Value Based Healthcare Flashcards
1
Q
value chain
A
all the activites an organization performs, which toghether create a valuable product or service
2
Q
patient value
A
the health related outcomes that matter to patients, devided by what it costs to achieve those outcomes
3
Q
outcomes
A
- What do patients want?
- What matters most to patients?
o To get better: to achieve the best possible treatment outcomes
o Outcomes: the effect of care on health status of patients
4
Q
value (formula) + goal
A
- outcomes / costs
- The best outcomes, as efficiently as possible
5
Q
key principle value
A
value in health care is crated at the level of medical conditions, over the full cycle of care
6
Q
implications (value)
A
- measurement & reporting: providers should systematically measure the outcomes and costs of their care cycles, results should be reported and publicly disclosed (transparency).
- organizing: structures based on value creation (IPUs)
- payment: aligned with value creation (bundled payment)
7
Q
value based payment
(explanation)
A
- Removing adverse incentives (e.g. for overtreatment)
- Alternative to fee-for-service (providers are rewarded for volume)
- Instead: rewarding good outcomes & efficiency:
o Rewarding with more patients (Porter)
o Financial bonus (pay-for-performance)
8
Q
value-based competition
A
- Systematic outcome measurement
- Excellent providers rewarded with more patients = more patients receiving excellent care
- Providers who cannot keep up should restructure or go out of business (which would be good for patient value)
9
Q
IPUs
A
organizational units in which a multidisciplinary team of (dedicated) professionals and supporting staff are grouped together (and co-located) to coordinate their interdependent tasks with the overarching goal to improve value for a particular group of patients
10
Q
unit grouping
A
Process of organizing tasks and positions into groups/units within an organization.
- Build the lines of authority (coordination via supervision)
- Close contact (coordination via informal communication)
11
Q
2 ways to grouping unit
A
- Function-based grouping: each line represents a group (unit) of people with a particular set of knowledge and/or skills, these units are grouped based on the means (functions) of a production process -> grouping by specialized functions or professional expertise (radiology).
- Market-based grouping: each line represents a group (unit) of people that serve a particular market (group of patients), these units are grouped based on the ends of a production process (customer need, product characteristics) -> by around the outputs/products of a specific market, client type, or service outcome (diabetes care)
12
Q
The value agenda
A
- Organize into integrated practice units (IPUs)
- Measure outcomes and costs for every patient
- Move to bundled payments for care cycles
- Integrate care delivery across separate facilities
- Expand excellent services across geography
13
Q
Integral Care Agreement (Integraal Zorgakkoord)
A
- Value-based
- Together with the patient
- Right care at right place
- Focus on health instead of disease
- Good working environment for healthcare professionals
14
Q
Three mechanisms for Value Based competition via (public) transparency
A
- Patient choice: patients choose provides based on transparent performance
- Provider learning: providers learn from systematic comparison of outcomes
- Value-based competition: providers competes on measurable results with payments tied to outcomes
15
Q
Donabedian framework
A
quality has multiple dimensions that are measured using quality indicators.
Structure:
- What healthcare providers have available to treat patients
- E.g. Staff, facilities, equipment, systems
Process:
- What healthcare providers do to treat patients
- Standardized measures of care activities (how well do they follow the guidelines)
- E.g. starting right treatment, treated the right type of patients -> measured with process indicators
Outcomes:
- Measures of what happens to patients’ health
- Quality of life, mortality
Operationalization of quality of care = structure + process
16
Q
How does VBHC differ from the Donabedian framework?
A
- Value = outcome/cost
o Direct focus on outcomes that matter to patients
o Process/structure secondary to results that matter
o Explicit incorporation of costs - Level of analysis
o Medical condition over full cycle of care
o Not individual health interventions or services - Freedom for provider
o No process or structure indicators
o Providers encouraged to:
Design care processes
Organize teams
Choose technology
Innovate delivery methods - Result drive adoption, not protocols
17
Q
observed differences in outcomes between hospitals
A
- Statistical uncertainty: variation in outcomes can occur due to chance, especially in hospitals with smaller patient numbers
- Case-mix: Differences in patient characteristics between hospitals, such as age, severity of illness, or comorbidities
- Residual confounding: unknown or unaccounted variables may continue to contribute to differences in outcomes -> e.g., lifestyle factors like smoking
- Registration bias: Errors or inconsistencies in how data is recorded
- Quality of care: Involves the hospital’s organizational aspects (structure) and the execution of medical procedures (processes) that impact outcomes.
o Structure = e.g., number of available beds
o Processes = e.g., effective communication among care teams
18
Q
Choosing the right outcomes
A
- Outcomes that matter to patients: between provider variation
- Validity:
o Does the instrument really measure what we want to know?
o Systematic error - Reliability:
o Will repeated measurements give that same result?
o Random error - Standardization: each provider must collect information the same way
19
Q
Rankability
A
the proportion of variation that is not due to chance
Rankability is a function of:
- The magnitude of between hospital variation (τ^2)
- Certainty of the estimation (s_j )
20
Q
direct costs
A
directly tied to patient care (e.g., medical staff salaries, medications, medical procedures)
21
Q
indirect costs
A
related to the general operation of healthcare facilities (e.g., administrative costs, utilities, facility maintenance)
22
Q
fixed costs
A
remain constant regardless of patient volume (e.g; rent, salaries for permanent staff)
23
Q
variable costs
A
change with patient volume (e.g., disposable medical supplies, variable staffing costs)
24
Q
costs
A
= cost price
- In healthcare: all expenses associated with providing a medical service
- Formula: cost price = direct costs + indirect costs
25
price
= selling price
- In healthcare: the amount billed to the insurer for priced medical services
- Formula: selling price = cost price + ‘profit’ margin
- Problem: calculation of costs prices are outdated or highly aggregated and therefore do not reflect the true cost price
→ Healthcare providers need to understand their costs to be able to negotiate prices with healthcare insurers and to avoid under-pricing.
26
Benefits of cost measurement
- Transparency: providers clear insights into resource utilization
- Benchmarking: allows comparisons between healthcare providers
- Resource allocation: informs strategic investments in services and process
→ Opportunities to measure and increase value.
27
Why is cost measurement underdeveloped in VBHC?
- Historical focus on outcomes: clinical outcomes are prioritized over costs analysis
- Knowledge and training gaps: limited expertise in advanced cost measurement in healthcare
- Data limitations: fragmented data (finance, medical records)
- Complexity of cost measurement: advanced cost accounting methods are resource-intensive and complex to implement
- Challenges with cost allocation: difficulty in assigning indirect costs (overhead) to specific patient care pathways.
28
Time driven activity based costing
= allocates costs based on time spent on different activities and the costs of resources used during that time
o Pros: use only two components: the cost per time unit for used resources ($/min) and the time spent on each activity. TDABC is very effective in complex and variable setting with diverse services and diverse patients. The model is detailed, dynamic and adaptable
o Cons: requires accurate tracking of time spent on activities, which can be challenging. May be difficult to implement without sufficient data infrastructure and data availability
o Suitable for VBHC
29
TDABC steps
1. Identify the study’s aim and the medical condition to be costed
2. Map the process of the care pathway at the activity level
3. Identify the direct and indirect resources supplied in the care pathway
4. Estimate the total cost of each resource
5. Estimate the practical capacity of each resource and calculate the CCR
6. Obtain and analyze time estimated for each activity in the care pathway
7. Calculate the cost of the care pathway by multiplying the capacity cost rated by the corresponding time estimates
30
TDABC: practical challenges
- Trade-off between granularity and feasibility
- Dependency on availability high-quality cost data
- Collecting time durations with direct observations is valuable, but time-consuming
31
Fee-for-service is poorly aligned with value as it
- Rewards volume
- Maintains fragmentation -> more prevention means less payment
- Discourages prevention
- Has no link with quality
- Conflicts with providers’ intrinsic motivation
32
types of value-based paymet
- bundled payment
- pay for performance
33
bundled payment
= one amount for the entire cycle of care for the condition -> one single price tag
- A single, prospective amount 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
- Aggregated payments for separate services along two dimensions:
o Across time
o Across providers
34
Bundled payment potential advantages
facilities and stimulates involves providers to:
- Minimalize costs, eliminate waste within the bundle
- Coordinate care well, realize seamless integrated care
- Improve quality, e.g. reducing harmful overtreatment
- Prevent complications (insofar part of bundle)
35
Bundled payment potential pitfalls
- Unwarranted increase in the number of bundles
- Underutilization of necessary services
- Risk selection of ‘profitable patients’
- Compartmentalizing patients into separate conditions -> people with comorbidities (= paradox)
- Complexity of design and implementation
36
pay for performance
measure the important things (outcome) and use money to stimulate that performance -> explicit financial incentives for performing well on a set of predefined performance indicators
- Performance often operationalized as quality of care in practice, usually measured using process indicators (not the same as outcome)
- Typically applied as small add-on to existing payment structures, leaving incentives in those underlying payments intact
37
Pay for performace potential advantages
- Intuitively appealing
- May contribute to better care (if done well)
- May enable providers to invest in further quality improvement
38
Pay for performance potential pitfalls
- Performance hard to measure and attribute (especially outcomes)
- Flawed incentives in underlying payment system are left intact
- Design and implementation very complex
- Might lead to undesired strategic behaviour, such as:
1. Focusing disproportionately on the things that are measured
2. Risk selection: only want to treat the ‘easy’ patients
3. Data manipulation
39
Key performance indicators
- KPI = metrics used to evaluate success in achieving specific healthcare objectives
- Serve as tools to monitor and incentive improvements in performance
- Used often in contracts between health insurers and large providers (hospitals)
- P4P: insurers are experimenting with paying for achieving KPIs
40
Challenges in VBHC contracting
- Health care insurers cannot disclose inappropriate care from contracting, due to limited information
- Integral cost full cycle of care scarcely available, especially if multiple care specialties collaborate
- Health care outcomes are more and more measured, but hardly transparent for health care insurers. Only trust relationships between insurer and provider facilitate contract outcome-based.
- Current regulation is complex, for innovation too
41
Outcome variation can partly be due to
- Patient and disease characteristics (case-mix): can be unmeasured (residual confounding)
- Statistical uncertainty
- Registration bias
42
Random variation
noise, that arrises when small sample sizes per hospital are compared. Because small sample sizes are likely to give more extreme averages than large sample sizes, the differences between hospitals can be exaggerated.
43
case-mix
different populations have different risk of poor outcome. It is not fair to compare a center that treats only fragile and high-risk patients to a center who only treats healthy adolescents
44
Rankability
reliability of ranking hospitals based on their quality of care. It is a percentage expressing the part of the observed variation that is not due to chance variation. High rankability indicates that a large part of the variation may be “true” differences as opposed to noise. Low rankability indicates that most of the observed differences were noise. If providers are compared, a high rankability is desirable.
45
Shared decision making
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, to achieve informed preferences. -> exploring what matters most to/has the most value to patients
46
How to do SDM
Three step model (Elwyn et al. 2012):
1. Introducing choice
2. Describing options
3. Helping patients to explore preferences and make decisions
47
Decision aids
- Focus on decision support interventions
- Decision aids aim to support the decision-making process based on clinical EBM guidelines
48
What type of evidence? (decision aid)
- Often based on clinical EBM guidelines
- To ensure patient centeredness focus on including PROMS
- Focus on numbers
49
Performativity of numbers: what do the numbers do? (Essen & Oborn 2017)
- Dominant idea: numbers represent an objective reality and thereby have authority
- Numbers are performative: they construct reality, e.g. by determining what is important
- Numbers construct boundaries between disease and life
- Numbers frame action
50
Healthcare Monitor
focuses on the follow-up phase -> electronic way to measure patient reported outcome measures (PROMs) which enables us to monitor the health status of patients throughout the entire patient journey process
51
Patient-reported outcomes (PROs)
a host of outcomes coming directly from patients about how they feel or function in relation to a health condition and its therapy without interpretation by healthcare professionals or anyone else
52
Important PROs are
- Symptoms (e.g. pain, fatigue)
- Perception of daily functioning (e.g. physically, socially)
- Health-related quality of life
53
patient reported outcome measures (PROMs)
the tools used (mostly questionnaires and survey’s) to capture information about PROs
54
Patient-reported experience measures (PREMs)
instruments to assess patients’ perceptions of their experience of the process (rather than outcome) of care -> e.g.:
- Satisfaction
- Subjective experiences
- Observations of healthcare providers’ behavior
55
Main limitation of PREMs
they are influenced by expectations which are in turn depending on preferences, personality and previous experiences with healthcare and treatments -> less usable for research
56
PROs in routine care
the use of PROs in clinical practice improves patient-provider communication and can also improve problem detection, management, and outcomes
57
Health-related quality of life (HRQoL)
The impact of disease and treatment on domains of physical, psychological, and social functioning
58
Key actions to implement VBHC
1. Organizing around care cycles: health care providers should be organized based on the full care cycle for medical conditions, not just by specialties
2. Integrated Practice Units (IPUs) that consist of multidisciplinary teams focusing on specific medical conditions
3. Measurement & reporting: providers should measure and report outcomes and costs for full care cycles, ensuring transparency for comparison
4. Payment aligned with value: a shift from fee-for-service to bundled payments that reward outcomes and efficiency, rather than volume of services provided
59
Value-based Competition
1. Outcome measurement: systematic measurement allows for comparisons, and excellent providers are rewarded with more patients.
2. Provider incentives: providers should be incentivized for achieving good outcomes and efficiency, not for providing more treatments.
60
Hospital structure and VBHC
traditional hospital structures are based on specialized medical functions (neurology), but VBHC advocates for reorganization around medical conditions to improve patient value
61
Mintzberg's Organizational Theory
Mintzberg’s design parameters suggest that hospitals should organize around market-based groupings (patient needs) rather than function-based (specialty-based) groupings
62
Example of practical application of value-based healthcare: Diabeter
- Co-located
- Multidisciplinary Team (endocrinologists, dietitians, nurses, and psychologists))
- Full Care Cycle
- Improving value by routine outcome Measurement and negoatiating Bundled Payments
- Diabetes
63
International consortium for health outcome measurement (ICHOM)
- Global standard sets of outcomes that matter most to patients
- Medical condition over full cycle of care
- Enable worldwide benchmarking of health outcomes
