PART I Value Added Care: Definitions and Choosing Wisely Dmitry Dukhovny, MD MPH Instructor in Pediatrics, Harvard Medical School Neonatologist, Beth Israel

PART IValue Added Care:

Definitions and Choosing Wisely

Dmitry Dukhovny, MD MPHInstructor in Pediatrics, Harvard Medical School

Neonatologist, Beth Israel Deaconess Medical Center

QI/Teaching Value CurriculumNovember 27, 2012

Acknowledgment

Carl J. Shapiro Institute for Education and Research at BIDMC

John Zupancic DeWayne Purlsey Jane Smallcomb EPIC – Economics in Perinatalogy

Investigators’ Collaborative

Conflicts of Interest

I have no conflicts of interest

Objectives

1. To understand the rationale for and approaches to studying costs in pediatrics

2. To understand the key definitions of economic analyses

3. To “choose wisely”

Agenda

PART I November 27th, 2012– Basics and Definitions of Cost-Effectiveness

Analysis– Choosing Wisely Approach

PART II February 12th, 2013– Costs and Charges: Where to Begin?– Case discussions

Development and Implementation of “Choosing

Wisely”:

A Practical, Multidisciplinary Approach

What is it?

Teaching Value Added Care

Multidisciplinary Approach at BIDMC NICU

Fellow Education and Involvement

Fellow Opportunities

Adding a value component to the QI Curriculum

Starting in projects/adding value to QI project

Opportunity to work with the BIDMC NICU Group on a project

Opportunity to start or continue current project you are working on

Why Now?

Part of ACGME Next Accreditation System (NAS) – to be initiated July 2013 (probably later)

– … “physicians demonstrate competence in efficient and cost-effective health care”

Critical time in health care

Big Picture Goal: not to make you a health economist, BUT

to help increase and enhance understanding about healthcare costs

Individualize it to the fellows interests

Make it practical:– You can actually do a project (either now or as an

attending in your first job)– Understand the published literature in health

economics that pertains to the NICU

Time Line

11 month cycle Nov 2012 – October 2013– But hope to continue beyond

2 Part Workshop in Nov-Feb Pre-implementation Survey Development of Value Audits Decide on 2 tests/procedures in the

BIDMC NICU to reduce waste (Feb-July)

Cost of Health Care

Figure 1 from Davis K. N Engl J Med 2008;359:1751-1755

Relatively speaking…

Image from http://www.takepart.com/blog/2009/10/09/how-the-american-health-care-system-stacks-up/

Projected US Health Care

Truffer, et al. Health Affairs, March 2010

U.S. Per Capita Health Expenditures: 1950–2007

Fuchs VR. N Engl J Med 2012;366:973-977.

International Health Care Spending: 1980-2007

Note: $US PPP = purchasing power parity.Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009) (from the Commonwealth Fund: “Mirror Mirror on the Wall” June 2010 Report).

Commonwealth Fund 2010 Report

Bodenheimer T, et al. NEJM 2009;361:1521-1523

Average Annual Per Capita Spending for Patients with Different Numbers of Chronic Conditions

(United States)

Schmidt B, et al.. JAMA 2003;289(9):1124-9

Figure 1 from Drummond, et al. Int J Technol Assess Health Care. 2008;24(3).

Potential Approach

SPR Workshop: Dollars and SPR Workshop: Dollars and Sense Sense © 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic© 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic

The Rationale

SPR Workshop: Dollars and SPR Workshop: Dollars and Sense Sense

Health

?

?

?

?

What Factors Affect Health?Organism

Environment

Delivery of Technology

Efficacy of Medical

Technology

Access Funding

© 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic© 2012 Dukhovny, Lorch, Profit, Kamholz, Zupancic


Health

Organism

Environment


Efficacy of Medical

Technology

What Factors Affect Health?

Access Funding



Health

Organism

Environment


Efficacy of Medical

Technology

Beyond the Limits to Health?

Access Funding



Health

Organism

Environment


Efficacy of Medical

Technology

Beyond the Limits to Health?

Access Funding

Public Health

Government

HospitalImagineering

EBM

Increase premiums, taxes

Improve efficiency

Reallocate between individuals

???



EfficiencyEfficiency

OR

Other social goals

0.25 0.50 1.00

1.50 1.50 1.50 4.50

1.75

2.25 2.25

0.75 1.50 2.25

4.50

1.75

3.50

Expenditure Units ($)

Health Units



Framing and the Analytic Approach



Framing: Type of Analysis

CONSEQUENCCONSEQUENCEE



Framing: Type of Analysis

CONSEQUENCCONSEQUENCEE

COSCOSTT


What does it mean for something to be

“Cost Effective”?

Definitions

“economical in terms of tangible benefits produced by money spent”

“cost effective describes something that is a good value, where the benefits and usage are worth at least what is paid for them”

Cost-Effective ≠Cost-Saving


Framing: Type of AnalysisFraming: Type of Analysis

CostingCosting Cost-minimizationCost-minimization Cost-effectivenessCost-effectiveness Cost-utilityCost-utility Cost-benefitCost-benefit

“Incomplete” Economic Evaluations

“Complete” Economic Evaluations



Cost-Effectiveness AnalysisCost-Effectiveness Analysis Cost-effectiveness studyCost-effectiveness study

– COST:COST: InterventionIntervention

– CONSEQUENCE:CONSEQUENCE: Quantifiable outcomeQuantifiable outcome

– Lives saved, life years saved, BP points reduced, hours of cryingLives saved, life years saved, BP points reduced, hours of crying

– OUTCOME MEASURE:OUTCOME MEASURE: Cost per consequence (cost per life saved, etc.)Cost per consequence (cost per life saved, etc.)

– PROBLEM:PROBLEM: How to compare different outcomes for different How to compare different outcomes for different

interventions?interventions?



Cost-Effectiveness StudyCost-Effectiveness Study

Cost-Effectiveness = Costs of Treatment A – Costs of Treatment B

Effects of Treatment A – Effects of Treatment B



The Cost-Effectiveness PlaneThe Cost-Effectiveness Plane

Diff in Effectiveness

Diff in Cost

- +

+

-





Diff in Cost

- +

+

-

Dominated*





Diff in Cost

- +

+

-

Dominated

Dominant

*

*




- +

+

-

Dominated

Dominant

**

*

Diff in Cost


*

*




- +

+

-

Dominated

Dominant

Diff in Cost


*

*

**

*


iCER Plot: Postpartum Depression

Cost Effectiveness Plane

-1500

-1000

-500

0

500

1000

1500

2000

-0.15 -0.1 -0.05 0 0.05 0.1 0.15 0.2 0.25

Difference on effects

Dif

fere

nce

on

co

sts

95%

*

Choosing Wisely

Initiative of ABIM Foundation (Advancing Medical Professionalism

to Improve Health Care) Encourages physicians, patients and

other stakeholders to think about unnecessary tests and procedures

“Five Things Physician and Patients Should Question”

http://choosingwisely.org/

Next Steps

Break up into groups Identify 1 to 2 items

AND/OR Think about a value component to

your QI project

Criteria

– There is evidence in the literature that the test does not improve patient outcome

– There is insufficient evidence that the test improves patient outcome

– The test unnecessarily utilizes staffing or material resources (i.e., the test is a waste of staff time or resources)

Small Groups

Choose 1 – 2 items Answer the following questions:

– WHY– POTENTIAL HARM– POTENTIAL BARRIERS– HOW

www.ValueAddedCare.com

Documents

PART I Value Added Care: Definitions and Choosing Wisely Dmitry Dukhovny, MD MPH Instructor in Pediatrics, Harvard Medical School Neonatologist, Beth Israel