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Aligning stakeholders' incentives in the shift to value-driven health

Singapore's bundle system has encouraged the shift to community-based care and prevention, with strong results.

Jeff Lagasse, Associate Editor

ORLANDO – Finding the right formula and structuring data are just the initial steps in enabling a shift toward value-driven health. The success of this shift also depends on aligning stakeholders' incentives – making sure they all have an interest in working together and coordinating services for best outcomes.

It's an area of concern all over the world, and for a little perspective on what's being done in Singapore, Jason Cheah, MD, MPH, and Kwek Kenneth addressed an audience at HIMSS19 regarding that country's efforts to join integrated care and value-based care in a cohesive way.

Cheah, the group deputy transformation CEO of the National Healthcare Group and CEO of the Woodlands Health Campus, said many different services touch patients, and that can be a challenge when it comes to care coordination. When patients move into the community, it can be tricky to ensure that information flows seamlessly from one place to another.

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There need to be interoperability standards, he said, so that providers are either on the same platform or use the same language; in that way they can communicate effectively about the patient.

Cheah spoke about the efficacy of shifting the center of gravity from treating illness to preventing illness, and shifting the focus to primary care within the community.

Kenneth, CEO of Singapore General Hospital and deputy group CEO of Organisational Transformation and Informatics at SingHealth, said there's a thrust within Singapore's Ministry of Health to move beyond quality to value.

"They say this is just another cost-cutting effort, but if you really want to align stakeholder interests, you have to go back to what this actually means," said Kenneth. "You focus on quality but move beyond to ensure the system is sustainable in the future by creating value, for patients and for caregivers."

The first thing Singapore General looked at was bundled care. There were a lot of pioneers in the U.S. when it came to value-based care, but Kenneth's team tried to contextualize it to Singapore's system -- a public/private system in which the government uses tax money to foot part of the bill, and the patient pays a copay based on a formula determining their financial ability to do so.

"If you want to align stakeholder interests, you need to simplify it to something that's easily understandable," said Kenneth.

And clinicians need to know that what they're doing is making a difference, especially when shifting the focus of care to communities and prevention. To dig into the data, Kenneth and his team looked at a few different metrics, including outcomes for hip fractures. Examining the average length of stay for hip fractures, the team found that length of stay declined while readmission rates dropped a couple of percentage points. Same with knee replacements.

"Even the patients who were not on our bundle showed a similar improvement in those scores as well, meaning some of the practices in the bundle group were leaking over, which we viewed as a positive development," said Kenneth.

This year, the Ministry of Health rolled out a single bundled price for patients, meaning they pay a flat price regardless of factors such as complications or length of stay. The hospital bears any extra costs, but also keeps any additional savings and returns some of those savings to the clinicians.

Shifting the center gravity to community hospitals was facilitated in part by the Ministry of Health extending the bundle to those hospitals, where the cost base is typically lower.

Singapore General saved over 1,000 patient days and reduced long stays by 37 percent. The information was incorporated into system-wide electronic health records, and on the third day of a patient's admission, an algorithm will kick in and predict which patients will be referred to community hospitals. The algorithm has an 85 percent accuracy rate on day three; at day four, it inches up to 87 percent.

The bundle program will soon be expanded to include other procedures, from tonsillectomies to spinal fusions.

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Twitter: @JELagasse
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