Overview of the Public-Private Partnership Concept and ... · Requirements of a Successful P3 •...
Transcript of Overview of the Public-Private Partnership Concept and ... · Requirements of a Successful P3 •...
Overview of the Public-Private Partnership Concept
and Cost/Benefit AdvantagesPiero Rinaldo, MD, PhDProfessor of Laboratory Medicine
T. Denny Sanford Professor of PediatricsMayo Clinic College of Medicine, Rochester, MN
Association of Public Health Laboratories (APHL)2007 Annual Meeting & First State Environmental Laboratory Conference
Jacksonville (FL), June 5, 2007
Outline• Past and current status of NBS in the US
• What is a public-private partnership?
• The MN model of newborn screening
• Cost/benefits and value-added
• What is next?
35%65%
% ofUS births
0%0%100%
Status of NBS in the US
83%
% ofUS births
2%2%98%
20072007Status of NBS in the US
The HRSA/ACMG Uniform Panel
Uniform Screening Panel (2006)• 29 primary conditions
– 20 detected by MS/MS (AA, FAO, OA)
– 3 Hb-pathies (S/S, S/βThal, S/C)
– 6 others (BIOT, CAH, CF, CH, GALT, HEAR)
• 25 secondary targets
– 22 detected by MS/MS (AA, FAO, OA)
– 1 Hb-pathy (many variants counted as one)
– 2 others (GAL-epimerase, GAL-kinase)
42/54 (78%) by MS/MS42/54 (78%) by MS/MS
The Arrival of MS/MSThe Arrival of MS/MS
Delivery of NBS Testingin the US (2007)
• Single state public health lab (± MS/MS)
• Public health “hub” for other state(s)
– Regional (geographical proximity)
– Non-regional
• Outsourcing to a private laboratory
• Public-private partnership
Outline• Past and current status of NBS in the US
• What is a public-private partnership?
• The MN model of newborn screening
• Cost/benefits and value-added
• What is next?
Public-Private Partnership (P3)"Public-private partnership" means any partnership between federal agencies, state agencies or individuals or any combination of federal agencies, state agencies or individuals, including corporations and private persons or organizations, where at least 1/3 of the funding is contributed by a non-governmental organization or individual.[2003, c. 414, Pt. A, §2 (new); c. 614, §9 (aff).]janus.state.me.us/legis/statutes/12/title12sec10301.html
Focus on Public Healthwww.unfoundation.org/files/pdf/2003/Public_Private_Part_Bro.pdf
Public-private partnerships involving governments, the private sector and civil society are increasingly recognized as an international solution for social issues of almost every type:• Building health care• Clean water systems• Sustaining the environment• Bridging the digital divide
Requirements of a Successful P3
• Examine the potential: Partnerships are time-consuming and often difficult. A P3 should deliver better results than what any partner could achieve alone
• Focus on the concrete: specific, shared activities leading to tangible outcomes are much better than simply a common vision or shared aims
• Agree to a shared governance structure: the best arrangements will adequately reflect underlying power relations
• Plan the details: a comprehensive strategy for building, maintaining and completing the partnership is vital, as is setting performance and management goals 11www.unfoundation.org/files/pdf/2003/Public_Private_Part_Bro.pdf
Requirements of a Successful P3
• Remain flexible: successful partnerships often evolve considerably during their lifespan, including in terms of membership. Plan explicit exit requirements
• Identify catalytic leadership: this can be particularly important at the early stages, to get the partnership off the ground; once operational, partnerships should be institutionalized, as senior leadership moves on to other opportunities
• Establish an appropriate time frame: partnerships usually take longer than expected to deliver results
22www.unfoundation.org/files/pdf/2003/Public_Private_Part_Bro.pdf
Requirements of a Successful P3
• Trust, but verify: trust is an essential part of public-private partnerships, particularly those attempting to span cultural differences. Trust is a necessary precondition, but it can also be reinforced through the process of partnering. Third party audits are useful
• Acknowledge that the job is difficult: partnerships are a challenge for most institutions. Even when all parties are committed and enthusiastic, successful P3 take significant resources to initiate and manage
• Write it down: a written agreement formalizes the partnership. At the outset, however, all parties should agree whether the purpose of the agreement is to define the partnership or the governance of the partnership
33www.unfoundation.org/files/pdf/2003/Public_Private_Part_Bro.pdf
• Better than individual components alone• Tangible outcomes• Shared governance structure• Performance goals• Exit strategy• Leadership succession• Time frame of deliverables• Trust, with adequate verification• Acknowledge that the job is difficult• Written agreement
Requirements of a Successful P3
www.unfoundation.org/files/pdf/2003/Public_Private_Part_Bro.pdf
Is the NBS program
in MN a P3?
Are we fulfillingthese requirements?
Are we successful?
YES
YES
YES
YES?
“Defining your criteria forsuccess is easier when you suck.
As you get better, it becomes harder. The steps are smaller.”
Bode MillerNewsweek, January 23, 2006 (p. 44)
“Defining your criteria forsuccess is easier when you suck.
As you get better, it becomes harder. The steps are smaller.”
Bode MillerNewsweek, January 23, 2006 (p. 44)
Outline• Past and current status of NBS in the US
• What is a public-private partnership?
• The MN model of newborn screening
• Cost/benefits and value-added
• What is next?
The Minnesota Model
A public-private partnership between
The Minnesota Department of Health (MDH)
The University of Minnesota
Mayo Clinic (Mayo Medical Laboratories)
What is the Minnesota Model?A public-private newborn screening
program based on COOPERATIONand COMMUNICATION between all parties involved with the goal toexpand and enhance the delivery of
•Laboratory tests
•Patient care
•Family services
Delivery of Laboratory Tests by the Newborn Screening Program in MN
S,FUS,FUS,FUS,FUFU
S,FUS,FU
-C-
2TS,C,2T
C-
Established Conditions Cong. HypothyroidismGalactosemia (GALT)
Sickle Cell Anemia21-Hydroxylase Def (CAH)
MS/MS (AA, OA, FAO)Biotinidase
Cystic Fibrosis
S ScreeningC Confirmatory
FU Follow up2T 2nd tier test in DBS
Delivery of Patient Care by the Newborn Screening Program in MN
• Notification of abnormal results
• Confirmatory testing (verification)
• Reporting and rapid disposition
• Clinical referral of true positives
• Short-/long-term follow up by specialist(s)
MN partnership=
Active cooperation&
constant communication
Screening Laboratory
BiochemicalGenetics
Laboratories
Primary Care
Provider
Metabolic Clinics
Notification• Phone• Fax• E-mail (website)
Please Visit SNS
E-mail Message (NO PHI)
Posting on Secure Website
• Commercial product (QuickPlace, IBM)• Provided by Mayo, at no cost to partners• Content sorted by topic (abnormals, unsat, etc..)• Messages “stringed” together in order of posting• Searchable by name, ID, keyword
• Commercial product (QuickPlace, IBM)• Provided by Mayo, at no cost to partners• Content sorted by topic (abnormals, unsat, etc..)• Messages “stringed” together in order of posting• Searchable by name, ID, keyword
MN P3: Expand and Enhance the Delivery of Patient Care
Verificationof Abnormal
Results
Screening Laboratory
BiochemicalGenetics
Laboratories
Primary Care
Provider
Metabolic Clinics
Discouragerepeat submission
and testingof blood spots1
Activaterapid
confirmatorytesting
3
Prevent "blind"referrals to specialists
of false positives
2
Reportingof Diagnostic
Testing
Screening Laboratory
BiochemicalGenetics
Laboratories
Primary Care
Provider
Metabolic ClinicsE-mail
notification
E-mailnotification
Referralof TRUEPositives
Confirmatorytesting is
already DONE
Screening Laboratory
BiochemicalGenetics
Laboratories
Primary Care
Provider
Metabolic Clinics
Screening Laboratory
BiochemicalGenetics
Laboratories
Primary Care
Provider
Metabolic Clinics
SHORT TermFollow-Up
BENEFITSAccurate statisticsLearning from experienceEducationCOST REDUCTION
E-mailnotification
Highlights of MN Model• Secure website for timely communication
– Every provider is on the same page• NO repeat blood spots
– Unless <24hr
States reported they spent over $120 millionon laboratory and program administration/ follow-up activities in state fiscal year 2001. Individual states’ expenditures ranged from $87,000 to about $27 million
GAO-03-449 State Newborn Screening Programs, March 2003
Routine Second SpecimenPEDIATRICS 117:S212-S252, 2006
~700,000 US newborns/yr are tested TWICEWhere is the evidence?
Is the Routine Collection of a Second Specimen Cost Effective?
MNMN
Why states with a two-specimensystem have a detection rateby MS/MS worse than ours?
Why states with a two-specimensystem have a detection rateby MS/MS worse than ours?
Highlights of MN Model• Secure website for timely communication
– Every provider is on the same page• NO routine second repeat blood spots
– Unless <24hr• Rapid confirmatory testing
– Completed in <48hr in most cases• NO clinical evaluation by metabolic
specialists of false positive cases• <1,800 g protocol (targeted repeats)• Second tier tests
2nd Tier Tests• A cost effective mean to implement clinically defined
cutoffs when normal population and disease range overlap (poor specificity)
• Performed in 1-2 batches weekly (except CAH)• Same specimen, no additional patient contact• Normal result overrules primary screening• Reporting of primary screening is not delayed
0.64% 0.06%
Why only 6 states?
Outline• Past and current status of NBS in the US
• What is a public-private partnership?
• The MN model of newborn screening
• Cost/benefits ratio and value-added
• What is next?
Exactly, what is the“cost/benefits ratio”? Exactly, what is the“cost/benefits ratio”?
= VALUE= VALUE
Definition of ValueDefinition of Value
Value =Quality
CostHow do we improvethe value of NBS?
How do we improvethe value of NBS?
The Cost Reduction Model
Value =Quality
Cost
Avenues of Cost Reduction (Avoidance of Unnecessary Costs)
• Recall and repeat analysis (2nd, 3rd, 4th…)
• Disruption of care (premature, sick newborns)
• Outpatient, ER visit(s)
• Confirmatory testing
• Referral to metabolic specialist
• Disruption of family life (stress)
Reductionof false
positives
Reductionof false
positives
The Quality Improvement Model
Value =Quality
CostQuality = PerformanceQuality = Performance
Period
Volume *
Detection rate
False Pos. Rate
Pos. Pred. Value
Jul 04 - May 07
275,845
1:1,662
0.09%
41%
Performance Metrics in MNsince the Beginning of P3 (MS/MS)
Target
<1:3,000
<0.30%
>20%* Includes 58,643 from out of state
Trend of Performance Metrics in MNsince the Beginning of P3 (MS/MS)
P3
Pediatrics 2006; 118:448Pediatrics 2006; 118:448
MN
MN 2005 FP cases (MS/MS)
Predicted scenarios FPRBest case 81 0.11%Intermediate 808 1.14%Worst case 1606 2.27%
ACTUAL 52 0.07%
Requirements of a Successful P3
Better than individual components
Tangible outcomes
Shared governance structure
Performance goals
Exit strategy
Leadership succession
Timeframe of deliverables
Trust, with adequate verification
Acknowledge that the job is difficult
Written agreement
Yes!
NBS expansion
Adv Committee
Metrics (exceeded)
5 yr, renewable
MDH, UoM, Mayo
On time (ahead)
Sight visits
Can do attitude
Yes
Canthis modelbe appliedelsewhere?
HRSA Regional Collaborative ProjectLaboratory Quality Improvementof Newborn Screening by MS/MS
MS/MS working group, May 6, 2007
MarziaPasquali
StephanieMayfield
Value-added by Mayoto NBS (MN and beyond)
• Familiarity with the diagnosis of IEM
• High-throughput MS/MS environment
• Rapid (and complete) confirmatory testing
• Focus on performance metrics and quality: Leadership of collaborative project (72 labs worldwide)
• Development, validation, and implementation of 2nd tier tests (training freely available to all)
• Second opinion of questionable MS/MS results
• R&D toward future expansions
Outline• Past and current status of NBS in the US
• What is a public-private partnership?
• The MN model of newborn screening
• Cost/benefits and value-added
• What is next?Nature Reviews/Genetics, 2005Nature Reviews/Genetics, 2005
Nomination Form for New Conditions to be Added to Uniform Panel was
posted on HRSA website on May 18, 2007
Nomination Form for New Conditions to be Added to Uniform Panel was
posted on HRSA website on May 18, 2007
Candidate Conditionsfor Expansion of Uniform Panel
• ALD
• CDG Ib
• CMV
• DMD
• G6PD
• FHC
• Fragile X
• HIV
• LSD (multiplex)
• SCID
• SLO
• SMA
• Toxoplasmosis
• Wilson
WHO is going
to do all this?
SpeedyScreening
Active Research at Mayoon Candidate Conditions
• ALD
• CDG Ib
• CMV
• DMD
• G6PD
• FHC
• Fragile X
• HIV
• LSD (multiplex)
• SCID
• SLO
• SMA
• Toxoplasmosis
• Wilson
Conclusions• A public-private partnership is a viable
option for the Minnesota NBS program
• Cost-benefit advantages are accrued as a combination of shared resources, frequent communication, R&D, and improved analytical/post-analytical performance
• The applicability of this model to NBS is likely to grow as the breath and complexity of testing will increase
Of all cooperative enterprises, public health is the most important and gives the greatest return
Of all cooperative enterprises, public health is the most important and gives the greatest return
WHY Do We Do This?WHY Do We Do This?
Charles J. Mayo, MDCharles J. Mayo, MD