Improving Health Care Value - Institute for Strategy and ...

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Improving Health Care Value - Institute for Strategy and ...

Facing Forward:

Improving Health Care Value

MEDNAX Medical Directors’ Meeting

Orlando FL

8 April 2013

Professor Elizabeth Teisberg

Geisel School of Medicine at Dartmouth

and

The Institute for Strategy and Competitiveness,

Harvard Business School

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


When it comes to health care

everyone has a story.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Surely, we can do better.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Health Care’s Challenges

Access

Effectiveness

Efficiency

Compassion

Communication

Safety

Variation

Convenience

Spending

Timeliness

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Why has it been so tough to fix?

Competition

occurs over cost shifting.

Zero Sum competition divides value and increases costs.

Positive sum competition to improve

health results creates value.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


What’s a nation to do?

Spend more?

Limit services?

Improve health care value

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Cost containment

is not the only goal

The goal of health care

is BETTER HEALTH

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Value in Health Care

Value =

Health Outcomes

Cost of delivering the outcomes

The goal of improving value for patients and families

aligns interests throughout the health care sector.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Value in Health Care

Value =

Health Outcomes

Cost of delivering the outcomes

Outcomes are the full set of patient health outcomes

over the care cycle.

Costs are the total costs of care for the patient’s

condition, not for a single provider or a single service.

.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Health Care Delivery Transformation

is essential

The challenge is

to drive dramatic and ongoing

improvements

in health care value.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Health

care

Patients and families want more health,

not more treatment.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Increase value by improving outcomes

in ways that reduce cost

Living in good health is inherently less

expensive than living in poor health.

Better outcomes often drive costs

down.

§ Diabetes

§ Stroke

§ Congenital Heart Anomaly

§ Diagnosis

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Better health outcomes contain costs

many ways.

- Prevention

- Early detection

- Right diagnosis

- Early and timely treatment

- Treatment earlier in the causal

chain of disease

- Right treatment to the right

patients

- Rapid care delivery process

- Fewer delays

- Fewer complications

- Fewer mistakes and repeats

- Less invasive treatment methods

- Faster recovery

- More complete recovery

- Less disability

- Fewer relapses or acute

episodes

- Slower disease progression

- Less need for long term care

E.g., Anesthesia improvement that reduces

post-operative stroke, MI and infections

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


You need to reduce waste, and

• It is not all about waste management!

Streamlining a fractured system has inherent limits.

• Today’s structure is organized to serve exceptions,

coordination always takes special effort

• Enormous innovation opportunities:

– structure and organization of care delivery

– service delivery

– support professional expertise

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Keys to accelerate dramatic

improvement in value

• Define services from

patients’ perspectives.

• Organize care delivery around solutions.

• Create interdisciplinary teams.

• Measure results to accelerate learning.

• Align financial success with medical success.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Redefining Health Care Delivery

Patients

Teams

Solutions

Measured Results

Partnerships

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Redefining Health Care Delivery:

patients w/ shared circumstances

Patients

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Design Care from

a Patient’s Perspective

• Organize care around patient segments with

frequently shared needs

• Define care by “conditions” (shared health

circumstances) across patient’s continuum.

– Not procedures; not medical specialties

– Include common co-occurring conditions

– Extend through the full cycle of care (breast cancer, not surgery)

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Patient Perspective: Diabetes

Outpatient

Endocrinologist

Podiatry

Psychiatrist/

Psychologist

Visit

Social Worker

Nutritionist

Primary

Care Physician

Diabetes

Nurse

Education

Laboratory

Outpatient

Neurologist

Outpatient

Nephrologist

Visit

Outpatient

Cardiology

Vascular

Surgeon

Inpatient

Cardiology

Ophthalmologist

Kidney Dialysis

Laser Eye

Surgery

Inpatient

Endocrinology

Inpatient

Vascular

Surgery

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Patient Pathway in the JoslinCare Model

The Joslin Diabetes Center

Exhibit 12: JoslinCare Model

8

7

3

6

2

5

4

9

1

1. Check-in

!

!

!

1. Check-in! !

2. Endocrinologist

3. Nurse !

2. Endocrinologist !

Coordinator

! !

3. Nurse Coordinator !

! !

4. Eye Exam !

! !

5. Laboratory –Blood, urine!

!

6. Diabetes Education!

4. Eye Exam

5. Laboratory

- Blood, Urine

6. ! Diabetes

7. Mental Health!

Education

!

8. Nephrologist!

!

9. Check-out

7. Mental Health

8. Renal

9. Check-out

Source:

!Joslin company documents.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Redefining Health Care Delivery:

Interdisciplinary teams

Patients

Team

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Clinically Integrated Care Team or

Collection of Fragmented Services?

Patient Pong!

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


What is Different with Teams?

• Learning

• Satisfaction

• Coordination

Health Outcomes

• Efficiency

• Research

• Clinical Judgments

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Driving Learning

Deeper Penetration

(and Geographic Expansion)

in a Medical Condition

Improving Reputation

Better Results,

Adjusted for Risk

Faster Innovation

Rapidly Accumulating

Experience

Rising Efficiency

Better Information/

Clinical Data

Broad expertise

develops over

the care cycle

for the patient.

Greater patient

volume over which

to spread costs

Wider Capabilities over

the Care Cycle

Rising

Capacity for

Specialized Expertise

More Fully

Dedicated Teams

More Tailored Facilities

Greater Leverage

in Purchasing

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Redefining Health Care Delivery:

Solutions

Patients

Team

Solutions

A solution conveniently, effectively

and efficiently enables better health

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Migraine Care in Germany

Old model: components, not solutions

Organized by

specialty in discrete,

fragmented services.

Most patients were

not getting effective

or appropriate care

for migraines.

Imaging

Unit

Inpatient

Treatment

and Detox

Outpatient

Neurology

Outpatient

Psychologist

Outpatient

Physical

Therapist

Primary

Care

Physician

Source: KKH, Westdeutsches Kopfschmerzzentrum

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


West German Headache Center

New model

Integrated Practice Unit

results:

Imaging Unit

-reduced pain,

-increased days

at work,

-lowered overall

costs of care.

Primary

Care

Docs.

West German

Headache Center

Neurologists

Psychologists

Physical Therapists

Day Hospital

Network

Neurologists

Essen

Univ.

Inpatient

Unit

Source: KKH, Westdeutsches Kopfschmerzzentrum

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Solutions for Type 2 Diabetes include

lifestyle support and non-medical services.

Group

discussions

Chronic health

self-management

Patients

Ongoing classes

Worksite

assessment

Regular clinical

team meetings

Coordinated

appointments

Team

Solutions

Web-based, telephonic

reporting of core metrics

(BS, weight, BP)

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace

Home

assessment

Pre-hospital

consults

Appointments

based on need,

not calendar


Redefining Health Care Delivery:

Outcomes

Patients

Team

Solutions

Measured Outcomes

What you measure will improve,

so measure outcomes and costs!

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Quality is better health care outcomes.

• Good process is important, and

• Measuring and improving inputs is not sufficient.

• “Best process” may or may not improve outcomes.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Outcomes have multiple dimensions

Health

Status

Achieved

Survival

Degree of recovery, health, capability

Recovery

Experience

Time to recovery or return to normal activities

Care process consequences (e.g. complications, errors;

pain reduction, self-care knowledge, confidence)

Sustainability

of Health

Sustainability of capability or health over time

Long-term consequences of therapy

(e.g., care-induced illnesses)

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Measuring Value: Essential Principles

• Clinicians need to measure results.

• Drive value improvement and learning.

• Adjust outcomes for initial patient conditions.

• Don’t wait for perfection: When used, measures and

risk adjustment methods improve rapidly.

Failure to measure outcomes slows improvement

and invites costly micromanagement

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Functional Outcome Measurement

Pediatric

Psych

Patient Reported

Really?

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Measuring OCD Treatment

Outcomes at CCHMC

OCD Function Level

Homework

10

9

8

7

6

5

4

3

2

1

0

Session Date

Show me how much your thoughts/worries and the things OCD tells you to do have interfered with concentra:on, work, fun.

Source: Copyrighted material of the Cincinna:

Children’s Hospital Medical Center. Used by

permission of the authors.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace

34


Appearance of graphs from original database

Outcome Patterns of

OCD Treatment at CCHMC

No Improvement

Saw Tooth

Slow Decline

Rapid Decline

Source: Copyrighted material of the Cincinna:

Children’s Hospital Medical Center. Used by

permission of the authors.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Measurement Enabled

Improvement at CCHMC

65% of the patients had significant severity

reduction in 4 sessions

Average sessions: 12. Predicted 18-24.

Drop out rate: 7%. Average 15-20%.

97% of the patients completing treatment achieve

subclinical status (CY-BOCS of


Redefining Health Care Delivery:

Partnerships

Patients

Teams

Solutions

Measured Outcomes

Partnerships

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


New partnerships are particularly

• Leading causes of death.

critical in Chronic Disease

• 65% to 80% of all health care spending.

• Need to enable the patient, not just treat the disease.

• Employers pay 2x to 7x more in lost productivity,

disability and early retirement cost.

• Inherently complex and interdisciplinary.

• Chronic health care today fails the doctors too.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Strategic Misalignment

Delivery organized for acute disease & injury

While . . . .

Expenditures on chronic care: 65%-80%

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Reimbursement should be aligned

with value.

Today…

Financial success of

system participants

Patient

success

Shift reimbursement to…

Bundled prices for cycles of care,

not global budgets or payment for discrete services.

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Change of Mindset

Designed around facilities,

locations and physicians

Organized by specialties or

types of practitioners

Treat diseases/incidents

Designed for patients with common

co-occurrences

Current vs. Redefined

Teams coordinating and integrating

care delivery

Create solutions for patients and

families

Measure volume of services

and process compliance

Measure value of services

(health outcomes/costs)

Bargain to shift costs

Partner to accelerate innovation

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


Increased incidence of chronic disease

requires a redefined perspective

The goal is treatment

The goal is health

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace


.

Thank you

elizabeth.teisberg

@dartmouth.edu

Copyright ©2012 Elizabeth Teisberg, Michael E. Porter and Scott Wallace

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