Operationalizing Value in Swedish Rheumatology


Published on

Presentation, Health foundation study tour in Sweden, at Karolinska Institutet, MMC, September.

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Vi kan från start till döden CO-morbitiites: hjärt och kärl, osteoporosis, KOL, cancer, lymfom, malignt melanom. Hypothesis based on the literature, these conditions higher frequence among RA population. Well known co morbidities. They may not be influencing the outcomes or costs significantly.side effects of medication.
  • Öppna jämförelser av alla landsting är också möjligt
  • Operationalizing Value in Swedish Rheumatology

    1. 1. Operationalizing value in Chronic Care: The case of Swedish Rheumatology <ul><li>A research project involving Karolinska Institutet/Medical Management Center, Stockholm University School of Business, Karolinska University Hospital, Stockholm County Council and Harvard Business School. </li></ul>
    2. 2. Defining the care cycle
    3. 3. DAS28 (Disease Activity) Time
    4. 4. Measuring outcomes over the full cycle of care over the full cycle of care
    5. 5. Disease cycle captured in the SRQ registry
    6. 6. Prioritizing measures based on the stage of the disease: defining two phases
    7. 7. First phase of disease: reaching low or no disease activity Early & aggressive treatment <ul><li>Outcome measures, phase 1 </li></ul><ul><li>Time to 1st visit </li></ul><ul><li>Disease activity </li></ul><ul><li>Work ability and functional ability preserved </li></ul><ul><li>Drug adverse events </li></ul>
    8. 8. Second phase: long-term management and prevention Maintain low DAS28 <ul><li>Outcome measures phase 2 </li></ul><ul><li>Patients’ global </li></ul><ul><li>Disease activity </li></ul><ul><li>Work and functional ability maintained </li></ul><ul><li>Trust in care </li></ul><ul><li>Quality of life (EQ5D) </li></ul><ul><li>Adverse events </li></ul><ul><li>Mortality </li></ul>
    9. 9. Second phase: long-term management and prevention Detect and curb flares <ul><li>Number, intensity and duration of recurrences (flares). </li></ul><ul><li>Disease activity </li></ul>
    10. 10. This guy wants no medication. Because they reduce his immune defense. He wants to be medication free in order to be able to see his grandchildren without fearing to catch their cold.
    11. 11. Measuring costs over the full cycle of care
    12. 13. Direct costs - Stockholm County Council data sources: In-patient and out-patient data and cost per patient (CPP). Cost per patient - RA 2009, KUH Cost per patient - RA 2009, KUH <ul><li>Costs – not charges </li></ul><ul><li>Number of out-patient visits 45 404 </li></ul><ul><li>Total cost 157 692 215 SEK </li></ul><ul><ul><li>Medical service 9 481 442 SEK </li></ul></ul><ul><ul><li>Operation 1 917 123 SEK </li></ul></ul><ul><ul><li>ICU 13 311 SEK </li></ul></ul><ul><ul><li>Drugs 93 835 356 SEK </li></ul></ul><ul><ul><li>Visits 52 444 983 SEK </li></ul></ul>
    13. 14. Indirect costs at macro level: Sick leave days/year level out with biologics Sick leave days/year level out with biologics
    14. 15. Sick leave days/year level out with biologics Controls
    15. 16. Risk adjustment <ul><li>Adjusting for aspects that influence outcomes </li></ul><ul><li>But are beyond the control of the provider </li></ul><ul><li>Avoid cherry picking </li></ul>
    16. 17. Tasks and issues ahead <ul><li>Delimiting the medical condition and care cycle </li></ul><ul><li>Using the available data to operationalize value </li></ul><ul><ul><li>Prioritizing outcomes and cost measures </li></ul></ul><ul><ul><li>Adding measures/creating new interfaces and linkages </li></ul></ul><ul><ul><li>Risk adjustment </li></ul></ul><ul><ul><li>Reimbursement implications </li></ul></ul>
    17. 18. Value-based reimbursement? <ul><li>Health care literature informs our work but... </li></ul><ul><li>Does not tell us what to do </li></ul>
    18. 19. Decisions to be made <ul><li>Rewards vs penalties? </li></ul><ul><li>individual vs group level bonus? </li></ul><ul><li>Relative vs absolute incentives? </li></ul><ul><li>Target vs improvement based? </li></ul><ul><li>Frequency and size? </li></ul>
    19. 20. Complexities related to outcomes-based reimbursement <ul><li>Value-added networks, solution shops, facilitated networks (Christensen et al 2009) </li></ul><ul><li>How can we deal with these issues? </li></ul>
    20. 21. Plan - reimbursement model <ul><li>Experimenting with different outcomes and weightings using historical data </li></ul><ul><li>Implementing a prototype model in a shadow budgets </li></ul><ul><li>Following the case with quantitative and qualitative data generation methods </li></ul><ul><li>Being sensitive to the interplay between the model and </li></ul><ul><ul><li>other in/formal organizational and financial structures </li></ul></ul><ul><ul><li>personal dispositions and internal motivations among professionals and patients </li></ul></ul>
    21. 22. Thank You! <ul><li>Anna Essén, [email_address] </li></ul>
    22. 23. Improvement of patients global health 6 months after diagnosis, 1994 - 2008
    23. 24. National result & per county
    24. 25. RA outcome measures in the three tiers <ul><li>Survival – Mortality </li></ul><ul><li>Health / recovery – Patients global, EQ-5D, Work ability, Daily function,DAS28, AUC Doctors global </li></ul><ul><li>Time to recovery – Time to remission, time to work ability regained </li></ul><ul><li>Disutility of care / Rx – Trust in care, Drug adverse events </li></ul><ul><li>Continuity, empathy, access etc? </li></ul><ul><li>Sustainability of health / flares – Health / recovery AUC </li></ul><ul><li>Long-term consequences of therapy – Patients global, EQ-5D, Work ability, Daily function,DAS28, AUC Doctors global, adverse events, co-morbidities </li></ul><ul><li>Control for case-mix variables (gender, age, biomarkers, socio-economic status etc) </li></ul>