A STRATEGIC APPROACH TO THE REALLOCATION OF RESOURCES BASED ON THE SOUNDNESS OF INTERVENTIONS

GERTRUDE BOURDON, CHIEF EXECUTIVE OFFICERDANIEL LA ROCHE, HEAD OF EVALUATION, QUALITY AND STRATEGIC PLANNING, EXTRA FELLOW COHORT 9

CEO Forum, CFHIFebruary 6, 2013

The CHU de Québec: recognized in the field and in the region

• Most important University Hospital in Quebec, among the 3 most important in Canada;

• Regional and superregional centre serving 1.7 M people• Named Canadian Model by Accreditation Canada in: • Governance

• TeleHealth• Skills Development

of managerial staff

• Systemic screening of distress among cancer patients

• Decision-making integrated to strategic directions•Most important employer in Quebec City

• 13,820 employees• 1,700 doctors,

pharmacists and dentists

• 550 researchers• 1,048 graduate students• More than 800 volunteers

A Four-Fold Mission

Healthcare 1,800 beds 235,000 yearly ER visits 584,000 visits for specialized external services 85,000 surgeries

Teaching 265,000 days of rotation

Research Funding of $89 M Close to 550 researchers

Health technology assessment Recognized by the Canadian Foundation for Healthcare

Improvement as a high-potential organization in the use of research evidence

The Intervention Project

Team of EXTRA fellows, cohort 9 Daniel La Roche, Head, Evaluation, Quality

and Strategic Planning (DEQPS) Martin Coulombe, Assistant, Evaluation,

DEQPS Dr Marc Rhainds, Medical and Scientific co-

manager, Health Technology Assessment Unit

Three studies have estimated that about a third of healthcare expenditures in the USA could be avoided: $700 to $910 billion each year

45%= sub-optimal utilisation of resources (over-treatment, utilisation not justified by evidence, inefficient utilisation, etc.)

55%= fraud, abuse, administration, price-fixing, etc.

The context: US Evidence

The context: Canadian Evidence

Canadian Association of radiologists (2010): 30% of diagnostic imaging procedures in

Canada might be unnecessary Operational costs of imaging in Canada

are $2.2 billion/year

The context: CHU de Québec

Committee of Major Cost Generators (CMCG): subcommittee of Management Committee, created in 2008

Mandate: identification of the major cost generators and development of strategies to generate savings and reduce expenditure increases. Medical and office supplies Human resources Specific professional practices

Main Strategies: Streamlining medical and office supplies in order to reduce

inventories Acting with suppliers (i.e. call for tenders)

A Reallocation Example

Project: Reducing the variety of anesthesia tubings at the CHU de Québec

A multitude of tubings with different types, sizes and suppliers

Clinicians selecting a reduced number of tubings

Call for tenders Recurrent savings of $300,000 Reallocation of savings to the Chronic Pain

Clinic

Aim and Objectives of our Project

•To include the consideration of evidence in the Major Cost Generators process (MCGC)

Aim

•To have a medical leader included in the MCGC

•To develop a disinvestment and reallocation process for the institution

•To identify local disinvestment opportunities

•To make the reallocation process permanent through a policy of the Board of Directors

Objectives

Relevant Factors

Easier access to resources might lead to overuse A disinvestment process implemented at the

institution level cannot target a similar level of potential savings as that identified for a full healthcare system as in the American studies

Institutions do not control the decisions of the MSSS (Health and Social Services Ministry) about access to resources

Some payments for services are not charged to the budgets of the institutions (RAMQ--Quebec Health Insurance Plan--, insurers, etc.)

Relevant Factors

Amount spent for medications and supplies for care provision and diagnostics at the CHU de Québec $155M/year

Realistic disinvestment potential 5% = $7.75M/year

Basic Principles

Voluntary disinvestment and reallocation based on: Evidence The situation at the CHU de Québec The participation of interested clinicians

Reallocation In the departments/units having generated

the savings (95%) In health technology assessment (5%) to

make the process permanent after EXTRA

Basic Principles

Initial focus should be on the overuse of medical resources major factor explaining the high level of

healthcare expenditures exposes patients to unjustified risks 

Reassessment and Reallocation

Reassessment of an intervention

based on evidence

Phased disinvestment and change

management

Follow-up of change implementation and

impacts, and measurement of

savings

Reallocation based on evidence

Follow-up of disinvestment

sustainability and its impacts

Benefits for Patients

Improvement of quality and safety of care

Increased accessibility of care Avoiding interventions having no added

value

Issues

Resources dedicated to the definition and support of disinvestment mechanisms

Limits of information systems Political, clinical and social challenges related

to the withdrawal of any established technology

Resistance to change Availability of scientific evidence Physicians’ compensation sytem (fee-for-

service)

Questions

Any questions?