Designing Patient-Centered
Baskets of Care
Concepts for discussion
January 9, 2009
Lawrence Lee, MD, MBA, FACP
Associate Medical Director
HealthPartners
What’s Needed to Specify “Baskets of Care”
Define the parameters
• Clinical scope
• Span of providers
• Economic unit
Focus of today’s
discussion
Articulate the rationale and motivation
• Evidence of deficiency
• Sizing of opportunity
• Dynamics of improvement
Propose a strategy of implementation
• Prerequisites and enablers
• Milestones and staged deliverables
• Metrics of implementation and effectiveness
2
Baskets Are Meant to Focus on Needs,
Objectives, and Results
Today
Future
Orientation of
care
A Task:
“Do something to the
patient”
An Objective:
“Fulfill the patient’s
need”
Accountability
of providers
Narrower: ends when
the task ends
Broader: ends when
the objective is met
Rationale for
payment
Justify each task
(input)
Focus on the result
(output)
Reward to
providers
Complete more
transactions
Serve more needs;
Make the results stick
3
Baskets Are Envisioned to Promote Accountability
and Value
Accountability
Quality of care
• Technical performance
• Coordination of handoffs
• Responsiveness in follow-up
Resources deployed
• Selection of cost-effective interventions
• Appropriate duration and intensity to achieve result
Value
Measurable clinical outcomes
Cost-consciousness, supported by prospective pricing
• By providers delivering care
• Between providers and payers during contract
negotiations and renewals
Fungible unit may support a dynamic of competitive
bidding
4
If Baskets Are Meant To Target A Person’s Health
Needs, We Should Categorize Needs
Acute:
Short-term
need (event)
Individual’s
Health
Needs
Chronic:
Long-term
need
Probabilistic event:
Cannot predict or
directly control
when/where/how
Planned event:
Can control
when/where/how
(“elective”)
Prescribed by age
& gender: routine
preventive care
Determined by a
chronic disease
Recoverable health event:
Individual can be restored to
previous state of health
Permanent health event:
Results in a permanent change in
health status or a chronic need
Early-stage chronic disease:
Low risk for acute destabilizing
events
Advanced-stage chronic disease:
High risk for acute destabilizing
events
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Birth
Chronic condition
(hypothetical individual)
Time
Withdrawal of care
Pre-terminal illness
Debilitating illness
Exacerbation of chronic condition
Illness, with resulting chronic condition
Elective procedure
Elective procedure
Pregnancy and childbirth
Injury
Illness
Infancy, early childhood
Intensity of Care
Needs of an Individual Unfold Over a Lifetime and
Drive the Intensity Of Care
Death
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As Needs Develop, Providers Engage in the
Individual’s Care
* discrete service that a
provider delivers to the
patient
Providers engaged
(hypothetical)
PCP
Chronic
disease
consultant
*
*
*
Surgeon
*
*
*
*
*
*
** *
*
*
*
*
* ***
Hospital
****
Anaesth
*
Hosp
consultant
*
** * * ** * **
*
*
** * **
*
*
**
*
*
**
Rehab
facility
*
** *
****
***
****
Chronic condition 1
Elective surgery
Time
Severe illness
Chronic condition 2
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Potential Baskets Have Dimensions of Condition,
Duration, Providers
* discrete service that a
provider delivers to the
patient
Providers engaged
(hypothetical)
PCP
*
Chronic
disease
consultant
*
*
*
*
*
*
*
Surgeon
*
** *
*
*
*
* ***
Hospital
****
Anaesth
*
Hosp
consultant
*
*
** * * ** * **
*
** * **
*
*
*
**
*
*
**
Rehab
facility
*
** *
****
***
****
Chronic condition 1
Elective surgery
Time
Severe illness
Chronic condition 2
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Providers Make Decisions Regarding the Use of
Discrete Resources for the Individual Patient
Potential for deficiencies
Flawed task performance
Gap in process
• Failed handoff
• Lack of follow-up
Resource
Diagnostic imaging
* **
*
Laboratory
***
Pharmaceuticals
*
*
*
*
*
*
*
*
*
*************
Hospital
Device or implant
*
Supplies, DME
Allied personnel
*
*
*
*
*
*
*
*
*
*
*
Over usage
• Redundant
• Too frequent
• Inappropriate (not needed)
• Wrong modality (too
aggressive)
Under usage
• Not frequent enough
• Delays
• Wrong modality (not
aggressive enough)
Elective surgery
Time
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Evidence May Guide What “Should Be” the
Content of a Basket and Its Result
Example Basket: “Knee Replacement for Degenerative
Disease, Without Major Co-morbidities”
For Each
:
Resources
What?
How much?
Start when?
End when?
Diagnostic imaging
Laboratory
Pharmaceuticals
Hospital
Device or implant
Supplies, DME
Allied personnel
Result
Self-care
Functional status
Clinical outcome
Time
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Baskets Will Need To Be Configured for Clinical
Scope, Provider Span, and Economic Unit
VARIABLES TO DEFINE WITHIN EACH PARAMETER
CONFIGURATION
PARAMETER
Start
“trigger”
Duration
Inclusiveness
Risk
adjustment
Clinical scope
• Event driven (acute)
or
• Condition focus (chronic)
Provider span
• Single
or
• Multiple
Economic unit
• “Hard” prospective price
or
• “Soft” flexible price
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