Elements of a National Health Strategy:Key Metrics and Performance

IndicatorsHealthcare 20/20: Cayman Islands International Healthcare Conference 2011

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Introduction Dale Sanders

Twitter: @drsanders

Text: 1-345-925-8329

Email: dale.sanders@hsa.ky

LinkedIn: http://www.linkedin.com/in/dalersanders

Blogs http://callitanything.blogspot.com/ http://healthsystemcio.com/tag/dale-sanders/

Text, email, or tweet your questions during the presentation

Overview

National Health Accounts: What Are They?

Sources of Benchmarks for National Healthcare Policy and Management

Related Health Services Authority Metrics All HSA/Cayman metrics are preliminary and need

refinement

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Key Messages

The old but true cliché: You can’t manage what you can’t measure

An effective national health plan requires national healthcare indicators and metrics

We have some Cayman Islands metrics already and our “data momentum” is increasing

But we should probably increase our focus and efforts

Becoming a “data driven culture” in healthcare is not easy

There will soon be three major skills shortages in healthcare Physicians, nurses and… Data analysts

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Data Quality JourneyP

erc

ep

tion

of

Data

Q

uali

ty

Lifecycle of the Data Driven Organization

High

Low

Hope & Illusion

Gloom, Despair, And Agony

Young Mature

Perseverance & Commitment

If I had kids, I can imagine this would be the conversation…

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National Health Accounts (NHA) WHO, OECD, World Bank and Gates Foundation

In lay terms- NHAs are an international standard for healthcare accounting at the national policy level

“NHA constitute a systematic, comprehensive and consistent monitoring of resource flows in a country’s health system financing.”

“…helps in developing national strategies for effective health financing and in raising additional funds for health.”

“…concerns itself primarily with the health care goods and services consumed by residents, irrespective of where that consumption takes place.”

Healthcare IT vendors should support NHA standards

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+NHA Healthcare Financing

Schemes

Government

Compulsory social insurance

Voluntary health insurance

Out-of-pocket payments

Foreign aid programs

Charitable programs

Agents

Government departments

Social insurance funds

Insurance companies

Households

Foreign countries

Charities & foundations

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10Progression of Disease and the Provision of Healthcare Goods and Services

Adapted from Norman, 2003

+ Sources of Metrics & Benchmarks for National Healthcare Policy

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World Health Organization, Pan American Health Organization Somewhat focused on the issues of Third World countries TB, HIV, Drinking Water, Malaria, Improved Sanitation Utilization,

parasites, etc. Sometimes tainted by political agendas in the United Nations

Organization of Economic Cooperation and Development Focused on the 34-member organizations Very thorough, very focused on the ratio of Cost-per-Outcome

The Commonwealth Fund Private US foundation, less prone to politics Motivated to change the US healthcare system Benchmarks against major democracies

All of these ignore mental and spiritual health measurement12

WHO/PAHO Categories1. Life Expectancy And Mortality

2. Cause Specific Mortality And Morbidity

3. Selected Infectious Diseases

4. Health Service Coverage

5. Risk Factors

6. Health Workforce, Infrastructure, And Essential Medicines

7. Health Expenditure

8. Health Inequities

9. Demographic And Socioeconomic Statistics

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Deaths By 19 Leading Factors,By Country Income Level, 2004

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OECD Categories

1. Health Status: Life Expectancy, Mortality, Chronic Conditions

2. Risk Factors

3. Health Workforce: Number Of Physicians, Nurses, etc.; Remuneration Of Physicians And Nurses

4. Consumption Of Healthcare: Diagnostics, Treatments, Pharmaceuticals

5. Quality Of Care: Life Threatening Acute Care; Chronic Disease

6. Healthcare Expenditure: Costs And Financing

Public Spending on Health Care per Capita, 2006Adjusted for Differences in Cost of Living

$1,906$2,011$2,027

$2,408

$2,591$2,591$2,597$2,750

$3,074

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

United

States

France Switzerland Canada Germany United

Kingdom

OECD

Median

Australia* New

Zealand

Source: OECD Health Data 2008, “June 2008.”

Cayman Islands?

$150M/50K = $3,000 per capita

Source: OECD and International Diabetes Federation (IDF) (2009), “Diabetes Atlas, 4th edition”.

Prevalence Of DiabetesAdults Aged 20-79 Years, 2010

5.8% of HSA patients have a diabetes diagnosis…but this number is probably low. Further analysis required.

The Number Of Physicians Per Capita

Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).

Cayman Islands:About 4 physicians per 1,000 population

Commonwealth Fund Categories

1. Quality Care

2. Access

3. Efficiency

4. Equity

5. Long, Healthy, Productive Lives

6. Health Expenditures per Capita

19

20

54

41

53

83

7061

5045

82

7280

0

25

50

75

100

AUSCAN FR

GER

NETH NZNO

RSW

ESW

IZ UK US

Percent

Wait Time for Specialist Appointment

28

41

28

716

22

34 31

5

19

9

Less than 1 month Two months or more

Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Base: Needed to see a specialist in past two years.

Obesity (BMI>30) Prevalence in 2004

30.6%

23.0%22.4%

20.9%

13.0% 12.9%10.9%

9.5%

3.2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

United

States

United

Kingdom

Canada New

Zealand

OECD

Median

Germany Netherlands France J apana

a

a2003b2002

a

b

Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

Cayman Islands…?

0%

10%

20%30%

40%

50%

60%

70%80%

90%

100%

U.S. Population Health Expenditures

Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 64 Percent of Expenses

1%5%

10%

49%

64%

24%

Source: The Commonwealth Fund. Data from S. H. Zuvekas and J. W. Cohen, “Prescription Drugs and the Changing Concentration of Health Care Expenditures,” Health Affairs, Jan./Feb. 2007 26(1):249–57.

50%

97%

$36,280

$12,046

$6,992

$715

Distribution of health expenditures for the U.S. population,by magnitude of expenditure, 2003

Expenditure threshold (2003 dollars)

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Cayman Islands Metrics

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Perspective Director of Public Health (Dr. Kumar) and team have been

reporting PH metrics to PAHO for a number of years

Challenged by the technology for data extraction from our Cerner system– the data is there, but wrapped in a proprietary programming language

Last two years at HSA – Financial Survivability & Stability

Next two years– Chronic Disease Management & Patient Satisfaction

Slowly gathering “Metrics Momentum”

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As Reported in the Compass

CI Government spend $93.4 million on health care in the last financial year

17.5% of the national budget

22% (about $20.5 million) was spent on overseas referrals for 2,500 persons;

More than $12 million per year on overseas referrals for the indigent population alone

CINICO budget: $59M for 13,000 covered lives

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$25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Australia

Austria

BelgiumCanada

France

Germany

Italy

Japan

Netherlands

Norway

SpainSweden

Switzerland

U.K.

USA

Total Health Expenditure per Capita and GDP per Capita,

US and Selected Countries, 2008

GDP Per Capita

Per

Capit

a H

ealt

h S

pendin

g

Cayman Islands…?

Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011).Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates.

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Leading Causes of Death in CI

CARDIOVASCULAR

CANCER

ACCIDENTS

RESPIRATORY

ENDOCRINE, N

UTRITIO

NAL

NERVOUS SYSTEM

ABNORMAL L

ABORATORY FIN

DINGS

GENIT

OURINARY S

YSTEM

DIGESTIV

E SYSTEM

COMM

UNICABLE D

ISEASES

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Top Ten Procedures (CPT) at HSA

1. Supplies and materials provided by a physician2. Level 3 office or other outpatient visit 3. Blood glucose monitoring4. Therapeutic, prophylactic or diagnostic injection5. Level 1 office or other outpatient visit 6. Comprehensive metabolic panel7. Emergency department visit8. Therapeutic, prophylactic or diagnostic injection9. Physical therapy re-evaluation

10. Level 2 office or other outpatient visit

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Top Ten HSA ICD9 Diagnosis

1. Hypertension

2. Diabetes

3. Routine health check for child

4. Upper respiratory infection

5. Change or removal of non-surgical wound dressing

6. Care involving physical therapy

7. High cholesterol (hyperlipidemia)

8. Pregnant

9. Long term anticoagulant use

10. Observation for unspecified conditions

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Other Key Performance Indicators

Metric 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Total Admissions   4,766 4,889 5,071 5,718 5,574

Bed Occupancy Rate 65% 68.6% 68.8% 73.5% 63.7% 59.4%

Average Length of Stay 4 4 4 4 4 4

Total ER Visits 25,302 26,901 27,041 29,859 34,032 33,172

Total Outpatient visits including Pharmacy

158,364 150,632 155,162 186,460 180,030 181,947

Total Surgeries 2,509 2,660 2,726 2,912 3,101 2,977

Total deliveries 628 634 647 664 691 695

Total C- Sections 228 252 247 270 281 280

Total Specialist Clinic visits 24,036 23,973 24,445 25,614 32,038 30,869

HSA Patients (Cayman Islands Residents) with an encounter during Oct 2010 – Sep 2011

These reported rates are artificially low, probably because the data relies only on diagnosis code (ICD9). Further analysis required.

Chronic Disease Rates for HSA Patients

Chronic DiseasePatient Count

Percent of all Patients US Rate

Hypertension 3571 10.80% 33%Diabetes 1903 5.80% 10%Mental Disorders 1619 4.90% 3.30%Respiratory Disease 539 2.50% 4%Cardiovascular Disease 407 3.00% 12%Cancer 356 1.10% 4%Kidney Disease 235 0.70% 2%Osteoarthritis 208 0.60% 23%Chronic liver disease 142 0.40% ?Osteoporosis 94 0.30% 3%

Paralysis and cerebral palsy 46 0.10% ?AIDS/HIV 16 0.00% 0.40%

HSA Patients with CancerCancer Type Patient Count Percent of all

Patients

Breast 93 0.28%Prostate 83 0.25%Leukemia and Myeloma 30 0.09%Other Non-Melanomatous Skin Cancer 28 0.08%Colon 26 0.08%Gynecologic 25 0.08%Urinary Tract 19 0.06%Non-colon GI 14 0.04%Head and Neck 12 0.04%Melanoma 11 0.03%Lung 11 0.03%Non-Hodgkin Lymphoma 9 0.03%Lymphosarcoma and Reticulosarcoma 6 0.02%Bones/Soft Tissue 5 0.02%Hodgkin Lymphoma 4 0.01%Brain 3 0.01%Endocrine 3 0.01%Carcinoid Tumors 2 0.01%Pleural Mesothelioma 1 0.00%

All Cancer patients (patient can have two cancer types) 365 1.10%

HSA Patients (Cayman Islands Residents) with an encounter Sep10 - Aug11 with a cancer diagnosis

These reported rates are artificially low, probably because the data relies only on diagnosis code (ICD9). Further analysis required.

4% of the US population has some form of cancer.

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Closing Thoughts

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Keeping It All In Perspective

What surprises you most about humanity?

Dalai Lama:

"Man. He sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future. He lives as if he is never going to die, and then dies having never really lived."

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We are entering the “Data Driven Age” of healthcare that informs… Government leaders and national policy Physicians and patient management Healthcare leadership and administration Patients and healthcare consumers Employers

Is it time for a national initiative to define and baseline our key performance indicators?

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