Quality is the New Black

Shaf Keshavjee MD MSc FRCSC FACSSurgeon-in-Chief, University Health NetworkJames Wallace McCutcheon Chair in Surgery

Professor of Thoracic SurgeryVice Chair, Innovation Department of SurgeryUniversity of Toronto

Learning Objectives

1. Understand why quality and value are more important than episodes of care

2. How to optimize funding in the new world of health care - VBP

3. How to thrive – lead in care delivery with quality, innovation and complexity

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“____ is the new black”

•Some suddenly popular thing

• It’s the new cool thing

•Colours that were temporarily displacing black’s position in fashion or industrial design as a versatile staple that complemented all other aspects and was generally unobjectionable

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“Orange is the new black”White House Press Correspondents Dinner May 3, 2014

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Quality…

•Is the new black

•Will keep us in the black!

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Overall Goals of Value Based Purchasing (VBP) in Medicare: Pay for Performance

1. Financial Viability Preserved for beneficiaries (patients) and taxpayers

2. Payment Incentives Linked to VALUE – quality and efficiency of care

3. Accountability Providers have both CLINICAL and FINANCIAL accountability

4. Effectiveness Funding of care is evidence based

5. Ensured access Restructured fee for service system provides ensured access (?)

6. Safety and transparency

Patients receive info on the quality, cost and safety of their care

7. Smooth transitions Payment systems support coordinated care across providers and settings

8. Improved technology Electronic Health Record to help providers deliver high quality, efficient, coordinated care

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Obama – Affordable Care Act. Source: cms.gov

Changes to Medicare in the USTowards Value Based Purchasing

•Move away from paying doctors solely on volume of services

•Reimburse based on quality and value of care provided

•Pay doctors based on how they perform on quality and other measures

•Standards will be determined by the Department of Health and Human Standards

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Staying in the Black in the Face of Competing Factors

•How do we survive and thrive in the new world of health care?

•Quality (Volume) Based Performance (QBP) will set the funding bar (Value Based Purchasing VBP)

•But complexity and innovation - increasing

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Pay for Performance

Five Principles that have served us well…

1. Deliver case volumes (wait times) earn funding

2. Reputation as “efficient” attracts new funding

3. Improving data quality for better decisions

4. Leaders in innovation it’s our interest & duty

5. Clinical expertise it’s our advantage

Ontario Hospital Funding Sources Where we get our $

Ministry of Health $45 B

Provincial Taxes$30 B

Federal Taxes$15 B

Priority Programs Emergency

Cancer Care Ontario Cdn Blood Services

PhysiciansDrugsHospital Revenues

Provincial Programs$5 B

Capital$1 B

14 LHINs$22 B

OHIP$17 B

Research GrantsFoundations

IndustryWSIB

UninsuredInternational

Retail

Health System Funding Reform: Move from Global to Patient Focused Funding

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Year 0 Year 1 Year 2 Year 3April 2011 April 2012 April 2013 April 2014

HBAM Quality-BasedProcedures Quality-Based

ProceduresQuality-Based

Procedures

HBAM

HBAM

GlobalHBAM

Global

Global

Global

Mostly Patient

Focused Funding

Mostly Global

Funding

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Year 0 Year 1 Year 2 Year 3April 2011 April 2012 April 2013 April 2014

HBAM Quality-BasedProcedures Quality-Based

ProceduresQuality-Based

Procedures

HBAM

HBAM

GlobalHBAM

Global

Global

Global

QBP: Quality Based Procedures

• Targeted activities funded at “price x volume”

• Funding based on evidence (utilization patterns, best practices)

• Payer objective Improve value for money, improve outcomes and reduce variation amongst providers

QBP Status

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Years 1 and 2 … underway Primary Hip Replacement Primary Knee Replacement Chronic Kidney Disease COPD Congestive Heart Failure Stroke Non-Cardiac Vascular (AA and LEOD)

Year 3 – 2014/15 + … in development Chemotherapy … ready to go live GI Endoscopy … ready to go live Pneumonia Hip Fracture Knee Arthroscopy Retinal Diseases Cancer Surgery (Prostate) Colposcopy Coronary Artery Disease Aortic Valve Replacement

Year 0 Year 1 Year 2 Year 3April 2011 April 2012 April 2013 April 2014

HBAM Quality-BasedProcedures Quality-Based

ProceduresQuality-Based

Procedures

HBAM

HBAM

GlobalHBAM

Global

Global

Global

QBP: Staying in the Black

Clinical excellence quality

Deliver volumes to earn revenue

Stay efficient attract new funding

Data quality accurate coding and outcomes

Patient focused funding can

present some unique opportunities

and challenges…

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Case #1

• 57 yo male, smoker

• New nodule on CXR

• Referred through LungRAMP

(1-866 - Lung 911)

• Operated upon within 28 days

(Cancer Care Ontario target)

• VATS lobectomy

• SDU – 1 day, ward 2 days

• Discharged home on postop day 3

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Case #2

• 70 yo male, hemoptysis

• COPD, 100 pack year smoker

• Hypertension, diabetes, remote myocardial infarction, 3 coronary stents

• Grade 1 LV, no ischemia

• Taken to OR in community hospital – tumour found to be invading left atrium

• Operation aborted, closed, referred to TGH for urgent reoperation

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Case #2

• Admit Mar 27

• Stepdown Mar 27-28

• Ward Mar 29-30

• OR Mar 30: Reoperation, Left pneumonectomy on CPB, after 6 pm (overtime) due to OR availability

• ICU – Mar 30-31

• SDU – Mar 31- Apr 2

• ICU – April 2-3 (afib, cardioversion)

• SDU April 3-5

• Ward – April 5-9, Discharge Apr 9

• Total Hospital stay – 14 days

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Two Cases: We provided the best care for our patients. CCO code “Lung Cancer Resection”

• 3 day hospital stay• CCO funding $12,888• UHN direct cost $7,139

• CPB, ICU, 14 day hospital stay• CCO funding $12,888• UHN direct cost $26,126

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What should our strategy begoing forward?

• Find opportunities to better define what we do – one cancer case is not the same as another – be able to prove it and document the cost

• Many of these not even “counted” because so few done or no one else does…

• Collect high quality data on outcomes and document case complexity (financial risk)

• Collect and report accurate risk adjusted data (benchmark)

• Need to be appropriately funded for the complex or unique cases we do

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What should our strategy be going forward?

• Understand HOW you are being evaluated and funded

• Optimize care delivery: performance - volumes, wait times, demonstrate efficiency, value for money, quality

• DATA – we need to collect data to quantify and document what we do

• Make sure we are getting paid right

• Document excellence in care, benchmark

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Where are we going?

•Leadership and excellence

• In the current era we need to become surgeons and “something more”

• Focus on patient care – quality and safety

• Surgical research and innovation

• Efficient delivery of healthcare services (cost)

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Where are we going?

• Health System Funding Reform

• Multiple (changing) models and formulas of different flavours in different jurisdictions (VBP – Value based Purchasing, HBAM - Health Based Allocation Model, QBP - Quality Based Procedures etc.)

• Common theme Pay for performance

• Funding decisions evidence based, performance based

• Provide leadership develop solutions to the challenges

• Look for opportunities to fund our business

• Understand how we are being measured

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Why do I think that Quality is the new Black?

• It is cool… it makes sense…should be how we are measured

• We get paid for performance, not just for being a player ;)

• Surgeons can handle being paid for performance – we ARE naturally high performers!

• Leaders in patient safety and quality, efficient use of resources

• Need to understand the rules of the game that will keep us in the black

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