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Vbc
1) The document discusses aligning healthcare reimbursement systems with value-based care principles by focusing on patient outcomes over volume of services. 2) It proposes defining integrated practice units that take accountability for the full cycle of care for a condition and bundling payments based on outcomes achieved. 3) The project aims to develop and test an outcomes-based reimbursement model for rheumatoid arthritis care in Stockholm County Council by defining important outcomes, experimenting with a prototype using historical data, and evaluating its effects and risks.
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Vbc
- 1. Aligning reimbursement-systems withvalue-based care principles Anna Essén, Ph D, Business Administration
- 2. There is roomfor improvement Health care delivery systems are not organized around value Current reimbursement models do not encourage care providers to re-design their inter-organizational process
- 3. Previous work Health care literature on payment models Informs our work, but… Does not tell us what to do
- 4. Issues to considerRewards vs penalties? Individual vs group level bonus? Relative vs absolute incentives? Target vs improvement based? Frequency and size?
- 5. Value-Based Care TheoryOur savior?
- 6. Value-Based Care Principles The purpose of care systems is to produce value Value= patient health outcomes/costs We need to evaluate care systems based on the value they produce
- 7.
- 8. Health Outcomes TierOne: Health status achieved (immediate outcomes) Tier Two: Process of recovery Tier Three: Sustainability of health (long-term outcomes)
- 9. Risk adjustment Adjustingfor aspects that influence outcomes but are beyond the control of the provider To avoid cherry picking
- 10. Costs We needto estimate costs per patient rather than cost per department, billing code etc. ABC (Activity Based Costing)
- 11. Who produces outcomesand costs Integrated Practice Units A dedicated team who provides the full cycel of care for the condition, encompasses inpatient, outpatient and rehabilitative care and supporting servieces (nutrition, behavioral health), includes patient education, engagement and follow up. Accepts joint accountability for outcomes and costs. IPUs vs clinical path ways, integrated care
- 12. Patients as co-producersIPUs should enable patients to produce value Treat patients as peers- integrate their work in formal structures Facilitated networks
- 13. Implication on reimbursementBundled Outcome-based
- 14. Rheumatology There isan outcomes-measurement system in place There are routines for entering and using data in everyday care practice Measurement has stimulated improvements Current structures discourage reinventing processes across care levels.
- 15. Rheumatology Todays structuresdo not encourage care providers to maximize the volume rather than value produced.
- 16. Agreement about outcomesSubjective, objective measures of outcome continuously accumulated
- 17. Uncertainty involved Value-addedprocess, solution shops, facilitated networks (Christensen et al 2009). How can we deal with these issues?
- 18. The project StockholmCounty Council (Purchaser) Three clinics in Stockholm Councils (Producer) Patient representatives (consumers) Researchers: Karolinska Institutet/Karolinska Sjukhuset (Ernestam,S. Lindblad S. ); Stockholm University (Essén A); Harvard Business School (Porter, M; Baron, J)
- 19. Suggesting an outcomebased reimbursement model adjusted to the context of rheumatology
- 20. The medical conditionin focus Rheumatoid arthritis
- 21. Defining the carecycle The first care cycle: Response to diagnosis (ends 3 months after diagnosis) Critical outcomes: time to 1st visit; time to remission; disease activity; regaining work ability
- 22. Defining the carecycle The second care cycle: long-term disease management and prevention Critical outcomes: number, duration and intensity of flares, maintaining good quality of life and functional ability. Controlling risk factors.
- 23. Developing a prototypeExperimenting with different outcomes and weightings using historical registry-data Implementing a prototype in a shadow-budget Following the case with quantitative and qualitative data generation methods
- 24. Questions Is themodel sensitive to important differences (does it reward effective reorganization?) The interplay between the model and Other in/formal organizational and financial structures Personal dispositions/motivations of individual professionals and patients
- 25. Questions Risks, e.g.possibilities of manipulating the model and unintended incentives such as cherry picking and reduced non-financial incentives Risks: supervision of the present towards outlooking future possibilities of creating value
- 26. Contributions Insights intohow value-based care principles operate in practice Examples of how to apply and integrate this theory in chronic care Extending and refining the value-based care theory by learning from our context Philosophical issues e.g. value, human motivation, innovation
Editor's Notes
- #2 This project has just been initiated and is just about to start. SLL will decide in two weeks. Today, breifly outline our assumptions, goals and ways in which we intend to dealing with this task.I will however, leave loots of room for discussion as we are amateurs and are grateful for any comments. Hence, the plan is incomplete. Further, the My My name is, and the other participants are: Staffan, SLL, Sofia etc. THecurrent version focuses on the practical task of designing a new reimbursement system. This process raises a lot of theoretical research questions, of philosophical nature.
- #3 Today’s systems are fragmented but current structures have not been good at ’solving’ the problem of fragmentation in health care. Providers are encouraged to improve isolated tasks rather than the overal lprocess. That is doing things better rather than doing the right things. Current systems pay attention to the quantity rather than quality of care. Hence, care providers are not rewarded for e.g. keeping their patients well and reducing the number of times the patients need to visit their doctor.Sofia can explain this with some examples. This is remarkable! There is something fundamentally wrong with this system.
- #4 Of course we’re not the first one to ask what we can do about this, and the potential of reimbursement systems. My impression of the literature is that alot of work has been done, but many projects confuse performance with process. Pay for Performance in the US mostly measure process aspects such as adherence to guidelines, patient safety etc. There are outcomes based models but the studies are poorly designed (often no controls) and reviews conclude that it is difficult to make any conclusions about the effectiveness of various designs. Hence, the literature, from what I’ve read, does not tell us how to design an outcomes based reimbursemnt model let alone the impact it could have in practice. Having said that, the literature does make us aware of anumber of issues that we need to consider.
- #5 Previous work highlights many issues we need to consider. However, few articles discuss the extent to which new reimbursement systems really encourage continuous organizational innovation. How we can create systems (institutionalize) that encourage the people in healthcare to critically evaluate current processes, asking themselves, could we make patients better by collaborating with e.g. primary care in new ways?
- #6 VBT provides a clear answer to the question: what is the purpose, the design, the basis and the recipient of the reward? Straightforward model telling us what to do. However, we need to adjust it to our context.
- #8 According to porter, the defitiion of value implicitly suggests that the amount of value possible to produce is not fixed but can be continously improved. Further, outcomes should not be monetized. He is pro diagnosis specific outcomes measures. Partly as outcomes measurement is primarily, a tool for learning and improvement.
- #9 Tier1: mortality, degree of health/recovery (e.g. functional and pain level achieved, degreeof independenc, ability to return to work, satisfaction with outcome) Tier 2: Time to recovery (or return to normal activities(to betw attainable activities) and disutility of care (e.g. pain, infection rate, length of hostipal stay.Cycel time. Tier 3: Sustailability of health status achieved (time to reccurence, seriousness of recurrences (ongoing pain status, ) negative long-term consequences of theorapy (eg complications, loss of mobility due to to inadequate reahab). Outcome measures should be selectedbased on thei relevance from patient perspective and medical knowledge.The improatnce of each tier will vary across patients. This model is useful as it encourages us to think about complementarities and tradeoffs between outcomes. For example, faster cycle times often means improved sustainability of health. From our view, it is important to revise the outcomes along with the develoment of medical knowledge.
- #10 Regression analysis and stratigying patient groups based on the major risk factors such as stageofdisease, typeof diseas,patient prerequisites. Christensen (2009) outlines differentprocesses based on the risk involved. Value shops where providers have to engage in pattern recognition based on experience and intuition, or can simply follow the odds but not guarantee outcomes. Such processesshould only be regulated in terms of their inputs. (by the people they employ). Risk factors need to be revised.
- #11 As far as I understand, ABC estimates the cost of resources actually used by activities inproducing services. Italso exploses unused capacity.traditional accounting systems focus on the availability of purahcesd rresources.
- #14 Reimbursement should be aligned with the unit of value. Flexibility as regards process. Process measures can be used, but primarily for internal purposes. Outcome measurement is esential to measure success ad minimize incentives to limitvalue-ehnacning services
- #22 In the first cycle, care providers should be rewardedfor reducing the disease activity as soon as possible. There are complementarities here, short cycle times influence long-term outcomes (and costs).
- #26 Se länk?clay shirky