Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined Ottawa, Chateau Laurier October 22, 2008 Presenter: Neil Stuart ibm.com/healthcare/hc2015
Agenda Agenda Issue The Case for Change Analysis Emerging Challenges Implications Delivery Models and Required Competencies Moving Forward / Recommendations Conclusion 2 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Healthcare systems worldwide are struggling to address increasing costs, inconsistent quality and/or inaccessible care Growth in healthcare expenditures 1 (Healthcare spend vs. GDP, per capita) Change in healthcare spend per capita, 2000-2004 60% 40% 20% 0% IND ESP UK USA MEX AUS NZL FRA ZAF CHE SWE CAN DEU SGP DNK JPN ITA CHN 0% 20% 40% 60% Change in GDP per capita, 2000-2004 Occurrence of adverse events at hospitals 2,3,4 (Percentage of total and preventable) Canada Denmark France New Zealand Spain U.K. U.S. (UT/CO) U.S. (NY) Preventable Australia 51.0% 10.6% 36.7% 40.4% 41.7% 37.1% 42.8% 47.9% 3.2% 3.7% 6.8% 9.0% 9.3% 10.8% 12.9% 0% 5% 10% 15% Hospitalizations with at least one adverse event (%) 15.4% Preventable not measured Examples of healthcare access issues 5 (Select countries) Canada: 36% wait 6+ days or never for Dr. appointment (vs. 10% AUS, 3% NZL, 15% UK, 23% US) China: 39% rural, 36% urban cannot afford professional care Denmark: Govt pledges to cap wait time to 2 months for all treatments Germany: 300K uninsured Japan: Long waits at popular hospitals, consult times getting shorter U.K.: More than 40K Britons wait more than a year just for diagnosis U.S.: 47M uninsured, 15M underinsured Note: (2) An adverse event is defined as an unintended injury or complication which results in disability, death or prolongation of hospital stay, and is caused by health care management rather than the patient s disease ; (3) despite attempts to minimize inter-study differences, some variation may be explained by methodologies (Marang-van de Mheen, 2007) Source: (1) WHO (2007); (4) AUS: Thomas (2000), CAN: Baker (2000), DNK: Schioler (2001), FRA: Michel (2004), NZL: Davis (2002), ESP: ENEAS (2006), UK: Vincent (2001), US (NY):, US (UT/CO): ; (5) CAN:, CHN:, DNK:, GER:, JPN:, UK:, US: U.S. Census Bureau (2007) and Schoen (2005) 3 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Issue High, rapidly rising costs No link between higher costs and quality or safety Access issues Despite having many fine care delivery organizations and providers, the Canadian health care system is facing stress and is increasingly unsustainable Growth in health spending has been out pacing growth in provincial revenues in 9 of 10 Canadian provinces over the last 10 years. Health spending in the provinces has grown at an average annual rate of 7.3%. Provincial revenues at a rate of 5.9% and provincial GDP growth has only been 5.6% Health spend in Ontario is growing 6.7% p.a. 10.3% in Alberta (last 10 yrs) 10% of GDP going to health care Ontario is spending 43% of available provincial revenue on health (2006-07) Up to 24,000 Canadians killed each year in hospitals by preventable errors Evidence of many more errors at hand-off of patient from hospital back to community High rates of hospital acquired infections Canada ranks 22nd among OECD countries on infant mortality, 15th on perinatal mortality, 17th on Disability Adjusted Life Years (OECD 2007) Health outcomes for aboriginals are a national shame 24% of Canadians visiting the Hospital Emergency Dept wait more than 4 hours to be seen (vs. 17% Australia, 12% NZ, 14% UK, 12% US, 4% Germany), 36% percent of Canadians find it takes 6 or more days or never to get an appointment to see a doctor (vs. 10% Australia, 3% NZ, 15% UK, 23% US, 13% Germany) (Schoen et al 2005) 4 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Analysis The growth in healthcare spending, combined with healthcare drivers will continue to have major impacts on health providers Healthcare 2015 Drivers Impact on Health Providers Source: and IBM Institute for Business Value 5 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
1 Analysis» Increasing focus on value A value-based health system should appropriately balance resources expended in keeping people healthy and in treating sickness. Health Status / Reversibility Health care spending Healthy/ Low Risk At- Risk High Risk Early Clinical Symptoms Active Disease Time Personal Lifestyle Plan Risk Modification Source: and IBM Institute for Business Value, adapted from Ralph Synderman 20% of people generate 80% of costs Disease Treatment and Management 6 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
1 Analysis» Increasing focus on value A proactive, value-based health system should help keep people well and stop them getting sicker - - we are not there yet 8,000 people are dying in Ontario each year as a result of chronic conditions that have not been well monitored and managed. And there are many more whose quality of life could have been improved (Ontario Health Quality Council, 2008) Less than half of those with diabetes have their blood sugar under control. Most are not getting foot exams, eye exams, the blood glucose monitoring that they require. More than half are not getting the medications they require Similarly, many with coronary artery disease are not taking medications that have been proven to help manage their condition Healthy/ Low Risk At- Risk High Risk Our health care system is too often failing to connect proactively with those with chronic conditions or known to be at risk. It is waiting for them to become sick 7 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
1 Analysis» Increasing focus on value Defining value for a healthcare system means balancing emphasis and decisions across multiple, possibly redefined dimensions Value Dimensions of healthcare systems Example Costs / affordability How will quality be defined? Generally focuses on areas such as: - Evidence-based treatment approaches - Clinical & patient-reported outcomes Ability to continuously improve and innovate Ability to activate citizens to live healthier lives Equity Overall health status of population Clinical quality and safe Service quality Access and choice Also could and should include: - Prediction / Prevention / Early detection and intervention. - Time and resources expended for a correct diagnosis - Communication with patients (comprehension, compliance, recall) - Responsiveness to patient preferences and values - Ability of patient / consumer to manage medical conditions & health - Care coordination Desired Current Source: and IBM Institute for Business Value 8 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
1 Analysis >> New approaches to promoting health and delivering care Personalized medicine will challenge scientists, health providers but holds great promise for improving value More Efficient Medical Care Disease Severity Reactive Medical Care Diagnose Disease; Treat Symptoms; Costly, Trial and Error Treatment Select Treatment Diagnosis Switch Treatment Switch Again Disease Severity Health Management; Molecular Screening; Early Detection; Rapid Effective Treatment; Improved Quality of Care Predisposition Right Treatment Diagnosis/Prognosis Screening Time Monitoring Preventive Medical Care Predisposition Guides Prevention; Treat the Molecular Markers vs. Symptoms and Disease Time Disease Severity Preventive Measures Monitoring Source: Adapted from Personalized Medicine Coalition Predisposition Screening Time 9 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
1 Analysis» Increasing focus on value The ability to consistently deliver value improves with access to relevant patient information and knowledge of what works for that patient Access to Relevant Patient Information Good Poor Experiencebased Trial & Error Poor More art than science More science than art Source: and IBM Institute for Business Value Increasing Value Clinician consensus Individual clinician knowledge & experience Access to Clinical Knowledge (e.g. Diagnostic tools, Comparative Effectiveness) Evidence-Based (Based on populations) One size fits all Good Personalized (Based on people like me) 10 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
2 Analysis» Increase in consumer responsibility With help from CDOs and other entities, consumers can play a pivotal role in their health and healthcare Activate lifestyle changes Increasing empowerment and activation Collaborate in clinical decisions Engage in self-care Increasing long-term impact on health Source: Adapted from WHO Health Promoting Hospitals and Bridgepoint Health 11 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
2 Analysis» Increase in consumer responsibility In assuming more responsibility for their healthcare, citizens must make wiser health and financial decisions as patients and purchasers Make better health-related choices Receive personalized high-value care Improve financial planning for healthcare Health Coach Prediction and risk Healthy lifestyles Behavioral change Living with disease Value Coach Articulating goals Finding providers Comparative value Creating pathways Wealth Coach Education on potential costs Financial planning Insurance options Improved access to relevant information Source: and IBM Institute for Business Value 12 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
2 Analysis» Increase in consumer responsibility Changing consumer behaviors requires different efforts from different entities, depending on the individual and the stage of change Care delivery teams Family and friends Support groups disease, advocacy Coaches Prochaska s Stages of Change Model Pre-contemplation Contemplation Preparation Action Maintenance Governments Employers Other payers Media Source: and IBM Institute for Business Value 13 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
2 Analysis» Increase in consumer responsibility Roles and responsibilities in helping consumers will need to be clearly defined to avoid confusing overlaps or gaps Government Care Delivery Team (typically led by a doctor) Health Region/LHIN Other Entities or Associations That Could Provide Help Personalized Health-related information for better choices Healthy lifestyles education / coaching Prediction of health problems / status Behavioral change Information/regulate re nutrition, smoking Health communities Healthy lifestyles education / coaching Prediction of health problems / status Behavioral change Appropriately selfmanage disease Prediction of health problems / status Appropriately self-manage disease Independent health infomediaries Genetic testing labs Support groups Web 2.0 (social networks, blogs, wikis, etc.) or PHRs Family and friends Receive personalized high-value health services Aligning incentives Provider selection Comparative effectiveness Patient navigators Provincial health call lines Knowing where to go next for care or who to contact for help/information Care navigation Help with compliance Care coordination Comparative effectiveness Information on providers Shared care Financial planning Insurance options (e.g., LTC, disability) Cost comparisons As is vs. predictive models Cost options with health planning Financing plans for consumer portion of payment Independent health infomediaries Support groups or associations Disease mgmt programs Family and friends Web 2.0 social networks, PHRs Financial institutions Independent financial planners Independent health infomediaries Family and friends Source: and IBM Institute for Business Value 14 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
3 Analysis» New approaches to promoting health and delivering care Healthcare models and approaches will need to be coordinated or integrated to meet changing requirements Wellness / prevention Wellness Centers Retail Clinics Acute care Complementary Medicine Concierge Medicine Medical Home Telehealth, Telemedicine, e-visits Medical Tourism Ambulatory Surgery Centers Centers of Excellence Specialty Hospitals Chronic care Source: and IBM Institute for Business Value Mobile and Home Care 15 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
3 Medical tourism is subjecting healthcare delivery to competitive pressures - - new consumer segments, new choices Value proposition of medical tourism Value Sample benefits/alternatives Costs Significant arbitrage opportunities Many doctors trained in renowned schools Quality and/or certified/licensed Clinical Good enough to high quality results reported Increasing number of accredited hospitals Quality Some emphasizing healthcare experience Service (e.g., amenities, state-of-art facilities) Language, cultural differences minor/non-issue Minimal wait times Access Accessible to non-citizens Complementary care Innovation Cutting-edge and experimental treatments Patient flows to select Asian countries (No. in thousands) 952 29% 1273 660 1596 840 530 374 324 230 232 103 174 89 115 150 2003 2004 2005 Thailand Singapore Malaysia India Emerging medical tourist segments Segment Value shoppers Quality/experience seekers Leisure/ business travelers Payer-directed Description Active cost/quality consumers Regional patients Expatriates Active but price insensitive consumers Range from cosmetic services to executive physicals Mandates by governments Incented by employers, payers Value Examples Traditional travel from S. Asia to India; E. Asia to Thailand, Malaysia, Singapore; W. Europe to E. Europe Developing countries to Middle East to Europe and N. America Travel to Thailand, South Africa U.K. NHS to other parts of Europe U.S. insurers to Mexico, Thailand 16 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
4 Analysis» Global resource shortages Longer term solutions to global resource shortages may be painful but must address both the supply and demand and be made in context of desired value dimensions for the healthcare system Supply Optimizing limited resources Conduct population-based planning Develop more of the desired types of clinicians and facilities Capacity planning Base care decisions on evidence of clinical effectiveness when it exists and patient preference, not on availability of resources Standardize and streamline, automate, delegate and coordinate to improve efficiencies Extend capabilities and access through non-traditional delivery channels (e.g. e- visits or telemedicine) Source: and IBM Institute for Business Value Demand Addressing the need for healthcare resources Activate consumers - - CDPM, inclusion in care planning, end-of-life Communicate better with patients Focus on prediction; prevention; early detection and treatment; and care coordination Make rational coverage decisions based on the total costs of prevention or care Know what works and properly incent it Recognize that some conditions can not be cured regardless of resources applied Minimize medical errors and the practice of defensive medicine 17 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
4 Analysis» New healthcare delivery requirements, capabilities and models Numerous countries will continue to struggle with workforce shortages which will be exacerbated in part, by a brain drain Distribution of health service providers 1 (Doctors, nurses and midwives per 1000 population) Doctor immigration to Australia, Canada, UK and US 2 (Select countries) <2.5 2.5 to <5.0 5.0 to <7.5 7.5 to <10.0 10.0 to <12.5 12.5+ No data The WHO estimates the global health worker shortage is 4.3M Practicing doctors who immigrated to Australia, Canada, UK and US (%) 40% 30% 20% 10% 0% JAM HTI IRL GHA LKA NZL ZAF NGA AUS ROU CAN Country type Developed Developing KOR Least developed PHL PAK IND (563K) 0 50,000 100,000 150,000 Total practicing doctors by the country where they were trained (No.) UK US (836K) Source: (1) World Health Organization. Global Atlas of the Health Workforce (http://www.who.int/globalatlas/default.asp); (2) Mullan, Fitzhugh. The metrics of the physician brain drain. New England Journal of Medicine 2005, 353:1810-8. 18 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Moving Forward CDOs may choose among a variety of service delivery models, placing different emphasis on value dimensions such as access, clinical quality, service quality and costs Impacts Increasing Focus on Value Service Delivery Models Community Health Network Focus Optimize access across a defined geography Changing Citizen Responsibilities Changing Delivery Requirements Growing Resource Challenges Center of Excellence Medical Concierge Price Leader Optimize safety and clinical quality for specific medical conditions Optimize the consumer / patient relationship or experience Optimize productivity and workflows Source: and IBM Institute for Business Value 19 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Moving Forward Although the value dimensions are not new, the focus or emphasis will continue to change Community Health Network Center of Excellence Medical Concierge Price Leader Historical Traditional, typically fragmented, physical locations and services Focus on treating medical conditions at a specific care venue Compete primarily on reputation Plush, amenity-rich facilities Friendly staff Streamlined processes Services centralized for economies of scale Focus on individual productivity Source: and IBM Institute for Business Value Current and Future Integrated, non-traditional locations (e.g. home) and services (e.g. prevention / wellness / health promotion) Electronic access and new channels (e.g. remote monitoring, telemedicine) Focus on prediction, prevention, diagnosis, treatment and rehabilitation, and ongoing management of certain medical conditions Compete on documented quality and safety Change the definition of and raise the bar for quality through data-driven improvements and innovation Comforting, safe, preference-sensitive facilities for patient and families Friendly, empowered (IT-enabled) staff Convenient, electronic access (e.g. registration, e-visits) Patient-friendly administrative processes Evidence-based, standardized processes Services performed at most cost-effective setting, fully exploiting IT-enabled capabilities Focus team productivity and on activating patients 20 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Moving Forward The new environment requires new competencies and the mix depends on the service delivery model Provider Competencies Community Health Network Service Delivery Models Center of Excellence Medical Concierge Price Leader Empower and Activate Consumers Collaborate and Integrate Innovate Optimize Operational Efficiencies Enable Through IT Differentiator More than threshold capabilities required Threshold Source: and IBM Institute for Business Value 21 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Implications Multiple types of innovation need to be considered New medical devices, drugs and diagnostic equipment Product Innovation Services Innovation Concierge medicine Hospital care at home Self service e-visits Government coverage and reimbursement policies Campaigns to fight AIDS, smoking or obesity, for example Policy & Society Innovation Healthcare Transformation Business Process Innovation Advanced clinical decision support Smart hospital rooms Capacity optimization Culture of safety, quality and team-oriented care delivered to activated patients Management & Culture of Innovation Business Model Innovation Retail clinics Medical home Ambulatory surgery centers 22 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Conclusion CDOs must redefine their relationships with citizens and other stakeholders Focus on prediction, prevention and early detection / treatment Base care decisions on evidence and on informed patient preferences Build a culture of value, safety, quality and innovation Coordinate care across providers, venues and time Win-Win Transformation Help consumers lead healthier lifestyles Enable selfmanagement and shared decisionmaking Source: and IBM Institute for Business Value Develop a robust information infrastructure 23 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Conclusion A transformation framework, implemented through strong leadership and a clear vision, is needed to affect major change. Experimental Innovation within a Provincial Framework Collaboration and Mutual Accountability Consistent, Evidence-based, High-value Care Wellness and Prevention Aligned Incentives Innovation, Safety and Quality Sustainable Cost Structure Robust Information Infrastructure Source: and IBM Institute for Business Value 24 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
Conclusion In conclusion, we recommend care delivery organizations take the following steps 25 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08
26 Healthcare 2015 and Care Delivery: Delivery models refined, competencies defined DRAFT 22-Oct-08