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. More information is available online: www.expo.nhs.uk

1. www.uk.gdit.com/health
Achieving the impossible –
better health outcomes at less cost
William E. Golden, MD, MACP,
Arkansas Department
of Human Services

2. Presenter
• Medical Director of Arkansas Medicaid,
Department of Human Services and clinical
lead for the programme’s multi-payer
payment reform initiative.
• Professor of Medicine and Public Health at
the University of Arkansas for Medical
Sciences and previously served as director
of the division of general internal medicine
for nearly 20 years.
GDIT Proprietary2 | www.uk.gdit.com/health
Dr. William E. Golden

3. Global challenge
• Have Service Demand and Limited
Resources
Taxes vs. Premiums vs. Co-Pays vs. Access
Limitations
• Need Greater Stewardship
Providers, Payers, Patients
• Should Explore New Incentives to
Shape Delivery
Reward Outcomes, Effectiveness
GDIT Proprietary3 | www.uk.gdit.com/health
1
2
3
All Health Systems

4. Same vision
Improving the experience of
care
Improving the health of
populations
Reducing the per capita
costs of healthcare
Triple Aim
Care and quality gap
Five Year Forward View
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GDIT Proprietary4 | www.uk.gdit.com/health
Health and wellbeing gap
Funding and efficiency gap

5. Similarities of public healthcare
Providers Providers
NHS
England
Wales
Scotland
NI
CCGs
Patients Patients
Everyone
Over 65
Registereddisabled
Low income Children
State
Medicaid
National
Medicare
Centers for Medicare & Medicaid
£
T
a
x
e
s
$
T
a
x
e
s
Department of Health &
Human Services
Department of Health
GDIT Proprietary5 | www.uk.gdit.com/health

6. a BRIEF history
of NHS reform
NOT so different
in the US
1997 The new NHS: Modern, dependable and the NHS Primary Care Act
1994 Reduction to eight regional health authorities
1990 New GP contract and National Health Service and Community Care Act
1989 Working for patients
1986 Neighbourhood nursing: A focus for care and Project 2000
1983 The Mental Health Act and Griffiths Report
1982 Area Health Authorities abolished
1979 Royal Commission on the NHS
1976 Report of the Resource Allocation Working Party
1973 NHS Reorganisation Act
1968 Department of Health and Social Security formed
1965 The Family Doctor’s Charter
1962 Enoch Powell’s Hospital Plan and the Porritt Report
1959 The Mental Health Act
1956 Guillebaud Committee inquiry into NHS costs
1951 One shilling prescription charge
1949 The Nurses Act
1948 NHS created
2009 American Reinvestment and Recovery Act
2008 Mental Health Parity Act (II)
2007 Census Bureau estimate 45.6m Americans uninsured (15.3% of population)
and the Healthy Americans Act
2006 Massachusetts halves uninsured rate and Medicare Part D Drug benefit introduced
2005 Deficit Reduction Act
2003 Medicare Drug, Improvement and Modernization Act
2000 Breast and Cervical Cancer Treatment and Prevention Act
1996 Mental Health Parity Act (I) and Health Insurance Portability and Accountability Act (HIPAA)
1993 White House Task Force on Health Reform
1990 OBRA mandates coverage for children under poverty threshold
and The Health Security Act blocked
1987 Census Bureau estimates 31M uninsured
1986 Emergency Medical Treatment and Active Labor Act
1983 DRGs introduced
1980 Department of Health, Education, and Welfare becomes
Department of Health and Human Services
1977 Health Care Financing Administration established
1965 Medicare and Medicaid programs introduced

7. 0
4
8
12
16
20
1980 1985 1990 1995 2000 2005 2010
Meanwhile costs increase
OECD Average in 2011= 9.3% of GDP
Healthcare Spending as Percentageof GDP
Source: OECD Health Data 2013.
Produced by Veronique de Rugy, Mercatus Center at George Mason University.
Cumulative publications
on health reform (est.)
USA
France
Germany
Switzerland
Canada
Japan
UK
Sweden
Italy
Australia
GDIT Proprietary7 | www.uk.gdit.com/health

8. 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
8 | www.uk.gdit.com/health

9. Arkansas’ statistics
GDIT Proprietary9 | www.uk.gdit.com/health
Our goal is to align payment
incentives to eliminate
inefficiencies and improve
coordination and effectiveness
of care delivery

10. UK (approximate) equivalents
GDIT Proprietary10 | www.uk.gdit.com/health
In total population (2.7m people)
and healthcare spend (£2.52b),
but only Dorset CCG in terms of
covered population (776k people)
East Anglia’s CCGs Stateof Arkansas
Total population 2.9m
Medicaid population 750k
Medicaid spend $4b (£2.6b)

11. Pay for results to control costs and improve quality
GDIT Proprietary11 | www.uk.gdit.com/health
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
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12. Episodes
Episodes have the potential to …
As in the UK, episodes were used to
organise the delivery of care
GDIT Proprietary12 | www.uk.gdit.com/health
Avoid complications, reduce errors and redundancy
Deliver coordinated, evidence-basedcare
Focus on high-quality outcomes
Improve patient-focus and experience
Incentivize cost-efficientcare
This new approach
enhanced the existing ‘fee for
service’ model

13. Payers recognise the value of working together
GDIT Proprietary13 | www.uk.gdit.com/health
Creates consistentincentivesand
standardised reporting rules and tools
Enables changeinpractice patterns as
programme applies to many patients
Generates enough scale to justify investments in
new infrastructure and operational models
Motivatespatientsto play a larger role in
their health and health care
Coordinated multi-funding commissioners leadership…

14. Three domains of care
GDIT Proprietary14 | www.uk.gdit.com/health
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

15. Episodes designed in collaboration with providers
GDIT Proprietary15 | www.uk.gdit.com/health
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

16. How episodes work for patients and providers
GDIT Proprietary16 | www.uk.gdit.com/health
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

17. 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
+
-
17 | www.uk.gdit.com/health

18. Cost Categories: Provider vs. Peer
GDIT Proprietary18 | www.uk.gdit.com/health

19. Initial promises
GDIT Proprietary19 | www.uk.gdit.com/health
Version 1.0
Clinical evidence, credible data
Encouragefeedback to build better system
Changethe conversation
Stimulate
creative
entrepreneurialism
Disrupt
businessasusual
Bendthecostcurve
(vs. absolutereduction)

20. Primary care strategy
• PM/PM as Investment in Practice Structure
– Access, Care Plans, Delivery Strategy
• Shared Savings
– Based on Risk Adjusted Total Cost of Care
– Passing Quality Metrics To Qualify for Shared
Savings
• Practice Coaches to help Improve
Performance
GDIT Proprietary20 | www.uk.gdit.com/health
New Stream of Payments
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21. Results: Quality of care
GDIT Proprietary21 | www.uk.gdit.com/health

22. Results: Cost savings
GDIT Proprietary22 | www.uk.gdit.com/health

23. GDIT Proprietary23 | www.uk.gdit.com/health

Lessons Learned
Continuous Cycle
Stretch the providers
Respond to Constructive Critiques
Face Validity, Flexibility
Reform Requires Communication, Trust
Create Learning System
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24. Questions?
William E. Golden, MD, MACP
Medical Director
Arkansas Department of Human Services
Division of Medical Services
Nena Sanchez,MS,PMP
Senior Director of Programs
General Dynamics Health Solutions
GDIT Proprietary
For more information
Join our Pop-upUniversity
Tomorrow at 11:00
"Better care at less cost: a “how to” for commissioners and providers"
24 | www.uk.gdit.com/health
Ben Breeze
UK Healthcare Director
General Dynamics Health Solutions
ben.breeze@gdit.com

25. Expanding Insight. Ensuring Value. Improving Outcomes.