Value based health care Flashcards
1
Q
value based health care
A
the optimal balance between the gain in health, costs and societal value considering characteristics of the individual patient
2
Q
balance
A
we do not give maximal treatment to everybody
health needs to be balanced with costs and societal value
3
Q
the big changes that allow us to change health care
A
- elektronic patient file
- ICT
- Validated questionnaires/PROM’s
- PREM’s: how the patient experienced his care
- (public) databases
4
Q
how is value measured?
A
- medical outcome
- PROMS
- societal outcome: (return to work)
5
Q
why is VBHC so hard to implement?
A
it is a cultural change
- doctors need to develop a broader view
- willingness to use data for continuous improvement
- patients must be ready for SDM
logistics: the right questionnaire on the right time
ICT
- questionnaires in EPF
- dashboards
- analytics
- decision aids based on all the data
6
Q
Michael Porter
A
can be considered the founding father of VBHC
- competition drives improvement
- value chain
- central premise
7
Q
value chain
A
all the activities a business organization performs, which together create a valuable product or service
8
Q
central premise
A
in any industry, a succesful and sustainable enterprise needs to create value for its clients
9
Q
what does creating value for your clients mean for the health care?
A
- value as the single goal
- in health care delivery, clients = patients
- goal= patient value
10
Q
patient value
A
why conclude that value = outcomes:costs?
value is that what matters to most patients
11
Q
how do professionals create value for patients?
A
- patients seek health care to address health related issues
- those issues are caused by a certain condition
- ergo: professionals create value by addressing specific conditions
12
Q
full cycle of care
A
from start to end
diagnosis to rehabilitation
13
Q
integrated practice unit (IPU)
A
multidisciplinary team, coordinating all the services necessary to address a medical condition
14
Q
value based payment
A
covers the full cycle of a certain condition
- bundled payments that cover all the necessary activities
15
Q
pros value based payment
A
- removes over or under treatment
- alternative to fee for service (providers are rewarded for volume)
- rewards good outcomes and efficiency
16
Q
value based competition (porter&teisberg)
A
the only way to truly reform health care is to reform the nature of competition itself
17
Q
porters three tiers
A
- health status achieved: survival rate
- time to recover
- sustainability of health
18
Q
what do patients value
A
uniqueness: every patient is unique
autonomy: respecting patient decision
partnership: equality
empowerment
compassion
professionalism
responsiveness
19
Q
PREM’s
A
patient satisfaction, communication with doctors
20
Q
NPS
A
what is the likelihood that you would recommend this hospital to a friend or colleague?
- NPS= %prospectors - %detractors
21
Q
PROM’s
A
any report of the status of a patients health condition that comes directly from the patient
22
Q
dimensions of integration (Valentijn)
A
- clinical and service integration
- professional integration
- organizational integration
- systems integration
- functional integration
- normative integration
23
Q
clinical and service integration
A
person focused care, shared decision making
24
Q
professional integration
A
partnerships based on shared competence
25
organizational integration
strategic partnership, sharing information, new contracts
26
systems integration
regulations on competition, paying for health care
27
functional integration
support: information management, organizing quality improvement
28
normative integration
shared vision and shared values, trust
29
Integrated practice units details (porter and lee)
a dedicated team made up of clinical and non clinical personnel
- organized around the patients medical conditions
- organized or experienced as an organizational unit
- taking responsibility for outcomes and costs of full cycle of care
- taking responsibility for engaging patients in care
- co located on dedicated facilities
- measuring outcomes and costs using a common measurement platform
- meeting formally and informally on a regular basis to discuss patients, processes and outcomes
30
stroke care
teamwork. multidisciplinary collaboration in the stroke care network
31
Why is it impossible to have 1 definition of quality of life?
quality of life is different for everyone, therefore anyone has there own definition
32
common items in definitions of quality of life
- not the doctor who reports
- quality of life is subjective
- quality of health is a part of quality of life
- quality of life is a multidimensional concept
33
how to measure quality of life from a clinical point of view?
- researchers select an item that they think relate to quality of life: are you able to walk long? do you feel depressed?
- they choose a response mode
- and combine items to dimensions of quality of life; sum up
34
SDM and VBHC in the netherlands
SDM and VBHC are intertwined in the netherlands. There is recognition that what values for patient, differs between patients
35
care before SDM
the doctor was more paternalistic in the old days. they did not tell all the information to the patients to prevent suffering. nowadays, this would be considered as bad care
36
modern day focus on SDM
-SDM part of patient centered care
- exploring what matters most to the patients
37
SDM definition (Elwyn, 2012)
an approach where clinicians and patients share the best available evidence when faced with the task of making decisions and where patients are supported to consider options.
38
how to do SDM; three step model (Elwyn, 2012)
1. introducing choice
2. describing options
3. helping patients to explore preferences and make decisions
39
implementing SDM is not easy...
- many professionals think they practice it, but this is not always the case
- most important decisions in medicine are not clear cut
40
decision aids
aim to support the decision making process based on evidence
41
What are decision aids based on?
- decision aids often based on clinical EBM guidlines
- To ensure patient centeredness focus on including Patient Reported Outcome Measures
- focus on numbers
42
complexities of SDM in practice
- performativity of numbers: what do numbers do
- creating boundaries
- framing action
- critique on SDM with a focus on choice and numbers
43
performativity of numbers: what do numbers do?
- dominant idea: numbers represent an objective reality and thereby have authority
- numbers are performative: they construct reality, by determining whats important
- numbers construct boundaries between disease and life
- numbers frame action
44
creating boundaries SDM
- patients describe their disease as a mystery
- PROMS and other registries do not always capture lived experience
- registries disciplines patients and doctors
- set boundaries between disease and the rest of patiens livesand therefore what the responsibility is of the doctor and what not
45
framing action SDM
- number construct illness as active to different degrees: who gets what drug? how inclined to become an active self manager are you as a patient?
- what roles should numbers play in managing illness? numbers vs patient stories
46
critique on SDM with a focus on choice and numbers
SDM focus on numbers and choice in standardized trajectory neglects:
- uncertainties in care trajectories
- searching character of much care
- lack of identifiable moments of choice
47
dashboard development
- monitoring: quality of life
- detecting: abnormalities and complaints in one clear visualization
- discussing: results with the patient
- empowering: patients insights in their functioning
48
benchmarking
measuring performance of an organization and comparing it to a standard developed using data from other similar organizations.
49
change pathway
organizations can be inspired by other organizations to improve
50
selection pathway
patients only go to providers with good quality
51
vbhc theory improvement
measure outcome -> competition -> improvement
52
conclusion of a study from Lingsma, different health outcomes
outcome differences are not explained by processes
- only a small proportion of the difference can be explained by differences in process of care
53
type 1 error
seeing differences that are not true
54
type 2 error
missing true difference
55
relevance of cost measurement in VBHC
- required for completing the value equation and thus for comparing and improving overall value
- provides insight in the process and cost of care delivery
- informs the design of payment strategies
56
Activity Based Costing
- Uses departments, procedures or services as unit of analysis
- practical vs theoretical capacity
- focuses on the time employees spend on activities
57
Time Driven Activity Based Costing
- uses patients and their conditions as unit of analysis
- acknowledges that resources will not work at full capacity
- focuses on the time it takes to complete a step in a care process
58
the seven steps of TDABC
1. select the medical condition
2. define the “care delivery value chain” CDVC
3. develop process maps for each element in the CDVC
4. obtain time estimates for each step in process maps
5. estimate the cost of resources involved
6. estimate the capacity of each resource and calculate its capacity cost rate
7. calculate the total cost of care per patient
59
select the medical condition 1
define the start and end of the care cycle for the condition
60
define the care delivery value chan CDVC 2
Provides an overall view of care delivery by charting all main activities and their locations occuring over the care cycle
- disregards boundaries between departments, specialties and organizations
61
develop process maps for each CDVC segment 3
each process map describes a segment of the care cycle and the path that patients follow therein
- for each step in a process, list all required capacity-supplying resources, both these directly used by patientsn and those needed to make the primary resources available
62
obtain time estimates for each process step 4
time in minutes each resource spends with a patient at each process step
- standard times vs actual times
63
standard times
could be used for common, short and inexpensive steps/activities that vary little across patients
- patient check ins
64
actual times
should be measured for complex, long and expensive steps/activities
a major surgical procedure involving multiple professionals
65
estimate the cost of resources involved 5
- estimate direct cost per period of all primary resources involved with care delivery (salary, equipment and supplies)
- estimate indirect cost of resources required to supply primary resources (cost of supervising, space, furnishings)
- estimate overhead/support cost of departments and asign these costs (central department to sterilize tools)
66
estimate the capacity of each resource 6a
instead of using primary resources full/theoretical capacity, obtain their practical capacity
- for equipment: estimate the days per month, the hours per day, and then the minutes per month each piece will be used
- for personnel: obtain the minutes per month by applying the formula by 6b using the estimates of:
- total days that each employee works each year
- total minutes per day that the employee is available for work
- average minutes per workday for nonpatient-related work
67
calculate the capacity cost rate 6b
divide the cost of a resource by its practical capacity over the applicable period
Capacity Cost Rate for Resource: Expenses Attributable to Resource (5) : Available Capacity of Resource (6a)
68
Calculate the total cost of patient care 7
Multiply the CCR of each resource (6b) by its duration of use in each process step (4) to obtain the cost per process step -> sum the cost of all process steps to obtain the cost per process -> sum the cost of all processes to obtain the cost for the full cycle of care for a patient with the medical condition
69
Reasons for applying TDABC
- Support operational/process improvement
- inform reimbursement/payment policy
- accurately capturing cost at level of care processes while managing the complexity of cost accounting
- more efficient and simpeler than ABC
70
Systematic review TDABC
- TDABC is applicable in health care and can help measure cost in a transparent, flexible and efficient way
- applications often constrained by organizational boundaries rather than spanning the full cycle of care
- TDABC applications that involve staff are more succesful because they allow for tailored implementation and foster ownership and cooperation
71
Case mix
baseline risk differences between the patient populationss
- this influences the validity of the indicator
72
Random variation
differences that are the result of variation by chance
- prevents an indicator from producing the same result on repeated measurements, thereby making the indicator less reliable
73
Rankability
whether its fair to rank for example hospitals according to their performance.
- the rankability of an indicator should be high
74
why do we need payment reform
- Financial incentives influence provider behavior
- Providers in position to influence demand
Therefore important to design the payment system such that its well-aligned with value
75
cons fee for service
- rewards volume
- maintains fragmentation
- discourages prevention
- has no link woth quality
- limits patient centred care and SDM
- Stimulates medicalization of social/behavioral apsects of health
76
VBP
Bundled payment + pay for performance
77
bundled payment
a single, prospective payment per period for accepting accountability for the provision of a bundle of care services related to a condition
- ideally covers the complete cycle of care
- across time or across providers
78
bundled payment stimulates providers to:
- minimize costs for care covered by the payment
- coordinate care well. realize seamless integrated care
- improve quality by reducing harmful overtreatment
- prevent complications
79
limitations/risks of bundled payment
- unwarranted increase in the number of bundles
- underutilization of necessary services
- risk selection
- compartmentalization of patients into seperate conditions
80
pay for performance
explicit financial incentives for good performance as measured by a set of predefined indicators
- performance often operationalized as quality of care, usually measured using process indicators (not outcome)
- a relatively small add-on to existing payment structures
81
advantages of P4P
- theoretically and intuitively appealing
- may contribute to better care
- may enable providers to invest in quality
82
limitations/risks P4P
- Performance difficult to measure
- Flawed incentives in underlying payment system intact
- Might lead to undesired strategic behavior
83
Design option P4P
- rewards and/or penalties?
- how much to pay?
-how to translate indicators
-how often to make payouts?
-who collects data?
-how to guarantee valid and reliable measurements
- who to incentivize?
84
Design options bundled payment
- Mechanism to distribute payment to the providers
- content of the bundle in terms of care activities
- use of additional incentives for quality
- accounting for casemix
85
Achmea's main challenge when making choices
- What kind of treatments do we contract?
- Which hospitals do we contract?
- What price do we pay?
- how much budget do we give a hospital>
86
in the bundle
all the care that is relevant in the patient journey. Payment is based on this care
87
influenced by the bundle
care that is seen as related to the bundle as avoidable complications. Shared savings are based on reducing these costs of care
88
outside the bundle
care that is excluded from the bundle because these complications are rare but extremely to prevent risk selection by providers
89
Outcomes (Porter)
health status achieved of retained
- survival
- degree of health or recovery
process of recovery
- time to recovery or return to normal activities
- disutility of care or treatment process
sustainability of health
- sustainability of health or recovery and nature of recurrences
- long term consequences of treatment
90
ICHOM standard sets
- 28 sets of outcome measures
- covering different conditions and for specific patient populations
- defined by global teams of patient advocates, healthcare professionals and researchers
91
Why Organisation for Economic Co-operaton and Development (OECD)
- International organisation
- Partner of G20 AND G7
- 36 countries are members
- focus on economic performance, education, health and social care
- works through thematic committees, expert and working groups, conferences
- participants; representatives from governments, parliaments, business, labour, non-governmental organisations and academia
92
PROM
Patient Reported Outcome Measures
-pain
93
PREM
Patient Reported Experience Measures
- communication
94
PaRIS (OECD)
Patient Reported Indicator Surveys
95
Aims of PaRIS
- Show how outcomes vary across and within countries
- allow countries to benchmark
- unit of analysis
96
European Organisation for Research and Treatment of Cancer (EORTC)
- institutional membership
- members in all the countries of the european union
- 54 members in the netherlands
97
Use of EORTC questionnaires
- ICHOM standard sets
- clinical trials
- market approval
- health technology assessment
- estimation of utilities (QALY)
98
Old way to measure outcomes
- patient groups
- interventions
- retrospective, evaluation
- rct
- before, after
- scientific publications
99
New ways to measure outcomes
- individual patients, providers, countries
- quality of care
- prospective, prediction
- obsercational studies
- continuous
- realtime monitoring
