Operationalizing value in Chronic Care: The case of Swedish Rheumatology

A research project involving Karolinska Institutet/Medical Management Center, Stockholm University School of Business, Karolinska University Hospital, Stockholm County Council and

Harvard Business School.

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Defining the care cycle

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DAS28 (Disease Activity)

Time

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Measuring outcomes over the full cycle of care

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Disease cycle captured in the SRQ registry

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Prioritizing measures based on the stage of the disease: defining two phases

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First phase of disease: reaching low or no disease activity

Early & aggressive treatment

Outcome measures, phase 1

• Time to 1st visit

• Disease activity

• Work ability and functional ability preserved

•Drug adverse events

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Maintain low DAS28

•Outcome measures phase 2

• Patients’ global• Disease activity• Work and functional ability maintained• Trust in care • Quality of life (EQ5D)• Adverse events• Mortality

Second phase: long-term management and prevention

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Detect and curb flares

Second phase: long-term management and prevention

•Number, intensity and duration of recurrences (flares).

•Disease activity

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This guy wants no medication. Because they reduce his immune defense. He wants to be medication free in order to be able to see his grandchildren without fearing to catch their cold.

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Measuring costs over the full cycle of care

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Direct costs - Stockholm County Council data sources: In-patient and out-patient data and cost per patient (CPP). Cost per patient - RA 2009, KUH Costs – not charges

Number of out-patient visits 45 404

Total cost 157 692 215 SEK Medical service 9 481 442 SEK Operation 1 917 123 SEK ICU 13 311 SEK Drugs 93 835 356 SEK Visits 52 444 983 SEK

Indirect costs at macro level:Sick leave days/year level out with biologics

Sick leave days/year level out with biologics

Controls

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Risk adjustment

Adjusting for aspects that influence outcomes

But are beyond the control of the provider

Avoid cherry picking

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Tasks and issues ahead

Delimiting the medical condition and care cycle

Using the available data to operationalize value Prioritizing outcomes and cost measures Adding measures/creating new interfaces and linkages Risk adjustment Reimbursement implications

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Value-based reimbursement?

Health care literature informs our work but... Does not tell us what to do

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Decisions to be made

Rewards vs penalties? individual vs group level bonus? Relative vs absolute incentives? Target vs improvement based? Frequency and size?

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Complexities related to outcomes-based reimbursement

Value-added networks, solution shops, facilitated networks (Christensen et al 2009)

How can we deal with these issues?

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Plan - reimbursement model

Experimenting with different outcomes and weightings using historical data

Implementing a prototype model in a shadow budgets Following the case with quantitative and qualitative data

generation methods Being sensitive to the interplay between the model and

other in/formal organizational and financial structures personal dispositions and internal motivations among professionals

and patients

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Thank You!

Anna Essén, aes@fek.su.se

Improvement of patients global health6 months after diagnosis, 1994 - 2008

National result & per county

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RA outcome measures in the three tiers

Survival – Mortality Health / recovery – Patients global, EQ-5D, Work ability, Daily

function,DAS28, AUC Doctors global

Time to recovery – Time to remission, time to work ability regained Disutility of care / Rx – Trust in care, Drug adverse events Continuity, empathy, access etc?

Sustainability of health / flares – Health / recovery AUC Long-term consequences of therapy – Patients global, EQ-5D,

Work ability, Daily function,DAS28, AUC Doctors global, adverse events, co-morbidities

Control for case-mix variables (gender, age, biomarkers, socio-economic status etc)