ADVANCING PRIVATE HEALTHCARE SUSTAINABILITY
THROUGH CLOSER COLLABORATION
Health Insurance SummitJuly 29 2016
Dr David RankinClinical Director - Medibank
HEALTH SYSTEM CHALLENGES
A sustainable healthcare system is driven to innovate and deliver efficiencies to offset these growing cost pressures
131220142
Growing and Aging
Population
Increasing
Prevalence of
Chronic Disease
New
Technologies
Consume 35 of all
hospital and medical
expenditure
HIGHER COST DOESNrsquoT EQUAL QUALITY
SOURCE Medibank claims data showing of total FY2013 admissions A comparison of 11 major Sydney
Hospitals with more than 100 beds and ICU
3
Hospital Acquired Complications
052
080074
049
149
072
112
047
151
091
138
Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Most ExpensiveHospital
Hospital 10 Hospital 11
VALUE BASED HEALTHCARE
bull Outcomes are the health results that matter
for a patientrsquos condition over the care cycle
bull Costs are the total costs of care for a
patientrsquos condition over the care cycle
bull Bundled payments
4
Health Outcomes
Cost of Delivering the OutcomesValue =
Source lsquoThe Strategy That Will Fix Health Carersquo Michael Porter Thomas Lee HBR October 2013
lsquoValue Based Health Carersquo Michael Porter Robert Kaplan HBS Webinar 2015
lsquoHow to Pay for Healthcarersquo Michael Porter Robert Kaplan HBR JulyAugust 2016
MEDIBANKrsquoS TRIPLE AIM
Outcome
bull Safe - treatment that results in the fewest injuries or complications
bull Appropriate - treatment that is delivered in an appropriate location by qualified professionals
bull Effective - the best treatment choice based on scientific evidence
Experience
bull Patient Centred - treatment that is responsive to the individual memberrsquos needs
bull Timely - treatment that will avoid potentially harmful delays
bull Informed - treatment about which our members have been appropriately informed both clinically and
financially
Affordability
bull Efficient - treatment that is provided in a way that avoids or reduces waste
bull Economical - treatment that is delivered on the number of occasions necessary
To Improve the outcome of patient care
Improve the memberrsquos experience of care and
Improve the affordability of health care
TRANSFORMING HEALTH CARE
6
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
TRANSFORMING HEALTH CARE
7
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
CORE PRINCIPLES
8
Criteria Explanation
Relevant to Medibank bull A direct and significant impact on Medibank Triple Aim
Outcome Focusedbull Focused on the memberrsquos health outcome (rather than the process of
delivering care)
Contributorybull Not readily available to the provider from internal data collection
bull Avoid duplicating existing reported measures
Motivational bull Must address something the provider perceives as important to motivate
change
Remediable bull Performance must be able to be changed with focused effort
Industry Accepted bull Indicators need to be accepted as valid and appropriate by providers
Benchmarkedbull Able to compare performance against comparable peers
bull Ideally there should be evidence based best practice targets for comparison
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
HEALTH SYSTEM CHALLENGES
A sustainable healthcare system is driven to innovate and deliver efficiencies to offset these growing cost pressures
131220142
Growing and Aging
Population
Increasing
Prevalence of
Chronic Disease
New
Technologies
Consume 35 of all
hospital and medical
expenditure
HIGHER COST DOESNrsquoT EQUAL QUALITY
SOURCE Medibank claims data showing of total FY2013 admissions A comparison of 11 major Sydney
Hospitals with more than 100 beds and ICU
3
Hospital Acquired Complications
052
080074
049
149
072
112
047
151
091
138
Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Most ExpensiveHospital
Hospital 10 Hospital 11
VALUE BASED HEALTHCARE
bull Outcomes are the health results that matter
for a patientrsquos condition over the care cycle
bull Costs are the total costs of care for a
patientrsquos condition over the care cycle
bull Bundled payments
4
Health Outcomes
Cost of Delivering the OutcomesValue =
Source lsquoThe Strategy That Will Fix Health Carersquo Michael Porter Thomas Lee HBR October 2013
lsquoValue Based Health Carersquo Michael Porter Robert Kaplan HBS Webinar 2015
lsquoHow to Pay for Healthcarersquo Michael Porter Robert Kaplan HBR JulyAugust 2016
MEDIBANKrsquoS TRIPLE AIM
Outcome
bull Safe - treatment that results in the fewest injuries or complications
bull Appropriate - treatment that is delivered in an appropriate location by qualified professionals
bull Effective - the best treatment choice based on scientific evidence
Experience
bull Patient Centred - treatment that is responsive to the individual memberrsquos needs
bull Timely - treatment that will avoid potentially harmful delays
bull Informed - treatment about which our members have been appropriately informed both clinically and
financially
Affordability
bull Efficient - treatment that is provided in a way that avoids or reduces waste
bull Economical - treatment that is delivered on the number of occasions necessary
To Improve the outcome of patient care
Improve the memberrsquos experience of care and
Improve the affordability of health care
TRANSFORMING HEALTH CARE
6
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
TRANSFORMING HEALTH CARE
7
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
CORE PRINCIPLES
8
Criteria Explanation
Relevant to Medibank bull A direct and significant impact on Medibank Triple Aim
Outcome Focusedbull Focused on the memberrsquos health outcome (rather than the process of
delivering care)
Contributorybull Not readily available to the provider from internal data collection
bull Avoid duplicating existing reported measures
Motivational bull Must address something the provider perceives as important to motivate
change
Remediable bull Performance must be able to be changed with focused effort
Industry Accepted bull Indicators need to be accepted as valid and appropriate by providers
Benchmarkedbull Able to compare performance against comparable peers
bull Ideally there should be evidence based best practice targets for comparison
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
Consume 35 of all
hospital and medical
expenditure
HIGHER COST DOESNrsquoT EQUAL QUALITY
SOURCE Medibank claims data showing of total FY2013 admissions A comparison of 11 major Sydney
Hospitals with more than 100 beds and ICU
3
Hospital Acquired Complications
052
080074
049
149
072
112
047
151
091
138
Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 Hospital 8 Most ExpensiveHospital
Hospital 10 Hospital 11
VALUE BASED HEALTHCARE
bull Outcomes are the health results that matter
for a patientrsquos condition over the care cycle
bull Costs are the total costs of care for a
patientrsquos condition over the care cycle
bull Bundled payments
4
Health Outcomes
Cost of Delivering the OutcomesValue =
Source lsquoThe Strategy That Will Fix Health Carersquo Michael Porter Thomas Lee HBR October 2013
lsquoValue Based Health Carersquo Michael Porter Robert Kaplan HBS Webinar 2015
lsquoHow to Pay for Healthcarersquo Michael Porter Robert Kaplan HBR JulyAugust 2016
MEDIBANKrsquoS TRIPLE AIM
Outcome
bull Safe - treatment that results in the fewest injuries or complications
bull Appropriate - treatment that is delivered in an appropriate location by qualified professionals
bull Effective - the best treatment choice based on scientific evidence
Experience
bull Patient Centred - treatment that is responsive to the individual memberrsquos needs
bull Timely - treatment that will avoid potentially harmful delays
bull Informed - treatment about which our members have been appropriately informed both clinically and
financially
Affordability
bull Efficient - treatment that is provided in a way that avoids or reduces waste
bull Economical - treatment that is delivered on the number of occasions necessary
To Improve the outcome of patient care
Improve the memberrsquos experience of care and
Improve the affordability of health care
TRANSFORMING HEALTH CARE
6
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
TRANSFORMING HEALTH CARE
7
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
CORE PRINCIPLES
8
Criteria Explanation
Relevant to Medibank bull A direct and significant impact on Medibank Triple Aim
Outcome Focusedbull Focused on the memberrsquos health outcome (rather than the process of
delivering care)
Contributorybull Not readily available to the provider from internal data collection
bull Avoid duplicating existing reported measures
Motivational bull Must address something the provider perceives as important to motivate
change
Remediable bull Performance must be able to be changed with focused effort
Industry Accepted bull Indicators need to be accepted as valid and appropriate by providers
Benchmarkedbull Able to compare performance against comparable peers
bull Ideally there should be evidence based best practice targets for comparison
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
VALUE BASED HEALTHCARE
bull Outcomes are the health results that matter
for a patientrsquos condition over the care cycle
bull Costs are the total costs of care for a
patientrsquos condition over the care cycle
bull Bundled payments
4
Health Outcomes
Cost of Delivering the OutcomesValue =
Source lsquoThe Strategy That Will Fix Health Carersquo Michael Porter Thomas Lee HBR October 2013
lsquoValue Based Health Carersquo Michael Porter Robert Kaplan HBS Webinar 2015
lsquoHow to Pay for Healthcarersquo Michael Porter Robert Kaplan HBR JulyAugust 2016
MEDIBANKrsquoS TRIPLE AIM
Outcome
bull Safe - treatment that results in the fewest injuries or complications
bull Appropriate - treatment that is delivered in an appropriate location by qualified professionals
bull Effective - the best treatment choice based on scientific evidence
Experience
bull Patient Centred - treatment that is responsive to the individual memberrsquos needs
bull Timely - treatment that will avoid potentially harmful delays
bull Informed - treatment about which our members have been appropriately informed both clinically and
financially
Affordability
bull Efficient - treatment that is provided in a way that avoids or reduces waste
bull Economical - treatment that is delivered on the number of occasions necessary
To Improve the outcome of patient care
Improve the memberrsquos experience of care and
Improve the affordability of health care
TRANSFORMING HEALTH CARE
6
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
TRANSFORMING HEALTH CARE
7
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
CORE PRINCIPLES
8
Criteria Explanation
Relevant to Medibank bull A direct and significant impact on Medibank Triple Aim
Outcome Focusedbull Focused on the memberrsquos health outcome (rather than the process of
delivering care)
Contributorybull Not readily available to the provider from internal data collection
bull Avoid duplicating existing reported measures
Motivational bull Must address something the provider perceives as important to motivate
change
Remediable bull Performance must be able to be changed with focused effort
Industry Accepted bull Indicators need to be accepted as valid and appropriate by providers
Benchmarkedbull Able to compare performance against comparable peers
bull Ideally there should be evidence based best practice targets for comparison
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
MEDIBANKrsquoS TRIPLE AIM
Outcome
bull Safe - treatment that results in the fewest injuries or complications
bull Appropriate - treatment that is delivered in an appropriate location by qualified professionals
bull Effective - the best treatment choice based on scientific evidence
Experience
bull Patient Centred - treatment that is responsive to the individual memberrsquos needs
bull Timely - treatment that will avoid potentially harmful delays
bull Informed - treatment about which our members have been appropriately informed both clinically and
financially
Affordability
bull Efficient - treatment that is provided in a way that avoids or reduces waste
bull Economical - treatment that is delivered on the number of occasions necessary
To Improve the outcome of patient care
Improve the memberrsquos experience of care and
Improve the affordability of health care
TRANSFORMING HEALTH CARE
6
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
TRANSFORMING HEALTH CARE
7
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
CORE PRINCIPLES
8
Criteria Explanation
Relevant to Medibank bull A direct and significant impact on Medibank Triple Aim
Outcome Focusedbull Focused on the memberrsquos health outcome (rather than the process of
delivering care)
Contributorybull Not readily available to the provider from internal data collection
bull Avoid duplicating existing reported measures
Motivational bull Must address something the provider perceives as important to motivate
change
Remediable bull Performance must be able to be changed with focused effort
Industry Accepted bull Indicators need to be accepted as valid and appropriate by providers
Benchmarkedbull Able to compare performance against comparable peers
bull Ideally there should be evidence based best practice targets for comparison
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
TRANSFORMING HEALTH CARE
6
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
TRANSFORMING HEALTH CARE
7
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
CORE PRINCIPLES
8
Criteria Explanation
Relevant to Medibank bull A direct and significant impact on Medibank Triple Aim
Outcome Focusedbull Focused on the memberrsquos health outcome (rather than the process of
delivering care)
Contributorybull Not readily available to the provider from internal data collection
bull Avoid duplicating existing reported measures
Motivational bull Must address something the provider perceives as important to motivate
change
Remediable bull Performance must be able to be changed with focused effort
Industry Accepted bull Indicators need to be accepted as valid and appropriate by providers
Benchmarkedbull Able to compare performance against comparable peers
bull Ideally there should be evidence based best practice targets for comparison
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
TRANSFORMING HEALTH CARE
7
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
CORE PRINCIPLES
8
Criteria Explanation
Relevant to Medibank bull A direct and significant impact on Medibank Triple Aim
Outcome Focusedbull Focused on the memberrsquos health outcome (rather than the process of
delivering care)
Contributorybull Not readily available to the provider from internal data collection
bull Avoid duplicating existing reported measures
Motivational bull Must address something the provider perceives as important to motivate
change
Remediable bull Performance must be able to be changed with focused effort
Industry Accepted bull Indicators need to be accepted as valid and appropriate by providers
Benchmarkedbull Able to compare performance against comparable peers
bull Ideally there should be evidence based best practice targets for comparison
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
CORE PRINCIPLES
8
Criteria Explanation
Relevant to Medibank bull A direct and significant impact on Medibank Triple Aim
Outcome Focusedbull Focused on the memberrsquos health outcome (rather than the process of
delivering care)
Contributorybull Not readily available to the provider from internal data collection
bull Avoid duplicating existing reported measures
Motivational bull Must address something the provider perceives as important to motivate
change
Remediable bull Performance must be able to be changed with focused effort
Industry Accepted bull Indicators need to be accepted as valid and appropriate by providers
Benchmarkedbull Able to compare performance against comparable peers
bull Ideally there should be evidence based best practice targets for comparison
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
IMPLEMENTATION PRINCIPLES
9
Criteria Explanation Compliant
Examples
Non-compliant
Examples
Sufficient
volumeStatistically significant incident rate
ICU admission rate
Rehab referral rateDeath rate
TimelyData needs to be available in a timely manner to
encourage improvement and track changeAnnual volumes
5 yr re-operation
rate
Transparent Clearly defined indicatorsLength of stay
Day case rate
OR time (lack of
clear definition)
ObjectiveData should not be subject to local interpretation
or manipulationLength of stay Hand hygiene rate
Available
Data must be readily available to Medibank
Collection should not pose an additional burden
on the provider
HCP data
Hand hygiene rate
SAB rate
ldquoAvoidablerdquo
admission
ComparableIndicators need to be risk adjustable to ensure
valid inter-provider comparisons
LoS for single
procedure or DRGService wide LoS
Discrete
Measures should not be subject to care
substitution change in coding practice or patient
selection
Patient comorbidity
Patient age
DRG complexity
coding
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
IDENTIFYING APPROPRIATE INDICATORS
gt 1200 14
Catalogue
International
metrices
Determine
Available Data
Set
Apply Core
Criteria
Apply
Implementation
Criteria
Build technical
specsSelect specific
metrics
1 3 4 5 62
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
MEDIBANK CLINICAL INDICATORS
11
AffordabilityOutcomes Experience
Length of stay
Same day rate Total episode cost
Prostheses cost30 day readmission
6 month reoperation
Hospital Acquired
Complication rate
ICU admission rate
Member OOPs
Multiple MBS items
Procedure specific(operative cholangiogram)
Medibank Triple Aim
Patient Experience
Inpatient Rehabilitation
Rate
Patient Reported
Outcome Measures
Modifiers
bull Patient Age
bull Volume of procedures
undertaken
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
TRANSFORMING HEALTH CARE
12
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
What Hospitals Believe
We believe
in quality
We have the
best doctors
We have the
sickest frailest
and most at risk
patients
We are
quality
champions
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
HOSPITAL VARIANCE REPORT
14
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
HOSPITAL BENCHMARK REPORT
331615
Hospital Group
Hospital A
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
16
x Hospital is performing outside expectations on this clinical indicator
y Hospital is a high performer on this clinical indicator
x Hospital is a significant outlier and Medibank has concerns
y This Hospital appears to be a significant high performer
Hospital Mix Vol LoS TLoS Rehab ICU Complex TransferSame
DayComments
Hospital A x y y y y Relatively few hip replacements
Hospital B x x x x x Only 3 HJR 100 rehab no day hernia
Hospital C y y y y y x x X 2 Whipples Chole transfers no day hernia
Hospital D x y x y X
Hospital E x x y y x y Only 5 THJR 5 Spinal fusion
Hospital F y y y X Low day colonoscopy rate
Hospital G y y y y x Only 2 Whipples
Hospital H x x y x x Low hernia day rate
June ndash July 2014 June ndash July 2015 Comment
Length of stay for hips and knees Hips - 58 Knees ndash 583 Hips 57 Knees 56 Reducing LoS
rehab for hips knees spine Hips 32 Knees 37 Spine 19 20 24 24 Significant reduction
ICU Hips 6 Knees 4 Spine 39 4 5 32 Reduction in spine
day stay Colonoscopy Hernia Eye 95 11 92 97 10 92 Stable
Trends (Jul ndash Jun 14 compared to Oct ndash Sep 15)
ldquoSamplerdquo Health Care Group ndash Clinical Indicator ReportClinical Report Oct 14 ndash Sep 2015
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
IDENTIFIED COMPLICATIONSMedibank Identified Complications are
bull likely to occur in an acute private hospital setting
bull frequently (gt0) occur on Medibankrsquos claims history and
bull evidence shows they can be reduced or avoided if clinical guidelines are followed
17
bull 5 Groups
bull 12 Categories
bull 82 CodesIdentified
Complications
bull 15 Groups
bull 39 Categories
bull 400+ Codes
Hospital Acquired Complications
(ACSQHC)
bull 4000+ CodesCHADx
Pressure
Injury
Falls Infection Surgical
Complications
VTE of PWO
Separations
38 43 997 3309 10 19
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
COMPLICATION RATE
Complication rate is independent of group size or case mix
18
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
Hospital Reaction
Itrsquos too
much too
soon
Few prepared to respond
to clinical quality
focused commercial
negotIations
Letrsquos work together
on data collection
but come to an
agreement in ldquosay
12 monthsrdquo
Lots of lsquoplaying the
manrsquo and lsquolooking
for weedsrsquo
Hospitals are only hotels
where surgeons operate
Talk to the surgeons
This is contract
related letrsquos not
tell the surgeons
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
SURGICAL VARIANCE REPORTS
20
Released Pending
General Surgery Urology ENT Vascular Surgery Orthopaedics
Lap Chole
Gastric banding
Gastric sleeve
Hernia
Bowel resection
Gastroscopy
Colonoscopy
bull with polyp
bull wrsquoout polyp
Cystoscopy
bull with resection
bull wrsquoout resection
Prostatectomy
bull Endoscopic
bull Radical
Sinus surgery
Tonsils and
adenoids
Myringotomy
Varicose veins
Endarterectomy
Hip replacement
Knee replacement
ACL repair
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
SAME DAY HERNIA REPAIR RATES
21
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Perc
enta
ge o
f patient
that
sta
yed in h
ospital
overn
ight
Surgeons by separation volume
US rate = 90
Australian rate = 20
Average SD hernia cost = $2160
Average Inpatient hernia cost = $3100
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
INPATIENT REHABILITATION REFERRAL RATES ndash KNEE REPLACEMENT
bull Inpatient Rehabilitation adds $10000 to the cost of a hip replacement
bull Growing evidence that inpatient rehabilitation does not improve patientsrsquo outcomes following joint replacements
22
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80
Perc
enta
ge o
f patients
tra
nsfe
rred to inpatient
rehabili
tation
Surgeons by separation volume
Ontario referral rate = 10
Medibank rate = 35
Significant variation
between surgeon hospital
and state
See Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013 Stolee 2011 Mahomed et al 2008 Buhagiar et al 2013Loacutepez-Liria et al 2015 Kauppila et al 2010
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
OUT OF POCKET CHARGE BY PRINCIPAL SURGEON
23
$0
$200
$400
$600
$800
$1000
$1200
$1400
$1600
0 10 20 30 40 50 60 70
Avera
ge s
urg
eon O
OP
charg
e
Surgeons by separation volume
Cystoscopy with resection
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
TRANSFORMING HEALTH CARE
24
Develop
ReportsExtract data
Analyse data
Validate data
Format data
Partner Endorsement
Print reports
Prioritise
ChangeKey variance areas
Drivers of variance
Barriers to change
Industry motivation
Level of Evidence
Identify LeversRecognition
Payment
Censure
Set targets
Engage providersMeasure
OutcomesEvaluate success
Report trends
Celebrate and reward
Identify PartnersEngage sector
representatives
Agree objectives
Establish relationship (MoU)
Agree MeasuresClinical Indicators
ProceduresConditions
Units and specifications
Risk AdjustmentDistribute
ReportsIdentify target
audience
Distribution
Media engagement
Implement
ChangeReport on evidence
Identify best practice
Set targets
Set timeframes
Activate levers
Engage providers
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
IDENTIFICATION OF PRIORITY FOCUS AREAS
25
Barr
iers
to C
hange
Clinician Ability to InfluenceLower Higher
Low
er
Hig
her
Same Day rate
LOS
Sep cost
Rehab rate
Prosthesis
cost
Surgeon OOP
Reoperation
s
30 day
Readmissions
ICU
Complications
Multiple MBS
High Low
Impact
(Outcome Experience
Affordability)
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
IDENTIFYING FOCUS AREAS
26
00
100
200
300
400
500
600
700
800
Rehab Transfer Rate RAPT Rehab Rate
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
LEARNINGS
27
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
CHALLENGES
bull Terminologyminus Clear definition of the clinical indicators
minus Implication of mistake avoidable preventable
bull Limitations and utility of administrative data
bull Role of Medibank
bull Variance in ldquoClinical Governancerdquo systems
bull Recording and reporting ldquominorrdquo and ldquoinevitablerdquo complications
bull Definition of Guidelines and best practice
bull Clinical expert review
bull Communicating the detailminus Contracted providers stakeholders interest groups
bull Speed of implementation
bull Fractured sector response
Engagement with our providerspartners is at the heart of changeMedibank cannot change the sector on its own
28
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
EARLY INDICATORS OF SUCCESS
Enhanced engagement
bull hospital and insurer
bull hospitals and surgeons
bull surgeon and anaesthetist
Exploration of what is best practice
Hospitals and surgeons are actively engaged in discussion about
bull Reducing inpatient rehabilitation referral rates
bull ICU utilisation rates
bull Inter-clinician variation
bull Low volume surgery
bull Complication rates
bull Out-of-Pocket charges
Outlier hospitals are clearly moving towards the mean
29
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
HOSPITAL SURVEYPositives
bull All hospitals welcomed the reports and appreciated the initiative
bull All hospital executives found the presentation simple and clear and the data easy to
interpret
bull Reports are very useful particularly in highlighting inter-hospital comparisons
bull Hospitals are optimistic that as the reports evolve the hospitals will share the good news
with their clinicians
Opportunities for Improvement
bull Reports only capture a subset of hospitalrsquos activity - would welcome wider scope of
reports
bull Seldom shared with clinicians ndash unless there was a particular area of concern
bull Concern that some measures (rehab referral rate) did not relate to quality and safety
Hospital Attitude to Medibank Reports Amongst Eight Major Hospital Groups Dr Anand Ponniraivan July 2016
30
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
TO CHANGE BEHAVIOR PROVIDERS MUST -
bull First be engaged
bull Be informedbull Providers seldom understand how they compare
bull Accept the data as valid
bull Acknowledge there is a problem
bull Be motivated to change
bull Accept that they can changebull Ability to overcome barriers and resistance
bull Grasp their opportunities
31
ldquoData Sharing is Just the Start of a Relationshiprdquo
Develop
Reports
Prioritise
Change
Identify
Levers
Measure
Outcome
s
Identify
Partners Agree
Measures
Distribute
Reports
Implement
Change
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32
ldquoTHE TRANSFORMATION IS
GOING TO HAPPEN ndash IT HAS TO
AND WE KNOW IT WORKSrdquo
MICHAEL PORTER ICHOM CONFERENCE MAY 2016
32