Overcoming the Barriers to Implementing Value -Based ... Overcoming the Barriers to Implementing

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Overcoming the Barriers to Implementing Value-Based Health Care

Harvard School of Dental Medicine Leadership Forum

September 2018

Robert S. Kaplan, Senior Fellow and Marvin Bower Professor of Leadership Development, Emeritus

2Copyright Harvard Business School, 2018

The central goal in health care must be value for patients, not access, volume, convenience, quality, or cost containment

Value =Health outcomes that matter to patients

Costs of delivering those outcomes

The unit of analysis for creating and measuring value is the treatment of a patients medical condition over a complete cycle of care.

Value-Based Health Care

MD encounter

Assess appropriateness

Assess risk

Schedule OR Procedure Recovery

Possible need for procedure

Shared decision making

Pre-procedure testing

Patient problem

Measure Outcomes and

Cost

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1. Fragmentation of care delivery by medical specialty

2. Lack of measurement of outcomes that matter to patients

3. Distorted measurement of costs at the patient level; confusion between charges and costs

4. Fee-for-service payments that reward volume but not value

Barriers to implementing Value-Based Health Care

3

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How to overcome the barriers to VBHC

Problem #1: Fragmentation of care delivery by medical specialty

Solution: Organize multi-disciplinary teams around the patients medical condition

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How we organize today for Diabetes

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Diabeter (NL): An IPU for Type-1 Diabetes

Multi-Disciplinary Team

Physician Specialists

Nurses

Dieticians

Psychologists

Care Managers

VCare IT Platform

Housed within Single Facility

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Diabeter Type-1 Diabetes Care Team

Achievements:

1. High percentage of patients with HbA1c levels < 7.5%

2. Lowest rate (

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OutpatientOncologist

Surgical Oncologist Speech &

Swallow

Dentist

Primary Care Physician

RadiationOncologist

Old Model: Organize by Specialty and Discrete Service

Organize Care Around Patient Medical ConditionsHead & Neck Cancer Care at MD Anderson

Radiologist

Source: Porter, Michael E., Jain, Sachin, The University of Texas MD Anderson Cancer Center: Interdisciplinary Cancer Care. February 26, 2013.

Pathologist

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OutpatientOncologist

Surgical Oncologist Speech &

Swallow

Dentist

Primary Care Physician

RadiationOncologist

Old Model: Organize by Specialty and Discrete Service

Organize Care Around Patient Medical ConditionsHead & Neck Cancer Care at MD Anderson

Social WorkSmoking Cessation

PharmacistsPatient Education

Integrative Medicine

MD AndersonHead & Neck CenterMedical OncologistSurgical Oncologist

Radiation OncologistDental Oncologist

PathologistRadiologist

Speech & SwallowAudiology

Prosthodontics

PrimaryCare

Physicians

Pathology LabOperating Rooms

ChemotherapyRadiation Therapy

Diagnostic Imaging Equipment

Current Model: Organize into Integrated Practice Units (IPUs) Around Conditions

Radiologist

Source: Porter, Michael E., Jain, Sachin, The University of Texas MD Anderson Cancer Center: Interdisciplinary Cancer Care. February 26, 2013.

Pathologist

Plastic Surgeons, &

Other Specialties

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Why IPUs: Three Compelling Reasons

1. Volume

2. Multi-Disciplinary Team

33.3%

15.0%Five large centers

< 26 weeksgestational age

All other hospitals 11.4%

8.9%

26-27 weeksgestational age

Mortality rate of low birth weight infants in Germany

MD encounter

Assess appropriateness

Assess risk

Schedule OR

Procedure Recovery

Possible need for procedure

Shared decision making

Pre-procedure testing

Patient problem

Outcome and cost measures

3. Cycle of Care

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How to overcome the barriers to VBHC

Problem #2: Lack of measurement of outcomes that matter to patients

Solution: Measure and communicate outcomes by medical condition

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Measure Outcomes for a Patients Medical Condition

Patient Experience/Engagement

PSA, HgA1b levels, Gleason score, surgical margin, Infection rates, Readmission rates, length-of-stay

Protocols, Quality, Safety, Compliance Guidelines & Checklists

Patient Initial Conditions

Processes Output Indicators

(Health) Outcomes

InputsStaff certification, facility standards

JCAHO accreditation

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Why does health care focus so much on quality and compliance metrics rather than outcome metrics?

13

Accountants desire for precision: If you cant measure what you want, want what you can measure!

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Measure Outcomes that Matter to PatientsM. Porter, NEJM Dec 2010

Survival

Degree of health/recovery

Time to recovery and return to normal activities

Sustainability of health /recovery and nature of recurrences

Disutility of the care or treatment process (e.g., diagnostic errors and ineffective care, treatment-related discomfort,

complications, or adverse effects, treatment errors and their consequences in terms of additional treatment)

Long-term consequences of therapy (e.g., care-induced illnesses)

Tier1

Tier2

Tier3

Health Status Achieved

or Retained

Patients Experience during Care

Cycle

Sustainability of Health

Mortality

Clinical status achieved

Functional status achieved

Time to care completion and recovery

Care-related pain/discomfortComplications

Reintervention/Readmission

Long-term clinical statusLong-term functional status

Long-term consequences of therapy

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Outcome Measures for Prostate Cancer at Martini Klinik, Hamburg

Clinical Outcomes Patient Outcomes

Length of Stay Mortality

Post-surgery PSA level (annually) Patient-reported erectile function (IntlIndex of Erectile Function)

Tumor volume Patient-reported urinary function (Intl Prostate Symptom Score)

High-grade cancer volume Patient-reported general quality of life (European Cancer QLQ-C30 Survey)

Number of positive lymph nodes Incontinence (ICS Score)

Positive surgical margin Surgical complications up to three months post-op (Clavien/Dindo) Radiotherapy complications

Metastasis

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Outcomes Measurement at Martini KlinikProstate Cancer Surgery Center in Hamburg

Outcomes data measured pre-surgery, at discharge from MK, and, post-discharge, 3 months, 1 year, 2 years, and 3 years.

1,200 surveys per month; 90% return rate (multiple phone reminders)

Data base on 20,000 prostate cancer patients

Now collecting molecular genetic data for every tumor tissue sample

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MK clinicians participate in a semi-annual meeting to compare clinical and patient outcomes by surgeon

o CEO/Urology Department Chairman, at one meeting, learns that his incidence of positive surgical margins had increased from 5% to 8%.

o He enters training with junior surgeons who had better performance.

o His subsequent incidence of positive margins dropped to 3.5%.

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9.2%

17.4%

95%

43.3%

75.5%

94%

Incontinence after one year

Severe erectile dysfunction after one year

5 year disease specific survival

Average hospital Best hospital

Prostate Cancer Outcomes in Germany

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Martini Klinik Outcomes versus the average German hospital

9.2

17.4

95

43.3

75.5

94

Incontinence

Severe erectile dysfunction

5 years disease specific survival

Percentage of patients treated

Average hospital Best hospital

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18% 35% 45%

1. Localized Prostate Cancer *

2. Lower Back Pain *

3. Coronary Artery Disease*

4. Cataracts *

Standard Sets Complete

(2013)

13. Breast Cancer*14. Dementia15. Frail Elderly16. Heart Failure17. Pregnancy and

Childbirth18. Colorectal

Cancer*19. Overactive

Bladder20. Craniofacial

Microsomia21. Inflammatory

Bowel Disease

Standard Sets Complete(2015-16)

5. Parkinsons Disease*

6. Cleft Lip and Palate*

7. Stroke *8. Hip and Knee

Osteoarthritis*9. Macular

Degeneration*10.Lung Cancer*11.Depression and

Anxiety*12.Advanced

Prostate Cancer*

Standard Sets Compl