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Ben Richardson: How payment innovation can change healthcare

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Ben Richardson: How payment innovation can change healthcare

  1. 1. How paymentinnovation can changehealthcareNuffield SummitBen RichardsonDiscussion Document8 March 2013CONFIDENTIAL AND PROPRIETARYAny use of this material without specific permission of McKinsey & Company is strictly prohibited
  2. 2. Changing how we pay for healthcare is key tounlocking innovation▪ Payment innovation is a way to align payors and multiple providers on the triple aim of improved quality, better experience and reduced cost▪ It can do this by helping to 1) making value conscious choices, 2) reduce needless variation in cost, 3) target resources where it is needed, 4) changing patient behaviour▪ Broadly three different models exist for payment: capitation, episodes, and pay for performance▪ These payment models are being put into place by different types of players▪ Note of caution: payment innovation on its own isn’t enough—other enablers are required▪ Putting in place payment innovation can be done at multiple levels McKinsey & Company | 1
  3. 3. 4 levers that payment innovation can support Lever Payment innovation Make value-conscious choices ▪ Allow provider to benefit from 1 ▪ Practice (eg. resolve in 1ry care) reducing cost ▪ Procedure (eg. decisions) ▪ Products (eg. Gx) ▪ Providers (eg referrals) Reduce unwarranted variation ▪ Upside better performance 2 ▪ Understand “normal” and/or improvement ▪ Peer review “abnormal” ▪ Downside for poor performance Better management of chronic ▪ Fund additional care 3 conditions ▪ Allow provider to benefit from ▪ Coordinate care reducing cost ▪ Faster response ▪ Proactively manage Change patient behaviour to support ▪ Incentivise individual behaviour 4 healthier lifestyles ▪ Provide personal budgets McKinsey & Company | 2
  4. 4. Unwarranted variation in practice-level activity and costActivity distribution by practiceActivity per 1000 weighted population (normalisedfor average IMD score) Non-elective Elective (R2 = 0.53) OP (R2 = 0.64) A&E (R2 = 0.64) 11-22% 2.7 2.6 2.6 2.6Weighted median = 136 Weighted median = 126 Weighted median = 1,565 Weighted median = 482SOURCE: HES 2010/11, McKinsey analysis, ONS, IMD, DH Exposition book McKinsey & Company | 3
  5. 5. 20% of patients drive 80% of costs2010/11 data, 4 London Average cost per Health spend TotalCCGs Population capita per annum, £ Social care spend spend, £m Very 4,757 39,600 118 high risk High 41,675 8,700 327 risk Moderate 142,773 2,400 There is a 40X 354 risk variation in spend (and needs) between There is a 40X average and highest variation in spend (and cost patients, the Low risk 322,609 500 needs) between 186 mostly flat, “one size average and highest fits all” payment risk patients model doesn’t address Very low this 378,020 300 104 risk Total / average ~890,000 1,230 10881 Includes elective admissions, outpatient, and A&E 2 Includes community health & primary careSOURCE: McKinsey team analysis, NHS NWL data; HES 2010/11, FIMS, Q research/NHS Information centre, PSSEX; McKinsey & Company | 4 NHS Reference Costs
  6. 6. There are 3 major complementary payment models being deployed in US Full Population-based payment Most applicable alignment of ▪ Capitation ▪ Primary prevention for healthy payment to ▪ Care for chronically ill outcomes (e.g., managing obesity, CHF) Episode-based payment ▪ Acute procedures (e.g., CABG, hips, perinatal)  Retrospective Episode Based ▪ Most inpatient stays including Payment (REBP) post-acute care, readmissions  Bundled payment ▪ Acute outpatient care (e.g., broken arm, URI, some cancers, some behavior health) ▪ Discrete services provided by Pay for performance entity with limited influence on ▪ Bonus payments tied to quality upstream or downstream costs (e.g., MRI, prescription, ▪ Bonus payment tied to value medical device, Health Risk Assessment) McKinsey & Company | 5
  7. 7. International experiments with a wide variety of new reimbursementand risk-sharing models Select examples Description “Payor-led” ▪ Payor-led affiliation or acquisition of health system seeking full clinical/operational integrated network integration to reduce costs, improve Full risk experience, and manage referrals “Provider-led” ▪ Provider system that takes full risk either with own health plan or under contract, using integrated network integrated clinical system to deliver value Risk sharing ▪ Provider organisation accountable for quality, ACO cost, and overall care; share cost savings if performance metrics are met ▪ Covers all aspects of preadmission, inpatient, Episodes of care and follow-up care, including postoperative complications within a set time period Patient centered ▪ Team of physicians and extenders, coordinated by a PCP, coordinate provide medical home high levels of coordinated care; typically tiedsharing Gain to P4P contract ▪ Payment bonus tied to efficiency metrics Pay for value (e.g., reduction in ER visits, imaging)SOURCE: McKinsey Analysis McKinsey & Company | 6
  8. 8. Payment innovation must meet 8 requirements to drive cost-reducinginnovation in care delivery Expand use of population-based and episode-based Setting expectations payment Maximize provider revenue and earnings subject to Significant outcomes-based reimbursement at Scale Ensure a critical mass of providers within a local market transition to outcomes-based reimbursement Stable Clarify long-term vision and commit to providers Striving, but practical Design approach to be effective in current regulatory, legal, industry structure Sustainable Ensure providers that adapt thrive financially Supportive Payment innovation necessary but not sufficient— needs support for transformation Supply-demand Align reimbursement with patient engagement, integration benefits, network design, etc. McKinsey & Company | 7
  9. 9. Significant impact of payment innovation internationally Country Example Impact achieved ▪ 25% lower cost per head ▪ 30% drop in admissions ▪ 90% patient satisfaction ▪ 13% reduction in cost per head ▪ 7% below median costs ▪ Top decile outcomes ▪ 58% fewer amputations ▪ 18-30% lower admission ▪ 17-43% lower readmissions ▪ 92% net promoter score McKinsey & Company | 8
  10. 10. The major success stories that we have studied have all had a majorinnovation around reimbursement Care delivery innovation: Segmentation of population by risk     Innovative delivery model matched to needs     Innovative payment mechanism at scale     Information flow and IT platform     Accountability and governance     Clinical leadership and development of culture     Patient/user partnership     McKinsey & Company | 9
  11. 11. How do you take this forward? Action ExampleSystem-  Establish and fund innovation model with 5 at  US: CMS Statelevel scale testing sites and 10 planning sites Innovation Model  Creates risk adjusted individual-level capitation  GE: mRSA payments  Change hospital reimbursement to create capitated  US: Medicare ACOs ACOsLocal Health  Create multi-payor/multi-provider partnerships  US: SacramentoEconomy with payment innovation, governance structure,  UK: NHS NWL information tools, clinical change and patient  DE: Bundes- engagement knappschaftCommissio-  Change reimbursement mechanisms and  US: Arkanasners information flow to transfer some risk to providers  US: BCBSMA AQC and incentivise management of total medical cost  DE: AOK  Accountable Providers with at-risk reimbursement  US: Chen MedProviders based on quality and performance, creating system  ES: Ribera Salud with clinical model, people model and information to drive superior performance McKinsey & Company | 10
  12. 12. Changing how we pay for healthcare is key tounlocking innovation▪ Payment innovation is a way to align payors and multiple providers on the triple aim of improved quality, better experience and reduced cost▪ It can do this by helping to 1) making value conscious choices, 2) reduce needless variation in cost, 3) target resources where it is needed, 4) changing patient behaviour▪ Broadly three different models exist for payment: capitation, episodes, and pay for performance▪ These payment models are being put into place by different types of players▪ Note of caution: payment innovation on its own isn’t enough—other enablers are required▪ Putting in place payment innovation can be done at multiple levels McKinsey & Company | 11
  13. 13. Arkansas Payment Improvement Initiative (APII): William Golden MD MACP Medical Director, Arkansas Medicaid UAMS Professor of Medicine and Public Health William.Golden@arkansas.gov 12
  14. 14. Preliminary working draft; subject to changeSTRATEGYThe populations that we serve require care falling into three domains Patient populations within scope (examples) Care/payment models Prevention, ‒ CHF • Healthy, at-risk Population-based: screening, ‒ COPD • Chronic, e.g., medical homes responsible for chronic care ‒ Diabetes care coordination, rewarded for quality, utilization, and savings against total cost of care ‒ AMI ‒ CHF • Acute medical, e.g., Episode-based: ‒ Pneumonia retrospective risk sharing with Acute and one or more providers, rewarded ‒ CABG post-acute for quality and savings relative ‒ Hip replacement care • Acute procedural, e.g., to benchmark cost per episode Supportive • Developmental Combination of population- care disabilities and episode-based models: • Long-term care health homes responsible • Severe and persistent for care coordination; episode- mental illness based payment for supportive care services 13
  15. 15. PAPs that meet quality standards and have average costs below thecommendable threshold will share in savings up to a limit Shared savings Pay portion of excess - costs Shared costs No change High No change in payment to providers Acceptable Receive additional payment as share as savings + Commendable Gain sharing limit Low Individual providers, in order from highest to lowest average cost
  16. 16. Draft thresholds for General URIs Provider average costs for General URI episodes Adjusted average episode cost per principal accountable provider1 Average cost / episode Dollars ($) Antibiotics prescription rate above episode average2 Antibiotics prescription rate below episode average2 Year 1 acceptable 67 Year 1 commendable 46 Gain sharing limit 15 Principal Accountable Providers1 Each vertical bar represents the average cost and prescription rate for a group of 10 providers, sorted from highest to lowest average cost2 Episode average antibiotic rate = 41.9%SOURCE: Arkansas Medicaid claims paid, SFY10
  17. 17. ▪ More information on the Payment Improvement Initiative can be found at www.paymentinitiative.org – Further detail on the initiative, PAP and portal – Printable flyers for bulletin boards, staff offices, etc. – Specific details on all episodes – Contact information for each payer’s support staff – All previous workgroup materials

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