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Solving for x - a solution to the healthcare conundrum?

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Presentation at Triple Ring Technologies, 5OCT17, Newark, CA - MedTech Frontiers Seminar Series

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Solving for x - a solution to the healthcare conundrum?

  1. 1. solving for x a solution to the healthcare conundrum? wayne pan, md Gottfried Wilhelm Leibniz
  2. 2. disclaimer This presentation is intended for discussion purposes only and does not replace independent professional judgment. Statements of fact and opinions expressed are those of the presenter individually, and are not the opinion or position of any of the current or former companies associated with the presenter. The accuracy, completeness or reliability of the information provided herein is solely the responsibility of the presenter.
  3. 3. background“The Return of Rip Van Winkle” John Quidor (1849)
  4. 4. http://www.pgpf.org/infographic/infographic-us-healthcare-spending
  5. 5. http://www.pgpf.org/infographic/infographic-us-healthcare-spending
  6. 6. Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group
  7. 7. Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group
  8. 8. Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group
  9. 9. Source: Kaiser Family Foundation analysis of data from OECD (2016), “OECD Health Data: Health expenditure and financing: Health expenditure indicators”, OECD Health Statistics (database) (Accessed on December 19, 2016)
  10. 10. Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group
  11. 11. Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group
  12. 12. Source: Kaiser Family Foundation analysis of National Health Expenditure (NHE) data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group
  13. 13. https://andireiss.wordpress.com/ok-now-what-cartoon/
  14. 14. how did we get here?here
  15. 15. Paul B. Batalden, MD Founding Chairman of the Board and Senior Fellow Institute for Healthcare Improvement (IHI) EVERY SYSTEM IS PERFECTLYTO GET THE RESULTS IT GETS DESIGNED
  16. 16. as a result of FFS
  17. 17. providers figured out a way to maximize reimbursement
  18. 18. fee-for-service reimbursement model provider #1 provider #2 provider #3 provider #4 provider #5 provider #6 quality
  19. 19. provider #1 provider #2 provider #3 provider #4 provider #5 provider #6 fee-for-service reimbursement modelquality
  20. 20. provider #1 provider #2 provider #3 provider #4 provider #5 provider #6 same payment regardless of quality fee-for-service reimbursement modelquality
  21. 21. 10X provider #1 provider #2 provider #3 provider #4 provider #5 provider #6 fee-for-service reimbursement modelquality
  22. 22. provider #1 provider #2 provider #3 provider #4 provider #5 provider #6 fee-for-service reimbursement model 10X quality
  23. 23. provider #1 provider #2 provider #3 provider #4 provider #5 provider #6 fee-for-service reimbursement model 10X volume driven health care quality
  24. 24. payers had a difficult time controlling costs total healthcare spend per capita spendingpercapitaUS$at2000PPPrates 7000 5250 3500 1750 1970 1980 1990 2000 2010 0
  25. 25. and ensuring that highqualityofcarewas actually being delivered colorectal cancer screening modality trends in adults ages 50-75, United States, 2000-2008 any exam colonoscopy home FOBT sigmoidoscopy 2000 2003 2005 2008 percentage 10 20 30 0 40 50 60
  26. 26. and ensuring that highqualityofcarewas actually being delivered colorectal cancer screening modality trends in adults ages 50-75, United States, 2000-2008 any exam colonoscopy home FOBT sigmoidoscopy 2000 2003 2005 2008 percentage 10 20 30 0 40 50 60
  27. 27. utilization management, high deductibles/co-pays, narrow benefits, narrow networks
  28. 28. MarketWatch Taking Stock Of Pay-For-Performance: A Candid Assessment From The Front Lines Data from the nation’s largest P4P program show some positive changes but no breakthrough improvements in the quality of care. by Cheryl L. Damberg, Kristiana Raube, Stephanie S. Teleki, and Erin dela Cruz ABSTRACT: Pay-for-performance (P4P) has been widely adopted, but it remains unclear how providers are responding and whether results are meeting expectations. Physician or- ganizations involved in the California Integrated Healthcare Association’s (IHA) P4P pro- gram reported having increased physician-level performance feedback and accountability, speeded up information technology adoption, and sharpened their organizational focus and support for improvement in response to P4P; however, after three years of investment, these changes had not translated into breakthrough quality improvements. Continued mon- itoring is required to determine whether early investments made by physician organizations provide a basis for greater improvements in the future. [Health Affairs 28, no. 2 (2009): 517–525; 10.1377/hlthaff.28.2.517] P ay-for-performance is being de- ployed at all levels of the U.S. health system to stimulate improvements in health care, little is known about what behav- ior changes have occurred as a result of P4P and whether the changes made by providers pay for performance bonus programs barely scratched the surface with respect to either improving quality or reducing costs
  29. 29. so whydoesn’t this work?
  30. 30. not enough moneyin bonus program to affect behavior
  31. 31. bonuses not paid timely
  32. 32. too much effortto collect “quality data”
  33. 33. smallsample sizes
  34. 34. need for risk adjustment
  35. 35. quality measurement dictated by payers
  36. 36. is it actually measuring qualityof the provider?
  37. 37. patients have to follow-throughon the provider’s care recommendations
  38. 38. patients don’t have skin in the game
  39. 39. quality scores generally defined by planand LOB, not at the whole practice level
  40. 40. even with higher quality, it doesn’t seem to reduce costs
  41. 41. at least in the short run
  42. 42. wait a minute…
  43. 43. what is the real purposefor measuring quality?
  44. 44. to move away from fee-for-servicemodel
  45. 45. to a pay-for-valuemodel
  46. 46. to enable value-based purchasing
  47. 47. value-based purchasing model provider #1 provider #2 provider #3 provider #4 provider #5 provider #6 quality
  48. 48. quality value-based purchasing model provider #1 provider #2 provider #3 provider #4 provider #5 provider #6
  49. 49. how do you measure quality? quality value-based purchasing model provider #1 provider #2 provider #3 provider #4 provider #5 provider #6
  50. 50. how do you measure quality? quality HEDIS / MACRA / MIPS value-based purchasing model provider #1 provider #2 provider #3 provider #4 provider #5 provider #6
  51. 51. USS FFS
  52. 52. how do you define “value”in healthcare?
  53. 53. adapted from IHI Triple Aim improvepopulationhealth lowerpercapitacostofcare improve healthcare experience the triple aim
  54. 54. triple aimvalue =
  55. 55. so how do you set up a payment systemto drive value?
  56. 56. instead of the bank model that is fee-for-service
  57. 57. we move to a model where we’re all in the same boat
  58. 58. providers taking on risk
  59. 59. providers taking on risk
  60. 60. aligning providers/payers and patients and driving value
  61. 61. value = clinical outcomes cost
  62. 62. this new payment model will demand a new wayof delivering healthcare services
  63. 63. because our “system” of silos won’t be able to deliver value to the patient (and the ultimate payer)
  64. 64. welcome to accountable care
  65. 65. perspective
  66. 66. what makes this approach different?
  67. 67. by aligning incentives, and having providers take on risk
  68. 68. it removes economic barriersto changing the delivery model
  69. 69. it also broadens the perspective of providers to manage at the population level, instead of just at the individual level
  70. 70. giving providers a reason to adopt a “systems” approach will help create a more sustainabledelivery model
  71. 71. philosophy
  72. 72. instead of volume
  73. 73. we need to think value
  74. 74. we need to think value
  75. 75. what existing business modelsfocus on value?
  76. 76. investment banks
  77. 77. what if we looked at healthcare from an investmentperspective?
  78. 78. for investors, it’s all about allocating resourcesto grow assets
  79. 79. getting the highest ROI
  80. 80. healthcare should be no different
  81. 81. let’s look at the populationthat providers are managing
  82. 82. using a forest as a metaphor
  83. 83. lush forest using a forest as a metaphor
  84. 84. lush forest forest fire using a forest as a metaphor
  85. 85. lush forest forest fire burnt forest using a forest as a metaphor
  86. 86. wellness chronic disease palliative care using a forest as a metaphor
  87. 87. wellness chronic disease palliative care this is where the majority of “healthcare” resources is focused
  88. 88. wellness chronic disease palliative care from a system perspective, we’re not allocating enough resources to wellness and palliative care
  89. 89. wellness chronic disease palliative care from a system perspective, we’re not allocating enough resources to wellness and palliative care
  90. 90. but it’s also about managing risks
  91. 91. notall healthcare assets are equal
  92. 92. what risksshould we be managing?
  93. 93. patient risk + provider risk + benefit risk health expense
  94. 94. patientrisk
  95. 95. patient behaviors
  96. 96. patient genomics/proteomics
  97. 97. patient environment
  98. 98. patient social determinants Asthma Hyper- Cholesterolemia Heart Disease Chronic Kidney Disease Stroke Hypertension Sleep Health Insurance
  99. 99. patient risk + provider risk + benefit risk health expense
  100. 100. providerrisk
  101. 101. provider behaviors
  102. 102. provider knowledge base
  103. 103. provider environment
  104. 104. patient risk + provider risk + benefit risk health expense patient-provider interaction risk
  105. 105. patient-provider interactionrisk
  106. 106. patient risk + provider risk + benefit risk health expense
  107. 107. benefitrisk
  108. 108. covered benefits premiums co-pays network
  109. 109. patient risk + provider risk + benefit risk health expense patient-benefit interaction risk
  110. 110. patient-benefit interactionrisk
  111. 111. patient risk + provider risk + benefit risk health expense
  112. 112. patient risk + provider risk + benefit risk health expense is this an actionable healthcare equation?
  113. 113. so what does this all mean, on a practical level?
  114. 114. execution
  115. 115. Old Perspective Short-Term Provider-Centric Individual Patient Volume Pay-For-Performance Uniform Assets
  116. 116. new long-term patient-centric population management value shared savings/risk models system-level focus risk adjustment vs.Old Short-Term Provider-Centric Individual Patient Volume Pay-For-Performance Uniform Assets Perspective
  117. 117. Old Philosophy Contracting Data-Challenged Practice Variation Volume
  118. 118. new self-management data-driven standards of care value vs.Old Philosophy Contracting Data-Challenged Practice Variation Volume
  119. 119. Old Fee-For-Service Siloed Care Minimize Costs Reactive Quality Reporting Provider-Focused Episodic Execution
  120. 120. new total cost of care/risk-bearing care continuum maximize ROI/manage risks proactive quality improvement provider- & patient-focused continuous/personalized vs.Old Fee-For-Service Siloed Care Minimize Costs Reactive Quality Reporting Provider-Focused Episodic Execution
  121. 121. transitions
  122. 122. from S. Basu et al., High Levels Of Capitation Payments Needed To Shift Primary Care Toward 
 Proactive Team and Nonvisit Care, Health Affairs 36(9):1599-1605 (2017)
  123. 123. patient responsibility
  124. 124. how can we integrate patient responsibility into the equation fairly?
  125. 125. BEHAVIOR
  126. 126. Medical FICO score? Care Plan Compliance Provider Visit Compliance Network Adherence Lifestyle Behaviors ER Utilization
  127. 127. co-pays for drugs
  128. 128. patients
  129. 129. purchaserspatients
  130. 130. payers purchaserspatients
  131. 131. providers payers purchaserspatients
  132. 132. providers payers purchaserspatients pharma
  133. 133. providers payers purchaserspatients pharma others
  134. 134. providers payers purchaserspatients pharma
  135. 135. providers payers purchasers patients pharma healthcare1.0
  136. 136. providers payers purchasers patients pharma healthcare1.0 RISK
  137. 137. providers payers purchaserspatients pharma healthcare2.0 RISK RISK
  138. 138. providers payers purchaserspatients pharma healthcare3.0 RISK RISK RISK
  139. 139. providers payers purchaserspatients pharma healthcare4.0 RISK RISK RISK? RISK
  140. 140. moving from maximizing the pill to maximizing total benefit To summarize, big pharma needs to rethink its role and broaden it conception of innovation to products beyond the chemical compound to adapt to the changing needs of their customers. In other words, companies should move from maximizing the pill to maximizing total benefit, in which the chemi- cal compound is one contributor. Those innovations, which we call medicines as a service, should address the true needs of patients and payers as the custom- ers and support sustainable commercial models. It should be kept in mind, however, that the attrac- tiveness of such models will differ across companies because of differences in product line-up, geographic reach, internal capabilities, and cost structure. Importantly, companies will have to have the trust of stakeholders in a given market and the ability to engage them effectively in order to deploy service- based models successfully.
  141. 141. accountable treatment organization (ATO) An advanced risk-sharing model could offer overall medication management for entire patient populations on a per-patient fee basis. The fee would reflect expected drug treatment cost based on patient characteristics, as well as expected cost of care for defined exacerbations, such as hospital admissions for uncontrolled hypertension. Thus, the pharmaceuti- cal company would assume financial risk and can reap rewards, if it manages drug therapy for a patient well, and lose money otherwise. This entity, which could be called an Accountable Treatment Organiza- tion (ATO) could partner directly with an ACO to agree on a formulary and treatment algorithms, and thus cut out intermediaries, such as distributors and PBMs. The attraction of this particular model is that it aligns the commercial interest of manufacturers in increasing sales with the policy goal of optimiz- ing patient care.
  142. 142. a biosimilar strategy? It also encourages the rational use of later- generation originator (e.g., innovator) drugs with improved tolerability and potency for patients with conditions that cannot be controlled with generics or who experience side effects because companies would be able to benefit from sales of generics (e.g., biosimilars) as well. Part of rational use could be genetic testing to identify patients whose molecular or genetic disease dependencies makes them likely to benefit from a given drug or who cannot tolerate a given drug.
  143. 143. true measurement of healthcare quality START HERE
  144. 144. ALIGNMENT
  145. 145. ALIGNMENT VALUE-BASED CONTRACTING
  146. 146. ALIGNMENT VALUE-BASED CONTRACTING COMPENSATION
  147. 147. ALIGNMENT VALUE-BASED CONTRACTING CULTURE COMPENSATION
  148. 148. adapted from IHI Triple Aim improvepopulationhealth lowerpercapitacostofcare improve healthcare experience the triple aim
  149. 149. patient risk + provider risk + benefit risk health expense solve for x? ax1 bx2 cx3 y+ + =
  150. 150. isn’t this what we all want?
  151. 151. q&a&d
  152. 152. thankyou
  153. 153. thankyou wtp94015@gmail.com

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