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WELCOME

April 14, 2016

OPTIMIZINGCOSTS AND OUTCOMESIN HEALTHCARE

From theory to real life

ROB TEN HOEDT

EXECUTIVE VICE PRESIDENT & PRESIDENT, EMEA

OPTIMIZING COSTS AND OUTCOMES IN HEALTHCARE

AGENDA

TIME TOPIC PRESENTER

11:00 – 11:15 WelcomeThe Role of Medical Technology in Value-Based Healthcare, Medtronic Value Work Underway

ROB TEN HOEDT, Executive Vice President and President,Medtronic EMEA

11:15 – 11:25 HBR ‘s Focus on and Definition of Value-Based Healthcare

JOSH MACHT, Executive Vice President & Group Publisher,Harvard Business Review

11:25 – 11:40 Measuring Outcomes: ICHOM perspective CHRISTINA AKERMAN, MD, PHD, President of International Consortium for Health Outcomes Measurement (ICHOM)

11:40 – 11:55 Measuring Outcomes: ERAS Society perspective PROF. OLLE LJUNGQVIST, Chairman and Founding Member , The Enhanced Recovery After Surgery (ERAS) Society

11:55 – 12:15 Panel DiscussionModerator: JOSH MACHT

12:15 – 12:30 Open Floor Q&A

12:30 Close

CORE SET OF UNIVERSAL HEALTHCARE NEEDSHAS EXPANDED BEYOND CLINICAL OUTCOMES ALONE

Optimize costs and efficiencies

Expand access

Improve clinical outcomes

REIMBURSEMENT MODELS SHIFTING TO VALUE

FEE FOR SERVICE(e.g. DRGs)

PAY FORPERFORMANCE

Reimbursed for volume of services, not value

Fee for service at risk for bonuses/penalties based on performance measures

“ACTIVITY” BASED PROCESS MEASURES

MEDTRONIC LEGACY BUSINESS MODEL

INTEGRATED CARE/ BUNDLED PAYMENT

Single payment for all services provided for an episode of care

HIGHEST COST PATIENTS

MEDTRONIC VBHC FOCUS

ACCOUNTABLE CARE/SHARED SAVINGS

Capitated payment for some, but not all, services

INCORPORATING BUNDLED PAYMENTS TO ADDRESS HIGH COST

STEPS TO VALUE-BASED HEALTHCARE

SELECT ADISEASE OR CONDITION

DEVELOPPATIENT COHORTS BASED ON RISK AND PROTOCOLS

DEFINEOUTCOME MEASURESTHAT AREMEANINGFULFOR PATIENTS

DEFINETIMEFRAMEREQUIRED TO ACHIEVE OPTIMAL OUTCOME

QUANTIFYBASELINE OUTCOMES AND COSTS FOR EACH PATIENT COHORT

DETERMINEPROSPECTIVE PERFORMANCE AND COST OBJECTIVES –THE VALUE PROPOSITION

DEVELOPBUSINESS MODEL

1 2 3 4 5 6 7

Critical to Medtech Innovation

New Partnerships and Business Models Based on Joint Accountability

IDENTIFY PATIENT COHORT

DEFINE AND BASELINE

OUTCOMES

DEVELOP BUSINESS MODEL

EXAMPLES OF VALUE-BASED INITIATIVES

DIABETER

Type 1 diabetes

patient management

DAVITA KIDNEY CARE

Dialysis services for

patients with

chronic kidney failure

DUTCH OBESITY CLINIC

Pre- and post-surgery care

for bariatric patients

CARDIOCOM

Remote patient management

for chronic conditions

including heart failure

MEDTRONIC

Integrated Health

Solutions

Managed Services

for CathLab/OR/ICU

ACROSS THE CARE CONTINUUM, FOR BETTER OUTCOMES

MEDTRONIC IHS MANAGED SERVICESHOLISTICALLY ADDRESS CUSTOMER NEEDS

KEY NEEDS

Manage capital investment: reduce burden on balance sheet

Reduce supply cost: increase operating margin

Improve operational performance: increase operating margin and outcomes

Increase footfall: optimize treatment numbers and patient referrals

Provide affordable access

to state-of-the-art infrastructure and technologies

Manage non-clinical operations to enable focus on patient care

Deliver best-in-class cost efficiency and patient outcomes

Accelerate patient access

to care; develop

services and enhance

reputation

TURNKEY SET-UP MANAGE

OPTIMISEDEVELOP

MULTI-YEAR CONTRACT WITH FEE-PER-PROCEDURE

PAYMENT MODEL AND RISK VALUE SHARING

IFC Meeting | January 6th, 2016 | Confidential, for Internal Use Only

JOSH MACHTExecutive Vice President & Group PublisherHarvard Business Review

The International Consortium for Health Outcomes Measurement (ICHOM)

14th April 2016

Standard Presentation.pptx 16Copyright © 2013 by the International Consortium for Health Outcomes Measurement. All rights reserved.

variation in 30-day mortality rate from heart attack in US hospitals

variation in bypass surgery mortality in the UK hospitals

Variation of major obstetrical complications among US hospitals

variation in complication rates from radical prostatectomies in the Dutch hospitals

variation in reoperation rates after hip surgery in German hospitals

variation in mortality after colon cancer surgery in Swedish hospitals

variation in capsule complications after cataract surgery in Swedish hospitals

Variation in outcomes is a worldwide problem

4x

9x

18x

20x

36x

2x

Source: ICHOM analysis, Martin Makary, How Health Care’s Successes Became Distractions”, Health Affairs August 2014

5x

“Despite achievements in areas of patient safety, the problem of variation remains endemic, and unmeasured.”

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75.5

43.3

94.0

80.0

50.0

94.0

34.7

6.5

95.0

0

10

20

30

40

50

60

70

80

90

100

This is why measuring and reporting meaningful outcomes matters Comparing outcomes of prostate cancer care

Swedish data rough estimates from graphs; Source: National quality report for the year of diagnosis 2012 from the National Prostate Cancer Register (NPCR) Sweden, Martini Klinik, BARMER GEK Report Krankenhaus 2012, Patient-reported outcomes (EORTC-PSM), 1 year after treatment, 2010

1 yr severe erectile dysfunction

%

1 yr incontinence5 year survival

Best-in-class: Martini KlinikGermany Sweden

Focussing on mortality alone…

…may obscure large differences in outcomes that matter most to patients














ICHOM was formed to drive the industry towards value-based health care by defining global outcome standards

Our missionWhere we come from

Three organizations with the desire to unlock the potential of value-based health care founded ICHOM in 2012:

ICHOM is a nonprofit▪ Independent 501(c)3 organization▪ Idealistic and ambitious goals▪ Global focus▪ Engages diverse stakeholders

Value =

Our mission

Unlock the potential of value-based health care by defining global

Standard Sets of outcome measures that really matter to patients for the

most relevant medical conditions and by driving adoption and reporting of

these measures worldwide

Cost of delivering those outcomes

Patient health outcomes achieved


The starting point for value-based health care reform is to measure meaningful outcomes

5 reasons why outcome measurement is essential:

Outcomes define the goal of the organization and its accountability to patients

Outcomes inform the composition of integrated care teams

Outcomes motivate clinicians to collaborate and improve together

Outcomes highlight value-enhancing cost reduction

Outcomes enable payment to shift from volume to results

1

2

3

4

5

See full article in Harvard Business Review: https://hbr.org/2015/09/better-value-in-health-care-requires-focusing-on-outcomes


In the state of Michigan, payer-provider collaboration around value is improving patient outcomes and lowering cost

Collaborative Quality Initiatives (CQIs)

Payer funds infrastructure for data collection and analysis across 20+ conditions

Coordinating Center (Univ. of Michigan) analyzes data from clinical registries and reports back to providers

Clinician-led provider meetings encourage quality improvement through collaborative learning

Patient representatives included in discussion to ensure initiative maintains strong patient focus Cost reduction

2878

230261

96

106

31

0

100

200

300

PCI Cardiac

surgery

General

surgery

Savings ($M)2008-2012

Bariatric

surgery

~$600M

50 65 8093

50 35 20

50

100

0

% of events

Avoided

Readmissions

Length of stay

>5days

Venous thrombo-embolis

m

Post-surgical

death rates

7

Actual

Outcomes improvement

Actual vs avoided events following bariatric surgery based on % change between 2007 and 2012

Statewide BCBSM


ICHOM have developed 13 Standard Sets, covering 35% of the disease

We have already developed 13 standard setsIn early 2016, 8 more will

be completedWith ongoing discussions

to launch...

1. Craniofacial Microsomia2. Heart failure3. Pregnancy and childbirth4. Colorectal cancer5. Breast cancer6. Older people7. Overactive bladder8. Inflammatory bowel

disease

1. Rotator cuff disease2. Bipolar disorder3. End stage renal failure4. Hypertension* 5. Malaria6. Adult population health7. Substance use8. Oral health9. Inflammatory arthritis10. Congenital hand

malformations11. Brain tumors12. Upper GI cancers13. Type 1 diabetes

Numbers not representing prioritization/ likelihood

*Focused on low and middle income countries


Strong global demand to measure and compare outcomes


ICHOM and Aneurin Bevan Health Board in South Wales have worked together to implement the Parkinson’s Standard Set

Capacity building provides targeted support using a mixture of on-site visits, teleconferences and weekly 1:1 calls.

Action Period

Call 1 Visit 1 Call 2 Visit 2

Action Period Action PeriodAction Period

Call 3 and 4

Action Period

Action Period

Visit 3

Patient +/- Carer arrives in clinic waiting room

Patient / Carer completes PROM’s

on tablet

Patient seen by Dr who reviews all

outcomes in real time

Other outcomes pulled from admin

and clinical data


We are currently developing a global benchmarking program –The GLOBE Program

Objectives of Global Comparisons project

Pool health outcomes data from 10-15 leading provider organizations – 2 conditions for pilot (Hip/Knee Osteoarthritis and Cataract).

Risk-adjust raw data and organize comparisons on key indicators▪ Particular focus on patient-reported

outcomes

Provide individual – and confidential –reporting to participating organizations

Identify the “best-in-class” and publish about their performance

Sample output – Hip and Knee

Worse Better

Mortality

Readmissions

Acute complications

Patient-reported

health status

Disease progression

Knee pain

Knee functioning

Work status

Time to recovery

Health-related QoL

Overall satisfaction

Need for surgery

Reoperation or revision

Case mix complexity

(risk-adjusted)

Other organization

Your organizations

World average (for participants)

0.6

Case-mix averageComplexity = 1.0

- +

- +

0

0

- +0

- +0


Royal Melbourne Hospital, Melbourne,

Australia

Erasmus, Rotterdam, Netherlands

Leiden University Medical Center, Leiden, Netherlands

Martini hospital (Santeon), Groningen, Netherlands

Medisch Spectrum Twente (Santeon), Leiden, Netherlands

Catharina (Santeon), Eindhoven, Netherlands

Bergman clinics, Naarden, Netherlands

Sahlgrenska, Gothenburg, Sweden

Connecticut Joint Replacement Institute (CJRI), Conneticut, USA

Brigham and Women's hospital, Massachusetts, USA

Mayo Clinic, Florida, USA

HOAG Orthopedic Insititute, California, USA

Providence, Oregon, USA

A global network of providers is working with ICHOM to perform the Hip and Knee Osteoarthritis Pilot


The Hip and Knee Pilot will follow a structured schedule over the next 18 months

▪ Data governance and data flow: demonstrate feasiblity of aggregating data across borders on a harmonized dataset

▪ Technological: demonstrate feasiblity of data collection within an ecosystem of different collection solutions

1

2

Can we build it?

Is it a valuable service?

▪ Is there meaningful outcome variation in our data?▪ Can we stimulate more rapid improvement informed by international

outcomes data?

The GLOBE pilot aims to address two main questions:

GLOBEPilot

18 months

Program Design(2~3 months)

Data Collection(1 year)

Reporting(1~2 months)


Join us in London for the Fourth ICHOM Conference!

In May 2016, the ICHOM team will hold our largest conference to date. We would be delighted if you would join us.

▪ When and where: May 16-17, University College London

▪ Content: The theme of the 2016 conference will be implementation and impact: how to implement the Standard Sets—and the positive results that can come from outcomes measurement.

▪ Format:Attendees will participate in two days of plenary sessions, small-group discussions, and networking, with opportunities to hear from members of the ICHOM team, distinguished guest speakers, and from one another.

▪ Register here:http://www.ichom.org/2016-ichom-conference/

http://www.ichom.org/2016-ichom-conference/

Measuring Outcomes:ERAS Society perspective

Olle Ljungqvist MD, PhDChairman ERAS Society

Professor of Surgery

Örebro University & Karolinska Insitutet

HBR-Medtronic Optimizing Costs and Outcomes in Healthcare

Gothenburgh Quality Forum

April 14, 2016

Improving Perioperative Care Worldwide

Health Care Challenges

• Growing and ageing population

• Pressure for better results

• Diminishing funding

• Better care for less cost – Fast

Obstacles

>15 years ago……

Last year: March 31, 2015

Understanding the playground

Hospital organization

The patient’s journey: in control

CLINIC PRE-OP

POST-OP WARD HOME

RECOVERY

SURGERY /ANESTHESIA

Interactive Team audit of outcomes & compliance

PREADMISSION

FOLLOW

UP

30DAY

Integrated ERAS protocol

Ljungqvist JPEN 2014

ERAS

Epidural

Anaesthesia

Prevention

of ileus/

prokinetics

CHO - loading/

no fasting

Early

mobilisation

Peri-op fluid

management

DVT

prophylaxis

Pre-op councelling

Short acting anestetics

No - premed

No bowel prep

Perioperative

Nutrition

Body heating devises

Oral analgesics/

NSAID’s

Incisions

No NG tubes

Early removal

of catheters/drains

Fearon et al, Clin Nutr 2005

Nice idea!

But…does it work?

Relevant outcomes

ERAS: Shorter length of stay

2010 meta analysis

Varadhan et al, Clin Nutr 2010

ERAS: Reduce complications by 40%

Greco et al W J Surg 2014: 38: 1531

ERAS: Cost savings Alberta, Canada

In 700 patients Savings of 2-4.5 M$

ERAS & Cost savings world wide

• New Zealand – $4,500– 4,000€ / patient in the first 50 patients. Study

visits & full time included

• Switzerland - $1,650– 1,500€ / patient per first 50 patients. Training &

full time nurse included

• Canada - $2,985– 2985 $/ patient (colorectal surgery)

– 2,200 €/ patient (esophageal surgery).

Roulin et al, BJS 2013, Sammour NZJS 2010, Lee BJS 2013, Lee Ann Surg 2014

ERAS Society approach

Lectures & protocols: not enough

• UK ER program

• Expert lectures, information – timelimited effort

• NHS Report: happy with -1 day LOS

• Many bed dayssaved = cost savings

ERAS® Implementation ProgramBuilding Blocks

• World Experts

– Guidelines

– Centers of Excellence (teaching)

• Structured Training

– Breakthrough tailored for ERAS

– Qulturum (IHI Sweden) and others

• IT support – ERAS Interactive Audit System

– Encare & Partners

Colorectal

Pancreatic resection

Cystectomy

Gastrectomy

2015: Anaesthesia

2015/16: Gynecology

Bariatric

Breast reconstruction

H & N cancer

Nephrectomy

Hip replacement

Knee replacement

Liver resection

Thoracic

Esophageal resection

ERAS® Society Guidelines

Do the guidelines work?A test of Compliance

ERAS® compliance:Length of stay & Readmissions

Gustafsson et al, Arch Surg 2011

n = 953

p < 0.05

Compliance with ERAS protocol elements

Colorectal cancer

ERAS® compliance:Complications

Gustafsson et al, Arch Surg, 2011

n = 953

p < 0.05

0

5

10

15

20

25

30

35

40

45

50

<50% >70% >80% >90%

Complica ons


Pe

r ce

nt

pa

tie

nts

affe

cte

d Colorectal cancer

ERAS® Society guideline compliance:5 year mortality


5 y

ear

ove

rall

mo

rtal

ity

0%

5%

10%

15%

20%

25%

30%

35%

40%

<50% >70%

Gustafsson et al, WJS 2016

ERAS® Society basics

ERAS

Epidural

Anaesthesia

Prevention

of ileus/

prokinetics

CHO - loading/

no fasting

Early

mobilisation

Peri-op fluid

management

DVT

prophylaxis

Pre-op councelling

Remifentanyl

No - premed

No bowel prep

Perioperative

Nutrition

Bairhugger

Oral analgesics/

NSAID’s

Incisions

No NG tubes

Early removal

of catheters/drains

Fearon et a al 2005, Lassen et al Arch Surg 2009

Local Leadership Team

Anaesthesiologist Surgeon ERAS Coordinating Nurse

ERAS team approach

• Surgeon

• Anesthestist

• HDU specialist

• Ward nurses

• Anesthesia nurses

• Physiotherapist

• Dietitian

• Management

Team work:

• Training

• Implementing

• Planning

• Auditing

• Updating

• Reporting

• Research

ERAS® Society network

700,000,000 users

ERAS® Interactive Audit System

• Implementation tool

– Help units implement ERAS and get full control

• Quality registry

– Continuous results updated, benchmarking

• Research tool

– Tailored for Audit research and PRCTs

• Updating tool

– New treatments – all users get it via the system

ERAS® Interactive Audit System Easy to use registration

Analysis & Reports: Dashboard

2010 – Before ERAS

62

ERAS®Society 2010A few leading academic centers forms the Society

More than one Implementation program

ERAS Center in place

ERAS center discussions

Implementation program running/announced

ERAS center in training

63

ERAS®Society May 2014Growing…




ERAS center established


64

ERAS®Society 2016100+ units in 18+ countries




ERAS center in training


Manilla

DubaiSingapore

Guadalajara

Bogota

LisbonTokyo

Nanjing

Melbourne

Krakau

Cape town

Buenos Aires

Auckland

Mayo Clinic

AHS, McGill Hamburg

CT, Charlotte

Soeul

Sao PaoloPorto Allegro

Ankara

Tallin

Health Care Challenges





Health Care Challenges & ERAS





• Better care

• Saves costs

• Implement in 8-10 mo

Summary

• Best practice is not in use

• Multi professional & Multi disciplinary

• Systematic implementation

• Teams

• Interactive Audit

ERAS improves outcomes

Winners: Patients, staff, payers

Summary

Best practice is not in use

Perioperative care is complex and important

Multi professional & Multi disciplinary apporach necessary

Systematic implementation in teams

Interactive Audit is a useful tool

ERAS improves outcomes

Winners: Patients, staff, payers

MODERATEDPANEL Q&A

OPEN FLOOR Q&A

THANK YOU FOR JOINING US!

MODERATOR QUESTIONS FOR PANEL Q&A**(THIS SLIDE WILL NOT BE PROJECTED FOR AUDIENCE)**

We have a number of healthcare provider executives in the audience with us today. What advice do you have for them as they navigate the shift from traditional fee-for-service models to value-based models, and have to show results in each area? (for all)

Integrated practice units sound lovely, but I don’t see many where I can get my care. Is this an idealistic notion, or are they really developing? (for Olle)

Who really uses outcomes data – patients who want to function like consumers, or providers? (for Christina)

What does a transformation from vendor to partner in outcomes measurement and accountability look like/require from medical technology company? How does Medtronic concretely contribute to VBHC going forward? (for Rob)

Our ability to access and use data effectively is key to improving outcomes. Can we solve our data challenges through registries? What other solutions would help? (for Christina)

Should outcomes – and our expectations for outcomes – change across different cultures and countries? (for Christina, then all)

A lot of the work to optimize for improving outcomes involves new models and processes for efficiency. Where does innovation come from in this environment, and is there room for breakthrough innovation? ( for Rob, then all)

What’s your impression about the availability of audits in general today? Are there organizations out there auditing effectively? (for Olle)

What are the key success factors for implementing VBHC in a hospital today (for All)

With respect to improving outcomes, our panelists have shared some examples of success. What are some other pockets of success in other parts of the world that we might replicate here in Europe? (for All)

Documents

This is the new PowerPoint template - BMJaws-cdn.internationalforum.bmj.com/pdfs/2016_D6.pdf · 4/14/2016 · Germany Sweden Best-in-class: Martini Klinik Focussing on ... Osteoarthritis