innovation & strategy office · any use, copying or distribution without written permission...

© 2017 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.

Onde estamos atuando?

Eduardo Maia – Diretor de Inovação

Innovation & Strategy Office

Agenda

• New Models

• ABP

• ACO

• Teias

• Theoretical Foundations

– Healthcare Waste

– Business Model - Eficiency

– Complex System Theory

– Economic Force Field

• Evidence Based Management

– Lean

– P4P

2


Innovation & Strategy

• Mission

– Design and put in place efficient value based care aligned

to customer needs, and follow up with analysis.

• Vision

– Build a sustainable healthcare system, with superior

quality and affordable to market.

3


Leading the Pack in Inefficiency

5

IBM Care process management: Using BPM tools and methodology in the healthcare environment


Health as a heterogeneous and hierarchical

complex system

Asymmetry of information: the buyer has strong limitations to evaluate the cost of the product

Health is "credential" good (an accredited specialist who is not a buyer indicates their need)

Instead, it can not be asked for by another, they are specific and essential

High degree of differentiation and market power

Complex technical details

• Strong inequality between people, companies and institutions in their capacity to transform

knowledge into innovation

• Heterogeneous and hierarchical relationships between buyers and sellers


Teoria dos Contratos

8

Complex AdaptiveSystem

CAS are dynamic systems able to adapt in and evolve with a

changing environment. It is important to realize that there is no

separation between a system and its environment in the idea that a

system always adapts to a changing environment.

MIT, 2001

Complex systems are collections of

simple units or agents interacting in

a system. A complex system is a

large-scale system whose behaviors

may change, evolve, or adapt.

Complex = difficult-to-understand or difficult to predict

Dynamic = moving, changing

Adaptive = changing to adapt to an environment or condition


Economic Force Field Analysis

13

Client

Gain with Health & SustainabilityGain with Disease & Waste

MCO

Government

Actual

Decision

Maker

Drives for

Healthcare

Delivery

Phisician AcademyIndustry

R&D

Hospital

Lab / Image

Advertising

FFS

Profit

Academy / University

Other Health

Professionals

AMS Hospitals


Economic Force Field Analysis

Client

MCOGovernment

Changing

Drives to

Value

Healthcare

Delivery

PhisicianAcademyIndustry

R&D

Hospital

Lab / Image

Advertising

Other Health

Professionals

Gain with Value HealthcareGain with

Disease & Waste

Old

Contracts

AMS Hospitals

16Change Business Model

Value Based Payment

Suply Chain

Tecnology

Innovation

& Strategy

Right

Incentives

Operational

Excelence

Right Metrics

Evidence Based

Health Delivery

Lean Healthcare

Health Prevention /

Promotion & Care

Coordination

Evidence Based

Management

Clinical and

Quality Outcomes

Affordable Competitive

Efficient

Technology

Healthcare System

Operacional ResearchChange

management

Change management

Healthcare

Managem

ent

Opera

tionalM

anagem

ent


Innovation & Strategy- UHG

New Business

Models

Care Coordination

& Clinical

Management

Operacional

Excellence

Evidence Based Medicine

Lean Healthcare

Outcomes

Evidence Based Management


Value Based Care Opportunity

18

* Delloite University Press

What’s going on?

20

EVENT-BASED

FEE FOR SERVICE

BUNDLED PAYMENT

Inpatient Grouper

(IPG)

PROSPECTIVE

BUDGET-BASED

CAPITATION

GLOBAL BUDGET

Adjusted Budget

Payment

(ABP)

VALUE - BASED

ACO

TEIAS

Clinical Outcomes

PROM

Shared Saving

Incentives to Volume Changing Incentives Incentives to Value

ABP – Adjusted Budget Payment

Health Budget Payment

Na Europa e outros Países OCDE...

Modelo de historicamente utilizado por diversos países.

No início dos anos 2000 foi revisado para a incorporação

do conceito de Case Mix na metodologia de orçamento

(DRGs “nacionalizados”)

Nos Estados Unidos...

Modelo de pagamento por pacote (DRG) é o

mais utilizado. Iniciativas recentes de

implantação do modelo por orçamento foram

promovidas na reforma do Medicaid/Medicare

Fonte: Budget Payment – Maryland – 2016 AHA

Fonte: “Hospital Payment Based On Diagnosis-Related Groups Differs In Europe

And Holds Lessons For The United States” Health Affairs 2013

Adjusted Budget Payment - ABP

25

The Budget payment model creates foreseeability for both payer and provider

• Encourage Lean Healthcare strategies within provider’s processes

R$ 0,00

R$ 2,00

R$ 4,00

R$ 6,00

R$ 8,00

R$ 10,00

R$ 12,00

R$ 14,00

jan/17 fev/17 mar/17 abr/17 mai/17 jun/17 jul/17 ago/17 set/17 out/17 nov/17 dez/17 jan/18 fev/18 mar/18 abr/18 mai/18 jun/18 jul/18 ago/18 set/18

Reinbursement Cost

net

operating

margin

FFS Budget ModelTrend


Observacional Unit – Patients at ICU changed

0

200

400

600

800

1000

1200

1400

604

678

Não possuíamindicação de CTI

Possuíam indicaçãode CTI

0

100

200

300

400

500

600

700

535

69Foram paraCTI

Não forampara CTI

52,89%

47,11%

11,42%

88,58%

No ICU

indication

With ICU

indication Went to ICU

No ICU

ABP 2.0Indicadores de Eficiência Clínica

1. Adequação do critério de admissão pelo Pronto Socorro

▪ Objetivo: garantir a qualidade e segurança ao paciente, através da avaliação da indicação de internação hospitalar de urgência,utilizando ferramenta de MBE ( MCG).

▪ Forma de Cálculo: volume de internações de urgência com critério adequado/ volume de internações de urgência no períodoX 100.

▪ Fonte: Documentation Tool

2. Adequação aos nível de cuidados para procedimentos eletivos de baixa complexidade*

▪ Objetivo: garantir a qualidade e segurança ao paciente, através da avaliação da indicação do nível de cuidado adequado para15 procedimentos de baixa complexidade.

▪ Forma de Cálculo: volume de admissões dos 15 procedimentos eletivo de baixa complexidade em Same Day / volume deadmissões dos 15 procedimentos de baixa complexidade em Same Day e Internação Regular X 100.

▪ Fonte: BI Autorizações SisAmil

3. Taxa de readmissão em 30 dias

▪ Objetivo: garantir a qualidade e segurança ao paciente, através da avaliação da taxa de readmissão em até 30 dias.

▪ Forma de Cálculo: : volume total de readmissões em qualquer hospital em até 30 dias/número total de internações dohospital onde houve a alta durante o mesmo período X 100.

▪ Fonte: SisAmil

*lista de procedimentos disponível no apêndice

ABP 2.0Score dos Indicadores de Eficiência Clinica

1. Adequação do critério de admissão pelo Pronto Socorro

▪ Score 0 - < 60%.

▪ Score 1 - Entre 60% e 94%.

▪ Score 2 – Entre 95% e 100%.

2. Adequação aos nível de cuidados para procedimentos eletivos de baixa complexidade*

▪ Score 0 - < 50%.

▪ Score 1 - Entre 50% e 84%.

▪ Score 2 – Entre 85% e 100%.

3. Taxa de readmissão em 30 dias*

▪ Score 0 - > 13%.

▪ Score 1 - Entre 9,0% e 13%.

▪ Score 2 - < ou igual a 9%.

ABP 2.0Score dos Indicadores de Eficiência Clinica

Bônus ou penalidades serão aplicados em razão de cada um dos 3 indicadores clínicos, avaliados trimestralmente,em percentual a ser acordado durante a discussão do contrato.

▪ Penalidade, em cima do pagamento em ABP.

▪ Não há penalidade ou bonificação

▪ Bonificação em cima do pagamento em ABP.

Score 0

Score 1

Score 2

O % de bonificação ou penalização por indicador bem como a periodicidade da aplicação serão definidos pela área de Network em negociação com a área Comercial dos hospitais.

ACO – Accountable Care

Organization


Organize Unidades de

Prática Integrada

Meça os resultados e

custos de cada paciente

Mude a forma de pagamento por

ciclo de cuidados

Integre o atendimento de

unidades separadas

Expanda serviços de

excelência para vários locais

Monte uma plataforma de tecnologia da informação

Road

map de

um

ACO

Fonte: The Strategy That Will Fix Health

Care, Michael E. Porter and Thomas H.

Lee, 2013 HBR

Accountable Care Organization

Pricing

70%

80%

Shared

savings

ACO’s pricing strategy

• Pop. Care Coordination

• Value Based Payment

• Integration

• Lean

• NPS2nd Year1st Year 3rd Year

70%

80%

BCR

Treated Pricing

scenario

Best

scenario

• Low Steerage

• Few Network changes

• Fragmentation, No integration

• Waste

Today’s Fee for Service

New Model

ACO Market Share Specialty ACO


Current process (as regulated by ANS)

36

Patient

Specialist

(many)

PCP

Some degree of

control

Increased

MLR


Market Share ACO process

37

Patient

Specialists (Reduction of

excessive providers)

Care

coordination

Specialty ACO BI ACO

follow up

Lower MLR

MKT Share

NPS

Quality

VBP

MKT Share


ACO Panel BI – example

ACO contract

Percentage of users in the

vascular surgery ACO

Niterói - RJ

ACO start39


Tests and simulations

What if…

The provider performs unnecessary visits only

to gain market share? There are patients that live

outside the ACO area?The provider’s patients are

more complex?

There is an outlier in the

ACO pacientes?

We use cost to weight

market share?We calculate market

share base on cost %

The ACO improves its results,

while others worsen?

We only have one

provider in the region?

There is an outlier in patients of

other providers in the same

specialty outside the ACO?

We attribute patients from the

first appointment with the ACO

provider?

We split patients according to the type

of service that was performed?

There are multiple specialty

clinics that service this speciality

in the region?

We use clinical kpis to define the shared

savings amount?

We pay the provider through FFS and

incentivize only by shared savings?

The provider increases volume but

doesn’t improve indirect costs?

Population complexity

changes?

Population increases?

There is aggressive competition?

The provider denies care to

lower indirect costs?

The physician starts

performing operations in a

lower cost hospital?

Surgical unit cost increases?

Utilization increases?

Scheduling wait time for visits

increases?The provider does not agree

with the kpis?

We pay the ACO for lowering

the cost of the entire specialty?

The % of direct cost for the

specialty changes?

We use the % of direct cost from

the physician and not the specialty?

The provider also sees

patients from network levels

not covered by the ACO

agreement?


Oncology


Concept

Treatments for cancer have been advancing at an

accelerated pace in recent years, offering notable

improvements in clinical benefit, as well as increased

specificity through selection according to biomarkers,

or through engineered cell or gene therapies. Global

spending on cancer therapies and supportive care

drugs now exceeds $133 billion, as the value of these

medicines is recognized and a greater share of drug

budgets is allocated to these products. Over the next

five years, this amount is projected to reach $180—

200 billion.

42


Contribution of services to overall spending for cancer care

44

Fonte1: The evolution of Oncology payment models - Deloitte

Soma de % Cost QT

74%

Soma de % Cost RT

3%

Soma de % Cost IP

21%

Soma de % Cost Others OP2%

Fonte2: Microstrategy CDW Oncologia

Rio de Janeiro, nível 200

45

As a proportion of current total public spending on health, this is about 3% in

upper-middle-income and 5% in lower-middle-income countries, but 13% in low-

income countries. As a broad benchmark, high-income countries devote 3–7% of

total health spending to cancer control.


Comparative Expenditure

ASSUMPTION:

5% WILL BE OUR ONCOLOGICAL BUDGET TARGET

5%

8,20%

10,17%

8,71%

UK Amil RJ SP

OPPORTUNITY


Comparasion – Population Age

47

Amil Population September 2018 - Microstrategy


Results


Ortopedia ACO Rio

Relação por pessoa

Quantidade de eventos

e Custo Médico


Vascular ACO

Relação por pessoa

Quantidade de eventos

e Custo Médico


Impact of an ACO

• Vascular Surgery – Niteroi and São Gonçalo cities (RJ) – 45.000 lives

– Median of conversion rate – 20%

– ACO conversion rate - 0,7% (First Year)

• Orthopedics – RJ – 120.000 lives

– Median conversion rate – 39%

– ACO conversion rate – 10% (Partial Year)

51

Source: Microstrategy with Provider Specialty filter, october 2017 to september 2018


Impact of an ACO

• Vascular Surgery – Rio de Janeiro (RJ) – 250.000 lives

– Conversion rate observed before – 40%

– ACO conversion rate - 4%

52

Source: Microstrategy with “Marca Otica” filter, october 2017 to september 2018


Specialty Vascular ACO early results

• Over-use (Correction)

– Varicose Vein Surgery is going down, with all costsincluded (i.e. Inpatient expenses, Anesthesiologist and others - R$ 2.486,57*).

• “Under-use” (Going up)

– Varicose Vein being treated with ambulatory approach (Foam Sclerotherapy – R$ 240,00 – 91,39% lower cost)

• Mis-use (Correction)

– Right patient doing the right procedure at right place* Data from Microstrategy IP trends, average cost 2017


Right patient doing the right procedure at right place

54

10 years of ulcer (both sides)

Many treatments not effectives (i.e. hyperbaric) - $$$

Few days and ulcer going to resolve


Right patient doing the right procedure at right place

55

Ambulatory Foam’s Treatment Day Follow Up Visit

15 days


OUTCOMES

Process

Clinical Outcomes

Patient-reported

Outcomes

Patient Experience

Value Based Payment

+

VALUE BASED HEALTHCARE ACCORDING TO PATIENT JOURNEY

57

Value Based Payment

Outcomes - ICHOM

Deployment Action: Variable compensation according to outcome

metric via ICHOM methodology

• Pilot: Hospital Alvorada Moema (SP)

• Procedures: Elective orthopedic surgeries: Knee, Spine and Hip.

• Measurement by hospital.

• Audit by the operator.

• Quarterly review.

• VC in bonuses proportional to the representativeness of

procedures throughout the hospital

• Start: 2018 Q2

• Other: Oncology, Cardiology, Obesity


Balanced Scorecard

58

Pati

en

t

Sati

sfa

cti

on

Pati

en

t

Rep

ort

ed

Clin

ical

Pro

cess

NPS

Quality of Life Disability

30 days Readmission

RateER Visits Reoperation Rate

Adverse EventsDevice Related

InfectionMCG agreement

Outcomes Dimensions Weight

0,2

0,2

0,3

0,3


VBP – Measurement partners

Integrated Territories of

Health Care• Territórios Integrados de Saúde (TEIAS)

“The general availability of medical services can only be effected by new

and extended organisation, distributed according to the needs of the

community. This organisation is needed on grounds of efficiency and

cost, and is necessary alike in the interest of the public and of the

medical profession. Measures for dealing with health and disease

become, with increasing knowledge, more complex, and, therefore, less

within the power of the individual to provide, but rather require

combined efforts. Such combined efforts to yield the best results must

be located in the same institution. As complexity and cost of treatment

increase, the number of people who can afford to pay for a full range of

service diminishes. Moreover, enlightened public opinion is appreciating

the fact that the home does not always offer the best hygienic conditions

for dealing with serious illness, which requires special provision in order

to give the patient a full chance of recovery.”

Dawson Report

1920

UK, 1920


Integrated Territories of Health Care

65

Producti. The entire system with Performed Based Contract (No FFS) or Value Based Contract

i. Global ACOii. Association between ACO providersiii. Own network services

✓ Primary Healthcare✓ Hospital✓ Outpatient (all specialties)


Integrated Territories of Health Care

Pernambuco – RecifePopulation: 1.538 KW/ insurance: 627.176Mkt Share Amil: 71.329 (11,37%)

Rio Grande do Norte – NatalPopulation: 803.739W/ insurance: 312.113Mkt Share Amil: 41.832 (13,40%)

Ceará – FortalezaPopulation: 2.627 KW/ insurance: 966.855Mkt Share Amil: 29.915 (3%)

Minas Gerais - BetimPopulation: 380.089W/ insurance: 155.471Mkt Share Amil: 2.899 (1,8%)Santa Catarina – Joinville

Population: 569.645W/ insurance: 212.460Mkt Share Amil: 3.191 (1,5%)

Joinville• Product completed for registration• Prospecting clients

Ceará / RN / Pernambuco• Hospital network study• Pricing study• SWOT analysis

Betim• SWOT analysis

Foz do Iguazu• SWOT analysis

Parana – Foz do IguazuPopulation: W/ insurance: Mkt Share Amil:


TEIAS

67

Client

MCOGovernment

Changing

Drives to

Value

Healthcare

Delivery

PhisicianAcademyIndustry

R&D

Hospital

Lab / Image

Advertising

Other Health

Professionals

Gain with Value Healthcare


Putting it together: design and re-design

68

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