1C: Achieving value-based care for better outcomes
Tracks
Track 3
| Monday, November 11, 2019 |
| 11:15 AM - 12:45 PM |
| Room 109 - 110 |
Details
Chaired by Chris Shipway, Director, Chris Shipway Consulting
Speaker
Ms Kylie Woolcock
Policy Director
Australian Healthcare and Hospitals Association
12 Value-based health care – setting the scene for Australia
Abstract
Introduction
Australians have had access to universal health care for more than 30 years. However, our health care system is not immune to pressures of an ageing population, a growing burden of chronic disease, increasing life expectancy, increasing individual and community expectations, and escalating health care costs associated with new technology and treatments.
Many health care systems around the world are facing similar challenges and are looking to maximise the value of health care for populations, narrowing the gap between need and demand on one hand, and resources on the other.
Policy context and objective
Value in health care has been defined as the health outcomes that matter to patients relative to the resources or costs required, reflecting the seminal work of Porter and Teisberg. However, the term has become a buzzword, and, depending on who is setting the agenda, its meaning can be unclear and shifting.
This presentation will discuss the findings from the recently published Deeble Institute for Health Policy Research Issues Brief, Value-based health care – setting the scene for Australia, including:
• How value in health care is defined, with consideration of the inclusion of societal value in the context of Australia’s universal healthcare system.
• The important enablers of value-based health care that are already present in Australia, and the barriers to adoption.
• The opportunities and limitations in applying international experience in an Australian context, and sharing examples of work in Australia to progress value-based health care and the enabling public policy for success.
Targeted population
A value-based approach to health care provides a patient-centric way to design and manage health systems. Realising its potential requires unprecedented cooperation, coordination and partnerships among all stakeholders – providers, funders and patients, in addition to regulators and the professions.
Highlights
Alignment with a value-based approach to health care was assessed by the Economist Intelligence Unit for 25 countries, including Australia. A country’s alignment was considered with reference to progress in:
1. Enabling context, policy and institutions for value in health care
2. Measuring outcomes and costs
3. Integrated and patient-focused care
4. Outcome-based payment approach.
While the international perspective is perhaps more optimistic than might be supported from a national perspective, this presentation will highlight that important enablers of value-based health care that are already present in Australia. A key limitation to greater alignment in Australia is that the components are being implemented individually and not as part of a coordinated strategy.
Conclusions
Sustained cultural change is needed at all levels and across all sectors. Recommendations for enabling value-based health care through public policy in Australia that will be discussed include:
1. A national, cross-sector strategy for value-based health care in Australia
2. Access to relevant and up-to-date data
3. Evidence for value-based health care in the Australian context
4. Health workforce strategies supporting models of care that embrace a value-based approach
5. Funding systems that incentivise the delivery of value-based health care.
Australians have had access to universal health care for more than 30 years. However, our health care system is not immune to pressures of an ageing population, a growing burden of chronic disease, increasing life expectancy, increasing individual and community expectations, and escalating health care costs associated with new technology and treatments.
Many health care systems around the world are facing similar challenges and are looking to maximise the value of health care for populations, narrowing the gap between need and demand on one hand, and resources on the other.
Policy context and objective
Value in health care has been defined as the health outcomes that matter to patients relative to the resources or costs required, reflecting the seminal work of Porter and Teisberg. However, the term has become a buzzword, and, depending on who is setting the agenda, its meaning can be unclear and shifting.
This presentation will discuss the findings from the recently published Deeble Institute for Health Policy Research Issues Brief, Value-based health care – setting the scene for Australia, including:
• How value in health care is defined, with consideration of the inclusion of societal value in the context of Australia’s universal healthcare system.
• The important enablers of value-based health care that are already present in Australia, and the barriers to adoption.
• The opportunities and limitations in applying international experience in an Australian context, and sharing examples of work in Australia to progress value-based health care and the enabling public policy for success.
Targeted population
A value-based approach to health care provides a patient-centric way to design and manage health systems. Realising its potential requires unprecedented cooperation, coordination and partnerships among all stakeholders – providers, funders and patients, in addition to regulators and the professions.
Highlights
Alignment with a value-based approach to health care was assessed by the Economist Intelligence Unit for 25 countries, including Australia. A country’s alignment was considered with reference to progress in:
1. Enabling context, policy and institutions for value in health care
2. Measuring outcomes and costs
3. Integrated and patient-focused care
4. Outcome-based payment approach.
While the international perspective is perhaps more optimistic than might be supported from a national perspective, this presentation will highlight that important enablers of value-based health care that are already present in Australia. A key limitation to greater alignment in Australia is that the components are being implemented individually and not as part of a coordinated strategy.
Conclusions
Sustained cultural change is needed at all levels and across all sectors. Recommendations for enabling value-based health care through public policy in Australia that will be discussed include:
1. A national, cross-sector strategy for value-based health care in Australia
2. Access to relevant and up-to-date data
3. Evidence for value-based health care in the Australian context
4. Health workforce strategies supporting models of care that embrace a value-based approach
5. Funding systems that incentivise the delivery of value-based health care.
Biography
Kylie Woolcock is Policy Director at the Australian Healthcare and Hospitals Association, a national peak body for public and not-for-profit hospitals and health care providers. Members span hospitals, primary care, community care, aged care, individual clinicians and state/territory health departments, providing a unique opportunity to advocate for health care that is effective, accessible, equitable, patient-centred. sustainable and outcomes-focused.
While a pharmacist by background, she works with a broad range of health professions and health services, facilitating cross-sector activity to increase collaboration and innovation, optimise patient outcomes, maximise efficiencies and achieve a sustainable health system. She recently authored the Issues Brief, Value-based health care – setting the scene for Australia, published by the Deeble Institute for Health Policy Research.
Ms Helen Howson
Swansea Unviersity Bevan Commission
257 Prudent Health and Care: from principles to practice
Abstract
This presentation will build upon the Plenary presentation given by Sally Lewis and outline how the Bevan Commission, an independent think tank in Wales, has influenced national, regional and local policy and practice. Prudent health and care will be examined from the macro, meso and micro levels through the lens of partnerships, professionals and the public, providing examples of the real-life innovation and transformational work being undertaken through the Bevan Academy programme. A proven successful model to engage people and practitioners as active partners in care re-design and social movement for change to ensure a health and care system fit for the future.
Biography
Helen is the Director of the Bevan Commission and the Bevan Commission Academy. She has played a lead role in the development of the Commissions work and particularly Prudent Healthcare. Helen was instrumental in establishing the Bevan Academy, Bevan Innovators and Innovation Hub programmes, helping to drive its thinking into practice. She was previously a Public Health Consultant with Public Health Wales, leading a major Ministerial review of health improvement interventions across Wales. Prior to this Helen held a number of senior positions within Welsh Government Health Policy and Strategy, latterly heading up the Primary and Community Health Strategy Unit. Helen has worked as an advisor with the World Health Organisation and also advised Russian, Spanish, New Zealand and other Governments on health policy. Helen taught for a number of years on the WHO masters at Karolinska University in Sweden and at Bristol University as Director of a post-graduate Leadership programme for clinicians.
Dr Sidney Chandrasiri
Group Director Academic and Medical Services
Epworth Healthcare
259 Leading the transformation in value based healthcare
Abstract
Transformation is coming. Whether the different health systems of the world are hurtling towards or crawling at glacial speeds towards the adoption of value based healthcare, this change is coming and is inevitable. In spite of countless health care reform efforts in Australia and around the world, unwarranted variation, frequent errors, and unsustainable costs continue to persist. Our status quo is untenable. To solve our healthcare crisis, we must begin to reorient health care around value for patients, we must nurture and equip our clinical leaders with new and specific skills to lead this transformation and we must begin to move away from the zero-sum competition nature that our health system is structured around. Having just returned from value based healthcare discussions in San Fransisco, California and Scottsdale, Arizona, in this presentation Dr Chandrasiri will discuss reflections in this movement from the United States, and explore Michael Porter’s teachings of generating positive-sum competition to achieve value based healthcare in Australia. This presentation will further explore the key leadership personas and leadership styles essential in the monumental shift from volume to value based healthcare in Australia. This session will be relevant for all healthcare stakeholders -providers, funders, employers, clinicians and administrators, in looking at how we can adapt and embrace the monumental transformation towards value based healthcare that is facing our industry today.
Biography
Dr Sidney Chandrasiri MBBS MHM FCHSM FRACMA CHIA GAICD, is a Fellow of the Royal Australasian College of Medical Administrators (FRACMA), a Fellow of the Australasian College of Health Service Management (FCHSM), Graduate of the Australian Institute of Company Directors (GAICD), and holds a Masters in Health Management and Certification in Health Informatics. She has medical management experience in both public and private health care organizations across Australia and New Zealand.
Dr Chandrasiri is currently the Chief Medical Officer at Alexandra District Health Service, Acting Group Director, Academic and Medical Services at Epworth HealthCare, the RACMA Victorian Jurisdictional Coordinator of Training and a PEER reviewer for Safer Care Victoria. Her portfolio encompasses private, public, metropolitan and regional/rural health service leadership, and a number of areas across clinical governance, through to clinical services and strategic planning.
M Lucille Chalmers
General Manager Commissioned Programs
Brisbane South PHN
148 Contracting for outcomes in the primary care setting – a case study
Abstract
As commissioning practices in Australia mature, funding organisations are looking to transition from activity and service-based procurement processes to outcomes-based commissioning. This approach aims to shift the focus of health care investment from volume to value and achieve better outcomes for communities and the health system. One way to achieve this is through contracting for outcomes, whereby payments to service providers are based on performance against predetermined outcomes rather than activities.
The complexity of the change required for commissioners and service providers to transition from activity-based to outcomes commissioning is universally acknowledged. Much of the research and evaluation is based on international examples where the health system, the size and scope of contracts and service delivery agencies are very different to the Australian landscape. To build the local evidence base, and assess the value of this approach in the primary health setting, a payment for outcomes contract trial is being undertaken by Brisbane South PHN and two service providers.
Brisbane South PHN recognised the challenges of adopting outcomes contracting in a primary care environment of small-scale service providers, many of whom are in the not for profit sector, and the need to adopt a collaborative and structured approach to this different way of working. We collaborated with service providers over a six-month period to refine a “shadow” contract that defined performance and payment against agreed outcomes. This included intensive workshops to develop a program logic model defining long-term outcomes and objectives for the programs, agreeing key performance indicators and payment mechanisms. This ‘shadow’ contract was then trialled for 12 months while providers continued to be legally contracted to deliver services through traditional arrangements, meaning actual payments to the provider were not impacted by the results of the trial.
This paper will present the findings from the stage one evaluation of the trial, including insights from a funder and service provider perspective, examples of the payment and incentive structures included in the shadow contract and lessons learned to date. Discussion of the relevance and value of the approach within the Australian primary care landscape will be presented, and the applicability of the approach to other settings and cohorts will be explored.
The complexity of the change required for commissioners and service providers to transition from activity-based to outcomes commissioning is universally acknowledged. Much of the research and evaluation is based on international examples where the health system, the size and scope of contracts and service delivery agencies are very different to the Australian landscape. To build the local evidence base, and assess the value of this approach in the primary health setting, a payment for outcomes contract trial is being undertaken by Brisbane South PHN and two service providers.
Brisbane South PHN recognised the challenges of adopting outcomes contracting in a primary care environment of small-scale service providers, many of whom are in the not for profit sector, and the need to adopt a collaborative and structured approach to this different way of working. We collaborated with service providers over a six-month period to refine a “shadow” contract that defined performance and payment against agreed outcomes. This included intensive workshops to develop a program logic model defining long-term outcomes and objectives for the programs, agreeing key performance indicators and payment mechanisms. This ‘shadow’ contract was then trialled for 12 months while providers continued to be legally contracted to deliver services through traditional arrangements, meaning actual payments to the provider were not impacted by the results of the trial.
This paper will present the findings from the stage one evaluation of the trial, including insights from a funder and service provider perspective, examples of the payment and incentive structures included in the shadow contract and lessons learned to date. Discussion of the relevance and value of the approach within the Australian primary care landscape will be presented, and the applicability of the approach to other settings and cohorts will be explored.
Biography
Lucille is the General Manager Commissioned Programs, Brisbane South PHN. Lucille is an experienced senior health and human services executive with a special focus on community health and primary healthcare. Lucille was formerly the Community Business Optimisation Lead at Uniting Care Queensland and a Health and Human Services Management Consultant at Ernst & Young. Lucille has previously held senior positions in Diabetes Queensland and has worked as a program manager with a range of health service providers focusing on allied health and family and community health in Queensland and prior to that in Melbourne, Victoria. Lucille holds a Bachelor of Applied Science, Speech Pathology from Latrobe University, a Masters of Public Health from Monash University and a Graduate Certificate in Business – Philanthropy and Non Profit Studies from QUT.
Dr Joanne Epp
Senior Research Fellow
Macquarie Centre for the Health Economy
218 Commissioning for coordinated care services using an outcomes based funding model: Insights from a process review
Abstract
Background
The Central Coast Local Health District (CCLHD) implemented the Outcomes Based Commissioning pilot program in 2017 to keep older people with chronic conditions healthy and at home. CCLHD commissioned two not-for-profit organisations to provide care coordination services to an allocated cohort of patients over one year. Payment to providers was based on saved unplanned hospital bed days.
Objectives
Our study objective was to determine the impact of the CCLHD commissioning process on hospital use, health outcomes, and patient experience of care coordination. We also sought to develop recommendations to improve outcomes based commissioning approaches to keep people healthy and at home within the NSW healthcare system.
Methods
We developed a commissioning assessment framework by reviewing best practice commissioning approaches for healthcare, and the NSW Government’s commissioning policies and guidelines. We collected information on the CCLHD commissioning process from provider contracts and interviews held with providers and CCLHD. We used the assessment framework to compare CCLHD’s commissioning approach to best practice.
Results
CCLHD’s commissioning approach was aligned to the NSW Government’s commissioning policies and guidelines. A strong relationship developed between CCLHD and providers helped manage risk, supported by a robust monitoring framework. However, privacy requirements limited providers from using patient data to adequately assess their funding risk before being contracted. Limited access to timely unplanned public hospital data and discharge summaries reduced the ability of providers to manage their ongoing financial risk. Not all funding risk could be transferred to providers by CCLHD due to community obligations. The payment model did not adequately incentivise other desirable activities sought by CCLHD such as GP engagement.
Conclusions
The Outcomes Based Commissioning program was an innovative but complex approach to funding care coordination. There was little precedent within the NSW healthcare system from which CCLHD could draw upon. CCLHD involved providers in co-designing their commissioning approach.
Discussion
Providers were incentivised to reduce unplanned hospital bed days. Outcomes Based Commissioning also sought to increase health outcomes and patient and carer satisfaction with the health care system. While providers were asked to collect information on health outcomes through the PROMIS 10 survey, they were not directly incentivised to improve health outcomes nor increase patient and carer satisfaction. This meant there was some potential disconnect between service outcomes desired by CCLHD and provider intentions.
Lessons learned
Create incentives for providers to undertake other desired behaviours through payment linked to key performance objectives. This could include secondary analysis of process measures alongside primary outcome measures.
Limitations
Our commissioning results are limited to a 12-month pilot study conducted in one setting involving two providers. In addition, the Outcomes Based Commissioning program was designed to address local needs and conditions and some findings are context specific. These aspects limit transferability of the results.
Suggestions for future research
Additional evaluation studies are needed on outcomes based commissioning approaches in order to develop greater guidance for policy makers on the powers and pitfalls of using commissioning approaches and outcomes based funding models to achieve integrated care aims.
The Central Coast Local Health District (CCLHD) implemented the Outcomes Based Commissioning pilot program in 2017 to keep older people with chronic conditions healthy and at home. CCLHD commissioned two not-for-profit organisations to provide care coordination services to an allocated cohort of patients over one year. Payment to providers was based on saved unplanned hospital bed days.
Objectives
Our study objective was to determine the impact of the CCLHD commissioning process on hospital use, health outcomes, and patient experience of care coordination. We also sought to develop recommendations to improve outcomes based commissioning approaches to keep people healthy and at home within the NSW healthcare system.
Methods
We developed a commissioning assessment framework by reviewing best practice commissioning approaches for healthcare, and the NSW Government’s commissioning policies and guidelines. We collected information on the CCLHD commissioning process from provider contracts and interviews held with providers and CCLHD. We used the assessment framework to compare CCLHD’s commissioning approach to best practice.
Results
CCLHD’s commissioning approach was aligned to the NSW Government’s commissioning policies and guidelines. A strong relationship developed between CCLHD and providers helped manage risk, supported by a robust monitoring framework. However, privacy requirements limited providers from using patient data to adequately assess their funding risk before being contracted. Limited access to timely unplanned public hospital data and discharge summaries reduced the ability of providers to manage their ongoing financial risk. Not all funding risk could be transferred to providers by CCLHD due to community obligations. The payment model did not adequately incentivise other desirable activities sought by CCLHD such as GP engagement.
Conclusions
The Outcomes Based Commissioning program was an innovative but complex approach to funding care coordination. There was little precedent within the NSW healthcare system from which CCLHD could draw upon. CCLHD involved providers in co-designing their commissioning approach.
Discussion
Providers were incentivised to reduce unplanned hospital bed days. Outcomes Based Commissioning also sought to increase health outcomes and patient and carer satisfaction with the health care system. While providers were asked to collect information on health outcomes through the PROMIS 10 survey, they were not directly incentivised to improve health outcomes nor increase patient and carer satisfaction. This meant there was some potential disconnect between service outcomes desired by CCLHD and provider intentions.
Lessons learned
Create incentives for providers to undertake other desired behaviours through payment linked to key performance objectives. This could include secondary analysis of process measures alongside primary outcome measures.
Limitations
Our commissioning results are limited to a 12-month pilot study conducted in one setting involving two providers. In addition, the Outcomes Based Commissioning program was designed to address local needs and conditions and some findings are context specific. These aspects limit transferability of the results.
Suggestions for future research
Additional evaluation studies are needed on outcomes based commissioning approaches in order to develop greater guidance for policy makers on the powers and pitfalls of using commissioning approaches and outcomes based funding models to achieve integrated care aims.
Biography
Joanne is a senior health economist with extensive international experience in economics, research and policy analysis including work at the World Bank (USA), UNFPA (USA), the Ontario Treasury (Canada), AMP Capital Investors (Australia), the Centre for Health Economics Research and Evaluation (Australia), NSW Treasury (Australia), KPMG (Australia), Primary Health Care Limited (Australia) and Macquarie University Centre for the Health Economy (Australia).
Joanne has experience in policy analysis includes a variety of quantitative and qualitative techniques, including economic evaluation, data analysis, process evaluation, development of performance metrics, and preparation of strategic policy documents.
Joanne has a PhD in Economics from the University of New South Wales.
Her achievements include:
• Provision of advice and strategic thinking: at Primary Health Care Limited (on patient-centred medical home model, private pathology market regulation, and healthcare commissioning opportunities), at New South Wales Treasury (social policy investment model, priority setting and funding model for mental health), at AMP Capital Investors (aged care investment)
• Health policy development in Australia: at New South Wales Treasury (on national hospital funding agreement, national health policy reform, and priorities in mental healthcare investments)
• International health investment advisor: at The World Bank (on prioritising health care investments and policies across African and Asian countries, providing training and capacity building on healthcare financing, and developing performance metrics for family healthcare funding)
• Health market communicator: at University of Melbourne (The Role of Corporate Medical Centres), and at International and Australian Health Economics Association conferences (Trends in Access to Treatment for Mental Health in Australia, Setting the Efficient Price for NSW Hospital Services, and Evaluating an Outcomes Based Care Program)
• Health economics research: at the Macquarie University Centre for the Health Economy (integrated care evaluation for New South Wales Health, and outcomes based funding models for New South Wales Treasury), and at KPMG (commissioned economic evaluations for healthcare clients)
Specialisation
• Health and aged care policy evaluation
• Economic evaluation (CBA, CEA, ROI)
• International health policy analysis
Mrs Catherine Turner
Exec Manager, Commissioning
HNECC PHN
52 Outcomes based commissioning, evaluation and the challenge of decommissioning
Abstract
HNECC is a commissioner of primary care services in rural and regional NSW. Its remit is to deliver improved integration of primary care services, and it has used the Quadruple Aim framework to plan and measure outcomes.
With the establishment of Primary Health Networks and the advent of commissioning into the Australian Primary Care setting, there have been challenges to the worth of these activities. The implementation of service contracts with measurable outputs has been a challenge for service providers but has enabled effective contract management.
HNECCs commissioned services program use the Quadruple Aim framework to assess impact.
The means of developing outcomes and outputs is contained within the HNECC Outcomes Framework.
HNECC works with more than 40 service partners to deliver $42M of deliver services across Mental Health, Drug and Alcohol, Aboriginal Health, Allied Health and After-Hours services among others.
Since 2015, each of the contracts and programs have been reviewed and measurable outputs have been developed with service partners to enable effective measurement of performance.
Outputs such as service contacts, improved descriptions of service delivery models and agreed units of measurement of performance have been developed and implemented in relevant service contracts. This has resulted in a number of challenging conversations and the revision of contract values and in some cases, termination of contracts. At times, this has been at the instigation of the contracted provider, when the scrutiny of the effectiveness of the program has highlighted difficulties with the service model, the eligibility of clients or the appropriateness of delivery method.
HNECC has also been able to implement an innovative payment structure based on Patient Reported Outcomes with some of its programs, which has demonstrated improved patient outcomes and improvements to service delivery models based on real time patient feedback.
The model of measurement of effectiveness of contracted services has increased the funding available for new services and has enhanced the sustainability of many of the programs. Where services have been decommissioned, the funds have been reinvested in services based on the identified needs across the region. This has enabled funds to be used more effectively.
As new funding streams have been provided by the Commonwealth, HNECC has worked to include measurable outputs in all service contracts. Including these in the procurement process has increased our ability to evaluate tenders, especially when measuring value for money.
Specific examples of outcomes will be described across all domains of the Quadruple Aim.
HNECC’s experience with decommissioning services will be outlined, from the decision making process, to the transition of clients to new services.
Effective contract management is only possible when agreed measurable outputs are included in service contracts.
Service partners need support in transitioning from block funding to outcomes based commissioning.
Decommissioning is a reality of the commissioning process and is an opportunity for more effective investment in services for the community.
References
Bodenheimer, T. & Sinsky, C. 2014. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 2014;12:573-576. doi: 10.1370/afm.1713.
Biography
Catherine is the Executive Manager, Commissioning with the Hunter New England Central Coast Primary Health Network. Her team have been managing over $45M in primary care contracts, enabling services to be delivered to the population.
