Clinical Integration: Strengthening Patient Care Services with a Systems Approach Brett D. Stauffer, MD, MHS, FHM Chief Quality Officer Baylor Scott & White Health Welcome to Texas What is this? A. Baby dinosaur B. Armored rat C. Leprosy vector D. Dinner? 100% 0% 0% 0% Baby dinosaur Armored rat Leprosy vector Dinner? Page 1 of 13
Learning Objectives Identify the imperative for clinical integration with pharmacy leadership Discuss executive challenges such as: setting goals for alignment care and cost optimization inter professional team development resource allocation Describe cases that demonstrate successful integration Achieving the Quadruaple Aim Improve the patient experience of care Improve the health of the population Reduce the per capita cost of health care Enhance clinical team fulfillment Accountable Care Organization (ACO) Quality Improvement Framework Page 2 of 13
Integrated Delivery Network (IDN) Building an Integrated Delivery Network Baylor Scott & White Quality Alliance Taking Action Care Value Proposition Page 3 of 13
Transforming Culture Generic Prescribing Antimicrobial Stewardship Pharmacy Management Technology Generic Prescribing Audience Question According to the 2017 Generic Drug Access & Savings in the U.S. Report produced by the Association for Accessible Medicines, generic prescriptions account for % of prescriptions dispensed but only account for 26% of total drug costs in the United States. A. 35% B. 89% C. 55% D. 62 100% 0% 0% 0% 35% 89% 55% 62 Page 4 of 13
Audience Question According to the 2017 Generic Drug Access & Savings in the U.S. Report produced by the Association for Accessible Medicines, generic prescriptions account for 89% of prescriptions dispensed but only account for 26% of total drug costs in the United States. A. 35% B. 89% C. 55% D. 62% Generic Fill Rate (%) 90 88 86 84 82 80 78 76 74 72 70 Generic Fill Rate: BSWH Employee 87.6 87.2 88.14 86.2 84.15 80.9 78.9 76.4 2013 2014 2015 2016 (YTD) CTX NTX Methods to Increase Generic Utilization 1. Alignment of prescribers 2. Formulary changes 3. Benefit design 4. Prior authorization criteria / step therapy edits 5. Therapeutic interchange programs Page 5 of 13
Baylor Scott & White Quality Alliance Traditional Drugs GPR and Cost/Rx All Payer Summary, 2016 June 2018 Savings from 1% GPR 2016 $7MM 2017 $11MM 2018* $11.4MM *Annualized %GPR (Bar) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% GPR Cost/Rx 89% 88% 86% $58.25 $59.93 2018 2017 2016 Year (Descending) $63.80 $100.00 $90.00 $80.00 $70.00 $60.00 $50.00 $40.00 $30.00 $20.00 $10.00 $0.00 Cost/Rx (Scatter) % GPR (bar) 92% 90% 88% 86% 84% 82% 80% 78% 76% Baylor Scott & White Quality Alliance Traditional Drugs GPR and Cost/Rx By Payer, 2017 Commercial Plans GPR Cost/rx Linear (Cost/rx) A B C D E F G H I J Commercial Payer * $100.00 $80.00 $60.00 $40.00 $20.00 $0.00 Cost/Rx (Scatter) % GPR (bar) 92% 91% 90% 89% 88% 87% 86% Medicare Plans GPR A B C Medicare Payer Trend: higher GPR generally have lower average costs Cost/rx * $100.00 $80.00 $60.00 $40.00 $20.00 $0.00 Cost/Rx (scatter) *Cost information not available Baylor Scott & White Quality Alliance Commercial Traditional Drugs GPR Rx Volume by Payer, 2017 92% 90% A B Largest Rx volume plans have largest opportunities for savings by increasing GPR % GPR 88% 86% 84% 82% C D E 889K Rxs F G H I 630K Rxs J 80% Bubble = Payer Rx Volume Page 6 of 13
90% 89% 88% 87% 86% 85% 84% 83% 82% 81% 80% % GPR Baylor Scott & White Quality Alliance Commercial Traditional Drugs GPR Potential opportunities for GPR increase, 2017 Potential Savings if below average GPR increased to average GPR = $3.4MM $790K $960K $4MM $1.7MM Avg GPR 86.6% A B C D E F G H I J Commercial Payer 90% 89% 88% 87% 86% 85% 84% 83% 82% 81% 80% % GPR Baylor Scott & White Quality Alliance Commercial Traditional Drugs GPR Potential opportunities for GPR increase, 2017 Max GPR $315K $8.3MM $791K $10MM 89.8% $192K $2.9MM $3.7MM $3.8MM $2.8MM A B C D E F G H I J Commercial Payer Potential Savings if GPR increased to max GPR = $26MM Antimicrobial Stewardship Page 7 of 13
Background: Regulatory and National Standards The CDC estimates 20 50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate Antibiotic misuse is associated with increased drug costs and increased costs of caring for patients with resistant organisms, C. difficile, etc. January 1 st, 2017 the Joint Commission created a new standard that required hospitals to have an antimicrobial stewardship program (ASP): Antibiotics must have a documented indication Must have antibiotic review procedure (i.e. antibiotic timeout) after 48 hours of active orders Hospitals must track antibiotic use (i.e. days of therapy or purchasing) Leadership and physician/pharmacist champions identified Currently there is no standard benchmark for antibiotic use Audience Question Does your organization have an antimicrobial stewardship program? A. No, but in the works B. Yes, pharmacy driven C. Yes, multidisciplinary team driven D. Yes, multidisciplinary team driven with benchmarking and reporting to front line staff E. Yes, all of the above and we have shown cost savings along with improved prescribing practices No, but in the works 0% 0% 0% 0% Yes, pharmacy driven 100% Yes, multidisciplinary... Yes, multidisciplinary... Yes, all of the above a.. Antimicrobial Stewardship Program Interventions Timeline May 2015 BSWH Inpatient ASP Council created June 2016 Automatic Renal dosing and IV to PO Policy December 2016 BSWH Ambulatory Stewardship Committee April 2018 C.diff guideline Diarrhea guideline December 2015 Carbapenem & daptomycin appropriate use guidelines August 2016 Fluoroquinolone guideline MedMined implementation Dorsata mobile app January 2017 Antibiotic Timeout Procedure implemented Page 8 of 13
Antimicrobial Stewardship Interventions Clinical Decision Software (MedMined ) 72 hour time out review Targeted guidelines and protocols Dorsata mobile app On iphone, Android, desktop computers Easy access to ASP guidelines and biograms >1300 user signups (446 physicians) Monthly CMO/CNO reports to track stewardship results at each site antibiotic days of therapy Antibiotic Days of Therapy (DOT) Reductions Total Antibiotic Days of Therapy FY17 FY18 643.0 650.0 621.0 Metric (DOT/1000) FY17 FY18 Percent Change P value 4 Total Antibiotics 1 643 621 3.5% 4 <0.01 Vancomycin 99.1 92.6 6.6% <0.001 Carbapenems 2 28.8 20.7 28.0% <0.001 Fluoroquinolones 3 77.1 57.5 25.4% <0.001 Daptomycin 4.6 4.5 2.5% 0.69 1. One antibiotic DOT is allotted for each antibiotic a patient is prescribed per day, including empiric, definitive and surgical prescriptions 2. Ertapenem, imipenem/cilastatin, meropenem 3. Ciprofloxacin, levofloxacin, moxifloxacin 4. Students t test 550.0 200.0 100.0 0.0 40.0 30.0 20.0 10.0 Total DOT Targeted Antibiotic Days of Therapy 99.1 92.6 77.1 Vancomycin 28.8 20.7 57.5 Fluoroquinolones 4.6 4.5 0.0 Carbapenems Daptomycin Cost Savings (based on antibiotic drug spend) Page 9 of 13
Future Projects National Healthcare Safety Network reporting for broader comparison of antibiotic use to other hospitals Able to compare observed vs. expected antibiotic use Continue developing additional guidelines/protocols as necessary to further promote appropriate antibiotic use Continue to monitor trends in antibiotic use, review antibiotic days of therapy data and report to leadership Pharmacy Management Technology On Feb 8th, 2018 a Baylor Scott & White Health (BSWH) pharmacy section was added to MyBSWHealth Page 10 of 13
The Baylor Scott & White Health pharmacy section includes functionality allowing users to: Primary Functions Order a Refill Transfer prescriptions between BSW pharmacies and from external pharmacies (i.e. CVS). Manage proxy accounts (i.e. spouse, child, etc.) View Prescriptions: Ready for pickup - estimated cost included Ready for refill Alerts/Notifications for refill available and ready for pickup Secondary Functions Change default BSW pharmacy Call a BSW pharmacy or get driving directions for pick-up Tasks have been streamlined to optimize the experience for our consumers EX: Streamlined Order Refill Process: Tap 1 Tap 2 Tap 3 Tap 4 Problem 24 hour accessibility to prescriptions for patients. Patient satisfaction & convenience. Solution ScriptCenter for 24/7 pickup of patient specific, finished prescriptions. Page 11 of 13
Baylor Scott & White Pharmacy Carrollton, TX Go-Live: 4/18/17 Carrollton Pickups by Type Carrollton Pickups by Time of Day Enrollments: 153 500 400 300 250 Total Pickups: 2,331 New Prescriptions 1,230 Refill Prescriptions 1,078 OTCs 23 300 200 100 200 150 100 50 After-hours Pickups: 1,183 (51%) New Prescriptions 636 Refill Prescriptions 536 OTCs 11 ScriptCenter Uptime: 99.9% ScriptCenter Errors: 0 0 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 2017 2018 Green = OTC Meds Red = Refills Blue = New Prescriptions 0 12 AM 2 AM 4 AM 6 AM 8 AM 10 AM 12 PM 2 PM 4 PM 6 PM 8 PM 10 PM 65% Said Yes Baylor Scott & White Pharmacy Round Rock, TX 74% Said Yes KEY TAKEAWAYS Integrated delivery networks (IDNs) within accountable care organizations (ACOs) is a evolving construct for the delivery of high quality value based health care Increasing generic prescription utilization can reduce pharmacy costs Antibiotic stewardship is critical to reducing antibiotic resistance and preventing misuse associated drug costs Deployment of novel technologies can improve the patient and provider pharmacy experience Page 12 of 13
Questions? Page 13 of 13