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Outcomes Based Commissioning: Diabetes Practical Case Study

Alison Verhoeven, Jay Rebbeck

2

Defining commissioning for outcomes

3

We need to start by defining what we mean by an outcome

“Changes that happen in the lives of people for the

better.”

4

OBC starts by understanding needs, identifying outcomes, then designing responses

Needs

Inputs Activities Outputs

Outcomes

Responses

Who are we trying to help?

1

What are we doing to help?

3

What will change for people?

2

5

Commissioning for outcomes for patients with diabetes

6

Start by understanding the program logic for patients with type 2 diabetes

What

resources are

used to do the

work

What is doneWhat is

delivered

What needs

exist for our

patients

Historical focus

Present and future focus

Commissioning for outcomes

NeedsShort-term

outcomes

Medium-term

outcomes

Long-term

outcomes

Outcomes

Activities OutputsInputs

Responses

GP,

Endocrinologist,

Dietician,

diabetes

Educator

Medication

review, diet,

exercise,

monitoring

GP diabetes

Care Plan

Patients with

poorly controlled

type 2 diabetes

at risk of loss of

sight, limbs &

mobility

What we want people to achieve

Primarily attributed

to the program

Partly attributed to

program, beginning

of shared attribution

Shared attribution

across healthcare

providers / sectors

Well controlled

blood sugar

levels

Retained eye

sight and limb

extremities

Maintained

Activities of Daily

Living (ADL) and

Quality of Life

7

Differentiating commissioning for outcomes from paying for outcomes

8

‘Outcomes-based commissioning’ does not mean ‘paying for outcomes’

Identify, Measure

and Drive Outcomes

Pay for Outcomes

Outcomes

Based

Commissioning= Pay for Outcomes

Outcomes

Based

Commissioning

Commissioning myth Commissioning reality

9

‘Outcomes based commissioning’ encompasses measuring, driving and paying for outcomes

Outcomes

Based

Commissioning

Measure and Drive Outcomes

Outcomes Based Payments

Setting up programs that are focussed on

outcomes, building the foundation for

outcomes contracting

Designing contracts whereby payments are

contingent on outcomes

Readiness considerations for implementing

outcomes based contract payments

10

Measuring and driving outcomes for diabetes patients

11

Select a balanced set of KPIs to monitor progress towards diabetes outcomes

What clinical

resources are

used to do the

work

What is doneWhat is

delivered

What needs

exist for our

patients

NeedsShort-term

outcomes

Medium-term

outcomes

Long-term

outcomes

Outcomes

Activities OutputsInputs

Responses

GP,

Endocrinologist,

Dietician,

diabetes

Educator

Medication

review, diet

advice, physical

activity advice,

patient activation

GP

Management

Plan (GPMP)

with Team Care

Arrangement &

Review

Patients with

poorly controlled

type 2 diabetes

at risk of loss of

sight, limbs &

mobility

What we want people to achieve

Primarily attributed

to the program

Partly attributed to

program, beginning

of shared attribution

Shared attribution

across healthcare

providers / sectors

Well controlled

blood sugar

levels

Retained eye

sight and limb

extremities

Maintained

Activities of Daily

Living (ADL) and

Quality of Life

• Clinical

staffing levels

adequate for

caseload &

case mix

• % of patients

under active

diabetic

treatment and

counselling

• % of patients

with a GPMP

• % of patients

with a TCA

• % of patients

with timely

GPMP

reviews

• Prevalence of

type 2

diabetes in

cohort

• Prevalence of

pre-diabetes

in cohort

• % of patients

within

recommended

HbA1C levels

• % of patients

with

peripheral

neuropathy

• % of patients

maintaining

eyesight

• % of patients

maintaining

Activities of

Daily Living

(ADL)

• Patient

reported

Quality of Life

• QALYs

KPIs

12

Measure and drive diabetes outcomes by tracking each provider’s trajectory towards outcomes

0

20

40

60

80

100

120

Needs Activities Outputs Outcomes

Pro

gre

ss

0

20

40

60

80

100

120

Needs Activities Outputs Outcome 1

ILLUSTRATIVE

Provider 1On track to achieving

outcomes target

Provider 2Needs attention

No. of patients

within

recommended

HbA1C levels

No. of patients

with a GP

Management

Plan

No. of patients

under active

diabetic

treatment and

counselling

No. of patients

with type 2

diabetes in

cohort

No. of patients

within

recommended

HbA1C levels

No. of patients

with a GP

Management

Plan

No. of patients

under active

diabetic

treatment and

counselling

No. of patients

with type 2

diabetes in

cohort

Target

ActualKey

13

Paying for outcomes for diabetes

14

Consider whether paying for outcomes makes sense for the diabetes care providers in question

Consensus around the outcomes to measure

0 1 2 3 4 5

15

Inputs Activities Outputs

Outcomes

(adjusted for

need)

When to use

Large

outcomes

payment

when circumstances

are highly favourable

Small

outcomes

payment

when circumstances

are less favourable

The outcomes payment size depends on provider-specific considerations

35% 10%35%20%

50%10% 20% 20%

16

Here is an illustrative payment mix

What

resources are

used to do the

work

What is doneWhat is

delivered

What needs

exist for our

patients

NeedsShort-term

outcomes

Medium-term

outcomes

Long-term

outcomes

Outcomes

Activities OutputsInputs

Responses

• GP

• Endocrinologi

st

• Dietician

• diabetes

Educator

• Medication

review

• Diet

• Exercise

• Monitoring

• GP diabetes

Care Plan

• Patients with

poorly

controlled

type 2

diabetes at

risk of loss of

sight, limbs &

mobility

KP

IsD

escriptio

n

What we want people to achieve

Primarily attributed

to the program

Partly attributed to

program, beginning

of shared attribution

Shared attribution

across healthcare

providers / sectors

• Well

controlled

blood sugar

levels

• Retained eye

sight and limb

extremities

• Maintained

Activities of

Daily Living

(ADL) and

Quality of Life

10%30% 30% 30%

17

Consider whether to use a ‘carrot’ or ‘stick’

0%

20%

40%

60%

80%

100%

120%

140%

Traditional paymentmechanism

Risk only Reward only Risk and reward

Risk / reward outcomes payment mechanisms

Non-outcomes payment Outcomes risk payment Outcomes reward payment

18

The risks of paying for outcomes

19

‘Gaming’ may be inadvertently encouraged by outcomes payments

Gaming type Description

Cherry pickingService providers ‘cherry pick’ less complex clients for whom outcomes can

more easily be achieved

Goal displacementProviders attempt to achieve the outcome performance targets at the expense

of other non-measured outcomes

Threshold effectsService providers only focus on achieving the target outcomes up to the

threshold of the target

Ratchet effectsService providers attempt not to exceed performance targets, even if easily

achieved, to ensure these targets are not increased in future

20

Considering outcomes across the wider social determinants of health

21

Consider the two-way linkages of outcomes between health and other parts of government

Home

Empower-

ment

Safety

Health

Social &

Community

Education

& skills

Economic

Client needsShort-term

outcomes

Medium-term

outcomes

Long-term

outcomes

Client outcomes

Activities OutputsInputs

Responses

Maintaining

eyesight & limbs

(for diabetics)

Reduced death

(from rheumatic

heart disease)*

Increased

sustainable

employment

Improved

housing

conditions

* Note the rheumatic disease example provided is unrelated to diabetes!

22

Thank you

If you have any questions about this presentation or would like to hear more about commissioning for outcomes, please get in touch with Jay Rebbeck:

+61 414 400 524jay@rebbeckconsulting.comwww.rebbeckconsulting.com

Rebbeck Consulting

Unit 222 Lifestyle Working

117 Old Pittwater Road

Brookvale

NSW 2100

Australia

+61 414 400 524

jay@rebbeckconsulting.com

www.rebbeckconsulting.com