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Better care at less cost - a 'how to' for commissioners and providers, pop up uni, 11am, 3 september 2015


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Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.

Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.

This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.

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Better care at less cost - a 'how to' for commissioners and providers, pop up uni, 11am, 3 september 2015

  1. 1. Better care at less cost – a ‘how to’ for commissioners & providers William E. Golden, MD, MACP Nena Sanchez, MS, PMP Ben Breeze
  2. 2. Introduction Ben Breeze UK Healthcare Director General Dynamics Health Solutions
  3. 3. Yesterday Similarreform initiatives over many years in UK and US Costs increasing year on year Need for a ‘self reforming’ system Incentivising quality, reduce cost and improve outcomes GDIT Proprietary3 | We talked about the ‘WHAT’
  4. 4. Today Quick recap How to approach a quality incentive programme Setting up and running the programme Results Applying this to the UK GDIT Proprietary4 | Is about ‘HOW’
  5. 5. Programme Overview William E. Golden, MD, MACP, Medical Director Arkansas Department of Human Services Division of Medical Services
  6. 6. Same challenge Improving the experience of care Improving the health of populations Reducing the per capita costs of healthcare Triple Aim Five Year Forward View    GDIT Proprietary6 | Care and quality gap Health and wellbeing gap Funding and efficiency gap   
  7. 7. Similarities of public healthcare Providers Providers NHS England Wales Scotland NI CCGs Patients Patients Everyone Over 65 Registereddisabled Children Low income State Medicaid State Medicare Center for Medicare & Medicaid £ T a x e s $ T a x e s Department of Health & Human Services Department of Health GDIT Proprietary7 |
  8. 8. Perspective: grading a physician’s value GDIT Proprietary8 |
  9. 9. Measure attributes GDIT Proprietary9 | Reliable Low Burden Actionable FeasibleMeaningful (importance)
  10. 10. Outcomes & Lessons Stretch the Providers Who… Provide Programme Feedback… That Modifies Requirements/Analytics… Which Support Practice Transformation… And Starts New Cycle of Dialogue GDIT Proprietary10 | Learning System
  11. 11. The need for a ‘self reforming’ system GDIT Proprietary Efficiencies at the price of lost funding or downsizing the organisation are a ‘hard sell’ Incentivising the right behaviours does lead to change, e.g. QOF programme for UK GPs Positive change in the clear interests of the organisation happens much faster The financial system must support clinical priorities, or at least not be in direct conflict Rewarding quality leads to higher quality 11 |
  12. 12. Terminology Same as episode in the UK, however these were developed as part of the payment improvement initiative. GDIT Proprietary12 | Episode Medicare Medicaid PaP Payer PCMH Provider Publicly funded care for the over 65s and registered disabled (20% of overall health spend). Publicly funded care for those on low incomes (15% of overall health spend). A high percentage of recipients are children. The Arkansas Health Care Payment Improvement Initiative focuses on Medicaid. Primary Accountable Provider, read as Provider. Insurer (public or private) who funds the treatment being given. Similar to a CCG or Social Services in the UK. Patient Centred Medical Home; a delivery model where care is coordinated by the primary care physician supported by technology. Same as UK, organisation delivering the care.
  13. 13. Episodes Episodes have the potential to … As in the UK, episodes were used to organise the delivery of care GDIT Proprietary13 | Avoid complications, reduce errors and redundancy Deliver coordinated, evidence-basedcare Focus on high-quality outcomes Improve patient-focus and experience Incentivise cost-efficientcare This new approach enhanced the existing ‘fee for service’ model
  14. 14. Pay for results to control costs and improve quality GDIT Proprietary14 | Eliminate coverage of expensive services, or eligibility Pass growing costs on to consumers through higher premiums, deductibles and co-pays (private payers), or higher taxes (Medicaid) Intensifypayer intervention in clinical decisions to manage use of expensive services (e.g. through prior authorisations) based on prescriptive clinical guidelines Reducepayment levels for all providers regardless of their quality of care or efficiency in managing costs Transition to system that financially rewards value and patient outcomes and encourages coordinated care    
  15. 15. Three domains of care GDIT Proprietary15 | Patient populations within scope (examples) Care/paymentmodels Population-based: medical homes responsible for care coordination, rewarded for quality, utilisation and savings against total cost of care Episode-based: retrospective risk sharing with one or more providers, rewarded for quality and savings relative to benchmark cost per episode Combination of population- and episode-based: health homes responsible for care coordination; episode- based payment for supportive care services Healthy, at-risk Chronic (Diabetes) Acute medical (Pneumonia) Acute procedural (hip replacement) Developmental disabilities Severe and Persistent mental illness Acute and post-acute care Prevention screening, chronic care Supportive care
  16. 16. Episodes designed in collaboration with providers GDIT Proprietary16 | Cliniciansareintegraltotheepisodedesignprocess Research around national guidelines and standards of care Clinical Advisors provide inputfor localisationof practice patternsand informthe process about the patient journey Programmers and Coders create algorithmsand logic to implementdesignelements
  17. 17. How episodes work for patients and providers GDIT Proprietary17 | seek care & select providers as they do today submit claims as they do today reimburse for all services as they do today Patients seek and providers deliver care exactlyas today (performance period) Patients CommissionersProviders
  18. 18. Shared savings Shared costs No change Low High Individual providers in order from highest to lowest average cost Acceptable Commendable Gain sharing limit Pay portion of excess costs No change in payment to providers Receive additional payment as shared savings Quality standards and average costs share in savings GDIT Proprietary + - 18 |
  19. 19. Mechanics, Technology & Data Reporting Nena Sanchez, MS, PMP Senior Director of Programs General Dynamics Health Solutions
  20. 20. Operationalize plan – data-to-episode outputs GDIT Proprietary20 | InputData Files EOC Engine (ReportCalculations) Report Engine (ReportProduction) Payment Providers Reports Call Centre Reports Statistical Reports Episode Based Payment System (EBPS) follows a modular designthat is maintained in such a manner that it will align business, architecture anddata
  21. 21. Providers given tools to measure & improve care GDIT Proprietary21 | Example of provider reports Reports provide performance information for provider episode(s): Overview of quality acrossa provider’s episodes Overview of cost effectiveness: how a provider is doing relative to cost thresholds and relative to other providers Overview of utilisation and drivers of a provider’saverage episode cost 6 10,625 433 1,062 1,400 1,251 2,260 944 1,321 1,307 1,237 3,409 3,865 9,492 643 Cost detail – Pharyngitis Care category All providersYou 51% 49% 3% 5% 5% 7% 11% 9% 77% 79% 97% 95% 52% 48% 81 51 59 2,500 3,000 600 500 1,062 179 62 1,400 81 194 69 Medicaid Little Rock Clinic 123456789 July 2012 Total episodes included = 233 Outpatient professional Emergency department Pharmacy Outpatient radiology / procedures Outpatient lab Outpatient surgery Other 89 77 221 184 21 16 12 # and % of episodes with claims in care category Total cost in care category, $ Average cost per episode when care category utilized, $ 5 Quality and utilization detail – Pharyngitis 5025 Percentile Metric You 25th Metric with a minimum quality requirement You did not meet the minimum acceptable quality requirements Metric 25th 50th 50th 75th You 75th 5025 Percentile You Percentile Percentile Medicaid Little Rock Clinic 123456789 July 2012 0 0 100 100 Minimum quality requirement 30% 5% % of episodes that had a strep test when an anti-biotic was filled % of episodes with at least one antibiotic filled 64% 44% % of episodes with multiple courses of antibiotics filled 6% 3% 81% 60% 10% 99% 75% 20% Average number of visits per episode 1.1 1.31.7 2.3 - - - Quality metrics: Performance compared to provider distribution Utilization metrics: Performance compared to provider distribution 75 75 4 Summary – Pharyngitis Quality summary 1823 45 80 292315 100 50 >$115$100- $115 $85- $100 $70– $85 $55– $70 $40- $55 $40 You (adjusted) 20,150 You (non- adjusted) 25,480 80 60 40 8184 All providersYou Cost summary Your total cost overview, $ Distribution of provider average episode cost Your episode cost distribution Average cost overview, $ Not acceptableAcceptableCommendableYou Minimum quality requirement All providers Key utilization metrics Overview Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29 Does not meet minimum quality requirements You did not meet the minimum quality requirements Your average cost is acceptable You are not eligible for gain sharing  Quality requirements: Not met  Average episode cost: Acceptable #episodesCost,$ You All providers Commendable Not acceptableAcceptable $0 Medicaid Little Rock Clinic 123456789 July 2012 % episodes with strep test when antibiotic filled 48% Quality metrics – linked to gain sharing 66% 58% 10% 6% 64% Quality metrics – not linked to gain sharing % episodes with multiple courses of antibiotics filled % episodes with at least one antibiotic filled 1.11.7 30% 64% Avg number of visits per episode % episodes with antibiotics Cost of care compared to other providers You Percentile Gain/Risk share All provider average < $70 > $100$70 to $100 3 Upper Respiratory Infection – Pharyngitis Quality of service requirements: Not met Upper Respiratory Infection – Sinusitis Average episode cost: Commendable Quality of service requirements: N/A You are not eligible for gain sharing Your gain/risk share You will receive gain sharing Your gain/risk share Upper Respiratory Infection – Non-specific URI Average episode cost: Not acceptable Quality of service requirements: N/A You are subject to risk sharing Your gain/risk share Perinatal Average episode cost: Acceptable Quality of service requirements: Met You will not receive gain or risk sharing Your gain/risk share Average episode cost: Acceptable Attention Deficit/ Hyperactivity Disorder (ADHD) Average episode cost: Acceptable Quality of service requirements: N/A You will not receive gain or risk sharing Your gain/risk share $0 $x $0 $0 $x Medicaid Little Rock Clinic 123456789 July 2012 Performance summary (Informational) * Episode and health home model for adult DD population in development. Tools and reports still to be defined. Example provider reports
  22. 22. Cost Categories: Provider vs. Peer GDIT Proprietary22 |
  23. 23. Provider portal GDIT Proprietary23 | Accessible to all providers – Login with existing username/ password – New users follow enrollment process detailed online Key components of the portal are to provide a way for providers to: – Enter additional quality metrics for select episodes (Hip, Knee, CHF and ADHD with potential for other episodes in the future) – Access current and past performance reports for all payers where designated Provider Portal allows providers to enter qualitymetrics for certain episodes and access their provider reports
  24. 24. Example data entry GDIT Proprietary24 |
  25. 25. Example provider reports GDIT Proprietary25 | Provider Report Displays provider-level reports for each time period that they were sent. Display supports Health administrators and APII call center staff
  26. 26. Example provider reports GDIT Proprietary26 |
  27. 27. Reporting GDIT Proprietary27 | Reporting Health Officials and support staff use an application tool to view provider reports and episode level statistical reports meet & exceed informational needs assist in interactions with the Health officials and GP community
  28. 28. Configurable elements GDIT Proprietary28 | Configurable Elements Allows approved administrators to update algorithm specific modules and allows Health officials to perform “what if” analysis by changing values for certain variables Working example:  EOC Engine provides ability to see the impact of changing acceptable threshold  Hip replacement costs reduced from $12K (£7.8K) to $10K (£6.5K)  Reports can be generated to see the impact of the change
  29. 29. Data system – design feedback loop GDIT Proprietary29 | RefinepreliminaryEpisode of Care (EOC) algorithmsby feedbackand investigation Focusedimprovementbasedon relevantdata and Businessprocess. Call Centre Provider Relations Data Research Provider Engagement EOC Refinement Practice Pattern Goal Focused Research Findings EOC Refinement Practice Pattern Billing Issues Identified the need for portal entry of QMs Length of stay analysis showed providers with greater than 3 days due to C-section births
  30. 30. Now that the programme is established, it’s time to measure the results. EOC programme details GDIT Proprietary30 | Since the initial release of the EOC programe in 2012:  14 quarterly EOC runs have been completed  6 payment runs have been completed, including generation of gain/risk share payments  The Episode Engine has identified approximately 2,000 PAPs  The Episode Engine has processedover 456.4m Medicaid claims and generated over 3.3m episodes  The Reporting Engine has generated over 26,000 PAP Reports
  31. 31. EOC dashboard GDIT Proprietary31 | Highlights  Includes all data for the history of the EOC programme  Data is presented through various visualisations including: – Trending graphs (line, bubble, bar, etc.)- provide “clear and actionable” information – Charts – Pivot Tables – State-based Geomapping  Multiple views to the data in print and export-ready formats  Drill-down, action-linked functionality for over 60 quality and utilisation metrics  Data files representing all of the hundreds of thousands of data points presented in the dashboard are available for download for the purpose of performing ad-hoc analysis on the data using any desired analytic tool  Provides detailed documentation explaining all of the measurements, instructions on using the dashboard, descriptions of changes to the EOCs over time, and other analytic information in order to fully inform dashboard users
  32. 32. EOC dashboard GDIT Proprietary32 | Layout Tab navigation Time period selector Export link Slider to select ranges for each grouping Chart type selector View data in tabular format
  33. 33. Geomapping GDIT Proprietary33 | % of episodes excluded by country and quarter
  34. 34. EOC dashboard GDIT Proprietary34 | Example Trending: Quality metric results URI-Nonspecific: Episodes with an antibiotic claim
  35. 35. EOC dashboard GDIT Proprietary35 | Example Provider Engagement PAP Report view counts by day per month and by provider
  36. 36. EOC dashboard GDIT Proprietary36 | Example Information: Variety of definitions, user guideand analytic notes Episode Changes Over Time documentation providesinformationon changes made to the EOC algorithms to assist with explainingtrends in the data
  37. 37. EOC dashboard GDIT Proprietary37 | Example Trending Gain share, Risk share by quarter (programme level)
  38. 38. Results: Quality of care GDIT Proprietary38 |
  39. 39. Results: Cost savings GDIT Proprietary39 |
  40. 40. UK application Whatdataisavailablenow? GDIT Proprietary40 | Whatlevelofcostingcandifferentiateepisodes? What data can be extracted from source systems? What are your local priorities? Whatarethemajorlessonsfromthe programme? What opportunities does the National Tariff System bring? What are the limitations of current tariffs/HRGs?
  41. 41. Questions? William E. Golden, MD, MACP MedicalDirector Arkansas Departmentof Human Services Divisionof MedicalServices Nena Sanchez,MS,PMP Senior Directorof Programs GeneralDynamicsHealthSolutions GDIT Proprietary Please rate our workshop using the app! For more information 41 | Ben Breeze UK HealthcareDirector GeneralDynamicsHealthSolutions
  42. 42. Expanding Insight. Ensuring Value. Improving Outcomes.