Value in Healthcare – Some GlobalPerspectives
March 2016
1
Value
Outcomes thatmatter to patients
=
Cost incurred
Value Based Healthcare - A simple proposition
2
6x 2008/09OECD mean
3x 2008/09OECD mean
2x 2008/09OECD mean
2008/09OECD Mean
0
Cer
ebro
vasc
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dis
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s
AMI
Preg
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ildbi
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nd th
e pu
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Ren
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ilure
AMI 3
0 da
y m
orta
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(in h
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tal)
Mat
erna
l mor
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Infa
nt m
orta
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% R
enal
failu
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atie
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func
tioni
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ant
Dia
bete
s s
hort-
term
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plic
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Dia
bete
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ext
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Dia
bete
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Col
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ance
r5y
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Cer
vica
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5yr s
urvi
val
Brea
st c
ance
r5
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urvi
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Asth
ma
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lth e
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apita
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urch
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ity
Dia
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ellit
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Mal
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eopl
asm
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and
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Mal
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of b
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Asth
ma
Isch
emic
stro
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ym
orta
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(in h
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Hem
orrh
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stro
ke 3
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ym
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(in h
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tal)
Ubiquity of variation suggests there is an opportunity
Spending Health outcomes Ave Length of Stay(example of clinical practice)
2008/09 OECD Health indicators
Source: OECD Stat Extracts, http://stats.oecd.org/
OECD Countries
3
What do we mean by outcomes
Mortality
Provider reported adverse events• Complications, iatrogenic events, readmission
Patient reported outcome measures (PROMs)• Health-Related Quality of life• Functional ability – ADL• Economic activity and social engagement
+ Consistency over time
4
The opportunities for mortality reduction are diminishing ...
10,000
Total Potential Years of Life Lost p 100,000
15,000
5,000
0
Total health expenditure /capita, US$ PPP
8,0006,0004,0002,0000
Highest value
Lowest value
Source: stats.oecd.org
USA 2004-2007USA 2000-2003USA 1990-1999
USA 2008-20102004-20072000-20031990-1999
2008-2010
Australia
OECD Countries
5
75.5
43.3
94.0
80.0
50.0
94.0
34.7
6.5
95.0
0
10
20
30
40
50
60
70
80
90
100
However, for many diseases we need to move beyondmortality
Swedish data rough estimates from graphs; Source: National quality report for the year of diagnosis 2012 from the National Prostate Cancer Register(NPCR) Sweden, Martini Klinik, BARMER GEK Report Krankenhaus 2012, Patient-reported outcomes (EORTC-PSM), 1 year after treatment, 2010
1 yr severe erectile dysfunction
%
1 yr incontinence5 year survival
Best-in-class: Martini KlinikGermany Sweden
Focussing onmortality alone…
…may obscure large differencesin outcomes that matter most to patients
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Impact of the Swedish cataract registry – avoidingunnecessary surgery
Source: NIKE: a new clinical tool for establishing levels of indications for cataract surgery, Mats Lundstrom, Susanne Albrecht, Ingemar Hakansson, Ragnhild Lorefors, Sven Ohlsson, Werner Polland,Andrea Schmid, Goran Svensson and Eva Wendel, Acta Ophthalmol. Scand. 2006: 84: 495–501, The Role of Value for Money in Public Insurance Coverage Decisions for Drugs in Australia: ARetrospective Analysis 1994-2004, Anthony H. Harris, MSc, Suzanne R. Hill, PhD, Geoffrey Chin, MPH, Jing Jing Li, BPharm, Emily Walkom, PhD, Costed infrastructure options for Australian clinicalquality registries, Australian Commission on Safety and Quality in Health Care, AIHW The burden of disease and injury in Australia, 2003 YLD by disease.
Mea
n in
dica
tion
scor
es (
out o
f 5)
(cen
tral c
ompo
nent
s of
the
NIK
E to
ol)
5
4
3
2
1
0
+0.20
+0.15
-0.19
-1.06-1.96
-0.20
-1.38-1.69
IG4IG3IG2IG1IG4IG3IG2IG1
After surgeryBefore surgery
Indication:Cataract symptoms(0 = fewest symptoms)
Indication:Independence
(0 = most independent)
"In IG 4 some item areas (perceiveddifficulties in day-to-day life and
cataract symptoms) evendeteriorated after surgery"
Swedish Cataract surgeries('000s)
60
40
20
02010
potential
50
Potentialreducedsurgeries
8
2010estimated
58
4%
54%
28%
14%
IG1IG2IG3IG4
AUD $m acutecosts per year
8
6
4
2
0Potential
disinvestment
$8m$950
Averagecost of
CataractSurgery inSweden
=
NIKE identified four indication groups (IGs) withcommon responses to surgery...
...which created the potential for $8m per yearin savings
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Sometimes the greatest value is in demonstrating thatoutcomes don’t differ systematically
1. Fecal occult blood test 2. Colonoscopies may be performed for indications other than suspected colo-rectal cancer Note: Chart excludes Latrobe-Moe as a significant outlierSource: VAED, MBS, Victorian cancer registry, BCG analysis
0.0
0.2
0.4
0.6
0.8
1.0
0 100 200 300 400 500 600 700 800
Cas
e fa
talit
y ra
te
Number of Colonoscopies per diagnosis
Pyrenees (S) - North
Greater Geelong (C) - Pt B
Yarra Ranges (S) - Seville
Port Phillip (C) - West
Mornington P’sula (S) - West
Maroondah (C) - Ringwood
Manningham (C) - West
Glen Eira (C) - South
Brimbank (C) - Sunshine
Size of ball represents thenumber of diagnosed cases inan SLA between 2007/08 –2010/11
Av No of colonoscopies perdiagnosis
Relationships between diagnostic colonoscopy rates, and colo-rectal cancer incidence and mortality(four year total 2007/08 – 2010/11)
Metro Rural Ratio47.4 14.0 3.4
UK NHS target
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Australia already has some successes - Hip and Kneearthroplasty
Source: Health Outcomes Australia analysis; AOANJRR registry data
Overall reduction for knee replacement revision burdenfrom 9% to 7.7%
(3900 avoided revision surgeries)
Cru
de p
erce
ntag
e of
revi
sion
s**
7
7.2
7.4
7.6
7.8
8
8.2
8.4
8.6
8.8
9
9.2
1 2 3 4 5 6 7 8 9 10 11 12 13
Years from baseline (1998)
Overall reduction for hip replacement revision burdenfrom 13.2% to 10.2%
(6700 avoided revision surgeries)
Cru
de p
erce
ntag
e of
revi
sion
s**
6
7
8
9
10
11
12
13
14
1 2 3 4 5 6 7 8 9 10 11 12 13
Years from baseline (1998)
Repeat hospitalisation costs avoided alone amount to $240m
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Surgeon feedback component alone worth $75 million, at acost of ~$15m
Note: Years of life saved discounted by 3% p.a.; Figures in 2014 dollars, including VSLY unitSource Health Outcomes analysis. OBPR protocol
$000 Cumulative
Net return attributed
Internal Rate of Return 29%
Total benefits$89m
Total costs (from 2000)$14.5m
Year Benefit tocost ratio
1999-2014 6:1
-20000
0
20000
40000
60000
80000
1999-2009 2010 2011 2012 2013 2014
Cumulative Benefits & Costs attributed to AOANJRR
Cumulative total costs Column1 Column2 Cumulative net run rate
Costs accrued from 1999
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Drives development of internationalstandard sets
• Organizes global teams of physicianleaders, outcomes researchers andpatient advocates per medical condition
• Ongoing support / updates to standards
Certifies IT solution providers throughtheir Certified Suppliers program
Enables global benchmarking and datasharing through a common platform
Provides practical implementationsupport for ICHOM standard sets
• Works closely with local clinicians andprovider organisations to helpmeasure, analyse and feedbackoutcomes
Tailors IT solution implementation, inpartnership with Pulse Infoframe
Drives advanced analytics & reporting• Risk adjustment and comparison
across similar patients• Identification of best practices
Global networks of innovation institutes• Workshops and remote coaching with
executive, clinical and ops teams• Coordinate support and participation in
working groups
Build local implementation networks• Coordinate stakeholders/players and
build coalitions for measurement• Clinician engagement to build momentum• Deliver on-the-ground, local support to
drive execution of project
ICHOM focuses on global standards & benchmarking;Health Outcomes provides support for local implementation
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Developed 12 Standard Sets thus far, covering 35% of theglobal disease burden
2016targets
▪ Dementia▪ Frail elderly care▪ Heart Failure
▪ Pregnancy and childbirth▪ Breast cancer▪ Colon cancer
▪ Overactive bladder &incontinence
▪ Inflammatory boweldisease
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Global uptake of standard sets circa Jan 2015
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Global movement rapidly gaining pace – driven by three keyfactors
Maturity : Outcomes measurement well developed for many years in Academianow being used for:
• Clinician feedback• Health system decision-making• Long term structural efficiency improvement• Patient communication
Scale : Coalescence of measurement initiatives across hospitals, cities andprovinces, and now countriesICHOM creates virtual scale
Technology : Digitisation of health information makes it cheaper and quicker tocollect store and analyseTechnology provides new cost effective way to collect data from patients
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Where might we get to?
400 pages of comparisons betweenevery health service region in Sweden
170 different conditions covered
Population health, behaviour, clinicaland patient reported outcomes covered
Produced every 2 years
Data drill down available that allowscomparison of individual hospitals,patient subsets and managingclinicians
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Example comparisons produced
Bowel cancer Cataracts