Cutting the Fat from Your Health Care Bill

1. Cutting the Fat from Your Health Care Bill ACHSA Conference - November 4, 2011 Utilization Management Ricki Barnett, MD

2. Goal-Accessible, quality health care that is cost effective.

3. Status in 2008 vs. 2011 • Health Care outcomes • Costs Increasing Access Challenges

4. More Bad News Transportation, guarding costs rising Hospitals full (bed days, ADC) High contract rates Slow payments Begging for specialist, hospital access No quality oversight

5. Defensive medical practices Burdensome peer review Multiple external pressures What is constitutional care?

6. Where did we start? Educate leadership Agree there is a problem Get permission to collect data and information Make it easy to do the right thing

7. Health Care Systems – The Ideal • Electronic claims payment systems • Encounter data capture to assess patient medical acuity • EMR • Electronic scheduling system • Daily census information for all hospitals and institutional beds Electronic authorization systems

8. The Minimum • Retrospective claims based reports • Laboratory results • Pharmacy results • Electronic daily hospital and institutional census • A scheduling system InterQual based volume reports

9. Is there any fat to trim, without affecting quality? TRIM THE FAT!

10. Medical Necessity Definition ‘Medically Necessary’ means health care services that are determined by the attending physician to be reasonable and necessary to protect life, prevent significant illness or disability, or alleviate severe pain, and are supported by health outcome data as being effective medical care. - Title 15 –Article 8 –Section 3350 (b)(1)

11. Archives of Internal Medicine / Mt. Sinai School of Medicine “Based upon research published in the May 2011 Archives of Internal Medicine, researchers at Mt. Sinai Medical School have identified at least $6.7 billion yearly wasted medical expenditures.”

12. The High Cost of Statins & Other Drugs “The October 1, 2011 issue of American Family Physician includes a Cochrane Review that fails to find any benefit from the use of statins in patients with no history of cardiac disease. No reduction of mortality or morbidity could be shown in the use of statins for patients with normal risk factors for heart disease and borderline cholesterol elevations.”

13. Identify cost drivers, manage them.

14. Top Volume/Cost Specialty Services Radiology Orthopedic Surgery General Surgery Hematology / Oncology Cardiology Ophthalmology Urology Trauma Hospital Based Physicians/Attending Staff

15. How many referrals are necessary?

16. Medically Unnecessary Categories Orthopedics Podiatry Oncology Neurology Neurosurgery Dermatology Imaging Cardiology

17. Specialty Referral Management • Mandatory review of outcomes • Aggressive goals • Accountability and responsibility stays local • Encourage institutions to know their specialists and talk to them Mandatory InterQual use

18. Managing Specialty Referrals with the Primary Care Team • Compare Outcomes • Meet • Feedback • Track Results Educate

19. Managing Specialists Services with Network Specialists • Communicate Expectations • Feedback Regarding Access, Availability, Outcomes, Treatment Philosophy Compare Outcomes

20. Top “Diagnoses”- ER Visits Chest Pain Trauma- minor, major Epilepsy Abdominal Pain Headache

21. How to Manage Emergency Cost s Morning huddles Primary care model and moving from “line based systems” to anticipatory primary care model Review of all outliers Training of all staff and outside resources

22. Top Reasons for Hospital Admissions Cellulitis Chest pain G.I. Conditions Hepatic Disorders Seizures, ALOC Cancer Orthopedics Trauma

23. Managing Hospital Services Monitor Daily Discharge Planning Begins on Admission Mandatory Concurrent Rounds Compare Outcomes Involve Hospitalists and Institution MDs Be ready to leave

25. Does Telemedicine Reduce Cost? Improves access Decreases transportation and custody costs Improves public safety Cost neutral on clinical costs Best for medical “evaluation and management “services, some surgical screening and services

29. What Costs Us the Most? Hospital Pharmacy Unsuccessful discharge planning Not enough institutional beds Aging population, end of life approaches Lack of anticipatory case management Primary care model not yet mature

30. Statewide Specialty Referral Costs

31. Statewide Emergency Room Costs

32. Statewide Hospital Costs FY 2010-2011

34. Current Challenges Costs of new technology and drugs Escalating expectations on all sides Developing the primary care model IT systems Realignment Aging population

35. Valuable Lessons • Leadership Buy-in • Health Care Team Buy-in • Contract Management • Claims management • Craft Legislation That Helps • An excellent UM team is MANDATORY! Align Objectives Throughout Health Care Continuum- institution, hospital, specialist