innovations in measuring value
TRANSCRIPT
Utah Regional Health Care Innovation Day 4.27.16INNOVATIONS IN
Measuring Value
Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah
David Dirks AVP, Population Health Analytics Intermountain Healthcare
Objectives
Understand the importance of culture in using measurement to improve value
Share innovative approaches to measure value for episodic care across a full care cycle
Illustrate innovative population approaches to measure and improve value
WHAT Every organization on the
planet knows WHAT they do.
WHY Very few organizations know WHY they do what they do.
HOW Some organizations know
HOW they do it.
THE GOLDEN CIRCLE
THE GOLDEN CIRCLE
DISCIPLINE OF HOW. Patients define value (clinical population) &
Respect for people (bottom up solutions) CONSISTENCY OF WHAT. Methods/approaches that support better outcomes at an affordable cost
Pre-2000 2000-2015 2016+++
ENCOUNTER-CENTERED
PATIENTS VALUE STREAM: FULL CARE CYCLES
VALUE
QUALITY
QA
MEASURING VALUE
MEASURING VALUE
Total Cost of Care and PCOs
Current State Proposed 2018
FEE FOR SERVICE (FFS)
(no ties to performance)
FEE FOR VALUE (FFV)
(ties to quality/cost Performance)
APM (risk bearing, built on FFV architecture)
FFVP R
O V
ID E
R R
IS K
C ar
e In
te gr
at io
n R
eq ui
re d
MEASURING VALUE
(Based on Figure 3. Alternative Payment Model (APM) Framework: Final white paper. HCPLAN, p. 9, 2016.)
“… A fundamental and largely unrecognized problem: We don’t know what it costs to deliver health care to individual patients, much less how those costs compare to the outcomes achieved.”
“Understanding costs could be the single most powerful lever to transform the value of health care.”
- Robert S. Kaplan & Michael E. Porter
MEASURING VALUE
2. Organize data around clinical conditions
3. Engage providers to define outcomes
4. Foster peer-to-peer transparency to explore variation
5. Empower & support improvements in value
(David Browdy, CFO, University of Utah Health Sciences 2015)
MEASURING VALUE
Quality/Outcome Rules
Designation of Cost Methods to Use for Allocating General Ledger Direct Clinical Care
Cost Encounters
General Ledger
Cost Methods
Encounter-Level Costs
O.R.C.A. Supply Usage by Case (Value Driven Outcomes Screen Capture)
VALUE DRIVEN OUTCOMES A
Billing Provider Dept. Expenses
Professional costs added in 2014
Discharge Month Quality Index: Percentage of all visits where selected care measure was met % to FY12 Average Cost: Ratio of that months avg. cost compared to baseline 2012 avg. cost
VALUE DRIVEN OUTCOMES Higher Quality Drives Lower Cost
33% COST
F Y1
2 Av
er ag
e C
os t
PERFECT CARE INDEX AND AVERAGE COST Outcome: Perfect Care % to FY12 Average Cost
(Pelt 2016)
• Reduce telemetry use by 20%4
• Standardize bronchodilator RX use: $248k/yr
Improve value of procedural based care and/or within clinical conditions. Examples: • TJA: cost decreased by 33%, increase quality2
• Soft tissue infection: cost decreased by 13%, increase quality5
• Renal Transplant: $408k annual savings, maintain quality
VALUE DRIVEN OUTCOMES
Current measurement emphasis on quality focuses on processes and complications of care—to patients, these are expectations.
Outcomes are the ultimate measure by which to judge quality—whether or not care actually helps the patient (or their families).
PROs have been validated as disease-specific measures (e.g. DASH), generic outcome measures (e.g. SF-36), and domain specific measures (e.g. PROMIS)
The Ideal Solution: 1. Patient/user friendly, reliable, valid, integrated, and scalable solution to assess
outcomes across a broad range of patient conditions; 2. Able to assess this in the context of both direct care provision as well as costs-of-
care and other quality metrics
VALUE MEASUREMENT
With Epic integration, we are able to compare patient progress to historical trends.
VALUE MEASUREMENT
Baseline
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 10 25 40 50 57 62 68 80 Patient
42009 42045 42083 42124 42157 42 188 42222 42257 42292 30 11 22 35 40 48
Sheet1
Date
Do Nothing
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 25 20 17 13 10 8 6 2 Physical Therapy
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 31 32 32 32 33 33 34 34 Arthoscopic Surgery
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 20 30 40 45 50 55 58 60 Knee Replacement
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 10 25 40 50 57 62 68 80
Knee Replacement
Baseline
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 10 25 40 50 57 62 68 80 Patient
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 11 22 35 40 48
VALUE MEASUREMENT
Built on a knowledge management infrastructure
Identify key roles and responsibilities to carry out standards of care
Integrate directly into workflow with focus on usability
Provide consistent attribution of members and patients to the appropriate care-giver
Provide feedback to all stakeholders on performance
1 2 3 4 5 6 7
VALUE MEASUREMENT Managing Population
Person-Level Data
Clinical Data Claims Data Financial Data Patient Reported • Problem List • Labs • Vitals • Etc.
• Demographics • Diagnosis/Procedure
• Wellness Data • Demographics • Family Hx • Etc.
Person-Level Data
Patient Data Interaction
Care Managers
Care Managers
Care Managers
• Decision Support Data • Care Gaps • Attribution
• Decision Support Data • Care Gaps • Attribution
Patient Data Interaction
“Our most important data is where the patient is today and where the
patient needs to be tomorrow.”
“I want to encourage all of us to pause and give thought to this:
Can we transform healthcare and change the data focus from big
data to actionable data that connects people, their teams and
their care plans?”
Care Managers
• Decision Support Data • Care Gaps • Attribution
• Decision Support Data • Care Gaps • Attribution
Reports Reports Reports Reports
Reporting is based on adherence to defined standards not variation between providers
Patient Data Interaction
Quality Measurement Dashboard
HOW CAN I IMPROVE THE HEALTH OF MY PATIENT POPULATION?
Patient-Level Gap Reporting
Patient Engagement & Q.I.
AM I CARING FOR MY PATIENT POPULATION AT A REASONABLE COST?
Cost & Utilization Analysis
Cost & Utilization Management
Thank you.
Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah
David Dirks AVP, Population Health Analytics Intermountain Healthcare
Citations
Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah
1. Kawamoto, K et al. Value driven outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes. J Am Med Inform Assoc 2015;22:223-235.
2. Pelt C. et al. Arthroplasty Today (2016). Epub ahead of print.
3. Yarbrough, PM et al. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs. J Hosp Med 2016 (ePub ahead of print)
4. Edholm, K. Presented Abstract: Multifaceted value measurement intervention. Research and innovations poster competition, Society of Hospital Medicine 2016.
5. Yarbrough PM, Kukhareva PV, Sydor Spivak E, Hopkins C, Kawamoto K. Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes. J Hosp Med 2015:10;780-786.
6. Horton D. Presented Abstract. SHM 2016. (listed data are projections)
Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah
David Dirks AVP, Population Health Analytics Intermountain Healthcare
Objectives
Understand the importance of culture in using measurement to improve value
Share innovative approaches to measure value for episodic care across a full care cycle
Illustrate innovative population approaches to measure and improve value
WHAT Every organization on the
planet knows WHAT they do.
WHY Very few organizations know WHY they do what they do.
HOW Some organizations know
HOW they do it.
THE GOLDEN CIRCLE
THE GOLDEN CIRCLE
DISCIPLINE OF HOW. Patients define value (clinical population) &
Respect for people (bottom up solutions) CONSISTENCY OF WHAT. Methods/approaches that support better outcomes at an affordable cost
Pre-2000 2000-2015 2016+++
ENCOUNTER-CENTERED
PATIENTS VALUE STREAM: FULL CARE CYCLES
VALUE
QUALITY
QA
MEASURING VALUE
MEASURING VALUE
Total Cost of Care and PCOs
Current State Proposed 2018
FEE FOR SERVICE (FFS)
(no ties to performance)
FEE FOR VALUE (FFV)
(ties to quality/cost Performance)
APM (risk bearing, built on FFV architecture)
FFVP R
O V
ID E
R R
IS K
C ar
e In
te gr
at io
n R
eq ui
re d
MEASURING VALUE
(Based on Figure 3. Alternative Payment Model (APM) Framework: Final white paper. HCPLAN, p. 9, 2016.)
“… A fundamental and largely unrecognized problem: We don’t know what it costs to deliver health care to individual patients, much less how those costs compare to the outcomes achieved.”
“Understanding costs could be the single most powerful lever to transform the value of health care.”
- Robert S. Kaplan & Michael E. Porter
MEASURING VALUE
2. Organize data around clinical conditions
3. Engage providers to define outcomes
4. Foster peer-to-peer transparency to explore variation
5. Empower & support improvements in value
(David Browdy, CFO, University of Utah Health Sciences 2015)
MEASURING VALUE
Quality/Outcome Rules
Designation of Cost Methods to Use for Allocating General Ledger Direct Clinical Care
Cost Encounters
General Ledger
Cost Methods
Encounter-Level Costs
O.R.C.A. Supply Usage by Case (Value Driven Outcomes Screen Capture)
VALUE DRIVEN OUTCOMES A
Billing Provider Dept. Expenses
Professional costs added in 2014
Discharge Month Quality Index: Percentage of all visits where selected care measure was met % to FY12 Average Cost: Ratio of that months avg. cost compared to baseline 2012 avg. cost
VALUE DRIVEN OUTCOMES Higher Quality Drives Lower Cost
33% COST
F Y1
2 Av
er ag
e C
os t
PERFECT CARE INDEX AND AVERAGE COST Outcome: Perfect Care % to FY12 Average Cost
(Pelt 2016)
• Reduce telemetry use by 20%4
• Standardize bronchodilator RX use: $248k/yr
Improve value of procedural based care and/or within clinical conditions. Examples: • TJA: cost decreased by 33%, increase quality2
• Soft tissue infection: cost decreased by 13%, increase quality5
• Renal Transplant: $408k annual savings, maintain quality
VALUE DRIVEN OUTCOMES
Current measurement emphasis on quality focuses on processes and complications of care—to patients, these are expectations.
Outcomes are the ultimate measure by which to judge quality—whether or not care actually helps the patient (or their families).
PROs have been validated as disease-specific measures (e.g. DASH), generic outcome measures (e.g. SF-36), and domain specific measures (e.g. PROMIS)
The Ideal Solution: 1. Patient/user friendly, reliable, valid, integrated, and scalable solution to assess
outcomes across a broad range of patient conditions; 2. Able to assess this in the context of both direct care provision as well as costs-of-
care and other quality metrics
VALUE MEASUREMENT
With Epic integration, we are able to compare patient progress to historical trends.
VALUE MEASUREMENT
Baseline
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 10 25 40 50 57 62 68 80 Patient
42009 42045 42083 42124 42157 42 188 42222 42257 42292 30 11 22 35 40 48
Sheet1
Date
Do Nothing
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 25 20 17 13 10 8 6 2 Physical Therapy
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 31 32 32 32 33 33 34 34 Arthoscopic Surgery
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 20 30 40 45 50 55 58 60 Knee Replacement
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 10 25 40 50 57 62 68 80
Knee Replacement
Baseline
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 10 25 40 50 57 62 68 80 Patient
42009 42045 42083 42124 42157 42188 42222 42257 42292 30 11 22 35 40 48
VALUE MEASUREMENT
Built on a knowledge management infrastructure
Identify key roles and responsibilities to carry out standards of care
Integrate directly into workflow with focus on usability
Provide consistent attribution of members and patients to the appropriate care-giver
Provide feedback to all stakeholders on performance
1 2 3 4 5 6 7
VALUE MEASUREMENT Managing Population
Person-Level Data
Clinical Data Claims Data Financial Data Patient Reported • Problem List • Labs • Vitals • Etc.
• Demographics • Diagnosis/Procedure
• Wellness Data • Demographics • Family Hx • Etc.
Person-Level Data
Patient Data Interaction
Care Managers
Care Managers
Care Managers
• Decision Support Data • Care Gaps • Attribution
• Decision Support Data • Care Gaps • Attribution
Patient Data Interaction
“Our most important data is where the patient is today and where the
patient needs to be tomorrow.”
“I want to encourage all of us to pause and give thought to this:
Can we transform healthcare and change the data focus from big
data to actionable data that connects people, their teams and
their care plans?”
Care Managers
• Decision Support Data • Care Gaps • Attribution
• Decision Support Data • Care Gaps • Attribution
Reports Reports Reports Reports
Reporting is based on adherence to defined standards not variation between providers
Patient Data Interaction
Quality Measurement Dashboard
HOW CAN I IMPROVE THE HEALTH OF MY PATIENT POPULATION?
Patient-Level Gap Reporting
Patient Engagement & Q.I.
AM I CARING FOR MY PATIENT POPULATION AT A REASONABLE COST?
Cost & Utilization Analysis
Cost & Utilization Management
Thank you.
Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah
David Dirks AVP, Population Health Analytics Intermountain Healthcare
Citations
Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah
1. Kawamoto, K et al. Value driven outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes. J Am Med Inform Assoc 2015;22:223-235.
2. Pelt C. et al. Arthroplasty Today (2016). Epub ahead of print.
3. Yarbrough, PM et al. Multifaceted intervention including education, rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs. J Hosp Med 2016 (ePub ahead of print)
4. Edholm, K. Presented Abstract: Multifaceted value measurement intervention. Research and innovations poster competition, Society of Hospital Medicine 2016.
5. Yarbrough PM, Kukhareva PV, Sydor Spivak E, Hopkins C, Kawamoto K. Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes. J Hosp Med 2015:10;780-786.
6. Horton D. Presented Abstract. SHM 2016. (listed data are projections)