accelerating value creation: an orthopedic example thomas l. walsh phd ms mspt
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Accelerating Value Creation: An orthopedic example Thomas L. Walsh PhD MS MSPT. My Two Overarching Objectives. Start a relationship Learn El Paso secrets that could i mprove the Big Green Football team. Big Green. Red Raiders. CEO Dartmouth-Hitchcock Health System Jim Weinstein DO, MS. - PowerPoint PPT PresentationTRANSCRIPT
Accelerating Value Creation: An orthopedic example
Thomas L. Walsh PhD MS MSPT
My Two Overarching Objectives
• Start a relationship• Learn El Paso secrets that could improve the
Big Green Football team
Big Green Red Raiders
CEO Dartmouth-Hitchcock Health System
Jim Weinstein DO, MS
“We must find a sustainable health system for patients, providers, payers, and our communities”
Healthcare Productivity in Theory & Practice
A
D B
C
The Implementation
Gap
Out
com
e
Spending
A. Current outcome per dollar spent in clinical service line
B. Proven efficacy Improved outcomes with more spending
C. Real world effectiveness. All the added spending, but little or no observed improvement in outcomes.
D. Fast & frugal options/Reverse Innovation bridge the Implementation Gap, achieve better outcomes at same or slightly higher spending
The Value Equation
Value = Patient Outcome Cost of Care
We need to design systems of care and inquiry to accelerate value creation
Clinically Relevant & Actionable Data to Support Vision Achievement
• Real-time data in the clinic to improve
quality of care for each patient• Measure outcomes / improvement for
the Microsystem over time
The Spine Center’s Data Collection
Available and Actionable
Case 1
Case 1
Case 2
Case 2
Case 3
Case 3
Case 2
Preference Diagnosis
http://www.kingsfund.org.uk/publications/patients%E2%80%99-preferences-matter
Preference Diagnosis
• Canadian surgeons identified patients “eligible” for knee replacement based on x-ray only– Of the fully informed sample, 15% wanted the
procedure – Hawker 2001• Doctors believe 71% of women with breast
cancer rate “keeping my breast” as a top priority– 7% of women report “keeping my breast” as a top
priority – Lee 2010
Providers are not yet trained to make preference diagnoses
Preference Misdiagnosis• Well informed
– men with prostate disease choose surgery 40% less often – Wagner 1995
– Patients with heart disease choose percutaneous intervention 20% less often – Morgan 2000
– Patients with disc herniation choose surgery 30% less often – Deyo 2000
– Patients with spinal stenosis choose surgery 30% more often – Deyo 2000
Two Types of Medical Errors
Medical Error 1 – Sue tears her right anterior cruciate ligament, but has her left knee operated on
Medical Error 2 – Joe has his right knee replaced then learns about alternative treatments and wishes he did not have the operation
Preferences are the Silent Misdiagnosis
Getting the Preference Diagnosis Right
Meta Analysis of 86 RCTs demonstrating patients make better decisions when fully informed• More knowledgeable about the condition• Treatment more likely to be congruent with
stated preferences• Less decisional regret
– Stacy et. al. Cochrane Review 2010
Getting the Preference Diagnosis Right
Group Health Experiment 2012 • emphasized the
use of clinical data to ensure steps were taken to get the preference diagnosis correct
CLINIC LEVEL OUTCOMES AS A LEARNING TOOL
Learning as a Clinical Microsystem
26
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Histogram: Physical Component Summary (PCS)
0100200300400500600700
0 10 20 30 40 50 60 70 80 90 100
Freq
uenc
y 4th Quartile Spine Center Patients N = 2,840 (w ith score)
US Norm-based mean 50 (SD 10)
Limitations in self-care, physical, social, and role activities, severe bodily pain, frequent tiredness, health rated "poor."
No physical limitations, disabilities, or decrements in well-being, high energy level, health rated "excellent."
Histogram: Mental Component Summary (MCS)
0100
200300
400500
600
0 10 20 30 40 50 60 70 80 90 100
Freq
uenc
y 4th Quartile Spine Center Patients N = 2,840 (w ith score)
US Norm-based mean 50 (SD 10)
Frequent psychological distress, social and role disability due to emotional problems, health rated "poor."
Frequent positive affect, absence of psychological dist ress, no limitations in usual social/role activities due to emotional problems, health rated "excellent ."
The 4th Quartile Generate More Charges Compared to All Patients (% increase)
26%32% 34%
0%10%20%30%40%50%
Spine Center Outpatient Inpatient
Anatomy of the Spine Center Patients4th Quartile*
732 patients from 1/1/01 to 3/31/02
*4th Quartile is defined as 25% of the patients from entire cohort (N= 2,928) who scored the lowest on an average index of MCS and PCS from the SF-36 Health Status Survey, and Oswestry Disability Index from a spine disease specific survey that assesses disability (ODI converted to higher is better & 100 point scale).
15% spine diagnosis in upper back (Occ to T10)
The aim of this poster is to provide a forum to assist the Spine Center in interpretation of the collected data and to identify opportunities which can lead to improvements in access (matching supply and demand in the most efficient manner). This is the first part of the Practice Profile, Know your Patients.
Interesting Facts MCS 2.5% of US population are expected to score 30 or less14.8% of Spine Center initial visit patients scored 30 or less40.4% of the 4th Quartile scored 30 or less
Interesting Facts PCS 2.5% of US population are expected to score 30 or less52.7% of Spine Center initial visit patients scored 30 or less87.4% of the 4th Quartile scored 30 or less
Interesting Facts The 4th Quartile patients are 3 times more likely to participate in the Functional Restoration Program compared to the other patients. The 4th Quartile patients are almost 2 times more likely to have surgery compared to the other patients.
Nucleus Communications, Inc
53% spine diagnosis in lower back (T11 to Ileum)Herniated disc, also known as ruptured disc, is when
a portion of the intervertebral disc material bulges and sticks out into the neural canal.
Charges: One year episode spine specific ICD-9 codes
InterestingFactsCharges
+8%
-8%
25%
The 4th Quartile patients are distributed evenly among departments for initial visit.
Department 4th Quart All Patients PercentPhysical Med 42 128 33%Occupational Med 25 85 29%Orthopaedics 133 475 28%Nurse Practitioner 37 133 28%Neurosurgery 131 507 26%Anesthesiology 103 401 26%Rheumatology 18 77 23%Physical Therapist 173 778 22%GIM 38 174 22%Neurology 26 135 19%Family Med 6 35 17%
Provider of Care at Initial Visit
Outcome: Difference between Follow-up and Initial. Follow-up was latest survey between 3 to 7 months (average 5 months between initial and follow-up surveys)
MCS 76% 56% 53% 35% 54% 54%PCS 45% 48% 38% 25% 31% 25%Bodily Pain 60% 60% 48% 43% 62% 50%Mental Health 69% 55% 61% 39% 69% 63%
% Satisfied 79% 83% 54% 59% 62% 58%% Same treatment 74% 77% 53% 53% 62% 58%**Improved = Difference between follow-up and initial score is 5 points or greater
Satisfaction
SF-36 Norm-based Scores
4th Quart (n=124)
All Patients (n=381)
Improved**
Functional Restoration ProgramNon-SurgicalSurgicalReturn rates (RR): 4th Quartile are
more likely to return than the non-4th Quartile. For all patients; Surgery RR= 45%, Non-Surgical RR= 14%, FRP RR = 86%
4th Quart (n=30)
All Patients (n=68)
4th Quart (n=13)
All Patients (n=24)
Professional $177,638 $258 $579,919 $216Physical Therapy $151,094 $315 $416,056 $208Subtotal $328,732 $574 $995,975 $424
Pain Clinic $106,845 $155 $231,311 $86Other Prof. Fees $627,886 $913 $1,711,506 $639Subtotal $734,731 $1,068 $1,942,817 $725
MHMH - surgical $496,675 $722 $1,261,178 $471Inpatient $715,615 $1,494 $1,643,818 $822Other $639,535 $1,335 $2,067,873 $1,034Subtotal $1,851,825 $3,551 $4,972,869 $2,327
Total $2,586,556 $4,619 $6,915,686 $3,052*Clinic charge file had 688 for the 4th Quartile patients and 2,679 for All patients. Hospital charge file had 479 for the 4th Quartile patients and 2,000 for All patients.
4th Quartile All PatientsSum of
Charges$ per 4th Quart*
Sum of Charges
$ per Patients*
Spine Center
Outpatient
Inpatient
4th Quart All Patients
Jan. '01 to Mar. '02 732 2928
<= 24 years 4% 5%25 to 64 years 85% 77%
65+ years 11% 19%
Female 55% 53%
Unique Patients
Age Distribution
Gender
4th Quart All Patients
1 or more year(s) w/condition 68% 68%Prior Surgery 21% 14%
Missed work > 3 months 30% 14%Currently taking Narcotics 56% 30%
2 or more co-morbidities 74% 60%Previously seen 2+ types of providers 87% 80%
other Descriptors
Herniated Disc 25%Other 18%
Chronic Pain 18%DDD/Aging Spondylosis 13%
Pain Unknown 7%Stenosis 6%
Chronic Sprain 4%Spondylolisthesis 3%
Acute Sprain 3%Trauma 1%
Top 10 Diagnoses for the 4th Quartile
Value = Patient Outcome Cost of Care
Healthcare Production Costs
The amount it takes to pay personnel, rent, and for materials used to provide healthcare.
–Charges–Institutional costs–Healthcare costs
Healthcare Population Spending
The amount spent to reimburse providers of healthcare services & equipment.
–Societal costs –Expenditures–Reimbursement–Healthcare costs
Population Spending on iPads is rising,
but the Production Costs of tablets are not.
Bending Population Spending Requires Bending Production Costs
$
Time
Current Production Costs
Operating Margin 4-10%
Production Costs > Population Spending
Population Spending Estimates Based on Past Claims
New Production Costs Required to Maintain Margin
THE POPULATION LEVEL
Founder of The Dartmouth Institute for Health Policy and Clinical Practice
Jack Wennberg"Given the magnitude of the variations the possibility of too much medical care and the attendant possibility of illness that is caused by medical care is presumably as strong as the possibility of not enough service and unattended morbidity and mortality."
Distribution of Healthcare Spending
Per Condition for Similar PatientsAdapted from “Cowboys and Pit Crews” by Atul Gawande, The New Yorker. May 26, 2011
Distribution of QualityHealthcare Provision
Cost and Quality Curves Match
Implication
Curves MatchReducing health care spending impairs quality
What the Data Tell Us
Cost & Quality Curves Do Not MatchSome Areas Provide Above Average Quality at Below Average Spending
Implication
Curves do not matchIt is possible to reduce spending and improve quality
Types of Variation
• Benefits outweigh risks• Problem of under-use
Preference-sensitive care
• Significant tradeoffs between 2 or more treatment options that affect quality or length of life
• Problem of mis-use
Supply-sensitive care• Supply of resources governs the
frequency of their use• Problem of over-use
Beta blocker use among patients post heart attack varies from 5%-92%, when it should approach 100%
71% of doctors rate breast conservation as one of the top 3 concerns of woman diagnosed with CA while 7% of woman rate it similarly
Two similar cities with similar populations – one has twice as many hospital beds.
Ratio of Rate in Highest to Lowest Spending Regions (risk-adjusted)
Reperfusion in 12 hours for AMI
Mammogram, Women 65-69
Effective Care (HEDIS measures)
Flu shot during past year, elderly
Aspirin at admission for AMI
Total Hip Replacement
Back Surgery
Cataract ExtractionPreference Sensitive Care
Total Knee Replacement
Office Visits
Initial Inpatient Specialist Consultations
Pulmonary Function TestTotal Inpatient Days
Supply Sensitive Care
Inpatient Visits
Chest X-ray
Inpatient Days in ICU or CCU
1.00 1.5 2.00.5 25 3.0
Lower in High Spending Regions Higher in High Spending Regions
Decreased Risk
Relative Risk of Death Across Quintiles of Spending
1.00 1.05 1.100.95
ColorectalCancer
Q1
Hip Fracture Q1Q2Q3Q4Q5
Q2Q3Q4Q5
MyocardialInfarction
Q1Q2Q3Q4Q5
Increased Risk
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, and Pinder EL.The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Annals of Internal Medicine, 2003. 138: 288-98.
Q1 = Lowest spending HSA’sQ5 = Highest spending
Benefit-Utilization Curve Effective Care
Benefit-Utilization Curve Preference-Sensitive Care
Benefit-Utilization Curve Supply Sensitive Care
Cost & Quality Curves Do Not Match
Some Areas Provide Below Average Quality at Above Average Spending
Implication
It is possible to reduce population spending and improve quality.
Healthcare Value
Value = Patient Outcome Cost of Care
The Population PerspectiveData within organizations – financial, operations, productivity – all point to increasing throughput & utilization to survive
Relative Efficiency Comparisons – A Tale of Two Cities
Larger perspective reveals a different perspective
Healthcare Productivity in Theory & Practice
A
D B
C
OutcomeThe
Implementation Gap
Spending
“All patients should receive the care they need, and no less. They should also
receive the care they want, but no more.”Al Mulley, Director of The Dartmouth Center for Healthcare Delivery Science
Dartmouth College’s 12th President
John Sloan Dickey“The world’s troubles are your troubles, …. and there is nothing wrong with the world that better human beings cannot fix.”