better health outcomes at less cost - future nhs stage, 4pm, 2 september 2015
TRANSCRIPT
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Achieving the impossible – better health outcomes at less cost
William E. Golden, MD, MACP, Arkansas Department
of Human Services
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.
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Dr. William E. Golden
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
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2
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All Health Systems
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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Health and wellbeing gap
Funding and efficiency gap
Similarities of public healthcare
Providers Providers
NHS
England
Wales
Scotland
NI
CCGs
Patients Patients
Everyone
Over 65 Registered disabled 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
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a BRIEF history
of NHS reform
NOT so different
in the US
2015 DevoManc and £22b savings by 2020
2014 Five Year Forward View
2012 Health & Social Care Act
2011 Dilnot Review
2010 Equity and excellence: Liberating the NHS
2009 NHS Constitution, CQC and £15-20b savings by 2014
2008 High quality care for all
2006 Our health, our care, our say and 28 SHAs become 10
2005 Commissioning a patient-led NHS
2004 Choosing health and Foundation Trusts
2003 Health and Social Care (Community Health and Standards) Act
2002 The National Health Service Reform and Health Care Professions Act
2001 The Health and Social Care Act
2000 The NHS Plan
1999 GP Fundholding abolished
1998 The Acheson Report and NICE established
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
2010 Affordable Care Act (aka ObamaCare)
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
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 Percentage of 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
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The need for a ‘self reforming’ system
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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
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Arkansas’ statistics
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Our goal is to align payment
incentives to eliminate
inefficiencies and improve
coordination and effectiveness
of care delivery
UK (approximate) equivalents
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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 State of Arkansas
Total population 2.9m
Medicaid population 750k
Medicaid spend $4b (£2.6b)
Pay for results to control costs and improve quality
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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)
Intensify payer intervention in clinical decisions
to manage use of expensive services (e.g. through prior
authorisations) based on prescriptive clinical guidelines
Reduce payment 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
Episodes
Episodes have the potential to …
As in the UK, episodes were used to
organise the delivery of care
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Avoid complications, reduce errors and redundancy
Deliver coordinated, evidence-based care
Focus on high-quality outcomes
Improve patient-focus and experience
Incentivize cost-efficient care
This new approach enhanced the existing ‘fee for
service’ model
Payers recognise the value of working together
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Creates consistent incentives and
standardised reporting rules and tools
Enables change in practice patterns as
programme applies to many patients
Generates enough scale to justify investments in
new infrastructure and operational models
Motivates patients to play a larger role in
their health and health care
Coordinated multi-funding commissioners leadership…
Three domains of care
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Patient populations within scope (examples) Care/payment models
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
Episodes designed in collaboration with providers
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Cli
nic
ian
s a
re in
teg
ral t
o t
he
epis
od
e d
esig
n p
roce
ss
Research around national guidelines and standards of care
Clinical Advisors provide input for localisation of practice patterns and inform the process about the patient journey
Programmers
and Coders create algorithms and logic to implement design elements
How episodes work for patients and providers
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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
exactly as
today
(performance
period)
Patients Commissioners Providers
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
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Initial promises
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Version 1.0 Clinical evidence, credible data
Encourage feedback to build better system
Change the conversation
Stimulate creative
entrepreneurialism
Disrupt business as usual
Bend the cost curve (vs. absolute reduction)
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
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New Stream of Payments
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Lessons Learned
Continuous Cycle Stretch the providers
Respond to Constructive Critiques
Face Validity, Flexibility
Reform Requires Communication, Trust
Create Learning System
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
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For more information
Join our Pop-up University
Tomorrow at 11:00
"Better care at less cost: a “how to” for commissioners and providers"
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Ben Breeze UK Healthcare Director
General Dynamics Health Solutions [email protected]