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Oliver Wyman at Age UK's For Later Life conference on 1 July 2014. Read more on http://www.ageuk.org.uk/forlaterlife
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© Oliver Wyman HEALTH & LIFE SCIENCES
New Models of HealthcareAge UK
June 2014
2© Oliver Wyman 2
2011
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Activity
A&EOutpatientInpatient
Example: Anonymised Patient ProfileHigh cost frail elderly patient
Diagnosis: Hypertensive renal diseaseProcedure: Magnetic resonance imaging NEC
5
Source: Hospital Episode StatisticsNote: some dates have been altered to maintain patient anonymity
Details Service Utilisation
Name Mr A. N. Other Activity 37 interactions
Age 80-85 Cost £26,000
Patient Segmentation: Example high cost frail elderly patientThese patients require complex care for a variety of different conditions, often delivered in an uncoordinated way
Admitted from A&EDiagnosis: Complications of cardiac & vascular prosthetic devices, implants & graftsProcedure: Insertion of tunnelled venous catheter
6
Admitted from A&EDiagnosis: Unspecified nephritic syndromeProcedure: Percutaneous needle biopsy of lesion of kidney
1
Admitted from A&EDiagnosis: Other and unspecified injuries of abdomen, lower back and pelvis Procedure: None
3
Diagnosis: Unspecified nephritic syndromeProcedure: Intravenous chemotherapy
2
Admitted from A&EDiagnosis: Unspecified nephritic syndromeProcedure: Intravenous chemotherapy
4
3© Oliver Wyman 3
Patient Segmentation: Example high cost frail elderly patientThese patients require complex care for a variety of different conditions, often delivered in an uncoordinated way
2012 2013
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
InpatientOutpatient
Activity
CommunityGPA&E
Example: Anonymised Patient ActivityHigh cost patient
i
Diagnosis: Angina pectorisProcedure: None
3
Diagnosis: Non-specific chest painProcedure: None
Diagnosis: Non-insulin-dependent diabetes mellitusProcedure: None
1
2
Details Service Utilisation
Name Mr A. N. Other Activity 34 interactions
Age 45-50 Cost £10,000
Source: Hospital Episode StatisticsNote: some dates have been altered to maintain patient anonymity
44© Oliver Wyman
Population cost segmentation, secondary care spend, 2011
85%143k
(32% used secondary care)
11%19k
3%5.6k
12%£14m
41%£45m
47%£52m
Population segments
Cost breakdown
Spend per head:
£9.3k
£2.3k
£0.1k
High CostOver £5,000 per year
Moderate Cost£1,000 to £5,000 per year
Low CostUnder £1,000 per year
Source: Hospital Episode Statistics, 2011
Patient Segmentation: Cost concentrationThe most expensive 3% of patients account for 47% of secondary care costs
55© Oliver Wyman
Patient Segmentation: The cost pyramid by LHE
High Cost
Moderate Cost
Low Cost
87%112k
10%13k
3%4k
26%£20m
34%£25m
39%£30m
Airedale, Wharfedale & Craven* Blackpool East Riding Fylde & Wyre
High Cost
Moderate Cost
Low Cost
NE Lincs North Tyneside Somerset Sunderland*
86%148k
11%19k
3%5k
14%£16m
39%£42m
47%£51m
85%257k
11%35k
3%10k
13%£26m
39%£79m
48%£96m
86%130k
11%16k
3%5k
14%£14m
38%£36m
48%£46m
85%246k
12%35k
3%9k
13%£25m
42%£81m
45%£85m
Hull
85%143k
11%19k
3%6k
12%£14m
40%£45m
47%£52m
82%177k
14%30k
4%8k
13%£22m
66%£39m
48%£41m
87%475k
10%55k
3%16k
15%£51m
36%£121m
48%£160m
84%239k
12%34k
3%10k
14%£29m
36%£77m
50%£106m
* Includes additional cost data
66© Oliver Wyman
Population cost pyramid2012/3 £17m Social care cost
2%~2,000
0.5%~600
0.4%~400
~20%~£3.4m
~30%~£5.3m
~50%~£8.5m
Population segments
Cost breakdown
High CostOver £13,000 per year
Moderate Cost£5,000 to £13,000 per year
Low Cost£1,000 to £5,000 per year
Patient Segmentation: Cost concentrationFor social care the picture is even more concentrated……
Source: South Somerset Symphony project data, Oliver Wyman analysisNote: Net social care costs used, self-pay contributions excluded
Note: Over half of the highest healthcare cost
cohort (~2,800 patients with >£7,000 healthcare spend) did not have a social care assessment or receive any
social care
No Cost£0 per year 97%
~112,000
7© Oliver Wyman 7
A variety of patient-centric clinical models exist globally and are yielding outcome and cost improvements in targeted populations
• Extensivist led multifunctional team wraps services around the sickest patients
• Responsible for patient across all care settings
• Single point of patient contact and capitated payments drive accountability
• Ultra high efficiency ambulatory surgery model focused on a limited set of interventions
• Exploits techniques borrowed from manufacturing
• Very high patient and physician satisfaction
• Reduced admissions and length of stay
• 20% lower cost
• Lower complication and infection rate
• 30 to 40% lower cost
• Specialised GP model focused on a polychronic population
• Highly integrated care delivery with GP responsibility for all aspects of care
• Model tailored to underlying population and cultural norms
Extensivist model Systematised surgeryPrimary care medical home
• Same day access utilisation reductions (40% A&E, 50% speciality, 20% primary care)
Source: The Quiet Healthcare Revolution The Atlantic; AMSURG; Nuka Model of Care Provides Career Growth for Frontline Staff Southcentral Foundation; Oliver Wyman
88© Oliver Wyman
Extensivist clinics focus on the sickest patients, including a significant number of frail elders
Frail elderly overview
• Highest need patients aged over 65 at risk of catastrophic decline
• Uncoordinated care and inadequate access leads to unnecessary admissions and poor disease management
• Drive seven times more spend than the population average
>2 comorbidities
• Myocardial Infarction
• Congestive Heart Failure (CHF)
• Peripheral Vascular Disease
• Cerebrovascular Disease
• Dementia
• Chronic Obstructive Pulmonary Disease (COPD)
• Connective Tissue Disease
• Ulcer Disease
• Diabetes
• Hemiplegia
• Moderate to Severe Renal Disease
• Liver Disease
• Cancer – all types
• HIV / AIDS
• Multiple Sclerosis
Patient segmentation
9© Oliver Wyman 9
An Extensivist coordinates and reorients care around the patient
Behavioural/social care Chronic condition
management
Environment and equipment
Home and community-based
care
Social Work
“Life” support (e.g. finances)
Substance Abuse
Smoking Cessation
Palliative Care
Crisis management
Diabetes andWound Care
CAD / CHFCOPD
AsthmaCKD ESRD
Hypertension
General Co-morbidityManagement
Home Care
Durable Medical Equipment (DME)
Mobility Assistance
Remote Monitoring
TelevisitsNursing Home / SNF Care
Dischargemanagement
Diet / Nutrition
Psychiatry / Psychology
Transportation
Hospice
After-HoursCare
Clinical Pharmacy
Strength and Balancing
Patient Navigation
CaseManager
Extensivist
ClinicalCare Centres
(CCC)
GPs
Extensivist-led model
10© Oliver Wyman 10
Care team roles
Role Scope of Services
Extensivist • Clinical leader and the “quarterback” for the patient’s care
Advanced Practice Provider
• Supports Extensivist by evaluating and caring for patients as appropriate
Patient Navigator • Primary patient contact and care coordinator
Nurses/ MAs • In-office patient care
Behavioral health resource team
• Provides mental health support services
Pharmacist • Assists in pharmacy and medication therapy management
Receptionist • Handles patient enquires and scheduling
Office Manager • Manages practice staff, administration and compliance
Social worker • Coordinates solutions to resolve home and family life issues
Dietitian • Helps patients develop and maintain diets appropriate for their conditions
Palliative care • Assists in reducing patients’ physical and psychological suffering at end of life
Related services • Range of services including physical therapy, home care, post-discharge care, etc.
1111© Oliver Wyman
The Symphony Expert Care Hub Network will be modelled as a number of local Expert Care Hubs, sharing central support
The Symphony Expert Care Hub Network
Local Expert Care Hubs
• Location for co-located multi-skilled Care Coordinator and Key Worker teams to enable effective team working
• Initial point of contact for all patient needs, e.g. Questions, concerns, urgent enquiries, carer concerns
• Locally accessible to cohort patients, e.g.
– Delivery of care as part of care plans
– Meeting core team members for review
Central OfficeSymphony central office
• Shared infrastructure and support functions e.g. IT, Finance / accounting, patient identification and tracking, etc.
• Central business functions and Symphony management, e.g. Care model refinement, geographic expansion, planning for extension to new cohorts, etc.
Care Hub 1 Care Hub 4
Care Hub 2 Care Hub 3
12© Oliver Wyman 12
The Extensivist clinic can provide a one-stop shop for patients and helps reduce isolation
Basic Care
Pre-Op
Strength Training
Foot Care
Example Care Center Layout
Class-room
MedicalRecords
Room
Reg
istr
atio
nD
esk
Office – Exam Rooms–
Supplies/Equip.
Storage
NPOffice
Wa
itin
g
Co
mm
un
ity
TV
Ro
om
PodiatryRoom
Ex
ten
siv
ist
Off
ice
StrengthTraining
Room
La
b/D
iag
no
sti
cR
oo
m
– Exam Rooms–
Blood Pressure Management
Nutrition & Wellness Classes
Social SpaceNurse Practitioner
Hospitalist’s Office
Wound care
Fall Prevention
Source: “Delivering Integrated Patient Care for Seniors,” CareMore 11/2008, p. 33
Example Extensivist clinic
For discussion
In some areas, a smaller clinic can be supported by existing virtual or distributed infrastructure to provide the same levels of care
1313© Oliver Wyman
Extensivist practice overview
Chronic care-specialized physician is interested in building a suite of services to fully meet the need of the most fragile patients
Day in the Life
• Physician sees 8-10 patients, with visits ranging from 30 to 90 minutes
• Average panel size of 400 patients
• Physician practice includes supporting care team, including NPs/PAs, embedded health navigator, and other embedded services
Core Patient Profile
• 95%+ of patients have more than 4+ chronic condition and have serious health needs (sickest 5% of patients – to be discussed further)
Embedded Patient Services
• All patients will be eligible to receive health navigation from the embedded health navigator
• Other in-house patient services and built out based on patient volume and may include Behavioral Medicine, Pharmacy, Hospice, Nutrition, and others
• Patients may be connected to other community-based services by their health navigator
Compensation (TBD)
• Combined compensation model based on salary or a combination of on RVUs and gain share
Extensivist PracticeFocused on the most complicated chronic care within one practice
1414© Oliver Wyman
Patients selected for the Extensivist clinic will fall into one of three categories
1Catastrophic Patients 2 Future Catastrophics 3 Physician Referrals
• The biggest, most catastrophic and costly cases
• Small number of patients
• A portion of these patients won’t be catastrophic “tomorrow” (e.g. trauma patients, other one-off episodes)
• Patients with comorbidities, behavioral risk factors, and heavy system utilization
• Patients who may not be top spenders today, but are likely to be higher cost “tomorrow”
• Patients referred to the clinic by their physicians
• “We know them when we see them”
• Referrals to the clinic will be greeted with a quick answer and a quick decision
Will be identified via an analytic-based approach Will be identified via ongoing engagement with physicians
Extensivist patient categories
15© Oliver Wyman 15
A number of potential issues need to be overcome when establishing an Extensivist model
HOSPITAL
Total population: 168k
Future NE Lincs Health Economy – overview
HOSPITAL
Scunthorpe General
Need to manage perception of preferential treatment given to urban patients
• CCG needs to contract based on risk to enable provider upside
• Patients must be prepared to change their main point of contact as they move between models
• Federated GP clinics share information, capabilities and patients
• Risk and outcomes based payments demand risk pricing and flow of fund management capabilities
Hospital specialists must work alongside the Extensivist in order to co-ordinate care
Extensivist needs privileges for ward rounds within the hospital setting
The Humber
A&E Department
GP surgeries
Acute provider hospital
Mental health/Social care providers
Extensivist clinic
• Provider build of significant capabilities to launch– Extensivist lead clinician– Care team composition– Workflow redesign– Risk stratification– IT / systems– Scheduling
• Change in patient behaviours will be required
• Community-based resources will need to have aligned incentives and coordinated activities
For discussion
1616© Oliver Wyman
The model has 6 major elements, providing us with a view of the overall impact of the Expert Care hub, and impacts across the system
New cohort costCurrent cohort cost Expert care hub costs Other incremental services
Efficiency, de-duplication & re-use
Lower cost of care
1 2 3 4 5
Symphony economic model elements
Co
st
6
Illustrative – not to scale
1717© Oliver Wyman
• Integrated, team-based delivery
• Shift to prevention and wellness
• Transformed outcomes and value for money, partly through selective partnerships
• New non-traditional healthcare players
• Intent to improve accessibility and wellness
• Extensive use of partnerships
• Widespread genomics sequencing
• Likely to entirely change health systems
• Baseline established for:
– Quality
– Safety
– Primary Care and Hospital efficiency
Wave 0BASIC SAFETY AND EFFICIENCY
Wave 1PATIENT-CENTRED CARE
Wave 2CONSUMER ENGAGEMENT
Wave 3SCIENCE OF PREVENTION
The UK healthcare system will undergo waves of innovation, transforming care delivery
Early effects already impacting the UK, continuing over the next decade Future waves
Source: Oliver Wyman Health Innovation Centre
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