An Auditors Perspective on Healthcare Sergei Pekh MBA, CPA, CMA - - PowerPoint PPT Presentation

An Auditor’s Perspective

• n Healthcare

Sergei Pekh MBA, CPA, CMA Audit Principal Doug McKenzie CA, LLB Audit Principal

Who Are We

• Alberta legislature’s independent audit office
• audit provincial departments and crown corps
• “clients” include MLAs and Albertans
• financial audits
• systems (or value for money) audits:



systems to ensure economy and efficiency



processes to measure and report effectiveness

• ~150 staff in Edmonton and Calgary, plus agents
• 2015-16 budget = $27M

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Three Examples

• chronic disease management
• mental health services
• seniors care

common themes:

– continuity of care over time and across continuum – integration of AHS and primary care – information sharing

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Why We Audited CDM

• affects all of us – individuals, family, friends, community
• prevalence high and increasing
• cost to public healthcare = $ billions
• medicine has developed systems to manage

chronic disease effectively:

1) patient’s medical home (continuity, care team) 2) clinical practice guidelines (e.g., diabetes care) 3) patient engagement in care planning

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CDM - Main Conclusions

• CDM is critical to health of Albertans and

sustainability of public healthcare

• significant opportunities exist to improve

CDM in Alberta

• improvement will take time, but dramatic

action must be taken now

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What is CDM?

• patients need continuity of care:

– a family doctor – a care plan that is actively managed – a care team

• good information systems to support

physicians, care teams and patients

• patient engagement

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Our Hope Today—Encouragement

• LPNs are key providers and members
• f the patient’s team
• across the system, we see improvements

driven from the ground up (vs. top down)

• support efforts to improve outcomes

measurement and evidence-based practice

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High Priority Chronic Diseases

“Long-lasting condition, usually progressive, and cannot be cured”

• Hypertension
• Heart failure
• Heart disease
• Depression
• Diabetes
• COPD
• Asthma
• Obesity

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Ministry Priorities 

High Priority Chronic Diseases

“Long-lasting condition, usually progressive, and cannot be cured”

• Hypertension
• Heart failure
• Heart disease
• Depression
• Diabetes
• COPD
• Asthma
• Obesity

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Affects All of Us

• ~25% of Albertans will develop diabetes
• > 90% will have high BP by age 80
• > 20% will have a mental illness at some point
• 1/5 women and 1/6 men will have a stroke
• cost to Alberta’s public healthcare system

is $ billions/year

Annual Cost

735,000 patients w hypertension, diabetes, COPD, heart disease:



1.8M hospital days (60%) = $2.9B



ALOS 11.8 days (~2½ x avg)



6M GP visits (34%) = $385M



4M specialist visits (38%) = $645M



> 10M prescriptions = $470M



575K ER visits (27%) = $105M 11

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Drivers

• Growing population
• Aging
• Unhealthy lifestyle factors



lack of exercise



poor diet



smoking



excessive alcohol consumption

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Rising Burden

14

10 20 30 40 50 60 70 80 90 1957 1985 2000 Age Year

Albertans' Life Expectancy at Birth

Disabled years Disability-free years

The “M” in CDM

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What We Examined

Whether Ministry of Health has systems to:

• manage the business of providing healthcare to

individuals with CD

• actively link all Albertans with a family physician

and care team

• plan and evaluate CDM delivered by AHS

and Primary Care Networks

• support CD patients through care plans
• support CDM with IT, including:

– EMRs in physician offices and AHS, and – personal health records 16

What We Did Not Audit

• social determinants of health (income, education, housing)
• social/economic impacts (pain & suffering, productivity)
• health promotion and prevention programs provided to all
• CD services by specialists, hospitals, home care,

long-term care or referral processes between them and family physicians

• the work of any specific individual physician or provider

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Findings - Department

“Alberta’s Primary Health Care Strategy describes the key elements of CDM. However, the department does not currently have a structured approach or business model to deliver CDM services at the level of a high-performing healthcare system.”

The ministry has:

• not set clear expectations for CDM services (e.g., care plans and care teams)
• no system to determine CDM demand or see it is met
• does not have formal processes to obtain assurance physicians or AHS

provide CDM in accordance with good practice

• does not have adequate systems to evaluate CDM effectiveness
• privacy concerns re sharing patient info but can overcome them

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Findings—GPs & PCNs

• ministry has no process to know if CD patients have a

family physician

–

many PCN physicians have identified their patients but most have not

–

~490,000 Albertans do not (>16,000 with CD)

• no requirement for PCN physicians to identify CD patients
• r patients with risk factors (e.g., pre-diabetes)
• ministry has not determined optimal size and distribution
• f care teams
• 750 GPs not in a PCN (> 520,000 patients/84,000 w CD)

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Findings – Care Plans

• no expectations set for physician care plans

– what it should contain – how it should be implemented – program coverage

• < 20% of individuals with chronic disease have a care plan, and the

number of patients without a care plan is increasing as the incidence

• f chronic disease rises
• no ongoing process to evaluate and improve care plan effectiveness

(data exists – e.g., AHS inpatient and lab)

• many GPs lack information systems to manage care plans effectively
• AHS does not obtain process to obtain patient’s care plan or

inform GP if it considers changes are necessary

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Care Plans

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Physician Care Plans 128,725

Pharmacist Care Plans 70,700

16,975

Long-term Care Plans?

Care Plans

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Physician Care Plans 128,725

Pharmacist Care Plans 70,700

16,975

Physio Care Plans?

Long-term Care Plans?

Care Plans

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Physician Care Plans 128,725

Pharmacist Care Plans 70,700

16,975

Physio Care Plans?

Long-term Care Plans?

Care Plans

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Physician Care Plans 128,725

Pharmacist Care Plans 70,700

16,975

Physio Care Plans?

Long-term Care Plans?

Mental Health Care Plans?

Findings—IT

AHS shares its hospital, lab, and DI data through Netcare

X > 12 different EMR systems and none communicate with others X clusters of EMR excellence are emerging but most GPs do not currently use their systems to manage care plans, maintain a chronic disease registry, or measure and report CDM effectiveness X the ministry and other providers have no access to GP EMRs X the ministry does not currently provide Albertans access to their personal health information

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26

Public Mental Health System

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Mental Health—Findings



no follow through on mental health strategies



no integrated case management – still work in silos

• fragmented care planning
• lack of care pathways
• no operating model to support care teams
• family physicians and AHS operate separately



IT systems remain incompatible and outdated

• CIS is still 10 years out – can patients wait?
• performance measurement and HoNOS
• thoughts on privacy and information sharing

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Mental Health—Findings



housing supports needed as part of integrated care

• no meaningful change at the front line from 2008
• supply/demand gap analysis not done
• no waitlist management (with few exceptions)
• lack of standardized assessment tool
• no coordinated placement mechanisms… even for

spaces AHS funds directly

• community placement for ALC patients in hospitals is

a problem – what about patients treated in the community?

• many entities are involved in housing—why should AHS

take the lead?

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Long-term Care

• continuing care = home care,

assisted living and long-term care

• we focused on long-term care
• 170 LTC facilities with 14,370 beds
• facilities receive:

– $910M from AHS for healthcare services – $285M from residents for accommodation services

• care plans

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Resident Care

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LTC Facility Oversight

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LTC Facility Oversight



No single program or function is responsible to manage overall performance of individual facilities, including authority to act on poor

• performance. Data to do so exists.



No process to identify high risk facilities, and no standard set of proactive compliance tools to escalate action based on risk.

What Needs To Be Done

 skills, resourcefulness and dedication of providers  many good practices in Alberta

Leadership and action is needed at the system level:

• the orchestra needs a conductor
• recognize vested interest and instill sense of purpose
• patient-centered and population-focused
• long-term commitment beyond annual fiscal cycles

and 4-year political terms You are vital as care providers and ministry allies in reshaping and revitalizing healthcare, including CDM.

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Questions