but shows a lot of variability.
“That was key for us,” Kaplan said. “We wanted to get the poor performing groups up to where the higher performing ones are.”
One step in achieving that goal has been to look at the different managed care organizations and see what practices are working well for them. Researchers discovered is that different organizations have found success with initiatives, but that each group is unaware of what the other is doing. Because of the California Right Care Initiative, those practices are starting to be made public.
For example, Kaiser has achieved 80% lipid-lowering and ACE inhibitor penetration among its population. However, that success did not come using the model of targeting every patient in the system, nor by the method of getting patients on the medicine, and then going through a process of titration over the course of many appointments.
Instead of screening everyone, Kaiser targeted those with diabetes more than 55 years of age, or who has had a prior heart attack or stroke and put them on a regimen of aspirin, statin, and ACE inhibitor. “And they got the cost down to $200 per year per patient,” Kaplan said. “The lesson from Kaiser is: don’t lose focus on the overall outcome.”
The California Right Care Initiative also took the step of gathering all of the information from the various care plans on their patient populations’ LDL cholesterol, blood pressure, and diabetes rates and published them online. “When we first started meeting with medical groups, they said, ‘It’s impossible. We’re doing everything we can.’ But when you look at the high-performance plans like Kaiser, they’re at 80%. So we know it can be done,” Kaplan said.
Challenge of Working Together
With a half-century of knowledge about CV risk factors, behavior remains the biggest challenge to achieving system-wide success, Kaplan said, referring to the behavior of care organizations as well as patients. When the initiative first began, the managed care groups did not relish the idea of having detailed information on their successes and challenges made available to their competitors.
“Medical groups in San Diego are viciously competitive with one another. So we started the San Diego Rotating University of Best Practices. The medical directors of these groups are now meeting once a month to review their best practices. We’re hoping to get them to the point where they share and monitor data together,” Kaplan said. “The big issue is they’re worried [all their] data will become public. Now we have a data-sharing agreement that will forbid the use of any of this data for competition.”
The solution, Kaplan said, is a redesign of these systems that allows for openness and transparency. To help provide guidance and support, the initiative is working with non-managed care systems in a coalition that includes VA and the military. The coalition has not been very successful in coaxing in the fee-for-service organizations to participate, Kaplan said, but he believes the managed care programs are solidly on board. “Health plans are interested in this because they believe it will improve quality, but also lower their cost.”