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Centers of Excellence

Centers of Excellence. The Way Health Care Gets Better™. Portrait of a Dysfunctional Market. Health Care Market Place Government pays for over 40% of the care delivered in the United States

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Centers of Excellence

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  1. Centers of Excellence The Way Health Care Gets Better™

  2. Portrait of a Dysfunctional Market • Health Care Market Place • Government pays for over 40% of the care delivered in the United States • The Federal Government dictates what fees will be paid to providers for Medicaid and Medicare recipients • Economic principal of supply and demand to determine price is ignored (increased volume for lower price) • No incentives to use efficient, quality providers • Results in a cost shift to the private sector • Cost and quality information not available to consume to foster a competitive marketplace • Over Utilization • Financial incentives encourage more services

  3. 2.93% of the members used 50.7% of the claims dollars 12.63% of the members used 79.3% of the claims dollars Why Centers of Excellence?

  4. Federal HHS “Four Cornerstones” • Connecting the System Standards and support for e-health. • Measure & Publish Quality Partner with providers to get measures that work. • Measure & Publish Price “Episodes of Care” model. • Create Positive Incentives Reward those who offer, provider and choose value (Quality/Price). “Every American should have access to a full range of information about the quality and cost of their health care options” - HHS Secretary, Michael O. Leavitt

  5. Some Enterprises Found Centers of ExcellenceCut Costs by 25-40% Procedure: Several Procedure: Cardiac, Spine, Orthopedic & Transplant Procedure: Cardiac & Orthopedic Procedure: Orthopedic Procedure: Cardiac & Orthopedic

  6. Creation of Centers of Excellence for episode of care payment • Global Fees for Episodes of Care • Includes all services to complete episode • Episodes with Complications • Complicated cases revert to fee for service • Payment Systems • Global fee paid to facility for disbursement • Global fee based on episode benchmark • 20% Physician withhold • Complete Episode • Physician receives withhold plus 50% of savings if total costs are below benchmark

  7. To enable the creation of Centers of Excellence a robust Data Base is required • Cost Effective Quality Providers Selected from Database • Health Insurers Data Base • All Payer Data Base • Utah Health Information Network • Designated Centers of Excellence • Chronic conditions • Outpatient surgery • Inpatient surgery • Centers of Excellence Increases Volume to Designated Providers • Increased volume used to negotiate global fees

  8. Maternity Selection For Center of Excellence

  9. Physician Review Specialty Episode Case-Mix Summary Top ETGs, by Total Costs (Complete Episodes of Care) Episodes

  10. Example: Fee-for-service Prostate Procedure

  11. Results: Centers of Excellence for Prostate • Total cost non-Center of Excellence: $38,533 (Patient paid $14,263) • Total cost Center of Excellence: $14,451 (Patient paid $1,298)

  12. Center of Excellence Member Engagement Online Consumer Guide • Procedure Education • List of DSP (Designated Service Plan) Providers • Favorable Co-Payments for DSP Providers • High, low and average cost for procedures

  13. Consumer Guide

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