Value Based Healthcare Dr Paul Buss Dr Sally Lewis Sir Muir Gray Speakers: Executive Medical Director/ Deputy CEO, Aneurin Bevan UHB Deputy Medical Director Aneurin Bevan UHB Chair, Health and Social Care Digital Service 2017 CONFERENCE
Building a value delivery-system for health Dr Paul Buss Executive Medical Director/Deputy CEO Aneurin Bevan University Health Board ABUHB VBHC
Value-Based Health Care Organising for value across a whole system ABUHB VBHC
Doing the right things with resource? ABUHB VBHC Aneurin Bevan: too many drugs are consumed in too large quantities whilst few doctors would disagree with this statement the fault lies primarily with them Note 20 Chapter 5 In Place of Fear -1952
We spend a great deal of money!! ABUHB VBHC Aneurin Bevan: the cost of looking after the visitor who falls ill cannot amount to more than a neglible fraction of 4m the total cost of the NHS A free health service In Place of Fear -1952
Clinical Responsibility and Resource Patients help us make lower cost clinical decisions (Prof Don Increasing evidence - better results at lower cost Better outcomes often COSTS LESS!! Rising costs - sign of concern? Rising unit cost per unit outcome..an early indicator!! George Akerlof: when returns for good quality accrue mainly to the entire group the incentive to differentiate goods on the side of better quality reduces - The Market for Lemons An Economist Theorists Book of Tales -1984 ABUHB VBHC
The value gap Rising demands/pressures Increased admission rates and older demographics A multi billion gap by 2025 Productivity? Efficiency? Value? Clinicians MUST TALK RESOURCE Teams MUST THINK VALUE Teams MUST measure OUTCOMES ABUHB VBHC
Influencing Clinical Behaviour Understanding the Porter standard Actively measuring clinical outcomes Using International Datasets (ICHOM) TDABC/PLics - tools for value-delivery Clinical costs as a nonclinical marker What is clinical value - what does it mean in my practice? To. Why don t we correlate clinical outcomes and costs routinely? Changing the culture from... ABUHB VBHC
Do we understand our Costs? The COSTING CHALLENGE Costing that influences clinical behaviour Costs - as an economic signal Clinical decisions Impact of clinical behaviours Clinical Leadership Culture Costing to close the Value Gap. Costing mechanism that accurately portrays clinical behaviour Richard Thaler: Prospect theory broke from the traditional theory that human behaviour can be normative and descriptive Misbehaving Making Behavioural Economics 2015 ABUHB VBHC
ABUHB-Strategic Partnership with ICHOM : support to deliver our strategic outlook & vision Scaling Implementation Support & Training in Methodology: Move towards measuring global consensus sets of outcomes Supporting the provision of a Value Based Health Care Course 04/05 th October, Life Sciences Hub Cardiff. Support delivery of Standard Set Workshops ABUHB VBHC
The Draft Programme
Impact of Care on QOL and Cost Dr Gareth Roberts clinical Business lead ABUHB Renal disease and EQ5D: mobility 5 Real-Life Costs of Care Anxiety 4 3 2 1 0 self care Pain activities ABUHB VBHC 80 60 40 20 0 6 months post No Better change Worse 90 80 70 60 50 40 30 20 10 0 6 months post No Better change Worse
Allocative/Technical Value Inpatients 3.1M 1,200 people 1,600 episodes COPD REAL-LIFE AB Prescribed COPD drugs 6.9M Population unknown Pulmonary Rehabilitation Cost est. 0.065M Current offer 429 places Home Oxygen service 0.3M 490 COPD patients Smoking Cessation Pharmacy scheme 0.1M (all conditions) NRT 0.5M (all conditions) Population unknown IDEAL - EBM Flu Immunisation 9,800 COPD population Immunisation fee 7.80 x 9,800 = 0.07M 8,487 General COPD Risk Register 4, 280 > MRC3 Risk Register 12, 867 pop n GP QOF Payment for management in primary care 0.5M Evidence based assessment of the effective interventions for COPD. Source: London Respiratory Team ABUHB VBHC Evidence based assessment of the effective interventions for COPD. Source: London Respiratory Team Rebecca Richards Senior finance leader ABUHB
TDABC or Traditional Costing 4 VALUE A blended way at ABUHB - the best of both worlds: Examine and / or improve existing cost data where fit for purpose employing PLICS TDABC as first choice for specific occasions or to fill pathway gaps in traditional data To produce clinically meaningful costing data: the resultant data gives a fair and useful reflection of the real (or improved) world providing the best chance of assessing value across a given condition or pathway ABUHB VBHC
The Clinical Leadership Challenge Value Based Management Coordinated value based approach Clinical Cost Leadership Education importance of value Clinical Value Analysis and Delivery Value weighting/indices for costing Clinical Costing Outcome measures Clinical Value Analysis Elinor Ostrom: Local appropriators of resource have too little motivation to contribute to sustainability Governing the Commons ABUHB VBHC
Thank you for listening : Paul.Buss@wales.nhs.uk
Dr Sally Lewis Assistant Medical Director Aneurin Bevan Health Board 2017 CONFERENCE
A Value Delivery System for Health: In Practice Dr Sally Lewis Assistant Medical Director Value-Based Health Care Email: Sally.lewis2@wales.nhs.uk Value Based Health Care Team; Aneurin Bevan University Health Board
Example 1: Implementing Outcomes Capture in Parkinson s Disease (Personal Value) Aim: Test use of standard set ICHOM by Patient & Clinician / Understand IT solutions/ challenges NOT linked to cost TDABC at this stage Testing methodologies and approach, i.e. process mapping Patients entering their patient reported outcomes via tablet form in a clinic environment Clinicians reviewing the things that matter to patients in clinic, focusing the consultation Findings/Observations: 1. Clinical Engagement is key to its success - we had total buy in 2. IT Support fundamental we had total buy in 3. ICHOM expertise required first time 4. Dedicated capacity to support the work 1. The Clinical Environment 2. The Clinic Flow 3. Staffing 4. Relationships and Awareness AT THIS STAGE THE PROGRAMME HAS Highlighted the increasing importance of close collaboration between clinicians, managers, finance and fundamentally the patients/carers/relatives in designing and delivering healthcare in such a way that patients have the best possible experience and outcomes with a high degree of VALUE in the system. Value Based Health Care Team; Aneurin Bevan University Health Board
What the patients told us: What matters? We asked: Please tell us what aspect of outcome information is important to you and/or how outcome information could have helped you when you were first diagnosed? Having real time info and better info about their likely trajectory really important It is our right to have access to this information! capturing outcomes in one point in time was all well and good, but really he d like an app that would ask him throughout so that he could feed in his thoughts and feelings as things were happening. Value Based Health Care Team; Aneurin Bevan University Health Board
What the data tells us: Initial views? Non motor functions against categories Complex Maintenance New 3 Sleep Sexual 2 Daytime 1 Fatigue 0 Pain and Dizzy on Constipation Urinary Non motor Averages for categories Complex Maintenance New Sleep Problems 3 2 2 Daytime sleepiness 2 2 1 Pain and other sensations 2 1 1 Urinary problems 2 1 1 Constipation 1 1 1 Dizzy on standing 1 0 0 Fatigue 2 1 2 Sexual function and sweating 1 2 1 Motor function averages against categories Complex Maintenance New freezing 3 balance and 2 1 getting out 0 saliva and Chewing eating tasks dressing tremor Hygiene turning in bed handwriting hobbies Quality of life against Categories Complex New Maintenance falls in 5 Falls Commun Embarra Cramps number Concentr 0 Ability Admissio Problems Getting to Depressi Dressing Motor function Averages for categories Complex Maintenance New Speech saliva and drooling 2 1 1 Chewing and swallowing 2.5 1 1 eating tasks 1 0 0 dressing 1 1 1 Hygiene 2 1 1 handwriting 2 1 1 hobbies 2 1 1 turning in bed 2 1 1 tremor 2 1 1 getting out of a deep chair or car seat 2 1 1 balance and walking 2 1 1 freezing 1 1 1
Example 2: Implementing Allocative/Technical value in COPD Value Based Health Care Team; Aneurin Bevan University Health Board
Inpatients 3.1M 1,200 people Prescribed 1,600 episodes COPD drugs 6.9M Population Pulmonary Rehabilitation unknown Cost est. 0.065M Current offer 429 places Home Oxygen service 0.3M 490 COPD patients Smoking Cessation Pharmacy scheme 0.1M (all conditions) NRT 0.5M (all conditions) Flu Immunisation Population 9,800 unknown COPD population Immunisation fee 7.80 x 9,800 = 0.07M 8,487 General COPD Risk Register 4, 280 > MRC3 Risk Register 12, 867 pop n GP QOF Payment for management in primary care 0.5M Value Based Health Care Team; Aneurin Bevan University Health Board Disinvestment in low value activity led by clinicians who have subsequently influenced decision making around high value reinvestment, thereby improving outcomes and reducing costs simultaneously. Example: Respiratory Care involving a collaboration of primary care, secondary care, pharmacy, finance and patient representative. Rationalise inhaler prescribing which was not of benefit to patients with chronic obstructive pulmonary disease. Savings for 2015/6 were 204K recurrently and work is expanding. Re-investment: proportion of saving in PR, providing equitable timely access, improving quality of life Reduce hospital admissions due to exacerbations. be highly cost-effective it is substantially below the NICE threshold for cost-effectiveness, at only 2,000-8,000 per QALY Pulmonary Rehabilitation is a cost effective intervention. Estimates of savings range from 890 per person per course (Griffith et al: Thorax 2001) to 1835 per person per year (Chakravorti et al : ISRN Pulmonology 2011) They will be doubling the number of places to 900 from 429. Therefore can see the economic benefit as well as the personal value
Example 3: Implementing Costing and Outcomes Capture in Cataract Surgery i.e. Outcomes/Cost = Value Globe Benchmarking Value Based Health Care Team; Aneurin Bevan University Health Board
Cataract Pathway Introduction Started with Costing Planned Care Programme: Evidence based pathway redesign and standardisation across Wales Measuring patient outcome, experience and value for money Approached Directors of Finance to advise on best approach to the latter From initial work on cataract pathway they knew the number of steps in pathways around Wales varied but so what Mark Bowling, Finance BPA and BI Lead Value Based Health Care Team; Aneurin Bevan University Health Board
Cataract Pathway Methodology From previous experiences ABUHB approached to pilot. Once internal version complete: 1. Presented to other Welsh Health Boards sharing tools, templates and models 2. Regularly meeting to manage issues 3. Key consistency apples with apples 4. Key decision the real cost of getting one patient through a cataract operation 5. Therefore capturing and segregating under-utilisation / wastage 6. Additional levels of analysis to allow deeper benchmarking and variation Mark Bowling, Finance BPA and BI Lead Value Based Health Care Team; Aneurin Bevan University Health Board 7. Feedback sessions locally and nationally 8. Comparison with traditional costing
Cataract Pathway Results : What would you ask? Mark Bowling, Finance BPA and BI Lead Value Based Health Care Team; Aneurin Bevan University Health Board total cost? 456 to 667 40% Can I dig into Pre Op Assessment Mins results? Medical 10 24.84 Nursing Band 5 and above 42 17.50 HCSW Nursing 4 0.95 Administration 73 15.15 Consumables 2.56 Wastage - DNA 2 1.61 Complexities 2 8.78 Total 133 71.39 For theatres: Headcount Skill mix Per list? 60% Within Health Board: By consultant By approach e.g. anaes.
Cataract Globe Benchmarking Pre- & post-op patient questionnaires plus intra-op data. Completed: Clinical Engagement Gap Analysis Started Data Collection Still to do: Data validation Complete data collection Feed back Value Based Health Care Team; Aneurin Bevan University Health Board
Value Based Health Care Team; Aneurin Bevan University Health Board Questions?
Sir Muir Gray Chair Health and Social Care Digital Service 2017 CONFERENCE
Value Based Healthcare THANK YOU 2017 CONFERENCE
Lower Hall Ground Floor 2017 CONFERENCE