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1 1 Copyright © Michael Porter 2015 Value Based Health Care Delivery: Strategy For Health Care Leaders No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means — electronic, mechanical, photocopying, recording, or otherwise — without the permission of Michael E. Porter and Elizabeth O.Teisberg. Professor Michael E. Porter Harvard Business School www.isc.hbs.edu American Hospital Association July 23, 2015
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Page 1: Value Based Health Care Delivery: Strategy For Health Care ... · 23/7/2015 · Value Based Health Care Delivery: Strategy For Health Care Leaders ... Creating a Value-Based Health

1 1 Copyright © Michael Porter 2015

Value Based Health Care Delivery: Strategy For Health Care Leaders

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means — electronic, mechanical, photocopying, recording, or otherwise — without the permission of Michael E. Porter and Elizabeth O.Teisberg.

Professor Michael E. Porter Harvard Business School

www.isc.hbs.edu American Hospital Association

July 23, 2015

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2 Copyright © Michael Porter 2015

•  Delivering high value for patients must be the central goal of every health care organization

-  financial success is the result of delivering value, not the end in itself

•  Health care delivery must shift from volume to value

Setting the Right Goal

•  The core purpose of health care is value for patients

Value = Health outcomes that matter to patients

Costs of delivering those outcomes

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3 Copyright © Michael Porter 2015

Principles of Value-Based Health Care Delivery

−  Outcomes are the full set of health results that matter for the patient’s condition

−  Costs are the total costs of care for the patient’s condition over the care cycle

•  The most powerful single lever for reducing cost is improving outcomes

Value = Health outcomes that matter to patients

Costs of delivering the outcomes

•  Value is created in caring for a patient’s medical condition over the full cycle of care

à not by a hospital, a site, a specialty, an episode, or an intervention

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4 Copyright © Michael Porter 2015

Creating a Value-Based Health Care Delivery Organization The Strategic Agenda

1.  Re-organize Care around Patient Conditions, into Integrated Practice Units (IPUs) −  For primary and preventive care, IPUs serve distinct patient

segments

2.  Measure Outcomes and Costs for Every Patient

3.  Move to Bundled Payments for Care Cycles

4.  Integrate Multi-site Care Delivery Systems

5.  Expand Geographic Reach To Drive Excellence

6.  Build an Enabling Information Technology Platform

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5 5 Copyright © Michael Porter 2015

Source: Porter, Michael E., Clemens Guth, and Elisa Dannemiller, The West German Headache Center: Integrated Migraine Care, Harvard Business School Case 9-707-559, September 13, 2007

Primary Care Physicians Inpatient

Treatment and Detox

Units

Outpatient Psychologists

Outpatient Physical

Therapists

Outpatient Neurologists

Imaging Centers

Existing Model: Organize by Specialty and Discrete Service

1. Organize Care Around Patient Medical Conditions Headache Care in Germany

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6 6 Copyright © Michael Porter 2015

Source: Porter, Michael E., Clemens Guth, and Elisa Dannemiller, The West German Headache Center: Integrated Migraine Care, Harvard Business School Case 9-707-559, September 13, 2007

Affiliated

Imaging Unit

West German Headache Center

Neurologists Psychologists

Physical Therapists “Day Hospital”

Essen Univ.

Hospital Inpatient

Unit

Primary Care

Physicians

Affiliated “Network” Neurologists

Existing Model: Organize by Specialty and Discrete Service

New Model: Organize into Integrated Practice Units (IPUs) Around Conditions

1. Organize Care Around Patient Medical Conditions Headache Care in Germany

Primary Care Physicians Inpatient

Treatment and Detox

Units

Outpatient Psychologists

Outpatient Physical

Therapists

Outpatient Neurologists

Imaging Centers

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7 7 Copyright © Michael Porter 2015

Outpatient Oncologist

Surgical Oncologist Speech &

Swallow

Dentist

Primary Care Physician

Radiation Oncologist

Existing Model: Organize by Specialty and Discrete Service

1. Organize Care Around Patient Medical Conditions Head & Neck Cancer Care at MD Anderson

Social Work Smoking Cessation

Pharmacists Patient Education

Integrative Medicine

MD Anderson Head & Neck Center

Medical Oncologist Surgical Oncologist

Radiation Oncologist Dental Oncologist

Pathologist Radiologist

Nurses Speech & Swallow

Audiology Prosthodontics

Primary Care

Physicians

Pathology Lab Operating Rooms

Chemotherapy Radiation Therapy Diagnostic Imaging

Equipment

New Model: Organize into Integrated Practice Units (IPUs) Around Conditions

Radiologist

Source: Porter, Michael E., Jain, Sachin, The University of Texas MD Anderson Cancer Center: Interdisciplinary Cancer Care. February 26, 2013.

Pathologist

Plastic Surgeons, &

Other Specialties

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8

Integrating Across the Care Cycle A Surgeon Teaches Independent Physical Therapists

About Rehabilitation

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9 Copyright © Michael Porter 2015

The Playbook for Integrated Practice Units (IPUs) 1. Organized around a medical condition or set of closely related conditions (or around defined patient segments for primary care) 2. Care is delivered by a dedicated, multidisciplinary team who devote a significant portion of their time to the medical condition 3. Providers see themselves as part of or affiliated with a common

integrated unit 4. The team takes responsibility for the full cycle of care for the condition 5. Patient education, engagement, adherence, and follow-up are

integrated into care 6. The unit has a single administrative and scheduling structure 7. To the extent feasible, the team is co-located in dedicated facilities

8. A physician team captain or a clinical care manager (or both) oversees each patient’s care process 9. The team accepts joint accountability for outcomes and costs 10. The team measures outcomes, costs, processes, and experiences for

each patient using a common measurement platform 11. The team meets formally and informally on a regular basis to discuss

patients, processes, and how to improve results

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10

Volume in a Medical Condition Enables Value Fragmentation of U.S. Care

Procedure / Specialty Est. Number of Inpatient

Procedures

% of Procedures at Hospitals Performing <10 Cases per Year

% of Procedures Performed at Below Minimum Adequate

Volume

Coronary stenting 558,349 <1% 38%

CABG 427,380 1% 38%

Radical prostatectomy 77,030 3% 47%

AAA repair 54,819 17% 50%

Bariatric surgery 48,672 28% 51%

Breast cancer surgery 120,704 23% 61%

Rectal cancer surgery 26,692 45% 65%

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11

Moving to IPU Certification Specialist Breast Centres in Europe*

•  Minimum overall volume requirement of 150 new cases annually •  Dedicated teams of specialists working with a multidisciplinary approach -  Includes surgery, oncology, radiation, pathology, radiology, nursing, psychology,

genetics -  Specialists each must spend a minimum % of time on breast care to qualify -  Surgeons, radiologists, and pathologists meet individual volume minimums to

maintain experience

•  Led by a Clinical Director –  Mandatory, weekly multidisciplinary case management meetings including all key

team members –  Meetings address care management decisions for at least 90% of patients –  Centers agree on written protocols for diagnosis, treatment and follow-up

•  Centers provide or direct all services throughout the patient’s pathway –  Affiliations with other needed services – e.g. plastic surgery, palliative care

•  Collect and audit clinical data –  Formally identify a data manager responsible for collecting and analyzing data on

diagnosis, pathology, treatment, and outcomes –  Participate in benchmarking and annual performance review

*European Society of Breast Cancer Specialists

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12 Copyright © Michael Porter 2015

Patient Experience/

Engagement/ Adherence

E.g. PSA, Gleason score, surgical margin

Protocols/Guidelines

Patient Initial Conditions

Processes Indicators (Health) Outcomes

Structure E.g. Staff certification, facilities standards

2.  Measure Outcomes and Costs for Every Patient The Quality Measurement Landscape

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13 Copyright © Michael Porter 2015

The Outcome Measures Hierarchy

Survival

Degree of health/recovery

Time to recovery and return to normal activities

Sustainability of health/recovery and nature of recurrences

Disutility of the care or treatment process (e.g., diagnostic errors and ineffective care, treatment-related discomfort,

complications, or adverse effects, treatment errors and their consequences in terms of additional treatment)

Long-term consequences of therapy (e.g., care-induced illnesses)

Tier 1

Tier 2

Tier 3

Health Status Achieved

or Retained

Process of Recovery

Sustainability of Health

Source: NEJM Dec 2010

• Achieved clinical status

• Achieved functional status

• Care-related pain/discomfort

• Complications

• Reintervention/readmission

• Long-term clinical status

• Long-term functional status

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14 Copyright © Michael Porter 2015

The Outcome Measures Hierarchy Lung Cancer Standard Set

•  ECOG score •  Shortness of breath •  Cough •  EORTC QLQ-C30

•  Time from diagnosis to

treatment

Survival

Degree of recovery / health

Time to recovery or return to normal activities

Sustainability of recovery or health over time

Disutility of care or treatment process (e.g., treatment-related discomfort, complications, adverse effects, diagnostic errors,

treatment errors)

Long-term consequences of therapy (e.g., care-induced illnesses)

•  Acute complications of treatment due to surgery, radiation, or medical therapy

•  Pain

•  Health-related quality of life

•  Duration of time spent in hospital at end of life

•  Place of death

•  Overall survival •  Cause-specific survival

Source: ICHOM

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15 Copyright © Michael Porter 2015

9.2%

17.4%

95%

43.3%

75.5%

94%

Incontinence after one year

Severe erectile dysfunction after one year

5 year disease specific survival

Average hospital Best hospital

Measuring Multiple Outcomes Prostate Cancer Care in Germany

Source: Martini-Klinik

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16 Copyright © Michael Porter 2015

9.2%

17.4%

95%

43.3%

75.5%

94%

Incontinence after one year

Severe erectile dysfunction after one year

5 year disease specific survival

Average hospital Best hospital

Measuring Multiple Outcomes Prostate Cancer Care in Germany

Source: Martini-Klinik

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17 Copyright © Michael Porter 2015

40

50

60

70

80

90

100

0 200 400 600 800 1000

Percent 1 Year Graft Survival

Number of Transplants

Adult Kidney Transplant Outcomes U.S. Centers, 1987-1989

16 greater than predicted survival (7%) 20 worse than predicted survival (10%)

Number of programs: 219 Number of transplants: 19,588 One year graft survival: 79.6%

Source: Scientific Registry of Transplant Recipients, http://www.srtr.org

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18 Copyright © Michael Porter 2015

40

50

60

70

80

90

100

0 200 400 600 800 1000

94.7%

Number of programs included: 209 Number of transplants: 38,370 1 Year Graft Survival:

4 greater than expected graft survival (1.9%) 5 worse than expected graft survival (2.4%)

Adult Kidney Transplant Outcomes U.S. Centers, 2011-2013

Percent 1-year Graft Survival

Number of Transplants Source: Scientific Registry of Transplant Recipients, http://www.srtr.org

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19 Copyright © Michael Porter 2015

Measuring the Cost of Care Delivery: Principles

•  Cost is the actual expense of patient care, not the charges billed or collected

Source: Kaplan, Robert and Michael E. Porter, “The Big Idea: How to Solve the Cost Crisis in Health Care”, Harvard Business Review, September 1. 2011

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20 Copyright © Michael Porter 2015

Measuring the Cost of Care Delivery: Principles

•  Cost is the actual expense of patient care, not the charges billed or collected

•  Cost should be measured around the patient, not for departments, service units, or the organization as a whole

Source: Kaplan, Robert and Michael E. Porter, “The Big Idea: How to Solve the Cost Crisis in Health Care”, Harvard Business Review, September 1. 2011

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21 Copyright © Michael Porter 2015

Measuring the Cost of Care Delivery: Principles

•  Cost is the actual expense of patient care, not the charges billed or collected

•  Cost should be measured around the patient, not for departments, service units, or the organization as a whole

•  Cost should be measured by condition, with costs aggregated over the full cycle of care

Source: Kaplan, Robert and Michael E. Porter, “The Big Idea: How to Solve the Cost Crisis in Health Care”, Harvard Business Review, September 1. 2011

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22 Copyright © Michael Porter 2015

Measuring the Cost of Care Delivery: Principles

•  Cost is the actual expense of patient care, not the charges billed or collected

•  Cost should be measured around the patient, not for departments, service units, or the organization as a whole

•  Cost should be measured by condition, with costs aggregated over the full cycle of care

•  Understanding costs requires mapping the care process

Source: Kaplan, Robert and Michael E. Porter, “The Big Idea: How to Solve the Cost Crisis in Health Care”, Harvard Business Review, September 1. 2011

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23 Copyright © Michael Porter 2015

Mapping Resource Utilization MD Anderson Cancer Center – New Patient Visit

Registration and Verification

Receptionist, Patient Access Specialist, Interpreter

Intake

Nurse, Receptionist

Clinician Visit MD, mid-level provider,

medical assistant, patient service coordinator, RN

Plan of Care Discussion

RN/LVN, MD, mid-level provider, patient service

coordinator

Plan of Care Scheduling

Patient Service Coordinator

Decision Point

Time (minutes)

Source: HBS, MD Anderson Cancer Center

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24 Copyright © Michael Porter 2015

Measuring the Cost of Care Delivery: Principles

•  Cost is the actual expense of patient care, not the charges billed or collected

•  Cost should be measured around the patient, not for departments, service units, or the organization as a whole

•  Cost should be measured by condition, with costs aggregated over the full cycle of care

•  Understanding costs requires mapping care process

•  Cost depends on the actual use of resources involved in a patient’s care process (personnel, facilities, supplies, and support services)

•  “Overhead” costs should be associated with the patient-facing resources and services (e.g. IT, billing, HR, space)

Source: Kaplan, Robert and Michael E. Porter, “The Big Idea: How to Solve the Cost Crisis in Health Care”, Harvard Business Review, September 1. 2011

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25 Copyright © Michael Porter 2015

Putting Cost and Outcomes Together Comparing Overall Value in Localized Prostate Cancer Care

100.0

0.0

10.0

20.0

90.0

30.0

40.0

60.0 70.0

80.0

50.0

Urinary Bother*

Recurrence Free Survival (%)

Brachytherapy Proton Therapy Prostatectomy Photon Therapy

Urinary Incontinence*

Sexual Function*

1 / Cost

* Collected on Expanded Prostate Cancer Index Composite Source: HBS, MD Anderson Cancer Center Bowel Function*

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26 Copyright © Michael Porter 2015

Major Cost Reduction Opportunities in Health Care

•  Reduce process variation that lowers efficiency and increases complexity of supplies without improving outcomes

•  Eliminate low- or non-value added services or tests −  Sometimes driven by protocols or to justify billing

•  Minimize use of physician and skilled staff for less skilled activities •  Move routine or uncomplicated services out of highly-resourced

facilities •  Improve utilization of expensive physicians, staff, clinical space, and

facilities through reducing duplication and service fragmentation •  Rationalize redundant administrative and scheduling units •  Reduce cycle times across the care cycle •  Add services that lower total care cycle cost •  Increase cost awareness in clinical teams

•  Many cost reduction opportunities will actually improve outcomes

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27 Copyright © Michael Porter 2015

3. Move to Bundled Payments for Care Cycles

Bundled reimbursement

for medical conditions

Fee for service

Bundled Reimbursement •  A single price covering the full care cycle for an acute

medical condition •  Time-based reimbursement for overall care of a chronic

condition •  Time-based reimbursement for primary/preventive care for

a defined patient segment

Global capitation

Global provider budgets

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28 Copyright © Michael Porter 2015

Principles of a Value-Based Bundle

•  Condition based, not specialty, procedure, episode or care site based

•  Risk adjusted, or covering a defined patient group in terms of complexity - 80/20 rule

•  Contingent on outcomes, including care guarantees •  Payment based on the cost of efficient and effective care, not

sum of past charges •  Specified limits of responsibility for unrelated care needs, and

stop loss provisions to mitigate against outliers •  A level of price stability

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29 Copyright © Michael Porter 2015

•  Components of OrthoChoice bundle

•  Initially applied to all relatively healthy patients (i.e. ASA scores of 1 or 2) •  Mandatory reporting by providers to the joint registry plus supplementary reporting •  The Stockholm bundled price for a knee or hip replacement is about US $8,300

-  Pre-op evaluation -  Lab tests -  All Radiology -  Surgery & related admissions -  Prosthesis -  Drugs -  Inpatient rehab

-  All physician and staff fees and costs -  1 follow-up visit within 3 months -  Responsible for complications and any

additional surgery to the joint within 2 years -  If post-op deep infection requiring

antibiotics occurs, guarantee extends to 5 years

Bundled Payment in Practice Hip and Knee Replacement in Stockholm, Sweden

Results: ‒  Complications fell 18% after 2 years ‒  Functional outcomes remained constant ‒  Length of stay fell 16% ‒  Volume shifted toward specialty hospitals and away from full service acute

hospitals ‒  Standardization and improvement of care processes and efficiency took place ‒  Patients were exceptionally satisfied

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30 Copyright © Michael Porter 2015

The Swedish Spine Bundle Condition: Spinal Stenosis Requiring Decompression

0

10,000

20,000

30,000

40,000

50,000

60,000

Base Payment Warranty Payment Performance Payment Total Payment

SEK Standard Payment

Risk Adjustment

54,537 ($8,139*)

* Based on Jan 1, 2012 exchange rate of 6.8 SEK to 1 USD

42,044 4,357

Average 10% of Base

Base Payment Covered: Preoperative consultation, surgery, inpatient stay, implants, medications, laboratories, radiology, physical therapy, and follow-up care.

Risk adjustment: Age, gender, patient-reported pre-operative pain measured by Visual Analog Scale (VAS)

Performance Payment Amount: Average of 10 percent of base reimbursement Criteria: Criteria: Based on the actual improvement in pain at 1 year after surgery (Global Assessment Scale) versus expected pain outcome based on registry data for similar patients

Warranty Payment

Risk adjustments: Age, gender, preoperative VAS, pain duration, smoking, comorbidities, operative treatment, employment status

Covered: • Surgery wrong side/level • Disk herniation • Re-stenosis • Mechanical complication • Pseudoarthrosis

• Cerebrospinal fluid leak • Ongoing Bleeding • Infection • Pain in neck/arm/back • Wound dehiscence • Implant related pain

8,136

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31 Copyright © Michael Porter 2015

CHOP Newborn Care

CHOP Pediatric Care

CHOP Newborn & Pediatric Care

Pediatric & Adolescent Primary Care

Pediatric & Adolescent Specialty Care Center Pediatric & Adolescent Specialty Care Center & Surgery Center Pediatric & Adolescent Specialty Care Center & Home Care

Harborview/Cape May Co.

Shore Memorial Hospital Harborview/Somers Point

Atlantic County

Harborview/Smithville

Mt. Laurel

Salem Road

Holy Redeemer Hospital

Newtown

University Medical Center at Princeton

Princeton

Saint Peter’s University Hospital

(Cardiac Center)

Doylestown Hospital

Central Bucks Bucks County

High Point

Indian Valley

Grand View Hospital

Abington Hospital

Flourtown

Chestnut Hill

Pennsylvania Hospital

University City Market Street

Voorhees

South Philadelphia

Roxborough

King of Prussia

Phoenixville Hospital

Kennett Square

West Chester North Hills

Exton Paoli Chester Co.

Hospital Haverford

Broomall

Chadds Ford

Drexel Hill

Media Springfield Springfield

The Children’s Hospital of Philadelphia

Cobbs Creek

DELAWARE

PENNSYLVANIA

NEW JERSEY

Network Hospitals:

Wholly-Owned Outpatient Units:

Main Campus

4. Integrate Multi-site Care Delivery Systems Children’s Hospital of Philadelphia Care Network  

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32 Copyright © Michael Porter 2015

1.  Define the overall scope of services where each unit can achieve high value

2. Concentrate volume in fewer locations in the conditions that providers treat 3. Choose the right location for each service based on medical condition, acuity level, resource intensity, cost level and need for convenience

–  E.g., shift routine surgeries out of tertiary hospitals to smaller, more specialized facilities

4. Integrate care across appropriate locations through IPU structures

Four Levels of Provider System Integration

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33 Copyright © Michael Porter 2015

Delivering the Right Care at the Right Location Rothman Institute, Philadelphia

Lowest Complexity

Low Medium Highest Complexity

Facility Capability

Patient Risk Factors: Age, Weight, Expected Activity, General Health, and Bone Quality

Ambulatory Surgery Center

Cost of Total

Hip Replacement: ~

$12,000 USD

Cost of Total

Hip Replacement ~$45,000 USD

Rothman Orthopaedic Specialty Hospital

Bryn Mawr Community Hospital

Jefferson University Academic Medical Center

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34 Copyright © Michael Porter 2015

Central DuPage Hospital, IL Cardiac Surgery

McLeod Heart & Vascular Institute, SC Cardiac Surgery

CLEVELAND CLINIC

Chester County Hospital, PA Cardiac Surgery

Rochester General Hospital, NY Cardiac Surgery

5. Expand Geographic Reach The Cleveland Clinic Affiliate Programs

Pikeville Medical Center, KY Cardiac Surgery

Cleveland Clinic Florida Weston, FL Cardiac Surgery

Cape Fear Valley Medical Center, NC

Cardiac Surgery

Charleston, WV Kidney Transplant

St. Vincent Indianapolis, IN Kidney Transplant

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35 Copyright © Michael Porter 2015

6. Build an Enabling Integrated IT Platform

Utilize information technology to enable restructuring of care delivery and measuring results, rather than treating it as a solution itself

Attributes of a Value-Based IT Platform • Combines all types of data (e.g. notes, images) for each patient • Uses common data definitions •  Data encompasses the full care cycle •  Allows access and communication among all involved parties, including

patients and referring entities •  Enables data exchange and aggregation among the different provider

organizations involved with each patient •  Provides views and templates by medical condition to enhance the user

interface for IPU teams •  Creates searchable “structured” data vs. free text •  The architecture allows easy extraction of outcome measures, process

measures, and activity-based costing metrics for each patient /medical condition

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36 Copyright © Michael Porter 2015

A Mutually Reinforcing Strategic Agenda

1 Organize into

Integrated Practice

Units (IPUs)

2 Measure

Outcomes and Cost For Every Patient

3 Move to Bundled

Payments for Care Cycles

4 Integrate

Care Delivery Systems

5 Expand

Geographic Reach

6   Build an Integrated Information Technology Platform

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37

Measuring Internationally Standardized Outcomes ICHOM Standard Sets

Standard Sets Complete (2013)

Conditions in Process (2015-16)

Standard Sets Complete (2014)

Burden of Disease Covered

18% 35% 45% www.ICHOM.org

1.Localized Prostate Cancer* 2.Lower Back Pain* 3.Coronary Artery Disease* 4. Cataracts

1.  Parkinson’s Disease 2.  Cleft Lip and Palate 3.  Stroke 4.  Hip and Knee Osteoarthritis 5.  Macular Degeneration 6.  Lung Cancer 7.  Depression and Anxiety 8.  Advanced Prostate Cancer

1.  Heart Failure* 2.  Dementia* 3.  Craniofacial Microsomia* 4.  Burns 5.  Congenital Heart Anomalies 6.  Pregnancy and Childbirth 7.  Peptic Ulcer Disease 8.  Inflammatory Bowel Disease 9.  Epilepsy 10.  Overactive Bladder 11.  End-stage Renal Disease 12.  Diabetes 13.  Bipolar Disorder 14.  Acute Lymphoblastic

Leukemia 15.  Brain Cancers 16.  Colorectal Cancer 17.  Breast Cancer 18.  Preventative health 19.  Frail Elderly  

* Sets Published in Peer-Reviewed Journals

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38 Copyright © Michael Porter 2015

Selected References •  Porter, M.E. and Lee, T.H (2015). Why Strategy Matters Now. New England Journal of Medicine. •  Porter, M.E. and Kaplan, R.S. (2015) How to Pay for Health Care. HBS Working Paper. •  Porter, M.E. and Lee, T.H. (2013). The Strategy that Will Fix Health Care. Harvard Business Review. October 2013. •  Porter, M.E. and Lee, T.H. (2013). Why Health Care Is Stuck — And How to Fix It. HBR Blog Network. Available from:

http://blogs.hbr.org/2013/09/ •  Porter, M.E., Pabo, E.A., Lee, T.H. (2013). Redesigning Primary Care: A Strategic Vision To Improve Value By

Organizing Around Patients’ Needs. Health Affairs; 32: 516‐525. •  Kaplan, R.S and Porter, M.E. (2011). How to Solve the Cost Crisis in Health Care. Harvard Business Review.

September 2011. •  Porter, M.E. (2010). What Is Value in Health Care? New England Journal of Medicine. •  Porter, M.E. (2008). Value‐Based Health Care Delivery. Annals of Surgery; 248: 503‐509. •  Porter, M.E., Teisberg, E.O. (2007). How Physicians Can Change the Future of Health Care. JAMA;297:1103‐1111. •  Porter, M.E., Teisberg, E. (2006). Redefining Health Care: Creating Value-Based Competition on Results. Harvard

Business Publishing. •  Carberry K., Landman Z., Xie M., Feeley T. (2015) Incorporating Longitudinal Pediatric Patient-Centered Outcome

Measurement into the Clinical Workflow using a Commercial Electronic Health Record: a Step toward Increasing Value for the Patient. Journal of American Medical Informatics Association. E-pub ahead of print.

•  Websites Including Videos –  http://www.isc.hbs.edu/ –  https://www.ichom.org/ –  Case studies and curriculum guide available at:

http://www.isc.hbs.edu/resources/courses/health-care-courses/Pages/health-care-curriculum.aspx