panel session 1: value-based delivered healthcare · and value‐based reimbursement systems ......

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AAGLAdvancing Minimally Invasive Gynecology Worldwide

Panel Session 1: Value-Based Delivered Healthcare

PROGRAM CHAIR

Stuart R. Hart, MD

James A. Greenberg, MDTodd R. Jenkins, MD, MSHA

Judith A.F. Huirne, MD, PhDCraig J. Sobolewski, MD

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Reimbursement in a Value‐Based System C.J. Sobolewski ............................................................................................................................................. 3 Can Expensive Disposables Be Used to Lower Costs? J.A. Greenberg .............................................................................................................................................. 6 Why Patient Engagement Matters Now More than Ever T.R. Jenkins ................................................................................................................................................... 9 E‐Health Improves the Value of Minimally Invasive Surgery J.A.F. Huirne ............................................................................................................................................... 14 Cultural and Linguistics Competency ......................................................................................................... 19

Panel Session 1: Value-‐Based Delivered Healthcare

Stuart R. Hart, Chair

Faculty: James A. Greenberg, Judith A.F. Huirne, Todd R. Jenkins, Craig J. Sobolewski The goal of Value-‐Based Healthcare is to improve quality and outcomes while lowering cost. Healthcare reimbursement was traditionally based on a Volume-‐Based model, or how many patients you evaluated and treated. This model is now changing to a Value-‐Based model with reimbursement now tied to patient outcomes and cost. This paradigm shift will require a new approach from healthcare providers to remain viable. This session will review some of the challenges of the Value-‐Based Healthcare model, and discuss ways to successfully navigate through the many changes that will affect all healthcare providers. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Describe some of the reimbursement challenges in the Value-‐Based Healthcare model; 2) explain the importance of patient engagement and satisfaction in this new model; and 3) discuss new ways to optimize value-‐based outcomes in minimally invasive surgery.

Course Outline 12:05 Welcome, Introductions and Course Overview S.R. Hart

12:10 Reimbursement in a Value-‐Based System C.J. Sobolewski

12:20 Can Expensive Disposables Be Used to Lower Costs? J.A. Greenberg

12:30 Why Patient Engagement Matters Now More than Ever T.R. Jenkins

12:40 E-‐Health Improves the Value of Minimally Invasive Surgery J.A.F. Huirne

12:50 Questions & Answers All Faculty

1:05 Adjourn

1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Erica Dun* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Intuitive Royalty: CooperSurgical Sarah L. Cohen* Jon I. Einarsson* Stuart Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Kimberly A. Kho Contracted/Research: Applied Medical Other: Pivotal Protocol Advisor: Actamax Matthew T. Siedhoff Other: Payment for Training Sales Representatives: Teleflex M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). James A. Greenberg Consultant: Channel Medical, Lattis, Inc., PROA Medical Stock ownership: Emmy Medical Stuart R. Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Judith A.F. Huirne* Todd R. Jenkins* Craig J. Sobolewski Consultant: Covidien, TransEnterix Asterisk (*) denotes no financial relationships to disclose.

2

Reimbursement in a Value‐Based System

Craig J. Sobolewski, MD, FACOG

Duke UniveristyDurham, NC

• Consultant:

• Covidien, TransEnterix

• Review the history behind value‐based reimbursement

• Discuss the difference between volume‐based and value‐based reimbursement systems

• Explain the basic features of the various models for value‐based reimbursement

• http://mhsdialog.com/mckesson‐research‐reveals‐the‐state‐of‐healthcares‐transformation‐from‐volume‐to‐value/#.VggozLQ1OFY

• http://valencehealth.com/uploads/default/Valence_Health_Emerging_Models_White_Paper.pdf

A 30,000 Foot View

March 24, 2014: Somewhere over the North Pole

3

Historical Model

• Fee for service (FFS)

– Provider renders a treatment and is reimbursed directly by the patient, by a third party payer (insurer), or a combination of the two

– Has dominated health care

– Rewards VOLUME

http://valencehealth.com/uploads/default/Valence_Health_Emerging_Models_White_Paper.pdfAccessed 09/2015

“The State of Value‐Based Reimbursement and the Transition from Volume to Value in

2014”

• Survey commissioned by McKesson Health Solutions and conducted by ORC International

http://mhsdialog.com/mckesson-research-reveals-the-state-of-healthcares-transformation-from-volume-to-value/#.VggozLQ1OFY. Accessed 09.2015

Some Major Trends

• Rapid adoption of VBR– 90% of payers and 81% of providers are already using some mix of value‐based reimbursement (VBR) combined with fee‐for‐service (FFS)

• Accountable Care Organizations (ACOs) are significantly closer to VBR adoption than non‐ACOs

• Pay‐for‐Performance leads the pack

Pay for Performance (P4P)

• Emerged in the early 2000’s

– Tactic for aligning provider payment with value

– Financial incentives or disincentives are tied to measured performance

• Performance thresholds

• Improvement thresholds

• Relative performance cut‐offs

4

Patient Centered Medical Home• Primary care‐driven initiative

– Team is responsible for coordinating care• Physician, RN case manager, MA, pharmacists

– Best for chronic conditions• Prevent hospital readmissions and ED visits

– EMR, disease registries, and central data repositories– Require physicians to follow a set of evidence‐based care guidelines

– Providers negotiate a FFS rate increase or a per‐member‐per‐month (PMPM) payment on top of standard FFS payments.

Shared Savings

• Reward providers that reduce total healthcare spending on their patients below an expected level set by the payer

– Provider is entitled to a share of the savings

Bundled Payment/Episode of Care• A single negotiated payment for all services for a specified procedure or condition– Pregnancy and birth, knee and hip replacement surgery, cardiac procedures

– Provider payment amounts based upon• Costs of adhering to clinical standards of care• Risk stratification• Complication allowances• Incentivizes provider performance based on a comprehensive score card

Shared Risk• Performance‐based incentives to share cost savings and disincentives to share the excess costs of healthcare delivery– Based on an agreed upon budget with a payer

– Provider must cover a portion of costs if savings targets are not achieved

• Since providers take on more risk the opportunity for financial gain is larger

Full Risk: Capitation

• Provider organization receives a set payment per patient for specified medical services

• Provider takes on 100% of the insurance risk for the covered patient and services– Monthly per‐patient‐fee

– Organization must determine how to divide up the single capitated payment

• Combination of incentives and fee‐for‐service agreements

Summary

• Change is inevitable

– Healthcare payment reform

• Providers must be aware of the various models of value‐based care

– Begin to align themselves with a model that best fits their goals

5

Can Expensive Disposables Be Used To Lower Costs?

Jim Greenberg, MD

Brigham & Women’s HospitalHarvard Medical School

Disclosures• Consultant: Channel Medical, Lattis, Inc., PROA Medical

• Stock ownership: Emmy Medical

• Discuss cost and value

• Describe ownership of cost

• Provide realistic long term value objectives

Can Expensive Disposables Be Used To Lower Costs?

• No…thank you.

Can Expensive Disposables Be Used To Create Better Value?

• Yes

Cost vs. Value• Cost is objective; value is subjective

• Cost: The amount of money needed to purchasesomething. Cost is from the purchaser’s viewpoint soit has negative connotations (cost is bad)

• Value: The usefulness of desirability of goods orservices; how much you love it or what is it “worth tome.”

6

Dissection of Results

• 36 (59%) of subjects allocated to vaginal hysterectomy could not be done via that route because “vaginal hysterectomy was not considered feasible by the assigned surgeon.”

Dissection of Results

• (61) 100% of the subjects allocated to robotic hysterectomy had their procedure done as planned.

My conclusion from this study

• Without the availability of more costly devices and equipment that enable surgeons to push their skills, 59% of women undergoing hysterectomy would have had an open laparotomy – BAD VALUE.

7

However…

• Physicians have been entrusted as the guardians of healthcare cost and need to embrace this responsibility.

• The “enabling technology card” needs to be played judiciously and responsibly.

Conclusion

• Enabling technology must be wedded to a goal of creating more VALUE in healthcare. Expensive technologies should be used to perfect technique with a plan to switch to lower cost tools as skills improve.

• Lonnersfors C., Reynisson P, Persson J. A Randomized Trial Comparing Vaginal and Laparoscopic Hysterectomy vs Robot‐Assisted Hysterectomy. J Minim Invasive Gynecol 2015 Jan;22(1):78‐86

8

Why Patient Engagement Matters Now More Than Ever

Todd R. Jenkins, MD, MSHA

University of Alabama – Birmingham (UAB)

Associate Experience Officer

Patient Engagement

• I have no financial relationships to disclose

Patient Engagement– Discuss the definition of patient engagement and federal programs including patient engagement as a metric

– Examine the evidence supporting patient engagement and clinical outcomes

– Articulate the strategies to improve theengagement of your patients

Quality mealAtmosphereTimely serviceFriendly service

Special experienceValue

Connection

Patient Engagement

Quality AtmosphereTimely serviceFriendly service

Special experienceValue

Engaged and Assured

Patient Engagement

• "Patient engagement"

– Interventions designed to increase activation

– Promote positive patient behavior

• “Patient activation”

– A patient's knowledge, skills, ability, and willingness to manage his or her own health andcare.

– Activated patients are satisfied patients; but satisfied patients are NOT always activated.

9

Patient Engagement Patient EngagementIncreased Market Share and Patient Volume

Patient Engagement

Patient Engagement

• Medical Care. 2009;47(8): 826

– Review of >100 observational and >20 experimental studies

– Physician communication strongly correlates with adherence rates by patients in acute and chronic disease

– Compliance with treatment regimens has significant influence on treatment measures

Improved Clinical Outcomes

Patient Engagement

• British Medical Journal. 2013

– Review article regarding patient satisfaction

• Positive associations 429 studies (77.8%)

• No association 127 studies (22%)

• Negative associations 1 study (0.2%)

– Patient experience is positively associated with clinical effectiveness and patient safety

http://dx.doi.org/10.1136/bmjopen-2012-00157.

Improved Clinical Outcomes

Patient Engagement

0

0.1

0.2

0.3

0.4

0.5

0.6

ForeignObject

PressureUlcer

Falls andTrauma

CLASBI Catheter UTI PoorGlycemic

< 25%

> 75%

Healthcare Acquired Conditions (HAC) by Doctor Communications

10

Patient Engagement

0.565

0.57

0.575

0.58

0.585

0.59

0.595

0.6

0.605

0.61

0.615

Patient Safety Indicators (PSI90)

< 25%

25‐49%

50‐74%

75‐99%

As Patient’s Perception of Care Increases, Patient Safety Indicators Improve

Patient Engagement

• Why do patients file malpractice claims?

– 3‐6% of hospitalized patients suffer an adverse outcome owing to medical negligence

– Of those injured by error, only 2% file a claim

– For every valid claim, 4‐5 individuals filed suit where there was no evidence of medical negligence

Brennan TA. NEJM 1991;324: 370-6.

Reduced Patient Complaints & Malpractice

Patient Engagement

• Why do patients file malpractice claims?

– Almost all families expressed dissatisfaction with physician‐patient communication

• Did not discuss potential complications 70%

• Attempted to mislead them 48%

• Would not talk openly 32%

• Would not listen 13%

Hickson GB. JAMA 1992;267(10): 1359-63


Patient Engagement

• Patients of the physicians with the leastcomplaints were most likely to report:

– Technical and cognitive competence

– Effective communication

– Empathy

– Reliability and Availability

– Personal Responsibility

– Respect

Hickson G. Obstet Gynecol 2010;115(4): 682-6.


Patient Engagement

0%

10%

20%

30%

40%

50%

60%

70%

Patients Would Definitely Recommend the Hospital

< 25%

25‐49%

50‐74%

75‐99%

As Patient Perception of Care Increases, Willingness to Recommend Increases

Increased Market Share and Patient Volume

Patient Engagement

• How do I know if my patient’s are engaged?

– Outcomes

– Compliance

– CGCAHPS

– HCAHPS

– * 55 reports

– Cards and letters

– Word of mouth

11

Patient Engagement

What can I do to enhance my patient engagement?

Patient Engagement

A Acknowledge

I Introduce

D Duration

E Explanation

T Thank You

Tools & Tactics

Patient Engagement

• Attributes of Genuine Interest

– Eye contact

–Appropriate touch

–Proximity

–Receptive posture (seated/leaning forward)

–Re‐enforcing statements

–Clarification and paraphrasing

Patient Engagement

Patient Engagement Patient Engagement

• Health Literacy

• Explain in a way that aligns with a patient’s education and intellect

• “Teach Back” is a tool to verify comprehension of key information

• “I have given you a fair bit of information today…Would you mind telling me what you understand about this illness?”

12

Challenges

• Provide more care than ever before

• Provide higher quality care

• Provide this care at a lower cost

• Provide care in a safer environment

• Provide this care with fewer providers

Patient Engagement

• Why Do You Do What You Do?

–Provide for family and personal needs

– Intellectual fulfillment

–Worthwhile and fulfilling work

– Improve the life of the people we serve

Patient Engagement• James J. Health Policy Brief: Patient Engagement. People actively involved

in their health and health care tend to have better outcomes‐and, some evidence suggests, lower costs. Health Affairs. 2013.

• Haskard‐Zolnierek KB, DiMatteo MR. Physician Communication and Patient Adherence to Treatment: A Meta‐analysis. Medical Care. 2009;47(8): 826‐34.

• http://dx.doi.org/10.1136/bmjopen‐2012‐00157

• Studor Group data

• Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH, NEJM 1991;324: 370‐6.

• Hickson GB, Clayton EW, Githens PB, Sloan FA. JAMA. 1992;267(10):1359‐1363.

• Hickson GB, Entman SS. Obstet Gynecol. 2010 Apr;115(4):682‐6

13

E-Health Improves the Value of MinimallyInvasive Surgery

Judith Huirne

VU University Medical Center, Amsterdam

Research Grants

I have no financial relationships to disclose.

Do you ask your patients on a routine base about their return to work after a LH?

Objective

• Provide insight and discuss tools to increase benefits from MIS

‐ Improve patient outcome

‐ Increase efficiency health professionals

‐ Reduce Healthcare related and societal costs

Do we take full benefit?

Minimal invasive surgery

Recovery after gynaecological surgery

After 6 weeks• < 30% VH/TLH• 15% AH

Days until return to work

% o

f p

atie

nts

Type of surgery

Vonk Noordegraaf BJOG 2014

Recovery after gynaecological surgery

Median 10 weeks

Days until return to work

% o

f p

atie

nts

Type of surgery


14

Predicting factors Return to work

1) Socio-demographic factor(age, living alone/with family, children in need of care)

2) Medical factors (type of surgery, complications)

3) Work-related factors (employment (salaried), Physical workload, work hours, satisfaction

4) Patients’ expectations for time to RTW compared to normal (delphi procedure)

5) Health statusphysical and mental (SF36)

6) Functional status (RI 10)

univariable and multivariable Cox regression analysis


Strongest predictors

• The level of invasiveness of the surgery- minor HR 0.51 (CI 0.32-0.81)

- intermediate HR 0.20 (CI 0.12-0.34)

- major HR 0.09 (CI 0.06-0.16)

• Expectation about time of RTW (HR 0.55 (CI 0.36-0.84)

• Functional status at baseline (RI-10) (HR 1.09;CI 1.04-1.13)).


Can be affected by counseling!

Effect of counseling on Return to work (RTW)

• Well-defined convalescence recommendations => sick leave 1-4

1. Callesen et al, 19992. Jones et al, 20013. Bisgaard et al, 20014. Clayton et al., 2007

Aim “I Recover-intervention”

Optimalisation perioperative care

Patient empowerment (e-health)

Patients Healthcarerecovery QualityQOL Efficiency

Costs

Development of eHealth intervention

Patients

Needs assessment: 3 focusgroups

Results focusgroups

Short comings of provided care

– Insufficient information on resumption of activities

– Inconsistency in given advice

– Inadequate information about e.g. complications

– What to do and who to contact in case of complaints

Pittens et al. Health expect .2013

15

Experts


Literature

• Systematic literature search RNA/RTW

• Delphi procedure : guidelines RNA : 37 activities • 11 procedures (4 gynaecology & 7 general surgery)

Date of surgery: 09-11-2011

Type of surgery: Total Laparoscopic Hysterectomy

Days after surgery

Activities

StretchingArms fully extended

Carrying or lifting5 kg

Sitting while at work6-8 hrs

Sustained walking Roughly 30 minutes

Vacuum cleaningHandling light obj.freq.Roughly 4 hrs (1kg/10 times a minute)

Riding a bicycleBending frequentlyRoughly 4 hrs (10times a minute)

Hours per dayAbout 8 hrs on average

Hours per weekRoughly 40 hrs per week

Individual tailored advice (work)

Experts


LiteraturePatients

“I recover”

Does it work? : RCT 1

RCT

• Usual care versus I recover 1.0

• N=215

• 4 procedures in gynaecology

• 9 clinics

Results RCT 1 “I recover 1.0”

Sick leave data available for 100% of patients (n=225)

Median 39 days

Median 48 days

P=0.018Hazard ratio

95% CI

1,43 1.003 – 2.037

Results “I recover 1.0”

After 26 weeks Intervention Usual Care P-value

Quality of lifetotal score [Mean,(SE)]

660 (17) 630 (19) 0.024

VAS pain intensity [Cum OR]

0.54 1 0.035

90% patient & care providers were

(very) satisfied!


16

Gynaecologicalsurgeryn=215

Results- 9 days sooner RTW- Better QOL- Less Pain

I Recover studies

I-recover 1.0RCT 1

GynaecologicalsurgeryKEAn=450

Abdominalsurgerye-consultAccelerometern=2x 225

I Recover 2.0RCT 2

I Recover 3.0RCT 3&4

Optimalisation perioperative care: E-health

Feedback

Recovery monitor

-12 days sooner RTW

-Savings $1562/ptn

Increasing efficiency

• E-consult: less consulations

• Reduction in counseling due to films:

– Before surgery: on the procedure

– Before discharge: instructions

– Before reïntegration: pitfalls, tips & trics

Demo Information on the surgical procedure

Pre-operative Instructions CONCLUSION

• Recovery after MIS takes longer then expected

• Preoperative expectations are predictive and can be affected by counseling

• Use of e-health intervention improves return to work, pain and QOL& saves

health care and societal costs

• Webportal provides a tool to utilize potential advantages of MIS !!

17

Questions

Judith [email protected]

18

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

19

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

panel session 1: value-based delivered healthcare · and value‐based reimbursement systems ......

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