Chronic Disease and Chronic Disease Management in Bupa - Dr Andrew Vallance-Owen Global Medical Director

 
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Chronic Disease and Chronic Disease Management in Bupa - Dr Andrew Vallance-Owen Global Medical Director
Chronic Disease
                      and
      Chronic Disease Management in Bupa

               Dr Andrew Vallance-Owen
                Global Medical Director

Prague Presentation June 2010
Chronic Disease and Chronic Disease Management in Bupa - Dr Andrew Vallance-Owen Global Medical Director
Bupa is an international healthcare group
          United Kingdom           Bupa Wellness        France                   Insurance businesses
          Bupa UK Membership       UK Care Services     Health Dialog CNAMTS
                                                                                 Provision businesses
          Bupa Health Assurance    Bupa Home Healthcare
          Bupa Health Dialog       Cromwell Hospital                             Integrated health services

US                                                                                     China
Health Dialog                                                                          Representative
                                                                                       Office Beijing
                                                                                       Hong Kong
                                                                                       Bupa Hong Kong
                                                                                       Thailand
Spain                                                                                  Bupa Thailand
Sanitas
                                                                                       Australia
Sanitas Hospitals
                                                                                       Bupa Australia / MBF
Sanitas Residencial
                                                                                       Bupa Care Services
Health Dialog Espana
                                                                                       Australia
Latin America
Bupa Latin America
(Offices in Miami, USA;
Mexico; Ecuador; Bolivia;
Dominican Republic)
International                                                         India       New Zealand
Bupa International                                                    Max Bupa    Bupa Care Services NZ
(Offices in Brighton, England;
Copenhagen, Denmark;
Dubai, UAE; Cairo, Egypt; and    Denmark            Saudi Arabia
Hong Kong, China)                Bupa Scandinavia   Bupa Arabia
Some facts about Bupa
 We commenced operations in 1947 and our founding principles remain core to
 our success and growth over 60 years and into the future

 Bupa’s core purpose is to prevent, relieve and cure sickness and ill health of
 every kind, across all of Bupa’s businesses and geographies. Our aim is to provide
 our customers with high quality health and care products and services

 We are a private company with no shareholders – our primary concern is for
 our customers. All our profits are reinvested in the company to provide more and
 better health and care to our increasing number of customers around the world

 We are in ~190 countries and employ more than 50,000 people worldwide

 Our businesses include: private medical insurance, hospitals, aged care,
 wellness, occupational health, chronic disease management, home nursing,
 primary care, commissioning, health data analytics
Chronic disease management has been identified as
a priority for Bupa

  •   Customer needs and wants

  •   Impact on health fund costs

  •   Opportunities in public sectors

  •   Acquisition of Health Dialog in the USA
The burden of chronic diseases is increasing and
   driving healthcare spend
     •      Non-communicable diseases, principally cardiovascular diseases, diabetes,
            cancers, and chronic respiratory diseases, caused an estimated 35 million
            deaths in 2005
                  • Total deaths from non-communicable diseases are projected to
                     increase by a further 17% over the next 10 years

     •      Roughly 70% of healthcare spend in Bupa’s core markets is currently
            attributable to this chronic disease burden

             % GDP spent o n
             healt hcare - 2 0 0 9
                                             Healt hcare spend on chronic disease         This spend is disproportionate
                                                                                             – for example in the UK
             % o f t o t al GDP
             spent o n chro nic           20.0                                          roughly 25% (15.4 million) of the
             care                         15.0                                                      population
                                                                                           have a long term condition,
                                  % GDP

                                          10.0
                                                                                    but account for 70% of healthcare spend
                                           5.0

                                           0.0

                                                 Aust r alia   Spain   UK   US

Sources available on request
80% of chronic disease deaths occur in low & middle
   income countries
        •       Predictions for the next 2 decades see a near tripling of ischaemic heart disease &
                stroke mortality in Latin America, Middle East & sub-Saharan Africa1
        •       The global number of individuals with diabetes in 2030 is projected to rise to 366
                million, (or 6.5% of the world’s population) – 298 million of whom will be in
                developing countries 1

        •       The costs associated with heart disease, stroke & diabetes are large across the
                globe, but most significant in the developing world2:
                 Impact on nat ional income of premat ure deat hs from heart                    The response to the challenge in
                     disease, st roke & diabet es bet ween 2 0 0 5 -2 0 1 5
                                                                                   China
                                                                                                developing countries may differ
                                                                                   Russia
                                                                                   India        Developed countries have health
                          600                                                      Brazil        systems designed to deal with
                          500                                                      UK
                                                                                                         acute illness
                            400                                                    Pakist an
      Lost $ (billions)
                                                                                   Canada
      be t we e n 2 0 0 5 - 300
            2015                                                                   Nigeria     Developing countries often have an
                            200
                                                                                   Tanzania    emerging healthcare system which
                          100
                                                                                                  offers real opportunity to trial
                             0
                                                   Count ry
                                                                                               different approaches to healthcare
                                                                                                              delivery
1. Derek Yach – The Global Burden of Chronic Diseases: Overcoming impediments to
                prevention & control (JAMA – 2004, Vol 291, No 21)
2. http://www.who.int/chp/chronic_disease_report/media/impact/en/index.html
Ageing populations and the rise in chronic disease

                        The proportion of the                                                                Project ed increases in t he percent age of regional
                         population that will                                                                             populat ions aged over 6 0
                                                                                                                                                            World                    Medical advances
                            be over 60 is                                                               40                                                                           also mean people
                         increasing globally                                                            35
                                                                                                                                                            Nort h America
                                                                                                                                                                                      liver longer with

                                                                          % populat ion aged over 6 0
                                                                                                        30                                                  Europe
                         - With this, the level                                                                                                                                     more conditions also
                                                                                                        25
                              of multiple                                                               20
                                                                                                                                                            Lat in America &        adding to healthcare
                                                                                                                                                            Caribbean
                             morbidities &                                                              15                                                  Africa
                                                                                                                                                                                             costs
                           treatment costs                                                              10
                                                                                                                                                            Asia
                               escalate                                                                  5
                                                                                                         0
                                                                                                                                                            Aust ralasia
                                                                                                                     2005                2050

                             Average per person annual cost of t reat ment for                                                          Percent age of t he populat ion wit h more t han one
                             an individual wit h one or more chronic condit ions                                                                 chronic condit ion by age group
                                                     (USA)                                                                                                     (USA)
                         7000
                         6000
$ per person per year

                         5000
                                                                                                                                Aged over 65
                         4000
                         3000                                                                                                                                                             Aged over 65
                         2000                                                                                                                                                             Aged 18-34
                         1000
                                                                                                                                 Aged 18-34
                            0
                                1 chronic condit ion   >1 chronic condit ion                            >1 chronic condit ion
                                                                                                            and over 65
                                                                                                                                               0   20      40        60        80   100

                        Sources on request
But this doesn’t just affect the elderly …

                Of all deaths attributable to chronic conditions the proportion
                   that occur before the age of 60 are (2003):

                             Low income                   Lower middle   Upper-middle   High income
                              countries                      income        income        countries
                                                            countries     countries

                                  44%                              33%      34%           19%

                This is as much of an issue for the working population as for
                   older retired populations

Oxford Health Alliance: Chronic disease: an economic perspective
Rising obesity
   morbidly obese,             Approximately 1 billion
    300 million               adults are obese globally1

                                                                                            40% increase in obesity
                                                                                             surgery in England in
                                                                                                   20083

                                                                              obese,
                                                                              1 billion

                                                                                          The number of adolescents
In 2005 the cost of obesity in Australia
                                                                                           that are overweight has
  was calculated as Aus $873million2*
                                                                                             trebled since 19801

                                             Raised BMI is a risk factor for:
  Cardiovascular disease (mainly heart disease and stroke) - already the world's number one cause of death, killing 17 million
                                                        people each year.
Diabetes – which has rapidly become a global epidemic. WHO projects that diabetes deaths will increase by more than 50% worldwide
                                                      in the next 10 years.
                                   Musculoskeletal disorders – especially osteoarthritis.
                                     Some cancers (endometrial, breast, and colon).
Chronic disease management – Bupa definition
•    Chronic disease management as a term is used loosely and can encompass a
     variety of activities, all centred around supporting the health of an individual with a
     chronic disease

•    Clarity is required on why activity is being undertaken in this sector – to improve
     health outcome of the patient or ensure cost-effective utilisation of healthcare
     resources

•    Therefore, in Bupa we are describing chronic disease management as:

     “co-ordinated, pro-active, patient-centred, healthcare interventions and
        communications for people with long term conditions to optimise the
          quality of patient care & health outcome while minimising overall
                                   healthcare costs”
    (long term conditions are those conditions that are permanent and require
                      ongoing supervision, observation or care)”
Tackling the issue of chronic disease requires both
       prevention & management
              •      With the issue of chronic disease growing across the globe, there is a need to
                     ensure that chronic disease is prevented wherever possible and people with chronic
                     conditions achieve the best possible health outcomes:
                                                                                         Reduce emergence of           Restore function/
                                                                                              symptoms               reduce complications

                             Primary                       Early diagnosis                     Secondary                  Tertiary
                            Prevention                                                         Prevention                Prevention

                                                                                                           Chronic disease
                  We know that there a small
                  number of risk factors that                                                               management
                      cause the majority
                     of the chronic disease                                                      Once a condition has been
                   burden1 and that primary                                                      diagnosed, it is crucial that
                           prevention                                                                  health outcome
                      & health promotion                                                         for the person is optimised
                  could prevent up to 70% of
                              the
                        disease burden2

1. WHO: http://www.who.int/dietphysicalactivity/publications/facts/chronic/en/index.html
                                   - high cholesterol, high blood pressure, obesity, smoking and alcohol
2. World Health Report 2008: Primary Health Care – Now More Than Ever
Objectives for managing chronic disease

 •   The hypothesis: it is possible to implement strategies that help people live
     with and manage their chronic disease(s) that both:

          • Optimise the health outcome for the patient
              - In terms of ameliorating progression, preserving functionality &
                  reducing suffering

          • Reduce or minimise associated healthcare cost
              – Reduction in acute emergency interventions
              – Reduction in overall hospital admissions related to poor management
                of the disease (e.g. diabetic retinopathy)
              – More pertinent use of primary care services

 •   The time period required to see effect could well be considerable
      – Short term cost for long-term gain often a challenge
Expectations of health
•   Who pays if the government needs to control its costs? Less public money for health
    will mean individuals will need to pay more for services or new forms or rationing may
    be imposed.

•   Uncertainty surrounds the level of care an individual should expect to be publicly
    provided

                           “silver power” : older populations have increasing
                            economic and/or political power for two reasons:
                        • there are more of them numerically (e.g. more
                          votes)
                        • they are wealthier than previous silver generations
                          attributable to the long period of prosperity in the
                          post-war years

•   An emphasis on personal responsibility, lifestyle and behaviour may become important
    with the onus of responsibility on individuals.
     – With more responsibility placed on individuals, access by individuals to the right
         information to manage their lifestyle, health and behaviour would become more
         important and a business opportunity for the provider and manager of that
         information

•   The economic and financial crisis from 2008 onwards has introduced financial as well
    as attitudinal factors into the question of regulation and responsibility
Changing location of healthcare delivery
                                                                                  With increased
       Technology as a disrupter                                                   formal care
 Technology has the capacity to erode borders in                            In 2008, there were 410,000
 healthcare and alter the provision of healthcare                           people in in nursing and
                                                                            residential care.2 This figure is
        Geographical location less fundamental;                            expected to increase to 493,0003
               Provision of care outside clinic (home;                     by 2020
               work; gym; pharmacy)
               cross-border healthcare                            Population ageing is expected to lead to a burgeoning
        Movement towards a less physician centred                demand for aged care services over the coming decades
        model of care: super-specialised medics and               across all of our key markets
        lower cost healthcare professionals                        Demand will be heavily influenced by care needs
                                                                  which are reflective of the changing pattern of disease
 Technological barriers a challenge: interoperability,            associated with increased longevity, including an increase
 data privacy, robustness etc                                     in the prevalence of co-morbidity

                      Analytics
  With healthcare spend spiralling and the electronic capture of clinical data, robust analytics are now
undertaken to:
 Monitor health trends and needs                                    Healthcare providers should expect increased scrutiny
 Prove cost efficiency of interventions                           on the outcomes of care & cost efficiency of their services
 Advise on most appropriate provision of care
Telehealth can transform healthcare delivery

Remote healthcare                On-line assistance and           Condition monitoring                  Medication compliance
  consultation                    information for self-
                                     management

Delivery of healthcare        Programmes and websites             Mobile/fixed devices to monitor       Devices that either remind
consultations remotely –      that motivate and help              key physiological markers             patients to take medication
eg via webcam, email etc      patients to manage their own        (weight, blood pressure etc)          or directly dispense to
                              health (eg diabetic diary)          and send alert to physician if        improve compliance
                                                                  values fall outside defined values

           All with the shared aim of minimising healthcare costs and improving patient outcome

                       Most activity is still at the pilot stage with this hypothesis still being tested.
                          This is an area of innovation with the evidence base being developed
            Many bodies are funding research in this area (eg. WSD in UK, AAL across the EU, ARRA bill, NIH etc.)

                               The marketplace is fragmented with many emerging competitors.
                               It is expected to become increasingly crowded in the next 5 years.
                  Integration of services (and therefore different providers) is likely to be essential for success
Bupa’s approach to chronic disease is defined by 5
principles

  1. Maximising the use of data, analytics & knowledge in all
     activity
     •   Insight and outcome are both crucial
  2. Utilising and demonstrating our healthcare expertise
     •   Both in healthcare & healthcare systems
  3. Creating advantage for customers through our scale &
     diversity
     •   Both frequency & geography
  4. Building ongoing consumer engagement through
     individualised outreach and empowering people to help
     themselves
     •   This can be remote
     •   Create a symbiotic relationship throughout life
  5. Treating the whole person, not the disease.
     •   Tailor to the individual – personalised interaction
Future trends

  There are a number of factors that are likely to affect the future
    of chronic diseases & their management

                                                                                                            Funding
                                                      “New” chronic diseases &                  •Who will fill gap between need &
   Genetics/evolution of medical                                                                           ability to pay?
                                                       changing disease profile                •Role of government, particularly in
            technology                                 •With medical advances, fatal               prevention likely to increase
    •Advances may require healthcare                 conditions may become chronic             •Evidence of effectiveness – how will
            systems to change                         •Huge anticipated increases in                        this evolve?
  •Individual responsibility issues raised                  obesity & diabetes                    •Role of the employer likely to
                                                   •How might environment & lifestyle          increase as the workforce becomes
                                                              be adapted?                                        older

                         Location of provision &
                        consumer empowerment
                           •Increased transparency &                     Pharmaceutical company
                            consistency in the sector
                                                                                interest
                          •Changing relationship with
                                                                        •How will innovation be funded?
                       professionals & ways of interaction
                                                                        •Role of the developing world in
                     (importance of both physical & virtual
                                                                        developing new pharmaceutical
                                    facilities)
                                                                                    products
                         •Different skill sets required in
                            healthcare professionals
                      •Management of information will be
                                     critical
Health Dialog Introduction

  • Mission : To reduce unwarranted variation.

                                   TM
                                        SM
Health Dialog

    • Unwarranted variation
Effective Care: “Proven effectiveness, no
significant trade-offs”
Beta blocker use among patients post heart
attack varies from 5% - 92%,
when it should be ~100%

Preference-Sensitive Care: “Involves trade-
offs, (at least) two valid alternative
treatments are available”
In Southern California, a patient is 6 times
more likely to have back surgery for a
herniated disk than in New York City

Supply Sensitive Care: “If they build it, you
will come”
Per-capita spending per Medicare enrollee
in Miami, Florida is almost 2.5 times as
great as in Minneapolis, Minnesota
Health Dialog

  • Solutions based on client need

                                     > 25,000,000
                                        Members

                                     > 30,000,000
                                       Individuals
Analytics: finding and reaching the right person at the right time

                                                                                                                                                                  A unique “Patient Profile” is created for each member from a
                                                                                                                                                                             variety of raw data and derived data
                                                                                                                                                                 Over 1,500 FACTS are maintained for each member on topics
                                                                                                                                                                 ranging from up-to-date contact details to chronic gap scores.

35000                                                                                                                                                     700

                                                                                                                                                          600

                                                                                                                                                                   Predictive modeling is used to identify members with high
30000

                                                      Average Cost
25000                                                                                                                                                     500
                                                      Admit Rate

20000                                                                                                                                                     400

                                                                                                                                                          300
                                                                                                                                                                                expected utilization and costs
15000

10000

 5000
                                                                                                                                                          200

                                                                                                                                                          100
                                                                                                                                                                High risk and costly members are identified for specific outreach
    0
                              0-10       11-20    21-30        31-40    41-50        51-60        61-70        71-80        81-90        91-95 96-100
                                                                                                                                                          0      campaigns aimed at helping them better manage their health
                                                          Predicted Financial Risk Percentile

                                                           Enage Model: Cumulative Gains Rate

                              100%
                               90%
                                                                                                                                                                Claims, outreach activity, lifestyle and geo-census data, are used
                               80%

                                                                                                                                                                    in models to help predict reach & engagement likelihood
        Cumulative Response

                               70%
                               60%
                               50%
                               40%
                               30%
                               20%
                               10%
                                0%
                                                                                                                                                                    Employing specific models allow Health Dialog to identify
                                     0           10       20           30       40           50
                                                                                       Percentile
                                                                                                          60           70           80       90     100

                                                                                                                                                                    members most likely to engage self management support
Whole person health coaching
Summary
•   Chronic diseases are a significant and growing issue across the globe
•   There are a number of key factors driving the increase in chronic disease -
    lifestyle & the ageing demographic are 2 key drivers
•   With chronic diseases accounting roughly 70% of healthcare spend,
    competencies in managing chronic disease will be needed by any
    organisation responsible for health of communities or populations
•   CDM is still an area of innovation: the evidence base is patchy (both in terms
    of quality improvement & cost effectiveness) & still under development
•   Tackling chronic disease requires both prevention and management
    strategies - chronic disease management cannot be viewed in isolation
    from prevention
•   Bupa’s approach is patient centred and aims to improve health status and
    reduce costs using analytics to define services
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