- Industry: Healthcare
- Type: Survey report
- Date: 4/16/2013
Something to teach, Something to learn Case Studies
Fierce Healthcare, a respected daily healthcare newsletter, reports that starting this year, hospitals can get more money from United Healthcare (an operating division of UnitedHealth Group, the largest single health carrier in the US) if they take action to reduce early deliveries without medical cause, as well as demonstrate lower C-section rates. Similarly, health insurer Aetna has adjusted prices for C-section surgeries and renegotiated maternity payments for 10 hospitals to cover the rising healthcare costs and risks associated with the procedure. Hospitals also are seeing no reimbursements at all for elective early deliveries from certain insurers, including South Carolina Medicaid program and BlueCross BlueShield of South Carolina.
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Safeway Stores (a large pharmaceutical chain in the US), Unite Here Health (a health benefits trust in the US), and the employee health plans of some states and cities (including California, Massachusetts, Minnesota and the city of Los Angeles) all use patient communications and strong patient incentives to move market share to higher-value providers.
Harvard Pilgrim, a full service health benefits company, is launching an online software application this year called Now iKnow, which ranks doctors and hospitals based on cost and quality. The online app will give members options, including cost estimates for a procedure and the amount already spent toward their deductibles that are specifically based on their health plan. Meanwhile, Blue Cross (a health insurance organization based in the US) is rolling out a new cost estimator tool called Find a Doctor to help its members find providers and compare out-of-pocket expenses for more than 100 medical services. It is also preparing a ‘very plain English version’ of its explanation of the benefits form.
Source: New England Journal of Medicine, 2013; 368:1-3.
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Discovery Health South Africa’s Vitality program is designed to incentivize members to be more committed to wellness by earning points for exercising, eating healthy foods and hitting physiological targets. This is done through a unique system based on the science of behavioral economics wherein members are provided with a range of immediate incentives similar to a consumer loyalty program. The more points earned, the steeper the discounts in accessing the rewards, with the top of the points range often being free.
These are typically lifestyle promotions such as deals on flights, hotels, car hire as well as discounts in many stores. Wellness promoting behavior is also made easy because the size of the member base allows Vitality to negotiate discounted access to gyms and retail food outlets as well as a wide range of health promoting partners. Vitality goes much further than similar schemes in richer countries; currently the scheme is paying for itself.
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De Friesland Zorgverzekeraar – How the insurers took the lead in reshaping hospital care
This initiative started when De Friesland Zorgverzekeraar (DFZ), a Dutch healthcare insurer primarily active in the northern part of the Netherlands, had the ambition to provide the right care at the right place at the right time, now and in the future. The burning platform for this ambition is a set of familiar challenges including a rapidly aging population, a lack of specialist doctors and nurses and the risk that small hospitals will not be able to meet quality and volume requirements.
A driving force to realize the ambition was the outline agreement between the Association of Dutch Healthcare Insurers, healthcare providers and the government, which made the health insurance companies primarily responsible for improving quality and efficiency. This changed the role of healthcare insurers that could become commissioners of care with a strong responsibility for appropriateness and continuity of care in the region (a sort of private organization with some parallels with regional health authorities). DFZ was one of the first to pick up a leading role. While some health insurance companies used purchasing power to negotiate with providers, DFZ had a strong commitment to cooperating with the providers in the region. It was their belief that only in this way could change of such magnitude be realized sustainably.
What did they do?
DFZ took a coordinating role by working with healthcare providers in the region to shape networks of care for critical care and care close to home. The networks of care included: emergency and intensive care, birth care, oncology, complex vascular care, elective care and chronic and elderly care.
How did they do it?
To realize this ambition they set up a program with:
- A steering committee intending to reach common decisions, consisting of: an independent chairman, the board of directors of DFZ, CEOs, chairmen and board medical staff of the five hospitals, a board member of the regional university medical center, patients, general practitioner representatives and KPMG.
- A program office, consisting of DFZ and KPMG employees;
- Seven expert groups, which made proposals for change. Every expert group consisted of a chairman (an independent, leading medical specialist), representatives of the hospitals, general practitioners and representative of the patients; and
- A ‘Council of Experts’ which could provide the steering committee with advice upon request, consisting of national recognized governors/medical leaders.
What decisions were made?
- DFZ composed their healthcare procurement plan for 2013. In this plan the first irreversible steps towards the future were made. For instance, no contracts will be made with certain providers for some forms of complex care if quality and volume requirements can’t be met.
- First fundamental decisions on scenarios:
- DFZ has delivered new medical centers that better connect primary emergency treatment; the centers claimed top prize in the Friesland patient representative body’s latest annual healthcare awards.
- The pathway approach is delivering authoritative care plans, based on proven data and financial modeling, overturning legislative, practitioners and administrators’ assumptions on healthcare and the supply agreements. In particular, the insurer has reduced its use of complex care contracts where providers could not guarantee its new volume and care quality targets.
- DFZ’s new program is already having a profound effect on commissioners, providers and patients. Local treatment centers are more accessible to elderly patients. Primary care teams are working more closely with the new care centers and hospitals – providing better, multi-disciplinary care closer to local communities.
- Friesland’s new primary care-led network is lifting demand from hospitals, with a 40% substitution from acute to care beds in one case.
- Improved quality of care with better targeting and reduced costs; the program’s comparison of GPs found those with highest quality results also had the lowest costs.
- DFZ is now commissioning services more flexibly in line with anticipated local care demands because of the pathways’ comprehensive number-crunching. DFZ also has the model to transform its cost base as well as those of its provider hospitals in the next few years.
- ‘Incentivized’ patients are becoming more active partners in the management of their own healthcare.
- The program put the professionals and the clients/patients in charge.
- Management follows professionals – as one expert said: “We are currently realizing something that our management should have done ten years ago.”
What were the lessons learned?
- Speed during the process is necessary, but too much speed is detrimental.
- A program of this magnitude can count on attention in the local media; make clear agreements on media handling.
- Importance of independent chairs for expert groups; bringing in independent professional medical leaders is an important driver for change.
- The program brought the professionals and the clients/patients back in the lead. Management follows professionals – as one expert said, “We are currently realizing something that our management should have done 10 years ago.”
- Relocating the care in the network will result in increasing pressure on primary care.
- Importance of maintaining the project infrastructure after ending the program; creating a platform for collective innovation from professionals.
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ParkinsonNet is a vision of the future for the management of a complex disease and illustrates the power of the patient as a participant in their own care. It is also an inspiring example of clinical leadership.
The model has been built by Professor Bloem, a consultant neurologist at the Radboud University Nijmegen Medical Centre in the Netherlands. His goal was to create a model that met the needs of the patient while dealing with some of the institutional challenges inherent in the system, such as: poor referrals being made to specialists, over-treatment, under-treatment, the wrong treatments being used, a lack of specific expertise and poor communication between professionals about patient care. His research led him to believe that the overall gap between evidence and actual clinical practice needed to be closed.
In redesigning his services, he identified five areas that were key to success:
- Helping to create an active patient able to manage their care and take key decisions.
- Defining what value-based care would look like from the perspective of the patient.
- Changing the way that doctors and other clinicians work with patients from ‘God to guide’ by shifting to a partnership approach with patients to identify the regimen that works best for them.
- Creating a network of experts.
- Linking all of these together with information technology tools.
Based on these assumptions, Prof. Bloem worked directly with patients to develop a set of comprehensive guidelines including a special version geared towards patients’ use. Interestingly, Prof. Bloem’s work found that a key part of the guidelines involved patients telling their professionals what they needed to stop doing rather than what they should be doing.
With these guidelines in hand, Prof. Bloem then set about identifying all the professionals working with Parkinson’s patients in his region, and then train a selection of these in the most up-to-date approach in the management of the condition, including the provision of physical therapy, symptom control, and so on. Essentially, this meant that Parkinson’s expertise was focused within a smaller number of providers.
The next step was to provide these specialists with tools that could facilitate greater communication and the sharing of best practices, new approaches and data about patient outcomes.
With this infrastructure in place, Prof. Bloem was finally able to enroll patients through a web portal, thereby allowing patients to choose an accredited provider, confident in the fact that they would be using the same approach as other professionals in the network. Patients are able to set their own priorities and build their own networks of care supported by electronic tools which also allow them to set their own priorities and goals for their care, exchange information with professionals, and connect to other patients. The same tools are used to connect the professionals to each other.
The results of Prof. Bloem’s work have been extremely impressive and show that sometimes the best thing leaders can do is give away their power. Patient outcomes and satisfaction have seen enormous improvements and the initiative has led to a reduction of hospital visits, a 50 percent reduction in hip fractures and substantial savings for payers valued at EUR20million across the Netherlands.
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Something to teach, Something to learn