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Managing the Transition to Accountable Models of Care

Managing the Transition to Accountable Models of Care. Mark Crockett, MD FACEP. Agenda. Accountable trends in healthcare Resource and employment needs in the new model HIT Analytics Staffing Future landscape. It’s hard to argue the case against payment reform.

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Managing the Transition to Accountable Models of Care

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  1. Managing the Transition to AccountableModels of Care Mark Crockett, MD FACEP

  2. Agenda • Accountable trends in healthcare • Resource and employment needs in the new model • HIT • Analytics • Staffing • Future landscape

  3. It’s hard to argue the case against payment reform • Rank of US healthcare amongst “industrial” nations - #7 (of 7) • Rank of US healthcare amongst “developed nations” #26 (of 27) • Spend per capita 2007 $7,290 • Spend per capita of #1 ranked country 2007 $3,387 (46%) Source: WSJ

  4. Where do we spend the money?

  5. Effect of Healthcare Reform and Aging Population Source: Plunkett Research, Ltd.TM

  6. Various estimations of cost growth

  7. Enter the “ACO” • Made “legal” under the healthcare reform act • Final rules expected by the end of the year • January 1 mandate for CMS to have the structure in place • Represents a bundled payment and cost savings model for healthcare

  8. How is an ACO reimbursed? Projected Spending Target Spending Shared Savings Actual Spending Source: Brookings

  9. The next few years will be interesting! Pay for Performance/Accountable Care Fee for Service

  10. ACOs

  11. Medicare’s Idea of an Accountable Care Organization* • Provider led organization • ACO is responsible for: • Improved clinical outcomes • Reduced cost growth • For a defined population of people • Organizations that may be treated as an ACO include • Group practices • Networks of individual practices • Partnerships or Joint Ventures • Hospitals employing physicians • Other groups as determined by the Secretary of HHS * Source: The Camden Group

  12. How does that currently work? • ACO reports quality metrics on particular patients/situations • Quality of care must remain high • Metrics negotiated in advance • Patient population affected negotiated in advance • ACO is privy to cost information from payors • ACO receives and distributes incentive payments based on cost containment and “shared savings” • Private and now Medicare patients both affected in certain markets

  13. ACO rules under Medicare • A 2-year participation contract • A formal legal structure • Inclusion of primary carephysicians with at least 5,000 patients • A list of primarycare physicians and subspecialty physicianswho are involvedprovided to the Centers for Medicare &Medicaid Services(CMS) • Contracts with care groups of specialty physiciansoutsidethe ACO • Management and leadership structure forjoint decision making • Defined processes for promotingevidence-based medicine andreporting on quality, cost reductionmeasures, and coordinatedcare.

  14. “The Unicorn”

  15. “The Unicorn” • United Healthcare will have 2 billion in providers in an “ACO” model by 2012 in 8 markets • Current projects • Scottsdale health • AppleCare /Daughter’s of Charity • Southwest Medical Associates (SMA) • Optum Health • Network contracting based on accountable models • Other organizations: Stanford, Advocate, Partners, etc…

  16. “West Side Story” • 2001: Advocate healthcare physician challenge • 2002: Advocate invests in primary care physicians • 2003: Cost savings model war • 2005: New model based on Generic drug benefits • 2007: Model expanded to 3 insurers, 4 metrics • 2011: 16 metrics, 5 insurers

  17. West Side Story – The Financials • 68M dollars to advocate physicians distribution • 2000 physicians eligible = 34,000 per physician • 4 metrics, then 10, now 24 • 100% CPOE • Client satisfaction, etc • Net Effect on Patient Care? • Sicker ED patients • 1.5 patients per hour • Care management focus

  18. Services: What has value under new models? Fee for Service Capitated Models Preventative care Disease surveillance Team care (30M new patients coming in) Chronic disease management Outcomes surveillance • Expensive Procedures • Preferably outpatient • Outpatient “urgent” care • Scans of all types • MRI, CT, Nuc Med • Billable infusions • Surgical admissions • Level 4,5, critical care ED visits

  19. Providers: What has value under new models? Fee for Service Capitated Models Primary Care Internal Medicine Care Team Management Physician extenders Care Management Pediatrics/Cancer??? Physicians with good outcomes • Surgical Subspecialists • Interventional Cardiologists • Trauma care • High referral physicians with sick patients

  20. Patients: What has value under new models? Fee for Service Capitated Models Well patients Patients that take their medicine Patients that follow instructions Patients that have chronic diseases that are manageable • Sick patients • Patients needing high value procedures • Clumsy patents • Patients who don’t follow instructions

  21. Key aspects of the new models • Capitated payments will increase as a portion of total • Hospitals taking population risk • Chronic disease management becomes a large focus • Admissions are the next to worst thing possible. • What’s the worst thing possible?

  22. S.C.R.E.W.E.D (f) • Someone • Capturing • Revenue (our) • Elsewhere • When • Emergency • Department • Is full…. • Net bills from other systems are anathema. (change in rule?)

  23. Employment opportunities in the new models • IT: Current systems woefully inadequate to manage outcomes • Analytics with old systems • Implementation of new systems. • Integration strategy • Healthcare information exchange is no longer nice to have • Coordination of Clinical Care • Care Teams • New staffing models • “Clinical Operations • CMIO, (CNIO?) and staff

  24. Why Exchange Care Information? Source S.E.C.

  25. Market Shift Underway - Meaningful Use to Accountable Care Vision The market is evolving from a fragmented ecosystem focused on fee-for-service reimbursement models to a collaborative network aligned on outcomes based reimbursement with shared risk management as a principle Required Competencies Accountable Care Management Service Progression • Deep clinical expertise & solution set in addition to revenue cycle leadership • Clinical informatics and applied business intelligence • Distributed and networked technology architecture and applications • Real time interactive point of care applications with integrated workflow • World class ability to manage risk; ability to go “at risk” to deliver outcomes • Industry leading customer base and distribution models in both clinical/revenue cycle sets and ambulatory/acute settings Integrated care/cost management • Population management • Chronic disease management • Distributed disease management • Risk management Outcomes Management Focus • Health risk assessment • Acuity classification • Predictive modeling • Outcomes Management (P4P) • Patient education and compliance programs • Care coordination and referral management Care Coordination Advanced Health Management Basic Service Delivery model sophistication

  26. Actuarial & Reinsurance Management High risk identificationand stratification Medical Policies & Procedures Medical Home &Coordinated Care Baseline Performance Measurement Physician Strategy, Alignment, Governance Physician Practice Profiling/EBM Payment Models (Bundled, P4P, Gainshare, Value) Provider Contracting, Alignment Health Information Technology Performance Tracking / Benchmarking Business Intelligence / Reporting Clinical Performance Analytics Revenue CycleManagement Payment ModelManagement Health Information Exchange Facility Operations Health Management Electronic Health Records Clinical Integration Medical Cost Management RCM / Financial Services Technology Outsourcing Capabilities To Enable ACO Development Consulting Services Technology Solutions Ability to Manage Risk Leverage of Technology Alignment of Clinical and Business Environments Integration of Clinical and Financial Systems/Data

  27. Who Benefits • Companies that provide an integrated inpatient/outpatient EMR (or have a good story) • Epic • Cerner • Companies that provide the infrastructure for same • Medicity • Axololtl • Companies with patient continuity data sets • Surescripts • Ingenix

  28. Back to The Future • “New” capitated models of care are inevitable • Infrastructure under “meaningful use” is better than it was, but still inadequate • “Clinical Operations” is getting better care done at less cost • Integrated care can be done a number of ways, but Analytics and Exchange are essential • Seeing more patients with fewer resources means more teams, more coordination • Expensive inpatient care is less preferable, and new models will reward outpatient management

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