Measuring Value Bob Pendleton, MD, FACP David Dirks Chief Medical - - PowerPoint PPT Presentation

INNOVATIONS IN

Measuring Value

Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah David Dirks AVP, Population Health Analytics Intermountain Healthcare

Objectives

Understand the importance of culture in using measurement to improve value Share innovative approaches to measure value for episodic care across a full care cycle Illustrate innovative population approaches to measure and improve value

WHAT Every organization on the planet knows WHAT they do. WHY Very few organizations know WHY they do what they do. HOW Some organizations know HOW they do it.

(Sinek, S. Start With Why. 2009)

THE GOLDEN CIRCLE

(Sinek, S. Start With Why. 2009)

THE GOLDEN CIRCLE

CLARITY OF WHY.

An absolute focus on the patient

DISCIPLINE OF HOW.

Patients define value (clinical population)

&

Respect for people (bottom up solutions)

CONSISTENCY OF WHAT.

Methods/approaches that support better outcomes at an affordable cost

Pre-2000 2000-2015 2016+++

ACCOUNTABILITY FOR VALUE

• +

RISK-BASED EVENTS PROCESSES OF CARE; FEW OUTCOMES NO UNDERSTANDING OF ACTUAL COSTS ENCOUNTER-CENTERED PATIENT OUTCOMES AND COSTS DEFINED AND MEASURED PATIENTS VALUE STREAM: FULL CARE CYCLES

VALUE

QUALITY QA

*Size of bubble = $ and/or reputation risk

MEASURING VALUE

MEASURING VALUE

QA/Risk Hospital Quality Hospital Service Hospital Cost Ambulatory Quality Provider Quality Provider Cost QA/Risk Hospital Quality Hospital Service Hospital Cost Ambulatory Quality Provider Quality QA/Risk Hospital Quality QA/Risk

Pre-2000 2000-2010 2016+ 2010-2015

Common Core IQR + MU - EH OQR + HEDIS PQRS + MU - EP MIPS Total cost of care & Patient Centered Outcomes (PCOs) Total Cost of Care and PCOs

Current State Proposed 2018 FEE FOR SERVICE (FFS)

(no ties to performance) FEE FOR VALUE (FFV)

(ties to quality/cost Performance)

APM

APM ALTERNATIVE PAYMENT MODEL (APM)

(population Based risk) APM

(risk bearing, built on FFV architecture)

FFV PROVIDER RISK Care Integration Required

FFS

MEASURING VALUE

(Based on Figure 3. Alternative Payment Model (APM) Framework: Final white paper. HCPLAN, p. 9, 2016.)

“… A fundamental and largely unrecognized problem: We don’t know what it costs to deliver health care to individual patients, much less how those costs compare to the

• utcomes achieved.”

“Understanding costs could be the single most powerful lever to transform the value of health care.”

• Robert S. Kaplan & Michael E. Porter

MEASURING VALUE

1. Define actual costs of care at patient level 2. Organize data around clinical conditions 3. Engage providers to define outcomes 4. Foster peer-to-peer transparency to explore variation 5. Empower & support improvements in value

(David Browdy, CFO, University of Utah Health Sciences 2015)

MEASURING VALUE

USED BY USED BY POPULATE USED BY

• E. REPORTS AND DASHBOARDS

Opportunity Identification Variance Analysis Performance Tracking

• D. OUTCOME

BUSINESS RULES

Quality/Outcome Rules Designation of Cost Methods to Use for Allocating General Ledger Direct Clinical Care Cost Encounters

• C. COST BUSINESS

RULES

Rules for Identifying Direct Clinical Care Costs with General Ledger Cost Methods

• A. DATA SOURCES

Clinical Data Sources Financial Data Sources

• B. ENTERPRISE DATA

WAREHOUSE

Clinical and Financial Data Marts Encounter-Level Costs Encounter & Patient-Level Quality & Outcomes (Kawmoto, K et al. JAMIA 2014)

O.R.C.A. Supply Usage by Case (Value Driven Outcomes Screen Capture)

VALUE DRIVEN OUTCOMES

AVERAGE COST PER VISIT

Source: Average hospital cost per visit, Discharges 2012-2014

Billing Provider

• Dept. Expenses
• Dept. Staff

Facility Utilization Lab Other Services Pharmacy Radiology Supplies Professional costs added in 2014

Discharge Month

Quality Index: Percentage of all visits where selected care measure was met % to FY12 Average Cost: Ratio of that months avg. cost compared to baseline 2012 avg. cost

VALUE DRIVEN OUTCOMES

Higher Quality Drives Low er Cost

33%

COST SAVINGS Quality Index % to FY12 Average Cost

PERFECT CARE INDEX AND AVERAGE COST

Outcome: Perfect Care % to FY12 Average Cost

(Pelt 2016)

VALUE DRIVEN OUTCOMES

Reduce resource use across clinical conditions without decreasing quality. Examples:

• Reduce lab use by 10%3
• Reduce telemetry use by 20%4
• Standardize bronchodilator RX use: $248k/yr

Improve value of procedural based care and/or within clinical

• conditions. Examples:
• TJA: cost decreased by 33%, increase quality2
• Soft tissue infection: cost decreased by 13%, increase quality5
• Renal Transplant: $408k annual savings, maintain quality

VALUE DRIVEN OUTCOMES Current measurement emphasis on quality focuses on processes and complications

• f care—to patients, these are expectations.

Outcomes are the ultimate measure by which to judge quality—whether or not care actually helps the patient (or their families). PROs have been validated as disease-specific measures (e.g. DASH), generic

• utcome measures (e.g. SF-36), and domain specific measures (e.g. PROMIS)

The Ideal Solution: 1. Patient/user friendly, reliable, valid, integrated, and scalable solution to assess

• utcomes across a broad range of patient conditions;

2. Able to assess this in the context of both direct care provision as well as costs-of- care and other quality metrics

VALUE MEASUREMENT

With Epic integration, we are able to compare patient progress to historical trends.

VALUE MEASUREMENT

VALUE MEASUREMENT

Organized around clinically defined conditions and diseases Provide clear standards of care for treatment Built on a knowledge management infrastructure Identify key roles and responsibilities to carry out standards of care Integrate directly into workflow with focus on usability Provide consistent attribution of members and patients to the appropriate care-giver Provide feedback to all stakeholders on performance

1 2 3 4 5 6 7

VALUE MEASUREMENT

Managing Population

Person-Level Data

Clinical Data Claims Data Financial Data Patient Reported

• Problem List
• Labs
• Vitals
• Etc.
• Demographics
• Diagnosis/Procedure

Codes

• Billing Data
• Etc.
• Utilization
• Premiums
• Total Cost
• Etc.
• Wellness Data
• Demographics
• Family Hx
• Etc.

Person-Level Data

Person-Level Data Source Patient Cohorts Care Modules Actionable Care Gaps Knowledge Management Core

Know ledge Management Core

Knowledge Management Core

Payers and Employers Members & Families Clinics & Physicians Hospitals

Patient Data Interaction

Knowledge Management Core

Payers and Employers Members & Families Clinics & Physicians Hospitals

Care Managers

Patient Data Interaction

Knowledge Management Core

Payers and Employers Members & Families Clinics & Physicians Hospitals

Care Managers

Patient Portal Workflow Workflow

Patient Data Interaction

Knowledge Management Core

Payers and Employers Members & Families Clinics & Physicians Hospitals

Care Managers

Patient Portal Workflow Workflow

• Decision Support Data
• Care Gaps
• Decision Support Data
• Care Gaps
• Attribution
• Decision Support Data
• Care Gaps
• Attribution

Patient Data Interaction

“Our most important data is where the patient is today and where the patient needs to be tomorrow.” “I want to encourage all of us to pause and give thought to this: Can we transform healthcare and change the data focus from big data to actionable data that connects people, their teams and their care plans?”

Knowledge Management Core

Payers and Employers Members & Families Clinics & Physicians Hospitals

Care Managers

Patient Portal Workflow Workflow

• Decision Support Data
• Care Gaps
• Decision Support Data
• Care Gaps
• Attribution
• Decision Support Data
• Care Gaps
• Attribution

Reports Reports Reports Reports Reporting is based on adherence to defined standards not variation between providers

Patient Data Interaction

HOW WELL AM I CARING FOR MY PATIENTS?

Quality Measurement Dashboard

Performance Measurement

HOW CAN I IMPROVE THE HEALTH OF MY PATIENT POPULATION?

Patient-Level Gap Reporting

Patient Engagement & Q.I.

AM I CARING FOR MY PATIENT POPULATION AT A REASONABLE COST? Cost & Utilization Analysis

Cost & Utilization Management

Thank you.

Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah David Dirks AVP, Population Health Analytics Intermountain Healthcare

Citations

Bob Pendleton, MD, FACP Chief Medical Quality Officer University of Utah

• 1. Kawamoto, K et al. Value driven outcomes (VDO): a pragmatic,

modular, and extensible software framework for understanding and improving health care costs and outcomes. J Am Med Inform Assoc 2015;22:223-235.

• 2. Pelt C. et al. Arthroplasty Today (2016). Epub ahead of print.
• 3. Yarbrough, PM et al. Multifaceted intervention including education,

rounding checklist implementation, cost feedback, and financial incentives reduces inpatient laboratory costs. J Hosp Med 2016 (ePub ahead of print)

• 4. Edholm, K. Presented Abstract: Multifaceted value measurement
• intervention. Research and innovations poster competition, Society of

Hospital Medicine 2016.

• 5. Yarbrough PM, Kukhareva PV, Sydor Spivak E, Hopkins C,

Kawamoto K. Evidence-based care pathway for cellulitis improves process, clinical, and cost outcomes. J Hosp Med 2015:10;780-786.

• 6. Horton D. Presented Abstract. SHM 2016. (listed data are

projections)