better health outcomes at less cost - future nhs stage, 4pm, 2 september 2015

www.uk.gdit.com/health

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.

GDIT Proprietary 2 | www.uk.gdit.com/health

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


1

2

3

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


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


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


The need for a ‘self reforming’ system

GDIT Proprietary

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

8 | www.uk.gdit.com/health

Arkansas’ statistics


Our goal is to align payment

incentives to eliminate

inefficiencies and improve

coordination and effectiveness

of care delivery

UK (approximate) equivalents


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


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


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


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


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


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


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

GDIT Proprietary

+

-


Cost Categories: Provider vs. Peer


Initial promises


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


New Stream of Payments

Results: Quality of care


Results: Cost savings



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

GDIT Proprietary

For more information

Join our Pop-up University

Tomorrow at 11:00

"Better care at less cost: a “how to” for commissioners and providers"


Ben Breeze UK Healthcare Director

General Dynamics Health Solutions [email protected]

Expanding Insight. Ensuring Value. Improving Outcomes.

better health outcomes at less cost - future nhs stage, 4pm, 2 september 2015

Health & Medicine