1. Quality is the New Black Shaf Keshavjee MD MSc FRCSC FACS Surgeon-in-Chief, University Health Network James Wallace McCutcheon Chair in Surgery Professor of Thoracic Surgery Vice Chair, Innovation Department of Surgery University of Toronto

2. Learning Objectives 1.Understand why quality and value are more important than episodes of care 2.How to optimize funding in the new world of health care - VBP 3.How to thrive – lead in care delivery with quality, innovation and complexity 2

3. “____ is the new black” Some suddenly popular thing It’s the new cool thing Colours that were temporarily displacing black’s position in fashion or industrial design as a versatile staple that complemented all other aspects and was generally unobjectionable 3

4. “Orange is the new black” White House Press Correspondents Dinner May 3, 2014 4

5. Quality… Is the new black Will keep us in the black! 5

6. Overall Goals of Value Based Purchasing (VBP) in Medicare: Pay for Performance 6 Obama – Affordable Care Act. Source: cms.gov

7. Changes to Medicare in the US Towards Value Based Purchasing Move away from paying doctors solely on volume of services Reimburse based on quality and value of care provided Pay doctors based on how they perform on quality and other measures Standards will be determined by the Department of Health and Human Standards 7

8. Staying in the Black in the Face of Competing Factors How do we survive and thrive in the new world of health care? Quality (Volume) Based Performance (QBP)  will set the funding bar (Value Based Purchasing VBP) But complexity and innovation - increasing 8

9. Pay for Performance Five Principles that have served us well… 1. Deliver case volumes (wait times)  earn funding 2. Reputation as “efficient”  attracts new funding 3. Improving data quality  for better decisions 4. Leaders in innovation  it’s our interest & duty 5. Clinical expertise  it’s our advantage

10. Ontario Hospital Funding Sources  Where we get our $ Ministry of Health $45 B Provincial Taxes $30 B Federal Taxes $15 B Priority Programs Emergency Cancer Care Ontario Cdn Blood Services Physicians Drugs Hospital Revenues Provincial Programs $5 B Capital $1 B 14 LHINs $22 B OHIP $17 B Research Grants Foundations Industry WSIB Uninsured International Retail

11. Health System Funding Reform: Move from Global to Patient Focused Funding 11 Mostly Patient Focused Funding Mostly Global Funding

12. 12 QBP: Quality Based Procedures Targeted activities funded at “price x volume” Funding based on evidence (utilization patterns, best practices) Payer objective  Improve value for money, improve outcomes and reduce variation amongst providers

13. QBP Status 13 Years 1 and 2 … underway Primary Hip Replacement Primary Knee Replacement Chronic Kidney Disease COPD Congestive Heart Failure Stroke Non-Cardiac Vascular (AA and LEOD) Year 3 – 2014/15 + … in development Chemotherapy … ready to go live GI Endoscopy … ready to go live  Pneumonia  Hip Fracture  Knee Arthroscopy  Retinal Diseases  Cancer Surgery (Prostate)  Colposcopy  Coronary Artery Disease  Aortic Valve Replacement

14. QBP: Staying in the Black Clinical excellence  quality Deliver volumes  to earn revenue Stay efficient  attract new funding Data quality  accurate coding and outcomes

15. Patient focused funding can present some unique opportunities and challenges… 15

16. Case #1 57 yo male, smoker New nodule on CXR Referred through LungRAMP (1-866 - Lung 911) Operated upon within 28 days (Cancer Care Ontario target) VATS lobectomy SDU – 1 day, ward 2 days Discharged home on postop day 3 16

17. Case #2 70 yo male, hemoptysis COPD, 100 pack year smoker Hypertension, diabetes, remote myocardial infarction, 3 coronary stents Grade 1 LV, no ischemia Taken to OR in community hospital – tumour found to be invading left atrium Operation aborted, closed, referred to TGH for urgent reoperation 17

18. Case #2 Admit Mar 27 Stepdown Mar 27-28 Ward Mar 29-30 OR Mar 30: Reoperation, Left pneumonectomy on CPB, after 6 pm (overtime) due to OR availability ICU – Mar 30-31 SDU – Mar 31- Apr 2 ICU – April 2-3 (afib, cardioversion) SDU April 3-5 Ward – April 5-9, Discharge Apr 9 Total Hospital stay – 14 days 18

19. Two Cases: We provided the best care for our patients. CCO code “Lung Cancer Resection” 3 day hospital stay CCO funding $12,888 UHN direct cost $7,139 CPB, ICU, 14 day hospital stay CCO funding $12,888 UHN direct cost $26,126 19

20. What should our strategy be going forward? Find opportunities to better define what we do – one cancer case is not the same as another – be able to prove it and document the cost Many of these not even “counted” because so few done or no one else does… Collect high quality data on outcomes and document case complexity (financial risk) Collect and report accurate risk adjusted data (benchmark) Need to be appropriately funded for the complex or unique cases we do 20

21. What should our strategy be going forward? Understand HOW you are being evaluated and funded Optimize care delivery: performance - volumes, wait times, demonstrate efficiency, value for money, quality DATA – we need to collect data to quantify and document what we do Make sure we are getting paid right Document excellence in care, benchmark 21

22. Where are we going? Leadership and excellence In the current era we need to become surgeons and “something more” Focus on patient care – quality and safety Surgical research and innovation Efficient delivery of healthcare services (cost) 22

23. Where are we going? Health System Funding Reform Multiple (changing) models and formulas of different flavours in different jurisdictions (VBP – Value based Purchasing, HBAM - Health Based Allocation Model, QBP - Quality Based Procedures etc.) Common theme  Pay for performance Funding decisions  evidence based, performance based Provide leadership  develop solutions to the challenges Look for opportunities to fund our business Understand how we are being measured 23

24. Why do I think that Quality is the new Black? It is cool… it makes sense…should be how we are measured We get paid for performance, not just for being a player ;) Surgeons can handle being paid for performance – we ARE naturally high performers! Leaders in patient safety and quality, efficient use of resources Need to understand the rules of the game  that will keep us in the black 24