Archive for WHCC Europe
by Lloyd Davis
March 10, 2008 at 10:14 am · Filed under WHCC Europe
CPME represents the interests of 2 million doctors in the EU and other european states. For doctors improving healthcare means improving the relationship between doctors and patients.
I’d just like to run through four areas are focusing our attention at the moment.
Do health policies improve health? Do health policies alone improve health? Well no, clearly economic policy has a great deal of influence too.
E-health - as healthcare becomes more complex, information management has to be improved.
Public Health - for example, with reference to alcohol.
Global Warming - we’ll be in the front-line of dealing with the consequences of climate change
More detail on Dr Wilks’s presentation can be found on the Attendee Website
by Lloyd Davis
March 10, 2008 at 10:12 am · Filed under WHCC Europe
This session was tight on time, but Patrick asked everyone to run over what they thought are the big challenges?
David Nicholson - You have to put a lot of investment into things that don’t have immediate payback. When you work in a political environment, politicians want benefits now. The biggest risk for us is that we lose public confidence. Rapid standardisation is required, but the people hate it - so it has to be really carefully managed.
Michael Wilks - there are developments that many people don’t know about. The issues are essentially those of technology and privacy which eclipse a lot of the things that are really exciting.
Richard Alvarez - agree that showing benefits beyond the electoral cycle is most difficult. Also that public perception is that these systems are already in place. It’s also a tough sell with clinicians - we’re revolutionising the way they work.
Uwe Reinhardt- let’s be hopeful, lots of people say it can’t work but we have lots of people working hard to make Health IT work well and the entry of Google and Microsoft into this area is really exciting.
by Lloyd Davis
March 10, 2008 at 9:56 am · Filed under WHCC Europe
I’m going to be the skunk at the garden party 
and debunk some common myths
Population aging drives health spending
Population is aging and relative health spending per capita is going up, but the aging of the population is not a major driver of health spending through the demand side, it may be a unit-cost driver on the supply side encouraging the development of labour-saving organisational innovation and technical innovation (electronic monitoring etc)
Preventive health care saves money
The evidence is weak, though it may lead to longer life and higher quality of life.
Healthcare spending is a drag on the economy
No, it’s a high-value-added powerful locomotive, however it pulls along a dubious cargo, ie waste fraud and abuse
Doctors know best
Since there is still wide and unexplainable variation between healthcare cost and quality in similar geographical areas, only clinical practice guidelines can be relied on.
Best provided by private sector
Government needs to put money into orchestrating the development of national health information systems - private approaches in the US have not been able to find a business model for hospitals to participate.
by Lloyd Davis
March 10, 2008 at 9:09 am · Filed under WHCC Europe
Some lessons from Canada
Federal government sets the standards and national principles while provinces do the heavy lifting (80%+ of spending) - within the 13 provinces there are 100 regional health providers.
We’re still trying to do a 21st century job with 19th century paperwork. This has a knock-on impact in terms of risk-management and prevention - people miss out on treatment, errors are made in diagnosis. But the need to manage health information will intensify - resource pressures are intensifying, consumerism is growing, population is aging, care settings are shifting - providers, managers, patients and the public are demanding more access, quality and productivity.
Canada Health Infoway was created as part of First Ministers Agreement in 2001. It’s an independent, not-for-profit corporation accountable to 14 different governments - estimated $10 billion total program cost.
Collaboration is the name of the game - as well as co-investment. We’ve been forming strategic alliances with the private sector, managing risk and remembering this is a people-solution so we’ve been focusing a lot on end-user acceptance.
We’re concerned to show benefits in terms of quality access and productivity - so we’ve developed 23 new key indicators to measure and show improvement.
We’ve made enormous progress, all the client registries are active and operational, e-prescibing and lab information systems are rolling out as is medical imaging. So we’re now in a position to start showing how EHR’s can be leveraged to improve care at a local level.
by Lloyd Davis
March 10, 2008 at 8:47 am · Filed under WHCC Europe
Let’s talk about systems - This is the 60th anniversary of the NHS in England- it is not just an organisation, it is a national social movement that is ingrained in our society and change is extremely fraught. The issue of whether it’s the time to retire or renew is one that we’re focusing on a great deal.
18 months ago we were in the third year of running a deficit and there’s nothing like that situation to erode confidence in staff and the public. But now this has been sorted out and this year we’ll deliver a surplus of £1.5bn and expect to do the same next year. It gives us enormous self-control and freedom to take things forward. Those things that we want to do, we are now able to invest in.
The second issue is that of access - we are not quite world-class but moving in that direction. A colleague of mine remembers 10 years ago when he got a letter from a local man who had been waiting 14 years for a cataract operation saying that he felt too old to have the operation, but could he leave his place on the waiting list to his 60 year old son! Now 70-80% of patients are seen within 18 weeks with an average of 6-7 weeks overall.
And finally the issue of infections - we’ve reduced the rate of MRSA by 46% over the last 2 years, but we’ve still got a lot to do.
So we think we’re in a reasonable position but it’s only a platform for what we can do in the future. Key to this is seeing what we do as a system. We’re about half way through a journey to decentralisation. We started by building capacity in 1997 - we had a massive expansion, driving change by big top-down national targets. That’s fine, but it only delivers so much change. Then we moved on to delivering reform, bringing more of a mix to supply and new organisational models. And the next stage in the last year or so is how do you drive systemic change to bring about services based on the needs of patients and treating patients as partners - a drive towards personalisation.
Change is always complex, but this is what we’ve learned, there’s a limited number of things you can do top-down. We need to be radically devolving power to clinical teams so that people can work together on the ground and we need to engage clinicians in this process.
We’re now much better equipped but we also need leadership and IT, but most important is how we engage with patients.
So we’ll be delivering more choice, bringing more private providers into primary care and a lot of this comes out of our work with patients and staff. Another thing they want is integrated care - primary care and specialist care connected in the same building and with common IT infrastructure. We increasingly see the system needing to predict and prevent. With better information management we have much better ways of managing risk and putting into place individual strategies for patient’s health care.
So I think we’ve a great platform for the future and we’re clear about the future we want and we have an IT programme that will help us to make a leap forward.
by Lloyd Davis
March 10, 2008 at 8:29 am · Filed under WHCC Europe
The congress is formally opened by Patrick O’Connell, PhD, Managing Director BT Health, UK.
The congress is the only forum where so many leaders in healthcare come together to talk about the future of healthcare and it’s improvement. Berlin is an excellent setting with it’s history of medical progress.
We’ll be talking about priorities and strategies, e-health and continuing to improve patient care.
The context: 10% of the total workforce in Europe is employed in healthcare. Cross-border interoperability is an increasingly important factor. Many countries feel the burden of an aging population. Patient engagement is changing and patients are already interacting online without reference to medical practitioners. New players like Google and Microsoft are coming into the health record market. E-health can improve and enhance medicine and enable new technologies, but the implementation of such strategies is extremely challenging.
We have an opportunity here to share what we know and are learning to provide better patient care.
by Lloyd Davis
March 10, 2008 at 7:58 am · Filed under WHCC Europe, 4th WHCC
Hi, I’m Lloyd Davis and I’m really pleased to be back blogging live from the WHCC Europe 2008. The conference hall is quiet at the moment, but I’m sure that will change rapidly over the next few minutes.
I’ll be here for the duration of the Congress, blogging live wherever possible and also taking photos and making small video interviews both with speakers and delegates to give you a flavour of what’s happening here.
If you’re here in Berlin, do come and say hello, I’m the English guy sitting on the far left hand side (facing the stage) of the hall tapping away on a laptop!
by Lloyd Davis
March 28, 2007 at 6:26 pm · Filed under WHCC Europe
Background: CEO, Humana Inc., USA
Theme: Consumer Engagement: A Model for Shared Decision-making
A US insurer’s perspective on reform in commissioning in the UK NHS
The challenge: achieving financial balance while delivering national targets.
Commissioning ensures that the NHS provides equity, choice, information transparency, and optimal care pathways within resources allotted. Commissioning depends on assessing providers, managing them, recruiting, capability, fostering local partnerships, and ensuring a system of accountability, so that people know that the monies they raise through taxes actually go towards what they want in the health system.
We’ve made data more available and improved links between health professionals. Allows for real time multi-payer services.
In engaging consumers we take the role of a cultural anthropologist to understand people first rather than getting people to understand us. For example, an emblem of the health care system is the hospital gown - no consumer-oriented operation would create it.
I have a USB device that tracks all of my activities - it’s a sort of “frequent flyer” program that provides incentives for people for what they do for their health. What we recognize is that health is co-created, not something that doctors do to patients. We also want to make things fun - traditionally we tell people what they shouldn’t do, don’t want to hear, prod, probe them, and make them wait for hours, and never make anything fun or engaging. If we’re really going to work on these things we have to truly engage them rather than just giving them information.
We’ve also focused on using information for predictive modeling - looking for predictive signals that you’re at risk for a heart attack and seeing what we can do to prevent that.
We did work with families doing diaries and this helps us to give them back information in a useful way. Everyone gets a statement from their bank often with suggestions of how you could improve your financial health, but you don’t get something like that from the health system - we’re starting to that with our “smart summary”.
Taking this to the UK means blending the best of both worlds, understanding the local culture and what’s important to people so that you can better engage with them. At the end of the day it’s in order to positively influence health inflation.
Q: Providing information back to the patient is very interesting - how are patients reacting?
A: We’ve approached it by saying you should have equal symmetric information. One of the problems in the U.S. is that no one doctor knows what other doctors have done. We give people a card so so they can see all of the medications they’ve been prescribed. It’s made practice easier especially with over-65-year-olds who are generally on 5+ medications.
Q: How do you measure the impact?
A: Our #1 focus is compliance with medication - we’ve seen a 12% increase since we’ve provided messages as well as statements. And now we’re also thinking of financial incentives.
Q: Who will drive the uptake of wellness programs in the U.S.?
A: We the health insurers are responsible for everything. We believe that more activity means more health and so we’re trying hard to get people over 65 active and promoting fitness clubs. It’s in our interest over time to have healthy people. We’ve just started a brain gym too and that is having a positive effect too.
Q: How do we have to change the payment systems to support preventive care?
A: You have to have a vision and culture that is focused on health as opposed to illness. Our industry has developed differently so we don’t always have good systems for looking after health. It’s not a bureaucratic change as much as a cultural change. If you take an ecologist’s view, we have the levers inside of our systems but we have to work out which ones work and we have to celebrate diversity and engage with people differently accordingly - remember that consumers are people too.
by Lloyd Davis
March 28, 2007 at 5:16 pm · Filed under WHCC Europe
John is Chairman, Sanitas, the Spanish arm of the BUPA Group, Britains largest private healthcare provider.
Theme: Balancing State and Private Contributions in European Healthcare Systems
I’ve been in the health business for 16 years - this is my penance for selling fast food snacks and soft drinks earlier in my career
If you look at an ideal health system, you want low cost, high quality and easy access and if you can do all three you’re doing well. Spain is good at cost and quality but access isn’t easy, they have crowding and waiting lists.
When Spain reached a population of 40m all predictions were that it would reduce, but now thanks to immigration, particularly in the last five years it’s gone up to 44m. We have universal coverage for people who live here, provided by 17 autonomous regions. Catalonia, where we are today was one of the earliest and so one of the most developed but still services are characterised by budget deficits and patient dissatisfaction.
We offer complementary services - eg adult dental care or IVF where the public services can’t or won’t provide but we also play a substitute roles where public services are farming out their services to private provders. In Spain we have the equivalent of PFI (Private Finance Initiative) both in terms of construction of a hospital, or as in the Valencia model the private provision of the core clinical practice. 7 new hospitals are being built this way in Madrid and others in the Balearics. Valencia is doing PPP in 5 hospitals and 1 such hospital is coming in Madrid.
Our investement so far is 144m euros and we expect an 80m euro per year turnover or 1,200m over 15 years. The challenge for us is that we are responsible for *all* the medical care.
We have oportunities in long term care too. In long term care, public and private have been working together since the start. Most nursing homes are privately owned and managed with a 60:40 ratio of private to public funding, although public funding is set to increase soon.
There’s a range of ways to cooperate with the public system.
Direct management of publically owned care homes.
Private ownership, private management, public offer
An allocation of a quota of publically funded beds within a private home
PFI project to build and manage for the provincial government.
I believe there’s quite a potential for us to work as partners with the public system. Because we can do things cheaper, because we control our costs and are willing to work with a capitative price. Theres been more interest in conservative-controlled areas, but it’s increasing in all the regions because the advantages are so clear.
Q: I’ve had responsibility for PPP and one difficult thing is service levels - who sets the clinical criteria by which you decide, say, how many transplants get done (or not)?
A: We haven’t really started on that battle yet as we’re just starting building. But it’s a joint decision. In the ones that are operating there is a dialogue - if we don’t have capacity then sometimes it will be picked up by public but occasionally, we will lose money and then we cry 
Q: How does a public system deal with profits or gains in productivity.
A: Profits are capped, so gains in productivity are immediate for the public purse. They allow us a certain margin but above that it goes back to them.
Q: Why was it necessary for this mix of public and private? (Why not just private?)
A: It’s a political objection, since it’s based on universal coverage and politicians are very unwilling to give the whole pie away because privatising the public system is a vote-loser.
by Lloyd Davis
March 28, 2007 at 4:58 pm · Filed under WHCC Europe
Jennifer is Director, Health Policy at the King’s Fund in the UK and is a board member of both the Audit Commission and the Healthcare Commission
Theme: risk segmentation and identifying populations at risk
We want to reduce preventable admissions, particularly among older people. There’s been a lot of guidance from NICE and elswhere and there have been funds for interventions. Meanwhile commissioners have been mandated to employ community matrons to carry out case management (though we’re not sure on what evidence this decision was made!)
So what we saw a real need for was a way to identify high risk, high cost patients and intervene before they got to a point of crisis.
We set up a project to find ways of predicting future high-risk patients. We did a literature review, confirming that the clinician’s hunch is probably not the most robust method of prediction, the best ways are statistical.
So we developed a first predictive model using inpatient data which we then developed using multiple sources.
Our model known as PARR uses HES and census data. We took two approaches: PARR1 focusing on emergency admissions for avoidable conditions (CHF, COPD, Diabetes, CAD, Sickle cell etc) that often lead to re-hospitalisation and then a second approach, PARR2 to broaden that to prevent emergency admissions.
We used statistical techniques to come up with a risk score from 0 to 100 (where 100 is certainty of admission). We took 5 years of data looking at year 4 we looked back at the previous 3 years and then correlated that data with actual admission in year 5.
No model works with 100% certainty but we were pleased to see that the proportion of false positives reduces at higher risk levels.
Not surprisingly we found that the high risk group contained a high preponderance of people over 75 and people from ethnic groups and a high proportion of people with chronic illness.
We’ve built an interactive tool now that you can use it in real-time so we’re suggesting to commissioners that they identify high-risk patients and interview them to find out why they have been admitted and then working with patients and their families to design a better intervention. We’re also encouraging PCTs to build evaluation methods into their adoption of the tool. The tool is freely available and downloadable from the internet. At least half of English PCTs are now using it
The final phase is to try to improve the model by adding in other data about individuals - eg A&E GP, Pharmacy and Outpatient activities
We looked at half a million patients from two PCTs, we split the sample to test, using logistic regression to model the predictive factors using 850 variables. With this one we just looked at the previous 2 years data.
This approach does identifiy new patients who had had no prior admission, so adding more data improves the prediction. It’s better but we have to consider whether it’s worth the cost of linking the data.
The highest risk patients have 20 times the average admissions and 24 times the average of emergency bed days so if you target your interventions lower down the pyramid you can make more of an impact than with the highest risk. We recommend that you don’t just focus on high risk patients.
The model also allows you to include your costs, so that you can predict savings and look for the most cost-effective risk management strategies.
PARR is now used across the country and the combined model is in a smaller number of PCTs because it’s so data intensive. The interventions are currently being evaluated. PARR is of growing usefulness for commissioners and regulators and we’re now looking at risk-adjusted person-based resource allocation which until now in the UK we’ve not been able to do.
Read more about this project on the King’s Fund website.
Here’s Jennifer talking to me between walking off stage and dashing to the airport, putting the project in a nutshell: http://www.worldhealthcareblog.org/lloydd/whcc-dixon.wmv
Jennifer Dixon on the Kings Fund Risk Prediction Model [2:00m]:
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