Accountable Care for Low-income and Marginalized Populations

1. Accountable Care for Low-income and Marginalized Populations Baylor Health Care System Office of Health Equity July 9, 2010

2. Purpose • Describe the development of a hospital-linked “Community Care Service Line” and the emerging Accountable Care Organizational (ACO) strategy • Expanding Capacity • Expanding Access • Improving Quality

3. The Context – Community Demographic Changes • Dallas County (2006) • 9th largest in U.S. (Pop. - 2,307,502) • Hispanics = 36.8% • AAs = 20.1% • Whites = 37% • 27.8% Uninsured Rate (National-15.9%) • 40.4% Medically Indigent (<200% fpl) • 932,231 people • 270,346 (29%) - Medicaid/CHIP (33% est. in 2020) • 661,885 (71%) - Uninsured Dallas County Community Health Checkup, 2007. Prepared by Parkland Health & Hospital System under the auspices of the Dallas/Fort Worth Hospital Council

4. The Context – Post-reform Health Care System Responses • Increasing Government-sponsored care losses for hospitals – 1-2% per year • Medicare – Avg. $0.12 on every dollar spent • Medicaid – Avg. $0.35 on every dollar spent • Limited cost-shifting to managed care • Increased negotiating power of health plans • Reduced investment income • Physician practices closing to new Medicare/Medicaid patients • Investing in profitable office-based ancillary services Kaufman, N. Bracing for the Failures of Incremental Health Care Reform, April 2010.

5. The Context – “Skating to where the puck is going to be” – Wayne Gretsky • Physician engagement strategies • New collaborative relationships • Investing funds to stabilize MD incomes generated from improvements in care efficiency • Cost control strategies – “Breakeven on M/C” • Labor, RX and Device supply costs • Unnecessary duplication & variation • Adding costs strategically – “Innovation” • HIT, Patient-centered medical homes, revenue cycle management, hospitalists, care coordination, ACO, etc. Kaufman, N. Bracing for the Failures of Incremental Health Care Reform, April 2010.

6. ACO: First ACO Steps – Reducing Health Disparities & Bad Debt Emergence of the Community Care Service Line A hospital-safety net clinic collaboration strategy for targeted (i.e. chronically ill) low income & marginalized populations The Community Care Model Innovation to reduce utilization & costs while reducing disparities and increasing quality (e.g. Accountable Care) Market changes demand better alignment Community Benefit Best Practice Stricter 990 reporting requirements Impending growth of Medicaid population Limited Primary & Specialty Care provider capacity Falling hospital reimbursement rates Expanding need for cost reduction innovations Increased competition around hospital quality

7. Definition • Accountable Care Organization • “A provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population” • ACO - Multiple forms: • Large integrated delivery systems • Physician-hospital organizations • Multispecialty practice groups • Independent practice associations • Virtual inter-dependent networks of hospitals, physicians & clinics Reference: Rittenhouse, Shortell, Fisher – N.Engl.J.Med 2009; 361: 2301-03.

8. “Starting with a vision”A Community Care Service LineConceptual Framework

10. “Building community-based ambulatory care capacity”Strategy #1: Aligning with Patient-Centered Medical Homes

11. Community Care’s Asset Map • Hospital-based residency clinics • Hospital-based chronic disease clinics • Diabetes, Heart Failure, Asthma • Community-based Primary Care • FQHCs • Charitable Clinics • Private Physicians • Specialty Care & RX Access Programs • Project Access

12. What is the Service Area for PAD – Health Information Exchange? 6 Major Health Care Systems: Baylor HCA Methodist Parkland THR UTSWMC 2000+ Volunteer physicians 10 Charity Clinics Strategic Alignment: Charity Clinics & Hospitals

13. Alignment with Local Safety Net Charity Clinics • Affiliated with Services Agreements • Central Dallas Ministries – Community Health Services • Christ Family Clinic • Hope Clinic of Garland • Irving Interfaith Health Center • Wholly-owned • Baylor Family Medicine @ Worth St. • Diabetes Health & Wellness Family Health Ctr.

14. Community Care Service Line Proposed Budget Increase – FY11 :

15. Community Care Service Line Patient Capacity – FY11 ~2,700 New Patients get a medical home in FY-11 *Assumes Patient Panel Size of 1,000 patients per FTE Provider: ACMPE Paper, Determining Provider Panel Size in a Staff-model HMO, 2006. ** Central Dallas Ministries has an average of 6.15 visits per patient annually, compared to an HMO benchmark of 3.3 visits per patient ***Both Clinics recruit volunteer providers to expand PCP capacity

16. Community Care Service Line: Increased hospital-to-medical home connections Dedicated Transitional Health Navigators enroll eligible patients from Baylor hospitals, establishing medical homes at partnering clinics. ~1,150 Unassigned hospitalized patients get a medical home in FY-11

18. Hospital Referrals

19. Hospital Referrals Capture Rate - % of Referrals Seen for CHSC Notes: n = the number of hospital referrals in that month that have been seen at the clinic at some point (does not include Low Acuity Referrals) Johns Hopkins Study: T. Gary, PhD, et al, The Effects of a Nurse Case Manager and a CHW Team on Diabetic Control, Emergency Department Visits, and Hospitalizations Among urban African Americans with Type 2 Diabetes Mellitus, Arch Intern Med, Oct 26, 2009, (57% referral to patient conversion).

20. Hospital Referrals Capture Rate - % of Referrals Seen by Clinic Notes: n = the number of hospital referrals in that month that have been seen at the clinic at some point (does not include Low Acuity Referrals) Johns Hopkins Study: T. Gary, PhD, et al, The Effects of a Nurse Case Manager and a CHW Team on Diabetic Control, Emergency Department Visits, and Hospitalizations Among urban African Americans with Type 2 Diabetes Mellitus, Arch Intern Med, Oct 26, 2009, (57% referral to patient conversion).

21. Productivity: CDM • *Note: Benchmark: 25% MGMA per 1 FTE • Physician (w/o OB): 3787 per Year / 316 per Month • Nurse Practitioner: 1590 per Year / 132 per Month

22. Productivity: Worth St. • *Note: Benchmark: 25% MGMA per 1 FTE • Physician (w/o OB): 3787 per Year / 316 per Month • Nurse Practitioner: 1590 per Year / 132 per Month

23. Patient ExperiencePress Ganey – Overall Mean Score *Survey Data by Discharge/Service Date

24. Outcomes: Quality Improvement • *Note: • Percent Opportunity Achieved (POA) = The sum of the services provided (or completed, i.e. "done") divided by the total services applicable to the patient

25. Baylor’s Community Care Service Line Budget Management (FY-10) *Note: 1Total Expense from Cash Financials (3380) 2Represents Revenue Brought In (i.e. Project Access Dallas, Clinic, or OHE) *Revenue of $22,719 Pending, for total of $30,801 in FY’10 Budget (Variance= 19,393 ; % Variance = 63.0%)

26. “There is a return on investment”Impacting Hospital Utilization, Uncompensated Costs & Quality

27. Outcomes: Reduced Uncompensated Hospital Care Costs Avoided $5,547 per patient in hospital costs 79.9% Reduction 61.4% Increase * At the end of CY-09, Total Patient Panel = 2,300 x $5,547 saved per patient in first year = $12,758,100 in avoided hospital costs *Note: Hospital Utilization data provided my BHCS Decision Support / Revenue Cycle. Analysis includes patients with a 1st Date of Service at Worth St. on or before 12/21/08 with hospital utilization data through 12/21/09.

28. Baylor’s Community Care Service Line–ROIBaylor Family Medicine @ Worth Street12 Month Pre and Post Enrollment Projected # of Worth St. Patients Utilizing Hospital in 12-mo period: 1,681 86.1% of Worth pts experienced hospital utilization (matched in database) 1,953 pts seen at Worth St. in past 12 mo (January ’09 – December ’09) Average Savings per Pt from avoided hospital utilization (Uncompensated Costs):$5,607 12-mo Pre-Initiation: Avg. Uncompensated Costs per Pt = $8,121 12-mo Post-Initiation: Avg. Uncompensated Costs per Pt = $2,514 Projected Savings for 1,681 Worth Street patients (Uncompensated costs): $9,425,367 $5,607 savings x 1,681 pts Cost of Worth Street Operations (12 months):($1,162,545) January ’09 – December ‘09 Net Program Benefit (Loss): $8,262,822

29. Outcomes: Reduced 30-day Post-Discharge Readmission Rate Improving 30-day Readmission Rates 1U.S. Department of Health & Human Services – Hospital Quality Compare. http://www.hospitalcompare.hhs.gov 2 “Hospital 30-Day Heart Failure Readmission Measure Methodology” Submitted by Yale University/Yale-New Haven Hospital Center for Outcomes Research & Evaluation (YNHH-CORE)

30. “It’s not all about the clinics”Strategy #2: Developing Community Care Coordination

33. Summary • Community Care Service Line emergence • A hospital-linked “Community Care Service Line” for low income & marginalized populations • Community Care’s model • Innovative collaboration for achieving an accountable care organizational vision • Market changes provide a need for ACO • Community Benefit Best Practice • Stricter 990 reporting requirements • Impending growth of Medicaid population • Limited Primary & Specialty Care capacity for low income patients • Falling hospital reimbursement rates • Expanding need for cost reduction innovations • Increased competition around hospital quality

34. For More Information: Jim Walton DO, MBA Vice President & Chief Health Equity Officer jameswa@baylorhealth.edu