Achieving Health Care Sustainability: A Patient- Centered Approach

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1 Achieving Health Care Sustainability: A Patient- Centered Approach Transforming Health Care in Puerto Rico Luis A. Pérez, President FARO LLC health strategists

2 Agenda Current State of Affairs Achieving Sustainability The Value Equation Strategic Sustainability Initiative (SuSI)

3 Current State of Affairs PUERTO RICO

4 Our Current Health Care Spend After a decade of healthcare costs outpacing overall inflation and economic growth, Puerto Rico has one of the most expensive per capita healthcare systems in the world. However, in 2015, healthcare expenditure per capita was still about $2,200 compared with the US expenditure of around $9,800. CAGR = 4.4% We cannot continue this trend in Puerto Rico! It is not realistic to think that we can continue to do everything. Can we implement the needed reforms to achieve sustainability or not?

5 The PR government highlighted that the one-time health care funding to Puerto Rico under the Affordable Care Act could be exhausted by December 2017, putting 900,000 Puerto Ricans at risk of losing coverage, which means the island's health system will need additional funding.

6 Fiscal Debt

7 Demographic Trends Demographic and economic trends have put substantial pressure on Puerto Rico's health system financing. According to the Kaiser Family Foundation, between 2006 and 2014, the overall Puerto Rican population contracted by 10% - even though those aged 65-plus increased by 22% from 501,000 to 610,000. Out-migration of younger Puerto Ricans to the US mainland contributes to such trends.

8 Demographic Evolution by Age Informe de enfermedades cronicas. Departamento de Salud, Puerto Rico 2014.

9 Workforce: Physician Exodus

10 Puerto Rico Chronic Conditions Rate Compared to the other non-continental US territories, Puerto Rico is mostly unhealthy, ranking last of all states in the region, an 45 th overall.

11 Comorbidity and the need to approach chronic conditions holistically

12 In Summary: The Challenges PR s Health Care System is Facing Physician Out- Migration Health System Financing Population Health Challenges Zika et al. Fiscal Debt Crisis

13 Achieving Sustainability Back to Basics

14 The Industrialization of Medicine In the s trend started that applied management tools from industrial world to health care delivery. We still pay and incentivize doctors and providers based on the number of services being performed. This does not make people healthier! We are not spending our money wisely. We are wasting money on: Overtreatment, failures to coordinate care, failures in care delivery, high administrative costs, high health care prices and fraud, waste and abuse. Drives our incapacity to reduce the burden of disease!

15 Principles of Medicine 1. Promote health 2. Preserve health 3. Restore health 4. Minimize suffering

16 WHO on Sustainability 1. Reduce low value added health care 2. Reduce excessive margins without reducing quality 3. Invest in efficiency, structural reforms, health promotion and prevention Health promotion and prevention would be at the core of our program. We find ourselves constantly reacting to diseases!

17 Social Determinants of Health ~60% of a person s health status depends directly on health determinants. To be efficient on health policy you need to leverage and depend on many government agencies working hand-in-hand. We need to have agreement as a country to make people healthier and start seeing healthcare as the key to economic productivity!

18 The Value Equation Patient-Centered Care

19 Porter s Value Agenda: Making Sustainability Viable in the Long Run We need to move from an industrialized view where systems are organized around what physicians do to a patient-centered model that organizes around what the patient needs and expects. We need to ask and understand patient expectations! We need to move system from paying based on service volume and costs towards paying based on outcomes and patient expectations being met. We need to get out of silos on to a network organized around a number of high burden of illness medical conditions and move towards bundled payment on the whole cycle of care. To ensure true sustainability, we need to ensure that every single patient within a community is diagnosed and his condition is controlled. Incentives need to be aligned with this premise.

20 Problem: Lack of Outcomes Data We are too much focused on the process. We assume that measuring the process will make the outcome better, but this is never true! We need standardized measures to be able to compare results consistently. We are not focusing on the patient and his needs.

21 Defining Patient-Centered Care Institute of Medicine:... Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions... Dr. Donald Berwick:... Patient-centerdness is a dimension of health care quality in its own right...its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it.

22 Value Based Healthcare Applied: Martini Klinik Case Before surgery, every patient filled out a quality of life survey for cancer patients (QLQ- C30) to document emotional state and general quality of life, as well as the International Index of Erectile Function (IIEF-5) questionnaire to determine preoperative urinary and sexual function.

23 Martini Klinik Case: Cancer Outcomes

24 Reducing Costs through Patient- Centered Care in VBP/ACO Environments Patient Centered Care Patient/Caregiver involvement and shared decisionmaking Engaged Patients Better Diagnosis of Patient Preference BENEFITS Cost-containment: maximum value for money, funding goes further. Outcomes improve: evidence-based approach to treatment, best practice spreads. Integrated care pathways: greater efficiency, clearer workload, faster patient throughput. Main beneficiaries = Payers and patients DISRUPTIVE EFFECTS Pricing pressures: uncertainty over ROI May deter innovation and R&D investment Changes to care pathways, payments, relationships. Increased paperwork/investment in IT systems Onus on providers/suppliers Potential Reduction in health care costs Stacey, D. et al. Decision aides for people facing health treatment or screening decisions. Cochrane Database Syst Rev, 2011; 10. Engaged Patients Consumed Less Health Care

25 Patient-Centered Care: The New Definition of Case Management? Value-based healthcare

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27 Disease Management Model Components 1. Population Identification Processes 2. Evidence-based Practice Guidelines 3. Collaborative Practice Guidelines 4. Patient Self-management Education 5. Process and Outcomes Measure 6. Routine reporting and feedback between patients, providers and health plans Health IT

28 SuSI Achieving Sustainability in Puerto Rico

29 Sustainability Strategic Initiative (SuSI) Keep levers to meet the project s goals Social Determinants of Health Know what affects health and people s daily life SuSI will improve individual and population health, and advance health equity by driving broad understanding of economic and social conditions that shape and influence health risks and status. Health Services Delivery Transformation Adopt a people-centered approach SuSI will define a strategic vision and an operational framework for action towards coordinated-integrated health services delivery focused on achieving disease control targets. Financing & Payment Reform Pay based on quality of care not cost of care SuSI will seek to improve the quality of care provided to our patients, define common baselines and measures, and emphasize the importance of reporting quality performance. Health IT Transform data into insights SuSI will develop standardized quality reporting tools to collect actionable clinical KPIs from system stakeholders and drive integration across providers, practice settings and delivery channels.

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