ronald ma, austin health - from margins to mainstream: clinical costing for clinical improvements
DESCRIPTION
Ronald Ma, Clinical Costing Analyst, Austin Health delivered the presentation at the 2014 Hospital Patient Costing Conference. The Hospital Patient Costing Conference 2014 examines the development and implementation of patient costing methodologies to reflect Activity Based Funding allocations. For more information about the event, please visit: http://www.healthcareconferences.com.au/patientcostingconferenceTRANSCRIPT
From margins to mainstream
Clinical Cos0ng = Clinical Improvement Ronald Ma
Experts say…1
• Not only for compliance and top-‐up funding • Obliga0on to engage clinicians and use it • Get out of your basement • Don’t produce reports, but show what cos0ng info can really do
• Help the pa0ent • Find clinical champions • Meaningless if not used for pa0ents
2
Experts say…2
• Clinically validated cost results • Comparability of the cost results • Cri0cal cost informa0on to improve processes and outcomes of pa0ent care
• Cost Outputs = Actual resource use = Price • Intra-‐organisa0on planning • Be part of clinical reviews and pathways since the cos0ng system is the eRecord of the journey
3
Experts say… 3
• Empower clinicians • Promote the ownership of the cos0ng info 1. Coverage = all services and models (e.g. ICU) 2. Accuracy = clinical documenta0on + cost
alloca0on 3. Consistency = comparability and inform price 4. Use = benchmark, review, plan, improvement
4
ICU @Aus0n
A0702 Intensive Care Unit Clerical
A0703 ICU Consumables
A5655 Intensive Care Unit -‐ Nursing
A5656 Intensive Care Unit -‐ Ancillary
A5659 Intensive Care HMO
A5660 Intensive Care Unit -‐ Senior Me
A5690 Intensive Care Unit -‐ Registrar
ICUAcute Services
HMO Services
MappingRuleMed Admiss-‐ICUD%Med Days-‐ICUD%Nrs Wards-‐A5655%Thtr Time-‐A5660%
Indirect FixedC*C
Direct FixedQ*C
TransferMed Adm/Days
Nursing ServiceNrs Wards
Theatre
Out-‐of-‐ICU workHDU = 2 recovery beds (Dr)2,400 MET calls200 Cardiac Arrest calls1,500 Liaison Nurse visits
5
Experts say…4
• Cos0ng + Clinical = Same team as “one” • Disprove the “blame” • Only compliance = unsustainable • Demonstrate the value = the system will invest
• Cos0ng info + your role = the success of ABF + the sustainability of the health system
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Don’t produce reports Drive and support improvement
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Epidemiology of the cos0ng system
• Core business: compliance • Cos0ng reports: not very user-‐friendly • Missing components (e.g. Variable Cost, P&L, Contribu0on Margin, MC by DRG, Cost/WIES)
• Input side: (+/-‐) FINANCE input • Output side: triangula0on, validity, credibility, comparability, generalisability??
8
Must be more highly valued
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Coding
Costing
Clinical
Finance
Research
Organisation
Public Health
Epidemiology
Costing Analyst
Process Improvement
TIMWOODS
Rapid Improvement
Quality & Safety
Costing System
Be a clinical person
• Morning mee0ngs • Literature review • 24/7 con0nuity of care • Holis0c • First do no harm • Ethical • Living with the phenomenon (Trochim, 2000)(Heron, 1996)
10
Be accountable!
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One and only system =
activity + cost + revenue
Clinical
Non-‐clinical
Blue Skies
TranslationalQuality
improvementPatient Safety
2b
Internal
External
Costing Submission
Quality improvement
State National150b International Benchmarking
Special-‐purpose
2045Health Spend > State + LG
revenue
23%Age >652050
Population Growth
26%Health Costs
2050
Top-‐up Funding
Top-‐up Funding
Top-‐up Funding
12
experimental observational
Cohort Cross-‐sectionalCase-‐control
RetrospectiveProspective
Observe the previous exposure
Enrol cases and controls
Observe the exposure and the
outcome simultaneously
Prevalence studies
Exposure*health outcome
Observe the outcome (disease
rate)
cases controls
Observe the outcome (disease
rate)
Exposure status by observing
Based on disease status
Causation/association Odds Ratio
1/02/2014 1/03/2014 1/04/2014susceptibility subclinical clinical Recovery, disability or death
14/02/2014pathologic changes
1/03/2014onset of symptoms
7/03/2014diagnosis
1/02/2014exposure Infectivity
PathogenicityVirulence
exposure by randomisation
cases controls
Case 1: Theatre Cost India 2013
• 40% of clinical care costs incurred in theatres • Major cost centres = Major revenue centres • Future resource alloca0on planning • 33% Capital + 67% Opera0ng • AUD7.45/theatre min (AUD447/theatre hour) • Siddharth, V., Kumar, S., Vij, A., & Gupta, S. (2013). Cost analysis of
opera0on theatre services at an Apex Ter0ary Care Trauma Centre of India. Indian Journal of Surgery, 1-‐6.
13
33.63
31.9
29.974.5 100
0
20
40
60
80
100
120
Manpower Capital Consumables Support service Total
14
Case 2: CHADx 1 • University of Alberta (Jackson, Nghiem, Rowell, Jorm, & Wakefield, 2011)
• Cos0ng data is underused • Marginal Cost • Incremental cost • Episode cost <> System cost
15
CHADx 2
• No maper the cost or the cost of reduc0on efforts, we would strive to reduce pa0ent safety problems
• Before/Arer study: Baseline data • CHADx coefficients = median incremental costs of the impact of CHADx
• Confounding – sicker pa0ents develop HADx, then control the cost of uncomplicated care
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CHADx 3 • HADs add 3% ($64M) to 22% ($505M) to a hospital’s budget
• At the median LOS, an addi0onal 28,500 casemix-‐adjusted pa0ents could be treated using exis0ng beds if all CHADx were avoided
• Search for: Preventable <> Reducible harm • What info is ‘good’ enough to guide ac0on (if you are going to fix the input side you will never reach this point)
• Costs of adverse events = core clinical business
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Case 3: Asthma example (USA)
• (Sullivan et al., 2002) • Interven0on = social worker-‐based educa0on • 𝐼𝐶𝐸𝑅= 𝑀𝑀𝐶𝑠 −𝑀𝑀𝐶𝑐/𝑀𝑆𝐹𝐷𝑠 −𝑀𝑆𝐹𝐷𝑐 • ICER = Incremental Cost-‐Effec0veness Ra0o • MMC = Mean Medical Cost • MSFD = Mean Symptom Free Days • Result: Addi0onal cost of $9.20/SFD
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2-‐year trial with 3% discount on the second year costs and benefits
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20
21
Fenwick, E., Marshall, D. A., Levy, A. R., & Nichol, G. (2006). Using and interpre0ng cost-‐effec0veness acceptability curves: an example using data from a trial of management strategies for atrial fibrilla0on. BMC Health Services Research, 6(1), 52.
Case 4: Rehospitalisa0on (ReH)
• Mary Naylor@Uni of Penn Sch of Nrs in 2004 • Interven0on = Transi0onal Care Model (TCM) • Measure = ReH at least once within 6 months
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RCT 1 RCT 2treatment $3,630 $7,636control $6,661 $12,481
$3,630
$7,636 $6,661
$12,481
$-‐
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000 ReH costs post-‐TCM 2004
treatment control
Case 5: Hydrocephalus
• 3-‐year hospital-‐based cost analysis in Children’s Hospital at Westmead
• Alan Pham, Chris0ne Fan and AP Brian K Owler
• USA: 38,000 ped adm = 391,000 bed-‐days = $1.4b = $3,580.56/bed-‐day
• Canada: CAD3.5M
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Purpose of hydrocephalus cos0ng
• Clinically validated and interpreted costs • Improve the process and outcome of care (Donabedian) • Improve comparability of results • Cost reflects actual à price sexng • Support planning and clinical reviews
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$22,959
$50,186
$-‐
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
H only (n = 158) H + other (n = 23)
Cost/Adm
Item TotalCost Cost/Adm #AdmH only (n = 158) 3,627,499$ 22,959$ 158H + other (n = 23) 1,154,287$ 50,186$ 23Total 4,781,786$ 73,145$ 181
Other = spina bifida, myelomeningocele and IVH of prematurity 25
$14,205
$29,077
$-‐
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
All new patients All complications
Hydrocephalus AverageCost/Adm
Hydrocephalus costs TotalCost AverageCost/AdmAll new patients 923,310$ 14,205$ New shunt (n = 40) 570,100$ 14,252$ New ETV (n = 25) 353,211$ 14,128$ All complications 2,704,189$ 29,077$ Shunt blockage/revision (n = 69) 780,254$ 11,308$ Shunt infection (n = 24) 1,923,935$ 80,164$ 26
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Lessons learned from Hydrocephalus
• Costs are underes0mated • Treatment of hydrocephalus = cost effec0ve • Complica0ons = expensive ($ x 5.3) • â complica0ons = á clinical + economic gains • Review clinical protocols • Research
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Costs excluded • Tumor-‐ and trauma-‐related hydrocephalus • Non-‐surgical +/-‐ treatment • Surgeon fees for private pa0ents • Outpa0ent visits • Inves0ga0ons • GP or Pediatrician visits • Indirect costs
loss of income, loss of produc0vity, 0me-‐off long-‐term economic costs of disability non-‐financial costs
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Case 6: Whipple – 1-‐year cost
• 1996 Washington, USA study • 25-‐month prospec0ve study on 30 Pancreatoduodenectomy (n = 30)
• Methodology = item-‐by-‐item prospec0ve micro-‐cost analysis
• 33% developed complica0ons (n = 10) • Post-‐op complica0ons = áward cost by 76% • Iden0fy cost driver = áquality = âcosts
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Whipple 2 OR costs disposable/non-‐disposable equipment
OR roomOR staffpostanesthesia careanesthesia
Ward costs hospital roompharmacyradiology
32
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Case 7: Post-‐allogeneic hematopoie0c Stem Cell Transplanta0on
• Swedish study 2012 (5-‐year from 2003 – 2007) • Mean 1-‐year$/pa0ent = AUD 204,031 (95% CI = AUD
179,688 – 227,015) • âcosts = Non-‐Myeloabla0ve Condi0oning (NMT) • $ of Reduced Intensity Condi0oning (RIC) = Myeloabla0ve Condi0oning (MAC)
• ácosts = complica0ons and re-‐transplanta0on • Mul0variate analysis à 76%á1-‐year costs of post-‐transplant complica0ons and re-‐transplanta0on (costs gone up to AUD 358,889).
34
35
ReTx = Re-‐transplanta0on
36
Lessons learned from SCT study
• HSCT is expensive • Unrelated Donor Transplant $ > HLA-‐iden0cal • HLA = Human Leukocyte An0gen • Re-‐transplanta0on = áá$ • Grar versus Host Disease (GVHD), rejec0on and Invasive fungal infec0on (IFI) = á$
• Beper preven0on and Tx of complica0ons = cost-‐effec0veness of HSCT
37
Case 8: Unplanned reopera0on rate
• Dartmouth-‐Hitchcock Medical Center USA 2001 • Any secondary opera0on required for a complica0on from the index opera0on
• 48 – 66% all adverse events related to surgery • > half ‘preventable’ • Colon resec0on, renal transplant, gastric by-‐pass and pancrea0c resec0on
• Reopera0on = higher costs + higher mortality rate
• 85% of complica0ons at original surgical site 38
Birkmeyer, J. D., Hamby, L. S., Birkmeyer, C. M., Decker, M. V., Karon, N. M., & Dow, R. W. (2001). Is unplanned return to the opera0ng room a useful quality indicator in general surgery? Archives of Surgery, 136(4), 405.
39
Lessons learned from re-‐op rate
• $ X 4 higher + mortality x 3 + sufferings • Charges ≠ Costs • Limita0ons – relying on admin data • To be precise – combined with clinical data • May hinder 0mely interven0on by surgeons if used as Quality KPI
• Find alterna0ve methods for re-‐op
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Case 9: Robo0c cardiac surgery
• (Morgan et al., 2005) New York • Q: comparison between robo0c and sternotomy costs from hospital perspec0ves
• Method: Retrospec0ve observa0onal study with independent sample t-‐test and X2
• Sample: atrial septal defect (n = 20) and mitral valve repair (n = 20)
• Data: Hospital cost data with amor0za0on
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Lessons learned -‐ Robo0c
• Retrospec0ve observa0onal: selec0on bias • Inherent limitaBons in the cost data • Small sample size • Absolute cost robo0c > conven0onal surgery • But, may jus0fy investment in this tech
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Inflamma0on = the star0ng point of healing
• They will ‘blame’ the cos0ng data = improve it • Work with the local clinical champion • 5Es for working ‘with’, (not working ‘on’)! (Envisage, Engage, Empower, Enable, Encourage) (your homework)
• Use PAR methodology • Ac0ve and full par0cipa0on = from planning to evalua0on = inclusive = ownership
44
Ul0mate goal = clinical improvement
• Observe = analyse the process and info • Successes à celebrate • Failures à don’t give up (it is too easy to give up) but learn
• Ul0mate goal = clinical improvement = mainstream
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Always reflect
• Reflect = cri0cal knowledge = ConscienBzaBon • Refine your data and approach or CPR your cos0ng system
• Celebrate with your team (it is a team work!)
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What’s your team?
Research Business Case Funding Negotiation
Process Improvement
Costing Analyst and Team
Benchmarking
AcademicsCSU MgrClinical Directors
Pricing Authority Whole Org Locally and
globally
47
Share your knowledge
• You + your system visible in the community • Share your experience and knowledge • Publish your journey of ‘fm2ms’ • Habermas, 1962: Communica0ve ac0on and the public sphere
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What clinicians want to see
• Sound sta0s0cal analyses • Referencing: Reputable journals • $ + human misery • Treatment plan cost*episode cost (<>FY concept) • Focus on process > individual errors • Just an awareness (health promo0on approach) = improvement
• # in wai0ng * $ = loss of revenue = waste
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You are expected to know…
• QALY • DALY • CHADx • Risk adjustment (e.g. the Charlson comorbidity index and score)
• Rate, ra0o and propor0on • Period Cos0ng
50
Plan
Do
Check
Act
Demming Cycle
Plan
Act
Observe
Reflect
Plan
Act
Observe
Reflect
PAR
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Policy implica0ons: Demand is there
• Health promo0on approach is needed: empowering the cos0ng sector
• Severely under-‐resourced and under-‐u0lised • Resourcefulness/resourcing • Joubert, N., & Raeburn, J. (1998) • Applica0on of the cos0ng data > polishing the cos0ng input process
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6 Cost Analyses
1. Cost Consequences (cost and outcome as is) 2. Cost Minimisa0on (outcome 1 = outcome 2) 3. Cost of illness (a popula0on, a region) 4. Cost Effec0veness (outcome = morbidity/
mortality) 5. Cost U0lity (outcome = QALY) 6. Cost Benefit (quan0fied in $)
53
• Pa0ent Safety Add-‐on (DATRIX) to the cos0ng • Harms avoided = projected savings • Pa0ent Sa0sfac0on/Experience à Happiness • Quality and Safety = core business • Pa0ent-‐Centred Healthcare of the 21st Century • This is much more powerful than LOS study… • Cos0ng System = eRecord of the journey
Further research: Healthcare is changing
54
Healthcare needs Cos0ng System • Legi0mise your cos0ng data with Finance and Clinical teams à your cos0ng data will ‘fly’
• Stay sufficiently with the phenomenon • Be a PAR researcher (crea0on of knowledge + ac0on)
• Can’t change it overnight but need a change • Success KPI à prevalence of cos0ng data usage, clinical and finance acceptance, and involved in quality and clinical improvement
• Failure à nobody uses it 55
Formulate own benchmark, KPIs and a plan for the next cycle of clinical improvement
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SKILL LEVEL
#STAFF SUPPORT
3S
Structure-‐process-‐outcome (Donabedian, 1980)
• 1919 -‐ 2000 • Outcome-‐based funding • Outcome-‐based cos0ng (holis0c cost) • Outcome-‐based management • Outcome-‐based resource alloca0ons • OBF <> ABF • Paradigm shir: Problem-‐based healthcare à outcome-‐based healthcare
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Mobilising the masses
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Timely and relevantAccurate
TransparentComplete data
Value-‐added analyses Engage
Finance
Clinical
Management
Show the value of the costing info for clinical
improvement
Seeing and believing it
They willInvest in it
Sustainable for the costing industry
From margins to mainstream
Thank you.