Joanne Conroy MD Chief Healthcare Officer April 2011

1. ACOs and HIZs: CME’s RolePresentation to SACME Joanne Conroy MD Chief Healthcare Officer April 2011

2. ACO definition Experts have proposed using financial incentives to create a new type of health care entity called an accountable care organization (ACO). Available literature describes them as structures dedicated to quality and efficiency, with the infrastructure to use performance, reporting and compensation standards to achieve their goal. Belief that they will create greater clinical integration of care across care settings, greater financial efficiency, and increased transparency about care cost and outcomes. In the legislation ACOs are seen as a tool for restructuring traditional Medicare coverage.

3. Ideal ACO Aligned networks of specialists, ancillary providers and hospitals focused on enhanced outcomes Emphasis on effective clinical care integration and coordination mechanisms Payer-provider contracted relationships and reimbursement models that facilitate and reward cost-effective high-value (not high-volume) health care Population health information infrastructure to enable community-wide care coordination, including integrated electronic health records (EHRs)

4. HIZ definition “…Healthcare Innovation Zones, consisting of groups of providers that include a teaching hospital, physicians, and other clinical entities, that, through their structure, operations, and joint-activity, deliver a full spectrum of integrated and comprehensive health care services to applicable individuals while also incorporating innovative methods for the clinical training of future health care professionals.” All in All missions

5. HZs and defined communities would… Reconfigure the health care workforce to promote efficiency and productivity aimed at improving both the patient and provider experience. Allow for training health professionals in a transforming delivery system and foster caregivers who will sustain the goal of innovation in delivery reform throughout their careers.

6. HIZ Goals • All in across all missions: to decrease cost and improve quality in research, education, and clinical care • Redesign the role of specialists around the care of patient populations • Develop and introduce new clinical processes and new technologies in clinically and cost-effective ways

7. HIZ and the defined communities would… Provide fertile ground to test and implement a variety of care-delivery changes and supportive payment methodologies designed to improve quality and constrain overall cost growth in a sustainable manner. Re-engineering academic health system processes and practices across all three missions Rapidly evaluate the effects of multiple interventions using their advanced information systems and health services research capabilities.

8. What do ACOs and HIZs have in common? Both trying to connect care delivery with payment methodologies to drive change Both trying to introduce a level of accountability ( of individual, practice, institutions) into the relationship of provider, insurers, and patients Both bold concepts waiting for a testing ground However…both may overestimate the role of institutions and insurers and underestimate the role of patients and individual providers in making these concepts a success

9. TI Initiative: Transforming Care • Implementing and testing new care delivery models • HIZs/ ACOs • Implementing and testing new payment methodologies • Bundling and Episode groupers • Hospital and Physician VBP • Fast tracking Quality • Best practices campaign • Web site with public and private reporting to drive change • Creating rapid cycle innovation and continuous learning • National effort to focus on clinical effectiveness and translation of practice ….Supported by dynamic learning networks to accelerate change ( Readiness for Reform)

10. BPBC campaign As the AAMC prepares for potentially tumultuous legislative session in which we may have to repeatedly go on the defensive, we are concurrently moving forward with a positioning campaign to highlight what academic medicine is doing to improve health care on a daily basis and to make public our commitment to quality and patient safety in clinical care, education and research.   Although some of you may think the list too bold and others, not bold enough, the power of the campaign is our unified commitment as the nation’s teaching hospitals (and medical schools). .

11. BPBC Our goal is to take quality/safety programs developed in academic medicine and deploy them over the coming months across our institutions. Additionally, we would highlight the importance of research and education in sustaining and advancing quality initiatives.  We have worked closely with UHC to ensure that these interventions are feasible and that related outcomes can be measured

12. Participating medical schools and teaching hospitals have • committed to: • Teach quality and patient safety to the next generation of doctors • Ensure safer surgery through use of surgical checklists • Reduce infections from central lines using proven protocols • Reduce hospital readmissions for high-risk patients • Research, evaluate, and share new and improved practices. • This list of commitments will grow over time.

13. Components • Web site (www.aamc.org/bestpractices) • Public launch end of March or beginning of April on the Hill • Inside-the-Beltway advertising (print, online, radio) • Tools, resources, and support for AAMC members

14. Success depends on Institutional Commitment Leadership Alignment of Education, Research and Care Delivery Goals Training physicians of the future in a different way Hundreds of thousand of foot solders…not just 200 academic institutions or 5000 hospitals But…we will need dramatic changes in the speed and impact of the educational process

15. Readiness for Reform Phase I The R4R Assessment Tool is designed to define succinctly the primary requirements and opportunities resulting from heath care reform and assist you to gauge your preparedness for the impact of its provisions. Organized by mission area, the Assessment Tool closely follows the legislation – in its intent to promote greater coordination of care and its specific provisions to this end. Preliminary results were compiled and shared at the Annual Meeting November 7, 2010. Additional materials, including commentary, can be accessed at https://www.aamc.org/initiatives/reform/reform_refcenter/ . These results will assist members in understanding the relevant health reform provisions, priority areas in which to enhance preparedness, and opportunities to develop or extend programs for which the government is providing funding support. The R4R Tool is intended to establish a national baseline of the AAMC members' preparedness for reform and to identify priorities for emphasis for the members as well as for the AAMC.

16. General Information • Respondents to the Assessment are predominantly integrated traditional AMCs or independent teaching hospitals: Question: Your role within your institution (Please pick which most approximates your role): (answers shown in graph above)

17. Transforming Care: R4R Framework AMC led “bend the curve” health care cost reduction – with sustainable improvements in quality Healthcare Innovation Zones/ACOs 1.Research Agenda: Patient outcomes & comparative effectiveness research; Population research; Informatics • 2: Patient Engagement • Communications • Connectivity • Education • 4.Payment Reform: • Value Based Purchasing; Episodes of Care; Bundled Payments; Readmissions • Accountable Care Organizations • 6. Quality Reporting • Core Measures • Quality Reporting • 3. Access: • Distributed network • Multi-specialty sites • Primary Care Network 5.Care Delivery Innovations: • Quality & Safety Performance; • Patient Centered Medical Homes; • Care coordination across continuum • Operational Efficiency; O/P optimization Clinical Agenda • 7.Health Information Technology: Electronic Health Records Implementation & Health Information Exchange. Privacy & Security of health Information. • 8.Education Agenda: “Training Medical Professionals for the Future” (Workforce Development & training; Inter-professional training; GME Financing)

18. Medical Education The majority of institutions clinical attendings do not have “well-developed” capabilities for teaching and role modeling skills required under health reform. 0 – inadequately prepared 1 – prepared 2 – adequately prepared 3 – well developed Question 1: HC Reform will require the teaching and role modeling of new skills to medical students and residents. On a scale of 0 (inadequately prepared)) to 3 (well developed), assess your clinical attending physicians' current ability to teach and assess these skills of learners.

19. Medical Education Institutions reported that they have the capacity to train attending physicians to teach these skills: Question 2: Does your organization have the capacity to train your attending physicians to teach and assess these skills in learners? Further, respondents believed that they had the capacity to train faculty these same skills: Question 3: HC Reform will also involve training of current part-time and full-time faculty in areas described above in order that they practice and role model these skills. Does your organization have the capacity to train its faculty to practice these skills?

20. Medical Education Attending physician education (rounds, in service, others) is mostly aligned with desired educational outcomes and least focused on PQRI and pay for performance. Question 4: Does your organization align its efforts in attending physician education (rounds, in-service sessions, other educational activities)?

21. Medical Education Institutions reported that offices of UME, CME and GME were fairly effective in assessing issues regarding teamwork, inter-professional education, quality improvement and patient safety: 0 – ineffective 1 – effective 2 – fairly effective 3 – highly effective Question 6: On a scale of 0 (ineffective) to 3 (highly effective) please rate each your offices of GME, CME, and UME in terms of their ability to assess institutional issues regarding teamwork, interprofessional education, quality improvement, and patient safety?

22. Medical Education 0 – limited 1 – adequate 2 – significant 3 – highly Simulation appeared to play a significant role in preparing attending physicians, staff, residents and students for the anticipated educational challenges: Question 7: On a scale of 0 (limited) to 3 (highly), please indicate how big a role simulation will play in preparing your attending physicians, staff, residents, and students for the educational challenges of the future 0 – insufficient 1 – sufficient 2 – fairly prepared 3 – fully prepared Just over half of respondents indicated that they are “fully prepared” for the use of simulation Question 8: On a scale of 0 (insufficient) to 3 (fully prepared) indicate your opinion as to whether your institution made an adequate investment in simulation to prepare for the future

23. Medical Education Two thirds of respondents are likely to apply for implementation and comparative effectiveness dissemination grants: Question 9: Assess the likelihood that your organization will apply for (options shown)

24. Medical Education Select comments regarding Medical Education: • We have one of six VA Quality of Care fellowships in the nation. • (We) are in a unique situation because of the separate governance of each institution, while closely collaborating in improving educational activities across the continuum of UME, GME, and CME. The need to integrate UME and GME is critical. The goals to practice with fiscal competency, cultural awareness and emphasis on prevention are part of one entity's strategic plan. In the post reform era, care needs to be taken to avoid emphasis on metrics, at the expense of patient care. • The Hospital & University have begun a Patient Safety Education Committee that meets monthly and has the following goals: 1. Provide innovative institutional oversight for Patient Safety & Quality to Residents 2. Recommend to GMEC, QI methods which align with (the hospital and university) quality and patient safety efforts 3. Support QI methods that integrate patient safety and scholarship 4. Develop a standard toolkit for resources which promote resident scholarship of patient safety 5. Encourage faculty development around patient safety 6. Achieve a national presence for the University in the education of quality and safety 7. Develop a resident council subcommittee on patient safety 8. Report on measures/efforts through GMEC. • Committed to Quality and Safety. Able to collaborate with patients and health care professionals are two of the eight key characteristics of our graduates. Question 10: Please indicate any additional information that relates to Medical Education at your institution.

25. Wrap Up – Organization & Communications Strategic discussion of health reform has not permeated throughout all the constituencies that will be affected and that will be integral to institutional success: Question 2: At what level and with which constituents have formal interactions occurred regarding the challenges and changes likely to occur due to health care reform?

26. R4R Learning Collaborative & Knowledge Exchange Collation of vignettes and results achieved in each of the R4R agenda areas. These will be prepared for inclusion into AAMC’s social media toolset, or into a AAMC Content Management System; Preparation and facilitation of three or four theme specific “fly-in’s” – linked themes which together support the R4R agenda of transformational change towards population health management and seamless care. The purpose of these fly-in’s is to provide tangible lessons learned to the participants and facilitate forums for peer group exchange Facilitated information exchange and dialogue at the 2012 AAMC Annual Meeting, with designated sessions associated with R4R topics.

27. Integrative Leadership for the Next Generation AMC – 2011 Forum A follow up to the September 2009 Integrative Leadership Forum which brought together members of the Council of Deans (COD), Council of Teaching Hospitals (COTH), and Group on Faculty Practice (GFP). The emphasis will be on function and the formulation of useful guidelines for governance and management, rather than on organization structure models. A Leadership “self – assessment” will be created and distributed to assist AMC leadership clearly discuss leadership alignment issues..

28. Targeted R4R Thought Leadership There are a number of critical issue areas which are of particular importance to AMC leaders in managing the R4R agenda: • The impact of Exchanges on market structure and the implications for AMC’s; • The emergence of Medicaid as the largest insurer; • Medicare ACO regulations and pros and cons for AMC participation; • Medicare Value Based Purchasing; • The development of ACO’s and the impact on AMC’s • Tools required for Care Coordination and lessons learned • ..and many others

29. Possible Flaws Is the speed and impact of this current effort adequate to support the necessary rate of change? How do we positively affect the education of practicing physicians….where is their learning network? What are the levers that make people change?

30. Haven’t we been here before?

31. What makes people change? Crisis Technological push Political Will Money ( more or less of it) Fear ( Regulations) Knowledge Shame Satisfaction

32. Leveraging Implementation Science A relatively new field of inquiry in the United States, implementation researchers study how best to ensure that evidence developed at one end of the research spectrum is taken up and consistently applied in practice at a scale that can improve patient and population health.  According to the AAMC’s Chief Science Officer, Ann Bonham, “Our nation’s medical schools and teaching hospitals have tremendous research expertise; now we must focus that talent like a laser beam on improving care for the patients we serve on our own campuses.

33. 3 Priorities Convening thought leaders to establish a national framework for using implementation science for quality and patient safety. Millie Solomon, EdD Senior Director Accessing readiness and capacity for implementation science and training across member institutions Implementing a hospitalist learning network for improving patient safety and quality. “Homerun Initiative” Using implementation science to develop an evidence base for improving patient safety and quality

34. What will the AAMC-Homerun Collaboration do? • Dissemination & Adoption to • Homerun Sites and Beyond • Via: • Technical Assistance • Shared Protocols & Pathways • Publications • Monthly Calls • Website Agreement on Outcomes Benchmarking Agreed upon series of studies in diverse environments New Knowledge of What Works Where Peer-to-Peer Exchange via Annual Meetings & Monthly Calls Improvements: quality of care, health outcomes, costs With Training Opportunities across All Phases & All Sites

35. Evolution and Role of CME? Payment reforms may link financial incentives to more outcomes focused CME. Outcomes focused CME should be a platform for maintenance-of-certification. It is essential to find ways to connect physician CME learning to everyday clinical duties. If physicians view CME as a financial and personal investment, the role of CME will change dramatically.

36. The Challenges • You cannot change your destination overnight, but you can change your direction overnight” • Jim Rohn • It is not necessary to change.  Survival is not mandatory. • W. Edwards Deming

37. Questions ? We love great ideas!