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New models of healthcare, Oliver Wyman at For Later Life 2014

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Oliver Wyman at Age UK's For Later Life conference on 1 July 2014.

Read more on http://www.ageuk.org.uk/forlaterlife

Veröffentlicht in: Gesundheit & Medizin, Business
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New models of healthcare, Oliver Wyman at For Later Life 2014

  1. 1. © Oliver Wyman HEALTH & LIFE SCIENCES New Models of Healthcare Age UK June 2014
  2. 2. 1© Oliver Wyman 1 2011 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Activity A&E Outpatient Inpatient Example: Anonymised Patient Profile High cost frail elderly patient Diagnosis: Hypertensive renal disease Procedure: Magnetic resonance imaging NEC 5 Source: Hospital Episode Statistics Note: some dates have been altered to maintain patient anonymity Details Service Utilisation Name Mr A. N. Other Activity 37 interactions Age 80-85 Cost £26,000 Patient Segmentation: Example high cost frail elderly patient These patients require complex care for a variety of different conditions, often delivered in an uncoordinated way Admitted from A&E Diagnosis: Complications of cardiac & vascular prosthetic devices, implants & grafts Procedure: Insertion of tunnelled venous catheter 6 Admitted from A&E Diagnosis: Unspecified nephritic syndrome Procedure: Percutaneous needle biopsy of lesion of kidney 1 Admitted from A&E Diagnosis: Other and unspecified injuries of abdomen, lower back and pelvis Procedure: None 3 Diagnosis: Unspecified nephritic syndrome Procedure: Intravenous chemotherapy 2 Admitted from A&E Diagnosis: Unspecified nephritic syndrome Procedure: Intravenous chemotherapy 4
  3. 3. 2© Oliver Wyman 2 Patient Segmentation: Example high cost frail elderly patient These patients require complex care for a variety of different conditions, often delivered in an uncoordinated way 2012 2013 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Inpatient Outpatient Activity Community GP A&E Example: Anonymised Patient Activity High cost patient i Diagnosis: Angina pectoris Procedure: None 3 Diagnosis: Non-specific chest pain Procedure: None Diagnosis: Non-insulin-dependent diabetes mellitus Procedure: None 1 2 Details Service Utilisation Name Mr A. N. Other Activity 34 interactions Age 45-50 Cost £10,000 Source: Hospital Episode Statistics Note: some dates have been altered to maintain patient anonymity
  4. 4. 33© Oliver Wyman Population cost segmentation, secondary care spend, 2011 85% 143k (32% used secondary care) 11% 19k 3% 5.6k 12% £14m 41% £45m 47% £52m Population segments Cost breakdown Spend per head: £9.3k £2.3k £0.1k High Cost Over £5,000 per year Moderate Cost £1,000 to £5,000 per year Low Cost Under £1,000 per year Source: Hospital Episode Statistics, 2011 Patient Segmentation: Cost concentration The most expensive 3% of patients account for 47% of secondary care costs
  5. 5. 44© Oliver Wyman Patient Segmentation: The cost pyramid by LHE High Cost Moderate Cost Low Cost 87% 112k 10% 13k 3% 4k 26% £20m 34% £25m 39% £30m Airedale, Wharfedale & Craven* Blackpool East Riding Fylde & Wyre High Cost Moderate Cost Low Cost NE Lincs North Tyneside Somerset Sunderland* 86% 148k 11% 19k 3% 5k 14% £16m 39% £42m 47% £51m 85% 257k 11% 35k 3% 10k 13% £26m 39% £79m 48% £96m 86% 130k 11% 16k 3% 5k 14% £14m 38% £36m 48% £46m 85% 246k 12% 35k 3% 9k 13% £25m 42% £81m 45% £85m Hull 85% 143k 11% 19k 3% 6k 12% £14m 40% £45m 47% £52m 82% 177k 14% 30k 4% 8k 13% £22m 66% £39m 48% £41m 87% 475k 10% 55k 3% 16k 15% £51m 36% £121m 48% £160m 84% 239k 12% 34k 3% 10k 14% £29m 36% £77m 50% £106m * Includes additional cost data
  6. 6. 55© Oliver Wyman Population cost pyramid 2012/3 £17m Social care cost 2% ~2,000 0.5% ~600 0.4% ~400 ~20% ~£3.4m ~30% ~£5.3m ~50% ~£8.5m Population segments Cost breakdown High Cost Over £13,000 per year Moderate Cost £5,000 to £13,000 per year Low Cost £1,000 to £5,000 per year Patient Segmentation: Cost concentration For social care the picture is even more concentrated…… Source: South Somerset Symphony project data, Oliver Wyman analysis Note: Net social care costs used, self-pay contributions excluded Note: Over half of the highest healthcare cost cohort (~2,800 patients with >£7,000 healthcare spend) did not have a social care assessment or receive any social care No Cost £0 per year 97% ~112,000
  7. 7. 6© Oliver Wyman 6 A variety of patient-centric clinical models exist globally and are yielding outcome and cost improvements in targeted populations • Extensivist led multifunctional team wraps services around the sickest patients • Responsible for patient across all care settings • Single point of patient contact and capitated payments drive accountability • Ultra high efficiency ambulatory surgery model focused on a limited set of interventions • Exploits techniques borrowed from manufacturing • Very high patient and physician satisfaction • Reduced admissions and length of stay • 20% lower cost • Lower complication and infection rate • 30 to 40% lower cost • Specialised GP model focused on a polychronic population • Highly integrated care delivery with GP responsibility for all aspects of care • Model tailored to underlying population and cultural norms Extensivist model Systematised surgery Primary care medical home • Same day access  utilisation reductions (40% A&E, 50% speciality, 20% primary care) Source: The Quiet Healthcare Revolution The Atlantic; AMSURG; Nuka Model of Care Provides Career Growth for Frontline Staff Southcentral Foundation; Oliver Wyman
  8. 8. 77© Oliver Wyman Extensivist clinics focus on the sickest patients, including a significant number of frail elders Frail elderly overview • Highest need patients aged over 65 at risk of catastrophic decline • Uncoordinated care and inadequate access leads to unnecessary admissions and poor disease management • Drive seven times more spend than the population average >2 comorbidities • Myocardial Infarction • Congestive Heart Failure (CHF) • Peripheral Vascular Disease • Cerebrovascular Disease • Dementia • Chronic Obstructive Pulmonary Disease (COPD) • Connective Tissue Disease • Ulcer Disease • Diabetes • Hemiplegia • Moderate to Severe Renal Disease • Liver Disease • Cancer – all types • HIV / AIDS • Multiple Sclerosis Patient segmentation
  9. 9. 8© Oliver Wyman 8 An Extensivist coordinates and reorients care around the patient Behavioural/ social care Chronic condition management Environment and equipment Home and community- based care Social Work “Life” support (e.g. finances) Substance Abuse Smoking Cessation Palliative Care Crisis management Diabetes and Wound Care CAD / CHF COPD Asthma CKD ESRD Hypertension General Co-morbidity Management Home Care Durable Medical Equipment (DME) Mobility Assistance Remote Monitoring Televisits Nursing Home / SNF Care Discharge management Diet / Nutrition Psychiatry / Psychology Transportation Hospice After-Hours Care Clinical Pharmacy Strength and Balancing Patient Navigation Case Manager Extensivist Clinical Care Centres (CCC) GPs Extensivist-led model
  10. 10. 9© Oliver Wyman 9 Care team roles Role Scope of Services Extensivist • Clinical leader and the “quarterback” for the patient’s care Advanced Practice Provider • Supports Extensivist by evaluating and caring for patients as appropriate Patient Navigator • Primary patient contact and care coordinator Nurses/ MAs • In-office patient care Behavioral health resource team • Provides mental health support services Pharmacist • Assists in pharmacy and medication therapy management Receptionist • Handles patient enquires and scheduling Office Manager • Manages practice staff, administration and compliance Social worker • Coordinates solutions to resolve home and family life issues Dietitian • Helps patients develop and maintain diets appropriate for their conditions Palliative care • Assists in reducing patients’ physical and psychological suffering at end of life Related services • Range of services including physical therapy, home care, post-discharge care, etc.
  11. 11. 1010© Oliver Wyman The Symphony Expert Care Hub Network will be modelled as a number of local Expert Care Hubs, sharing central support The Symphony Expert Care Hub Network Local Expert Care Hubs • Location for co-located multi-skilled Care Coordinator and Key Worker teams to enable effective team working • Initial point of contact for all patient needs, e.g. Questions, concerns, urgent enquiries, carer concerns • Locally accessible to cohort patients, e.g. – Delivery of care as part of care plans – Meeting core team members for review Central Office Symphony central office • Shared infrastructure and support functions e.g. IT, Finance / accounting, patient identification and tracking, etc. • Central business functions and Symphony management, e.g. Care model refinement, geographic expansion, planning for extension to new cohorts, etc. Care Hub 1 Care Hub 4 Care Hub 2 Care Hub 3
  12. 12. 11© Oliver Wyman 11 The Extensivist clinic can provide a one-stop shop for patients and helps reduce isolation Basic Care Pre-Op Strength Training Foot Care Example Care Center Layout Class-roo m Medical Records Room Registration Desk Office – Exam Rooms– Supplies/ Equip. Storage NP Office Waiting Community TVRoom Podiatry Room Extensivist Office Strength Training Room Lab/Diagnostic Room – Exam Rooms– Blood Pressure Management Nutrition & Wellness Classes Social SpaceNurse Practitioner Hospitalist’s Office Wound care Fall Prevention Source: “Delivering Integrated Patient Care for Seniors,” CareMore 11/2008, p. 33 Example Extensivist clinic For discussion In some areas, a smaller clinic can be supported by existing virtual or distributed infrastructure to provide the same levels of care
  13. 13. 1212© Oliver Wyman Extensivist practice overview Chronic care-specialized physician is interested in building a suite of services to fully meet the need of the most fragile patients Day in the Life • Physician sees 8-10 patients, with visits ranging from 30 to 90 minutes • Average panel size of 400 patients • Physician practice includes supporting care team, including NPs/PAs, embedded health navigator, and other embedded services Core Patient Profile • 95%+ of patients have more than 4+ chronic condition and have serious health needs (sickest 5% of patients – to be discussed further) Embedded Patient Services • All patients will be eligible to receive health navigation from the embedded health navigator • Other in-house patient services and built out based on patient volume and may include Behavioral Medicine, Pharmacy, Hospice, Nutrition, and others • Patients may be connected to other community-based services by their health navigator Compensation (TBD) • Combined compensation model based on salary or a combination of on RVUs and gain share Extensivist Practice Focused on the most complicated chronic care within one practice
  14. 14. 1313© Oliver Wyman Patients selected for the Extensivist clinic will fall into one of three categories 1Catastrophic Patients 2Future Catastrophics 3 Physician Referrals • The biggest, most catastrophic and costly cases • Small number of patients • A portion of these patients won’t be catastrophic “tomorrow” (e.g. trauma patients, other one-off episodes) • Patients with comorbidities, behavioral risk factors, and heavy system utilization • Patients who may not be top spenders today, but are likely to be higher cost “tomorrow” • Patients referred to the clinic by their physicians • “We know them when we see them” • Referrals to the clinic will be greeted with a quick answer and a quick decision Will be identified via an analytic-based approach Will be identified via ongoing engagement with physicians Extensivist patient categories
  15. 15. 14© Oliver Wyman 14 A number of potential issues need to be overcome when establishing an Extensivist model HOSPITAL Total population: 168k Future NE Lincs Health Economy – overview HOSPITAL Scunthorpe General Need to manage perception of preferential treatment given to urban patients • CCG needs to contract based on risk to enable provider upside • Patients must be prepared to change their main point of contact as they move between models • Federated GP clinics share information, capabilities and patients • Risk and outcomes based payments demand risk pricing and flow of fund management capabilities Hospital specialists must work alongside the Extensivist in order to co-ordinate care Extensivist needs privileges for ward rounds within the hospital setting The Humber A&E Department GP surgeries Acute provider hospital Mental health/ Social care providers Extensivist clinic • Provider build of significant capabilities to launch – Extensivist lead clinician – Care team composition – Workflow redesign – Risk stratification – IT / systems – Scheduling • Change in patient behaviours will be required • Community-based resources will need to have aligned incentives and coordinated activities For discussion
  16. 16. 1515© Oliver Wyman The model has 6 major elements, providing us with a view of the overall impact of the Expert Care hub, and impacts across the system New cohort costCurrent cohort cost Expert care hub costs Other incremental services Efficiency, de- duplication & re-use Lower cost of care 1 2 3 4 5 Symphony economic model elements Cost 6 Illustrative – not to scale
  17. 17. 1616© Oliver Wyman • Integrated, team-based delivery • Shift to prevention and wellness • Transformed outcomes and value for money, partly through selective partnerships • New non-traditional healthcare players • Intent to improve accessibility and wellness • Extensive use of partnerships • Widespread genomics sequencing • Likely to entirely change health systems • Baseline established for: – Quality – Safety – Primary Care and Hospital efficiency Wave 0 BASIC SAFETY AND EFFICIENCY Wave 1 PATIENT-CENTRED CARE Wave 2 CONSUMER ENGAGEMENT Wave 3 SCIENCE OF PREVENTION The UK healthcare system will undergo waves of innovation, transforming care delivery Early effects already impacting the UK, continuing over the next decade Future waves Source: Oliver Wyman Health Innovation Centre

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