© Oliver Wyman HEALTH & LIFE SCIENCES

New Models of HealthcareAge UK

June 2014

2© Oliver Wyman 2

2011

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Activity

A&EOutpatientInpatient

Example: Anonymised Patient ProfileHigh cost frail elderly patient

Diagnosis: Hypertensive renal diseaseProcedure: Magnetic resonance imaging NEC

5

Source: Hospital Episode StatisticsNote: some dates have been altered to maintain patient anonymity

Details Service Utilisation

Name Mr A. N. Other Activity 37 interactions

Age 80-85 Cost £26,000

Patient Segmentation: Example high cost frail elderly patientThese patients require complex care for a variety of different conditions, often delivered in an uncoordinated way

Admitted from A&EDiagnosis: Complications of cardiac & vascular prosthetic devices, implants & graftsProcedure: Insertion of tunnelled venous catheter

6

Admitted from A&EDiagnosis: Unspecified nephritic syndromeProcedure: Percutaneous needle biopsy of lesion of kidney

1

Admitted from A&EDiagnosis: Other and unspecified injuries of abdomen, lower back and pelvis Procedure: None

3

Diagnosis: Unspecified nephritic syndromeProcedure: Intravenous chemotherapy

2

Admitted from A&EDiagnosis: Unspecified nephritic syndromeProcedure: Intravenous chemotherapy

4

3© Oliver Wyman 3

Patient Segmentation: Example high cost frail elderly patientThese patients require complex care for a variety of different conditions, often delivered in an uncoordinated way

2012 2013

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

InpatientOutpatient

Activity

CommunityGPA&E

Example: Anonymised Patient ActivityHigh cost patient

i

Diagnosis: Angina pectorisProcedure: None

3

Diagnosis: Non-specific chest painProcedure: None

Diagnosis: Non-insulin-dependent diabetes mellitusProcedure: None

1

2

Details Service Utilisation

Name Mr A. N. Other Activity 34 interactions

Age 45-50 Cost £10,000

Source: Hospital Episode StatisticsNote: some dates have been altered to maintain patient anonymity

44© Oliver Wyman

Population cost segmentation, secondary care spend, 2011

85%143k

(32% used secondary care)

11%19k

3%5.6k

12%£14m

41%£45m

47%£52m

Population segments

Cost breakdown

Spend per head:

£9.3k

£2.3k

£0.1k

High CostOver £5,000 per year

Moderate Cost£1,000 to £5,000 per year

Low CostUnder £1,000 per year

Source: Hospital Episode Statistics, 2011

Patient Segmentation: Cost concentrationThe most expensive 3% of patients account for 47% of secondary care costs

55© Oliver Wyman

Patient Segmentation: The cost pyramid by LHE

High Cost

Moderate Cost

Low Cost

87%112k

10%13k

3%4k

26%£20m

34%£25m

39%£30m

Airedale, Wharfedale & Craven* Blackpool East Riding Fylde & Wyre

High Cost

Moderate Cost

Low Cost

NE Lincs North Tyneside Somerset Sunderland*

86%148k

11%19k

3%5k

14%£16m

39%£42m

47%£51m

85%257k

11%35k

3%10k

13%£26m

39%£79m

48%£96m

86%130k

11%16k

3%5k

14%£14m

38%£36m

48%£46m

85%246k

12%35k

3%9k

13%£25m

42%£81m

45%£85m

Hull

85%143k

11%19k

3%6k

12%£14m

40%£45m

47%£52m

82%177k

14%30k

4%8k

13%£22m

66%£39m

48%£41m

87%475k

10%55k

3%16k

15%£51m

36%£121m

48%£160m

84%239k

12%34k

3%10k

14%£29m

36%£77m

50%£106m

* Includes additional cost data

66© Oliver Wyman

Population cost pyramid2012/3 £17m Social care cost

2%~2,000

0.5%~600

0.4%~400

~20%~£3.4m

~30%~£5.3m

~50%~£8.5m

Population segments

Cost breakdown

High CostOver £13,000 per year

Moderate Cost£5,000 to £13,000 per year

Low Cost£1,000 to £5,000 per year

Patient Segmentation: Cost concentrationFor social care the picture is even more concentrated……

Source: South Somerset Symphony project data, Oliver Wyman analysisNote: Net social care costs used, self-pay contributions excluded

Note: Over half of the highest healthcare cost

cohort (~2,800 patients with >£7,000 healthcare spend) did not have a social care assessment or receive any

social care

No Cost£0 per year 97%

~112,000

7© Oliver Wyman 7

A variety of patient-centric clinical models exist globally and are yielding outcome and cost improvements in targeted populations

• Extensivist led multifunctional team wraps services around the sickest patients

• Responsible for patient across all care settings

• Single point of patient contact and capitated payments drive accountability

• Ultra high efficiency ambulatory surgery model focused on a limited set of interventions

• Exploits techniques borrowed from manufacturing

• Very high patient and physician satisfaction

• Reduced admissions and length of stay

• 20% lower cost

• Lower complication and infection rate

• 30 to 40% lower cost

• Specialised GP model focused on a polychronic population

• Highly integrated care delivery with GP responsibility for all aspects of care

• Model tailored to underlying population and cultural norms

Extensivist model Systematised surgeryPrimary care medical home

• Same day access utilisation reductions (40% A&E, 50% speciality, 20% primary care)

Source: The Quiet Healthcare Revolution The Atlantic; AMSURG; Nuka Model of Care Provides Career Growth for Frontline Staff Southcentral Foundation; Oliver Wyman

88© Oliver Wyman

Extensivist clinics focus on the sickest patients, including a significant number of frail elders

Frail elderly overview

• Highest need patients aged over 65 at risk of catastrophic decline

• Uncoordinated care and inadequate access leads to unnecessary admissions and poor disease management

• Drive seven times more spend than the population average

>2 comorbidities

• Myocardial Infarction

• Congestive Heart Failure (CHF)

• Peripheral Vascular Disease

• Cerebrovascular Disease

• Dementia

• Chronic Obstructive Pulmonary Disease (COPD)

• Connective Tissue Disease

• Ulcer Disease

• Diabetes

• Hemiplegia

• Moderate to Severe Renal Disease

• Liver Disease

• Cancer – all types

• HIV / AIDS

• Multiple Sclerosis

Patient segmentation

9© Oliver Wyman 9

An Extensivist coordinates and reorients care around the patient

Behavioural/social care Chronic condition

management

Environment and equipment

Home and community-based

care

Social Work

“Life” support (e.g. finances)

Substance Abuse

Smoking Cessation

Palliative Care

Crisis management

Diabetes andWound Care

CAD / CHFCOPD

AsthmaCKD ESRD

Hypertension

General Co-morbidityManagement

Home Care

Durable Medical Equipment (DME)

Mobility Assistance

Remote Monitoring

TelevisitsNursing Home / SNF Care

Dischargemanagement

Diet / Nutrition

Psychiatry / Psychology

Transportation

Hospice

After-HoursCare

Clinical Pharmacy

Strength and Balancing

Patient Navigation

CaseManager

Extensivist

ClinicalCare Centres

(CCC)

GPs

Extensivist-led model

10© Oliver Wyman 10

Care team roles

Role Scope of Services

Extensivist • Clinical leader and the “quarterback” for the patient’s care

Advanced Practice Provider

• Supports Extensivist by evaluating and caring for patients as appropriate

Patient Navigator • Primary patient contact and care coordinator

Nurses/ MAs • In-office patient care

Behavioral health resource team

• Provides mental health support services

Pharmacist • Assists in pharmacy and medication therapy management

Receptionist • Handles patient enquires and scheduling

Office Manager • Manages practice staff, administration and compliance

Social worker • Coordinates solutions to resolve home and family life issues

Dietitian • Helps patients develop and maintain diets appropriate for their conditions

Palliative care • Assists in reducing patients’ physical and psychological suffering at end of life

Related services • Range of services including physical therapy, home care, post-discharge care, etc.

1111© Oliver Wyman

The Symphony Expert Care Hub Network will be modelled as a number of local Expert Care Hubs, sharing central support

The Symphony Expert Care Hub Network

Local Expert Care Hubs

• Location for co-located multi-skilled Care Coordinator and Key Worker teams to enable effective team working

• Initial point of contact for all patient needs, e.g. Questions, concerns, urgent enquiries, carer concerns

• Locally accessible to cohort patients, e.g.

– Delivery of care as part of care plans

– Meeting core team members for review

Central OfficeSymphony central office

• Shared infrastructure and support functions e.g. IT, Finance / accounting, patient identification and tracking, etc.

• Central business functions and Symphony management, e.g. Care model refinement, geographic expansion, planning for extension to new cohorts, etc.

Care Hub 1 Care Hub 4

Care Hub 2 Care Hub 3

12© Oliver Wyman 12

The Extensivist clinic can provide a one-stop shop for patients and helps reduce isolation

Basic Care

Pre-Op

Strength Training

Foot Care

Example Care Center Layout

Class-room

MedicalRecords

Room

Reg

istr

atio

nD

esk

Office – Exam Rooms–

Supplies/Equip.

Storage

NPOffice

Wa

itin

g

Co

mm

un

ity

TV

Ro

om

PodiatryRoom

Ex

ten

siv

ist

Off

ice

StrengthTraining

Room

La

b/D

iag

no

sti

cR

oo

m

– Exam Rooms–

Blood Pressure Management

Nutrition & Wellness Classes

Social SpaceNurse Practitioner

Hospitalist’s Office

Wound care

Fall Prevention

Source: “Delivering Integrated Patient Care for Seniors,” CareMore 11/2008, p. 33

Example Extensivist clinic

For discussion

In some areas, a smaller clinic can be supported by existing virtual or distributed infrastructure to provide the same levels of care

1313© Oliver Wyman

Extensivist practice overview

Chronic care-specialized physician is interested in building a suite of services to fully meet the need of the most fragile patients

Day in the Life

• Physician sees 8-10 patients, with visits ranging from 30 to 90 minutes

• Average panel size of 400 patients

• Physician practice includes supporting care team, including NPs/PAs, embedded health navigator, and other embedded services

Core Patient Profile

• 95%+ of patients have more than 4+ chronic condition and have serious health needs (sickest 5% of patients – to be discussed further)

Embedded Patient Services

• All patients will be eligible to receive health navigation from the embedded health navigator

• Other in-house patient services and built out based on patient volume and may include Behavioral Medicine, Pharmacy, Hospice, Nutrition, and others

• Patients may be connected to other community-based services by their health navigator

Compensation (TBD)

• Combined compensation model based on salary or a combination of on RVUs and gain share

Extensivist PracticeFocused on the most complicated chronic care within one practice

1414© Oliver Wyman

Patients selected for the Extensivist clinic will fall into one of three categories

1Catastrophic Patients 2 Future Catastrophics 3 Physician Referrals

• The biggest, most catastrophic and costly cases

• Small number of patients

• A portion of these patients won’t be catastrophic “tomorrow” (e.g. trauma patients, other one-off episodes)

• Patients with comorbidities, behavioral risk factors, and heavy system utilization

• Patients who may not be top spenders today, but are likely to be higher cost “tomorrow”

• Patients referred to the clinic by their physicians

• “We know them when we see them”

• Referrals to the clinic will be greeted with a quick answer and a quick decision

Will be identified via an analytic-based approach Will be identified via ongoing engagement with physicians

Extensivist patient categories

15© Oliver Wyman 15

A number of potential issues need to be overcome when establishing an Extensivist model

HOSPITAL

Total population: 168k

Future NE Lincs Health Economy – overview

HOSPITAL

Scunthorpe General

Need to manage perception of preferential treatment given to urban patients

• CCG needs to contract based on risk to enable provider upside

• Patients must be prepared to change their main point of contact as they move between models

• Federated GP clinics share information, capabilities and patients

• Risk and outcomes based payments demand risk pricing and flow of fund management capabilities

Hospital specialists must work alongside the Extensivist in order to co-ordinate care

Extensivist needs privileges for ward rounds within the hospital setting

The Humber

A&E Department

GP surgeries

Acute provider hospital

Mental health/Social care providers

Extensivist clinic

• Provider build of significant capabilities to launch– Extensivist lead clinician– Care team composition– Workflow redesign– Risk stratification– IT / systems– Scheduling

• Change in patient behaviours will be required

• Community-based resources will need to have aligned incentives and coordinated activities

For discussion

1616© Oliver Wyman

The model has 6 major elements, providing us with a view of the overall impact of the Expert Care hub, and impacts across the system

New cohort costCurrent cohort cost Expert care hub costs Other incremental services

Efficiency, de-duplication & re-use

Lower cost of care

1 2 3 4 5

Symphony economic model elements

Co

st

6

Illustrative – not to scale

1717© Oliver Wyman

• Integrated, team-based delivery

• Shift to prevention and wellness

• Transformed outcomes and value for money, partly through selective partnerships

• New non-traditional healthcare players

• Intent to improve accessibility and wellness

• Extensive use of partnerships

• Widespread genomics sequencing

• Likely to entirely change health systems

• Baseline established for:

– Quality

– Safety

– Primary Care and Hospital efficiency

Wave 0BASIC SAFETY AND EFFICIENCY

Wave 1PATIENT-CENTRED CARE

Wave 2CONSUMER ENGAGEMENT

Wave 3SCIENCE OF PREVENTION

The UK healthcare system will undergo waves of innovation, transforming care delivery

Early effects already impacting the UK, continuing over the next decade Future waves

Source: Oliver Wyman Health Innovation Centre