Upload
hiroko
View
36
Download
0
Tags:
Embed Size (px)
DESCRIPTION
PsychOdyssey. Discussion with the NJ Mental Health Planning Council Tom Pyle, January 9, 2013 www.psychodyssey.net. The Concept of Value in Mental Health Services. The Family Experience. From our last meeting…. “…Investors…”. “…Business Models...”. BizSpeak : “Investments” ?…. ROI - PowerPoint PPT Presentation
Citation preview
1
The Concept of Valuein Mental Health Services
Discussion with the NJ Mental Health Planning CouncilTom Pyle, January 9, 2013www.psychodyssey.net
PsychOdyssey
2
The Family Experience
3
From our last meeting…
4
“…Investors…”
5
6
“…Business Models...”
7
BizSpeak: “Investments” ?…
ROI1. (n.) The French word for “king.” 2. Abbr. for return on investment, a way to measure the benefit of an investment. Photographer: Adam Frans van der Meulen/Getty Images
8
In other words…
9
Value in Mental Health Services
10
What is the Problem? (Kaplan & Porter, 2011)
“…almost complete lack of understanding of how much it
costs to deliver patient care, much less how those costs compare with
the outcomes achieved.”Robert Kaplan & Michael Porter
11
What is the Goal?
Access? Availability? Equity? Cost containment?
VALUE for the Consumer
12
Value: Definition (Oxford English Dictionary)
The regard that something is held to deserve; the importance, worth, or usefulness of something: your support is of great value
the material or monetary worth of something
the worth of something compared to the price paid or asked for it
13
Value in Health Care
14
Value: A Calculation (Porter, 2010)
Value = ❑❑
𝑂𝑢𝑡𝑐𝑜𝑚𝑒𝑠𝐶𝑜𝑠𝑡𝑠
15
Outcomes (Porter, 2010)
Multidimensional By steps… Over time…
16
Outcomes Measures Hierarchy (Porter, 2010)
17
Challenges of Health Care Costing (Porter, 2010)
Complex delivery Many resources Each with different capabilities and costs
Fragmented delivery “Idiosyncratic” (i.e., “Individualized”) Highly customized “job shop”
18
Costs: How To Measure? (Kaplan & Porter, 2011)
Track the… sequence and duration
0f the… clinical and administrative processes
used by the… individual patient
Time-Driven Activity-Based Costing (TDABC)
19
Time-Driven Activity-Based Costing(Kaplan & Porter, 2011)
Patient Jones’ outpatient visit…Provider Tasks Time Rate CostAdministrator
Check-in, register, document payment
18 minutes (0.3 hours)
Nurse Take temp, weigh, take BP, prep
24 minutes (0.4 hours)
Doctor Direct exam, consultation
9 minutes (.15 hours)
20
Time-Driven Activity-Based Costing(Kaplan & Porter, 2011)
𝐸𝑥𝑝𝑒𝑛𝑠𝑒𝑠 𝐴𝑡𝑡𝑟𝑖𝑏𝑢𝑡𝑎𝑏𝑙𝑒𝑡𝑜𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖𝐴𝑣𝑎𝑖𝑙𝑎𝑏𝑙𝑒𝐶𝑎𝑝𝑎𝑐𝑖𝑡𝑦 𝑜𝑓 𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖
Capacity Cost Rate for Resourcei =
21
TDABC(Kaplan & Porter, 2011)
𝐸𝑥𝑝𝑒𝑛𝑠𝑒𝑠 𝐴𝑡𝑡𝑟𝑖𝑏𝑢𝑡𝑎𝑏𝑙𝑒𝑡𝑜𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖𝐴𝑣𝑎𝑖𝑙𝑎𝑏𝑙𝑒𝐶𝑎𝑝𝑎𝑐𝑖𝑡𝑦 𝑜𝑓 𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖
Capacity Cost Rate for Resourcei =Salary (nurse) $65,000Supervision cost $9,000Occupancy (9 m2 x $1200/m2/yr)
$10,800
Tech & support $2,560Annual nurse cost $87,360Monthly nurse cost $7,280
❶
❶
22
TDABC(Kaplan & Porter, 2011)
𝐸𝑥𝑝𝑒𝑛𝑠𝑒𝑠 𝐴𝑡𝑡𝑟𝑖𝑏𝑢𝑡𝑎𝑏𝑙𝑒𝑡𝑜𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖𝐴𝑣𝑎𝑖𝑙𝑎𝑏𝑙𝑒𝐶𝑎𝑝𝑎𝑐𝑖𝑡𝑦 𝑜𝑓 𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖
Capacity Cost Rate for Resourcei =Salary (nurse) $65,000Supervision cost $9,000Occupancy (9 m2 x $1200/m2/yr)
$10,800
Tech & support $2,560Annual nurse cost $87,360Monthly nurse cost $7,280
Start with 365 daysLess: w/e, vac’t’n, holidays, sick, etc.
141 days
Available 224 days/yr
Available days (a)
18.7 days/mo
Start with 7.5 hours/day
Less: breaks, meetings, etc.
1.5 hours
Available hours (b)
6.0 hours/day
Total Capacity (a x b)
~112 hrs/mo
❷
❷
❶
❶
23
TDABC(Kaplan & Porter, 2011)
𝐸𝑥𝑝𝑒𝑛𝑠𝑒𝑠 𝐴𝑡𝑡𝑟𝑖𝑏𝑢𝑡𝑎𝑏𝑙𝑒𝑡𝑜𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖𝐴𝑣𝑎𝑖𝑙𝑎𝑏𝑙𝑒𝐶𝑎𝑝𝑎𝑐𝑖𝑡𝑦 𝑜𝑓 𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖
Capacity Cost Rate for Resourcei =Salary (nurse) $65,000Supervision cost $9,000Occupancy (9 m2 x $1200/m2/yr)
$10,800
Tech & support $2,560Annual nurse cost $87,360Monthly nurse cost $7,280
Start with 365 daysLess: w/e, vac’t’n, holidays, sick, etc.
141 days
Available 224 days/yr
Available days (a)
18.7 days/mo
Start with 7.5 hours/day
Less: breaks, meetings, etc.
1.5 hours
Available hours (b)
6.0 hours/day
Total Capacity (a x b)
~112 hrs/mo
Nurse’s Capacity Cost Rate = $7,280 -:- 112 hrs = $65/hr
❸
❸
❷
❷
❶
❶
24
TDABC(Kaplan & Porter, 2011)
Patient Jones’ outpatient visit…Provider Tasks Time Rate CostAdministrator
Check-in, register, document payment
18 minutes (0.3 hours)
Nurse Take temp, weigh, take BP, prep
24 minutes (0.4 hours)
$65/hr
Doctor Direct exam, consultation
9 minutes (.15 hours)
❸
25
TDABC(Kaplan & Porter, 2011)
Patient Jones’ outpatient visit…Provider Tasks Time Rate CostAdministrator
Check-in, register, document payment
18 minutes (0.3 hours)
$45/hr $13.50
Nurse Take temp, weigh, take BP, prep
24 minutes (0.4 hours)
$65/hr $26.00
Doctor Direct exam, consultation
9 minutes (.15 hours)
$300/hr $45.00
$84.50
26
Value Measurement (Porter, 2010)
What is the proper unit?
All services and activities that jointly determine success in meeting a set of consumer needs.
“Integrated practice units”
27
Value Measurement, 2 (Porter, 2010)
Separately for each condition…with other conditions “risk adjusted”.
Not separately by department or billing unit
28
Care Needs in Mental Health…Integrated Care Resource Center (2013)
29
Care Problem in Mental Health…Integrated Care Resource Center (2013)
30
Limits of the System…(Unutzer, 2011)
31
The Experience in Washington…(Unutzer, 2011)
32
Costing: The Whole Process (Kaplan & Porter, 2011)
1. Select the condition
33
Costing: The Whole Process (Kaplan & Porter, 2011)
1. Select the condition2. Define the care delivery value
chain (CDVC)
34
2. Care Delivery Value Chain (Kaplan & Norton, 2011)
35
2. Care Delivery Value Chain (Kaplan & Norton, 2011)
36
1. Select the condition2. Define the care delivery value
chain (CDVC)3. Map each activity
Costing: The Whole Process (Kaplan & Porter, 2011)
37
3. Map the Process (Kaplan & Porter, 2011)
38
1. Select the condition2. Define the care delivery value
chain (CDVC)3. Map each activity4. Obtain time estimates
Costing: The Whole Process (Kaplan & Porter, 2011)
39
1. Select the condition2. Define the care delivery value
chain (CDVC)3. Map each activity4. Obtain time estimates5. Estimate resource supply cost
Costing: The Whole Process (Kaplan & Porter, 2011)
40
1. Select the condition2. Define the care delivery value
chain (CDVC)3. Map each activity4. Obtain time estimates5. Estimate resource supply cost6. Estimate resource capacity;
calculate capacity cost rate
Costing: The Whole Process (Kaplan & Porter, 2011)
41
5. Capacity Cost Rate(Kaplan & Porter, 2011)
𝐸𝑥𝑝𝑒𝑛𝑠𝑒𝑠 𝐴𝑡𝑡𝑟𝑖𝑏𝑢𝑡𝑎𝑏𝑙𝑒𝑡𝑜𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖𝐴𝑣𝑎𝑖𝑙𝑎𝑏𝑙𝑒𝐶𝑎𝑝𝑎𝑐𝑖𝑡𝑦 𝑜𝑓 𝑅𝑒𝑠𝑜𝑢𝑟𝑐𝑒𝑖
Capacity Cost Rate for Resourcei =Salary (nurse) $65,000Supervision cost $9,000Occupancy (9 m2 x $1200/m2/yr)
$10,800
Tech & support $2,560Annual nurse cost $87,360Monthly nurse cost $7,280
Start with 365 daysLess: w/e, vac’t’n, holidays, sick, etc.
141 days
Available 224 days/yr
Available days (a)
18.7 days/mo
Start with 7.5 hours/day
Less: breaks, meetings, etc.
1.5 hours
Available hours (b)
6.0 hours/day
Total Capacity (a x b)
~112 hrs/mo
Nurse’s Capacity Cost Rate = $7,280 -:- 112 hrs = $65/hr
❸
❸
❷
❷
❶
❶
42
1. Select the condition2. Define the care delivery value
chain (CDVC)3. Map each activity4. Obtain time estimates5. Estimate resource supply cost6. Estimate resource capacity;
calculate capacity cost rate7. Calculate total cost
Costing: The Whole Process (Kaplan & Porter, 2011)
43
6 Strategic Objectives (Porter, 2012)
1. Organize system around patient2. Measure outcomes and costs 3. Pay in “bundles”4. Affiliate better (less all-service
stand-alone)5. Expand beyond narrow geographies6. Build IT, but not for a broken
system
44
Obj. 1: Organize around patient…(Porter,2012)
45
… Throughout Continuum of Care (Porter, 2012)
46
Obj. 2: Measure…the whole chain… (Porter, 2012)
47
…and up and down the hierarchy (Porter, 2012)
48
Obj. 3: Pay in bundles(Porter, 2012)
NB
49
Obj. 4: Affiliate better (Porter, 2012)
50
Obj. 5: Expand… (Porter, 2012)
51
Obj. 6: Build IT (Porter, 2012)
…but not for an unreconstructed delivery system!
52
Implications for Government (Porter, 2012)
Establish universal measurement and reporting
Shift reimbursement systems bundled Medicare to lead…
Remove obstacles to integration Stark Laws limiting referrals (“conflict of interest”)? Separate payments to hospitals and doctors? Illegal to hire a doctor as an employee?
Open competition Encourage patient responsibility Set standards and mandate EMR adoption
53
Application to Mental HealthCHALLENGES…
Medical model Localization (120
agencies) Reimbursement rates Political barriers Length of
“continuum” Individualization Scaling State v. Federal Excessive
dehospitalization Funding limits
OPPORTUNITIES…
PsyR model Wellness focus Recovery ideal PACT team model Behavioral Health
Homes Hospital consolidation Funding limits …
54
References
Integrated Care Resource Center. (2013). Exploring Medicaid Health Homes: The Collaboration Care Model: An approach for integrating physical and mental health in Medicaid Health Homes [Webinar]. Washington, DC: Integrated Care Resource Center, Center for Medicare and Medicaid Serviceso.
Kaplan, R. S., & Porter, M. E. (2011). How to solve the cost crisis in health care. [Article]. Harvard Business Review, 89(9), 46-64.
Porter, M. E. (2010). What is value in health care? New England Journal of Medicine, 363(26), 2477-2481. doi: doi:10.1056/NEJMp1011024
Pyle, T. H. (2012). Value: A better measure for health care and mental health services. Unpublished paper.
Unutzer, J. (2011). Collaborative care: Integrating physical and mental health care in medicaid health homes [Presentation as part of webinar]. Seattle, WA, Univeristy of Washington. http://uwaims.org/overview-integrated.html
55
YouTube: Porter on Health Care Big Think: http://bigthink.com/ideas/14761
Porter & Kaplan interviewed by HBR (9 mins): http://www.youtube.com/watch?v=Y7HMHiv7xRg
Lecture at Center for Public Policy (90 mins): http://youtu.be/Z3fKyWydweo