tough choices: values, costs & efficient allocation to...

Tough Choices: Values, Costs & Efficient Allocation to Improve Quality

Welcome

Value and efficiency in health care: defining what we mean

Stirling Bryan, PhD

Director, Centre for Clinical Epidemiology & Evaluation, VCHRI

Professor, School of Population and Public Health, UBC

www.c2e2.ca

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Overview

• Introduction to economics – Or ‘How dismal is the dismal social science?’

• What do we mean by ‘value’?

• Efficiency in health care – ‘Technical’ versus ‘Allocative’ – Marginal analysis

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Background

• Central problem addressed by the discipline of economics: – Resource scarcity

• Central concept is ‘opportunity cost’: – The value of the benefits forgone by choosing to

deploy resources in one way rather than in their best alternative use

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‘Value’ in health care

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‘Value’ in health care

‘In health care, the overarching goal for providers, as well as every other stakeholder, must be improving value for patients, where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.’

Porter & Lee (2013)

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And, in our continuing effort to minimize surgical costs, I’ll be hitting you over the head

and tearing you open with my bare hands.

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Efficiency definitions

• Technical efficiency – Are we doing it right?

• Allocative efficiency – Are we doing the right things?

• Marginal analysis – Are we doing too much (or too little)?

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Technical Efficiency: producing the maximum possible output from the inputs used

This is ‘efficiency in production’ - largest possible outputs from given inputs - or, smallest possible inputs for given outputs

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Technical Efficiency

Programs to treat 100 people with depression

Program Hours of

CBT Drug therapy

doses

A 2500 200

B 1500 250

C 1500 300

D 500 600

• Which program(s) can be ruled out because of technical inefficiency?

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Technical Efficiency

Programs to treat 100 people with depression

Program Hours of

CBT Drug therapy

doses Total program

cost

A 2500 200 $304,000

B 1500 250 $185,000

C 1500 300 $186,000

D 500 600 $72,000

CBT = $120/hour Drugs = $20/dose

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Cost-effectiveness plane Cost Difference

Output Difference A

B C

D

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Evaluating the Cost-Effectiveness of Fall Prevention Programs that Reduce Fall-Related Hip Fractures in Older Adults

Journal of the American Geriatrics Society Volume 58, Issue 1, pages 136-141, 4 JAN 2010 DOI: 10.1111/j.1532-5415.2009.02575.x http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02575.x/full#f1

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Allocative efficiency

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Opportunity cost when it matters

• Competing claims on health care resources: – Helicopter ambulance – Heart surgery – Hip replacement

• What is the opportunity cost of purchasing a new helicopter ambulance?

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Cost-effectiveness plane

Drummond, et al. 2005. Methods for the economic evaluation of health care programmes: Oxford University Press

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Cost Difference

Effect Difference

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The Time Investment Model

Ovretveit, J. 2000. “The economics of quality--a practical approach.” Int J Health Care Qual Assur Inc Leadersh Health Serv 13(4-5): 200-7

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Marginal analysis

How much safety do we really want in health

care?

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Cost of safeguards and errors

Warburton RN (2005) Patient safety — how much is enough? Health Policy 71(2):223–232

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Summary • Value

– Health outcomes that matter to patients relative to the cost of achieving those outcomes

• Technical efficiency – Are we doing it right? Can we avoid throwing dollars down

the toilet?

• Allocative efficiency – Are we doing the right things? Hips, hearts, helicopters, falls

prevention?

• Marginal analysis – Are we doing too much (or too little)? How much safety do we

really want?

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Allocative efficiency Technical efficiency

Q4: Biggest savings to be had

Pre-forum survey

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Welcome & Opening Remarks

BC Health Technology Review: Capturing Value from Health Technologies in Lean Times

Marc Pelletier, Fraser Health Kevin Samra, Ministry of Health

http://www.health.gov.bc.ca/htr/

Purpose Today:

1. Outline the rationale for more aggressive, formal, objective HTA;

2. Outline our approach thus far in BC; 3. Speculate on the future.

Health Technology Review Not new, but rising in prominence in most

health systems; Reflective of the relative success of

managing pharmaceuticals through a more objective process; Reflective of financial context. Reflective of the critical need to more

aggressively pursue value: Effectiveness, Utility --- at both an individual and

societal level.

Why focus on Non-drug Technologies?

38% of the change in healthcare spending in

Canada over the period from 1996-2008 was due to technology change.

$5 billion dollars of the increase was due to drugs, while $23 billion (82%) due to non-drug sectors

Why focus on Non-drug Technologies?

Growing recognition of the: Low value of many technologies; Potential for unintended impacts of technologies; Opportunity costs in fixed budget; Variation in decision making across Hospitals and

HAs

BC Health Technology Review

Established in 2011/2012 A process for making evidence-informed

recommendations about public coverage of new non-drug, non-IT health technologies. MOU committing to the process signed

by all health authority CEOs

Making Choices

“3T technology is the undisputed king of MRI”

Development of the HTR Leadership Council initiated discussions on

the need for a consistent process to assess emerging technologies in 2009 MOU signed in November 2011 Industry and patient consultations were

carried out in September 2012 The first business case was reviewed in

January 2013

Process Rationale

No transparent, centralized process for non-drug health technology coverage decision-making; dispersed, ad hoc market entry

A gap between evidence of effectiveness and Health Canada’s licensing based on safety

An opportunity to balance improving health outcomes with the need to constrain health care costs

Process Objectives Support timely, evidence-

informed decision making about public provision

Efficiently allocate limited health care funds in a fair, equitable and transparent process

Review technologies that reflect health authority and population needs

Why do we need an evidence informed process?

Dr. Google

Zamboni treatment - Millions spent on research worldwide

Physician Preference Items

Physician owned distributorships

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Why do we need a process?

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Non-Drug Technologies in Scope

New technologies used in direct patient care, screening or diagnosis; generally hospital based

Threshold of $25,000 per patient or $1,000,000 across the province

Screening criteria are described further in the Expression of Interest form

Deputy Minister of Health or Leadership Council can request that any technology be reviewed

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Triple Aim and the HTR

1. Improving the patient experience of care (including quality and satisfaction);

2. Improving the health of populations; and

3. Reducing the per capita cost of health care.

The HTR considers all of the above factors

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Vision of the HTR

Health technologies in the province are assessed in a coordinated and consistent manner informed by the available evidence, to help ensure citizens of British Columbia receive the best health care that the province can afford.

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Role of HTAC Provide recommendations to senior health

executives on the uptake, diffusion, distribution or removal of non-drug health technologies.

Evaluate high budget, disruptive technologies with significant patient or system impact that are candidates to be diffused across health authorities.

Ensure that the use of ineffective, wasteful, or obsolete technologies are minimized and effective technologies that provide value for money are diffused into the system. 39

CADTH clinical and cost

effectiveness report

Overview of condition & technology;

jurisdictional scan

Implementation Factors

Value Criteria

Non-Scored Criteria

Business Case Components

Costs

Decision-Making Framework Value (Scored and Weighted) Criteria Health benefits Non-health benefits Condition severity Environmental impact

Costs Incremental costs and savings Budget impact Implementation costs Sector costs

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Reassessment in BC

Leadership Council directed HTAC to develop an initiative aimed at reviewing health technologies already diffused within the health system in November 2013. A review of the existing literature on reassessment

undertaken. Draft framework completed and approved by LC.

Consultations with provincial agencies and committees are being initiated.

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Rationale for Reassessment Obsolescence Increasing demand for health services and fiscal

pressures. – Opportunity cost of paying for health technologies and treatments that are less than

optimally effective.

Potentially unnecessary or harmful treatments Some technologies in use have never been formally assessed against contemporary

evidence of safety, effectiveness and cost effectiveness.

Off label use - application to new patient populations where benefit has not been demonstrated.

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Considerations

Choosing Wisely Canada

Selecting technologies whereby: – Implementation activities are within the current scope of

health authority influence; – Mechanisms are readily available or can be developed for

practice change; and – Potential cost savings are significant enough to warrant the

considerable effort and resources required to assess the technology and change practices.

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The Future: Much better clarity that most decisions are

trade-off decisions; Patient and provider engagement in these decision

making; Much more transparency of decisions.

Much more demand for high quality evidence within decision making processes;

Much more literacy regarding evidence based decision making 45

Questions?

Redesigning Health Care Services in Kimberley, BC

Craig Mitton & Andrew Neuner

Case study: Redesigning Health Care Services in Kimberley, BC

Evelyn Cornelissen1,2, Craig Mitton1,2, Andrew Neuner3, Glenn Kissmann3, Dianne Kostachuk3 1 – University of British Columbia 2 – Vancouver Coastal Health Research Institute 3 – Interior Health Authority BCPSQC Quality Forum 2014, Vancouver, February 26th

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Outline

• Kimberley, PHC, timeline Context

• Research questions, methods Project

• Experience, quality, cost Findings

• Limitations, trends, next steps Summary

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Kimberley’s evolving health services

May 2002

•ER closed •5 GPs leave;

4 remain

Oct-Nov 2002

•City buys hospital building

•Mayor appoints Health Centre Society as landlords

July 2003

•MOHS announces $2.5M over 3 yrs for Kimberley PHC

Fall 2004

•Renovations $463,000

•PHC RN hired

Jan 2005

•PHC opens • IH programs,

Xray •Operating

budget 04/05 $217,852

Sept 2005

•GPs, lab move in

•6 GPs •CHF program

funded by PHCTF $86,500

2006-present

•Evolving programs, funding

•e.g., IHN with GPs funded by Health Innovation Fund

•e.g., CHF TeleHome Care funded by Canada Health Infoway

•6-8 GPs

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Research questions 1. What are residents’ perspectives on the impact of the PHC?

2. What are the PHC clinicians’ perspectives on the impact of the PHC?

3. How does the PHC compare to IH overall on pre-determined quality & cost indicators?

4. How does the PHC compare to similar IH communities with acute/ER services, and to other IH PHCs without acute/ER services, on pre-determined quality & cost indicators?

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Methods Ex

perie

nce

Qualitative interviews, focus groups: • Local residents, patients,

KHCS members (n=11) • Local clinicians (n=13)

Qua

lity

& C

ost

Retrospective data: • Staffing levels • PHC & hospital utilization • Standardized mortality

ratios • C-section, low birth weight • Costs - physician, PHC

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Residents’ perspectives on impact of PHC on Kimberley

“PHC is good (e.g., CDM programs; nice to have everything under one roof) but it’s not an equal replacement for the hospital”

“Will take another generation before there is true acceptance”

It’s all relative “Often see ambulance

parked on highway between Cranbrook and Kimberley – is this cost effective?”

“Public is so dependent on the ambulance service now"

Reliance on

ambulance

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Residents’ perspectives on impact of PHC on Kimberley

“We aren’t even aware that the PHC has evolved since the start”

“They plucked the jewel out of our community by closing the hospital”

PHC needs

PR “Most people would rather have a hospital”

“Care responsibility was transferred to families when hospital closed”

Missing acute

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PHC clinicians’ perspectives on impact of PHC

“Communication is very easy because we’re all under one roof”

“Communication with EKRH is not standardized in current [hospitalist-dependent] system”

Commun-ication mostly

improved “No coordination of care before; dealt with acute issues; didn’t provide a lot of education or send referrals”

“People still work in own silos a bit but people are increasingly understanding each other’s roles”

Inter-disciplinary

care enhanced

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PHC clinicians’ perspectives on impact of PHC

“MD: loss of skills (acute, ER, obs) [but also] don’t get up at nights anymore or work weekends”

“Admin in IH has been restructured – used to know who did what”

Evolving roles

“One stop shopping for healthcare services; felt disjointed before”

“Urgent care is available here but people might not know it; not everyone knows what’s available”

Compre-hensive

care (when open!)

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Comparing public and clinician perspectives

see improved teamwork, communication, comprehensive and interdisciplinary care – and believe that this must translate into better patient care. However…

Public did not identify these features; instead focused on loss of acute/ER. Opportunity for some PHC PR/promotional work!

Clin

icia

ns

Public

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Quality and cost – comparison sites

Kimberley

IH overall

IH communities with ER: Cranbrook (also acute), Kaslo (Kootenay Lake),

Chase (Kamloops)

IH communities without acute/ER:

Enderby

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Quality and cost indicators

Quality • C-section, low birth weight, acute utilization (ED

visits, average length of stay, ACSC, readmissions), community utilization (adult day services, case management, homecare nursing, home support), Standardized Mortality Ratios (SMRs)

Cost • PHC, physician

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C-Sections

Source: BC Vital Statistics Annual Reports Notes: - Caution should be taken in interpreting this data as volumes are low. - Kimberley, 30.3% of live births delivered by C-section. Similar to IH overall, Cranbrook, Enderby. - The Kamloops LHA averaged the highest at 35.0%. - Kootenay Lake lowest at 19%. - Over the 5 years, there has been little change observed in rates.

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Acute utilization: LoS

Data Source: IH Data Warehouse, Discharge Abstracts Database, Ministry of Health. Based on Acute and Rehab care levels, excluding newborns. Filtered by Patient Residence.

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Acute utilization: readmission rates

Data Source: IH Data Warehouse, Discharge Abstracts Database, Ministry of Health. Based on Acute and Rehab care levels, excluding newborns. Filtered by Patient Residence. Caution should be taken in interpreting this data as volumes are low.

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Acute utilization: ACSC

Data Source: IH Data Warehouse, Discharge Abstracts Database, Ministry of Health. Based on Acute and Rehab care levels, excluding newborns. Filtered by Patient Residence.

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ED visits by CTAS level ED Visits/1,000 population CTAS Level 4&5, 2008/09 - 2012/13

CTAS level data only available for 2010/11 to 2012/13 for Chase. Data Source: Admissions Universe.

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CIHS utilization: adult day services (clients)

Data Source: IH HCC Universe & PEOPLE 2013

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CIHS utilization: case management (clients)

Data Source: IH HCC Universe & PEOPLE 2013

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CIHS utilization: homecare nursing (clients)

Data Source: IH HCC Universe & PEOPLE 2013

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CIHS utilization: home support (clients)

Data Source: IH HCC Universe & PEOPLE 2013

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Standardized Mortality Ratio

Data Source; Standardized Mortality Ratio - Causes of Death by Local Health Area, British Columbia, 2006-2010 and 2011, Table 33, 2011 Annual Report, BC Vital Stats

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Low birth weight

Low Birth Weight Live Births by Local Health Area and Gestational Age, Table 16, C & E, 2009-11 Annual Reports, BC Vital Stats Take caution in interpreting due to low volumes.

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Costs: initial data

• Wide variation between Kimberley and comparison sites due to differences in allocation to cost centers; direct comparisons are thus challenging

PHC

• Wide variation in physician payment; possibly due in part to inclusion of EKRH billings and non-Kimberley patients; further assessment required

Physicians

• Ministry Blue Matrix report – includes MSP, pharmacy and health authority costs at the LHA level

Next steps

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Limitations 1. PHC evolved over many years along with implementation of

primary care initiatives - difficult to attribute outcomes

2. Operational implications on data – differences in practices between communities

3. Small numbers – caution with interpreting data as LHA volumes are low

4. Alternative explanations – social determinants of health

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Summary (1)

Experience: clinicians appreciate the benefits (interdisciplinary care, communication) of the PHC model; public still comparing to acute model and may not be fully aware of what PHC offers.

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Summary (2) Quality: Kimberley vs. comparison sites: - acute: lower ED CTAS 4&5, ACSC and Length of Stay (last few yrs); higher readmission rates (for first few yrs) - CIHS: acute length of stay trend is decreasing, while at same time CIHS adult day service and case management are increasing (while CIHS homecare nursing and home support are stable). - Similar for C-section; higher for LBW (caution with interpreting) - Variable SMR

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Summary (3) Cost: wide variation in data available at site or service-level make comparisons challenging. More work required. If we can show equal or better outcomes for less cost then the new model (PHC) would be preferred, notwithstanding other social and economic arguments arising from hospital closure. Key point is that this type of in depth assessment is required to inform IH Senior Executive of policy decisions. Data needs to come around.

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Next steps

Further data

analysis

• PHC costs including GP costs • Ministry Blue Matrix

Compare findings to other PHCs in:

• BC • Canada • Elsewhere

Questions? Comments?

Thank you: participants; IH analysts – Jonathan Osman and Raman Mundi

Funding: grant from BCPSQC.

Asking the Right Questions

#QF14

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Misuse Overuse Underuse

Coun

t Which do you feel is the biggest concern?

“Generally speaking in residential care we default to using the acute care system when not necessary and this generally causes decreased

well-being for our clients. For example, inability to access to primary care services "out of hours"

means that we often send people to the emergency department for medical assessment. While there, they appear significantly "worse"

and end up getting admitted and are often significantly worse from a functional

perspective on return.” #QF14

At your tables …

Identify examples of: – Overuse – Underuse – Misuse

#QF14

What Can We Do?

Select one example and discuss: – What strategies might we use to address? – Who needs to be engaged? – What might success look like (how will we

know we’ve made a difference?)

#QF14

Get Ready for a Debate: Is Our Current System Over- or Under-Managed?

#QF14

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It's perfect as is! Over-managed Under-managed

Coun

t Do you feel BC's system is ...

Get Ready for a Debate: Is Our Current System Over- or Under-Managed?

Walking the Cost and Quality Tightrope

Table Discussions

1. What does this mean for us in the BC context?

2. What are the challenges and opportunities for moving forward?

#QF14

Closing Reflections

#QF14

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Primary Care Acute Care Home andCommunity Care

Residential Care Palliative Care

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Where do you see the most opportunity for improved efficiencies?