Session 3: Can the Best Practice Tariff and price benchmarking lead to better care?

Elaine YoungDirector of Operations

National Joint Registry & Peter Howard

Orthopaedic surgeon member, NJR Steering Committee and Chairman,

NJR Surgeon Outlier Sub-committee

About us

The National Joint Registry for England, Wales and Northern Ireland•Largest arthroplasty register in the world•Hold more than 1.75 million records covering hip, knee, ankle, elbow and shoulder joint replacements•Monitor the performance of implants, hospitals and surgeons•Collaborating nationally (MHRA, CQC, Monitor)•Collaborating internationally – a growing agenda (FDA, EU, international orthopaedic societies)

Best Practice Tariff(BPT)

New BPT

• For hip and knee replacement surgery in England• Started April 2014 • NJR data reported at hospital-level quarterly, on NHS-

funded procedures in England• Two NJR measures contribute

– Compliance– Patient consent

• National PROMs data also forms part of the tariff requirements

BPT leading to better care?

Through use of the tariff we hope to see improved:•Data completeness – allowing a full picture of activity and performance to be reported•Data quality – improving the active consent process to ensure we have patient details to monitor outcomes i.e. linking primary and revision operations together to calculate revision rates•Best practice and engagement – organisations given financial incentive for their participation in national audit

BPT – learning so far

Though it is early days for the NJR: •Intention to increase the levels of compliance and patient consent required to drive up standard practice•In 2015/16, the requirements for compliance will increase•Impact - large number of trusts have already contacted the NJR to enter historical data

Price benchmarking

Background to price benchmarking

Quality, Innovation, Productivity and Prevention (QIPP)•Collaboration with the QIPP team at the DH•Price benchmarking is one initiative that forms part of the QIPP programme to support clinical teams and NHS organisations to improve the quality of care they deliver while making efficiency savings

Background to price benchmarking

Overview•Initial pilot covering five hospitals, moving to 30 additional organisations across England and Wales •Award winning initiative for benchmarking, Best Practice Institute 2013•Following this success, the pilot is now rolling out nationally as a free of charge NJR service

– Trusts also have the option to buy enhanced reporting services, dependent on their requirements

Price benchmarking

Objectives•Provide local and national insight into the relative cost effectiveness of joint replacement surgery by individual prosthesis•To enable providers to develop action plans around exploitation of this data to improve cost effectiveness of joint replacement surgery

Relating price to care

Lower CostBetter Outcome

Higher CostBetter Outcome

Higher CostLower Outcome

Lower CostLower Outcome

At the heart of the pilot, was the intent to examine patient outcomes, not just cost.

What we set out to look at

• Measure price of implants

• Measure outcome (multi-faceted)

• Visualise this data to attempt to understand relationships between cost and outcome by implant

• Recognise that ‘comparisons’ need to be cautioned relative to volume and case-mix

What data?

NJRPatient

Reported Outcome

HES/SUS

Local Prosthesis Price

ProsthesisRevision Outcome

HospitalVolume of activity at hospital

Patient Age and Sex demographic

12 month PROMPre-operative score

6 month Health gain (PROM)Length of Stay

Local Prosthesis Price

Implant costs data analysis

• 35 Trusts/units

• 5 largest manufacturers

• Annual spend on implants

Distributor Count of Priced Components Total PriceBiomet 9,992 £4,511,333DePuy 34,273 £13,681,324

Smith & Nephew 5,125 £2,225,748Stryker 17,854 £5,999,144Zimmer 6,537 £2,708,850Other 125 £30,286

TOTAL 73,906 £29,156,685

Findings: total spend and usage

Findings

• £29m annual spend in hip and knee implants across the 35 organisations with the 5 suppliers included in the pilot

• Average hip implant cost - £1,368– averages range from £800 - £2150

• Average knee implant cost - £1,395– average range from £1000 - £1950

Findings

• If all 35 trusts purchased these components paying at most the AVERAGE price, the annual saving across the trusts would be £1.98m

• at the BEST price the annual saving would be £7.76m

Findings

Link between volume purchased and cost paid is weak

•In many cases, prices paid not directly related to volume even to same company•In any trust there is a wide variation in the average cost of implants between surgeons

– Driven by usage of different implants/manufacturers

Trusts

Trust Maximplant cost

Trust Minimplant cost

Trust Average implant cost

No or primary procedures undertaken

Variation in Implant Cost – Primary Knees

Trusts

Procedure Device Costs by Trust - HIPS

Findings – Hip Stem Brand Pricing by Trust

Findings

• Wide variation in the average cost of implants between surgeons

• Wide variation in implant usage within single trusts

What did participants say

Clinical• Can I see my detailed data?• Which procedure cost x and why?• I wasn’t aware that component x cost more than component y!• Can we link with clinical outcomes data / ODEP ratings for products?Procurement • Who is paying £x for product y!• I have alerted supplier x to the data and asked them to explain.• Can we model the cost implications if we migrate to supplier x?Management• Why do we pay more for product x?• Who is consultant x?

What is happening now in Trusts

• Each Trust has now been invited to submit data to the scheme and receive an individual pricing report

How can this contribute to better care?

• Managing device costs ensures best use of finite healthcare resources

• Supports trusts and surgical teams in using data to evidence device choice

• Supports trusts in developing implant usage protocols• Enhances evidence-based discipline around implant

choice

Future study options

• Correlation with other variables– PROMS– Revision rates– Length of stay– Readmission

Knee Surgeons

0

0.5

1

1.5

2

2.5

3

3.5

4

0 5 10 15 20

Expected Number of Revisions

PT

IRKneeSurgeons Upper 99.8% Upper 95% Average Outlier

Thank you

Mr Peter HowardOrthopaedic surgeonNJR Steering CommitteeElaine YoungDirector of operations,National Joint Registry