The Development of a Rural ACO Model: The Taos Experience

1. The Development of a Rural ACO Model: The Taos Experience

2. Taos, NM Jemery Kaufman, MD Internist, Taos Medical Group Erin Doherty, MD Internist/Hospitalist Holy Cross Hospital Michael Kaufman, MD Internist, Taos Medical Group No Disclosures

3. The Background • Taos County: • Population 30,000 • ¼ Medicaid • ¼ Medicare • ¼ Comercial • ¼ Uninsured

4. The Background • PHO with long standing vision for integrated healthcare system • Some systems in place: • Innovative integrated programs designed to serve ambulatory and home bound patients in place • Several practices now using same EMR interfaced with hospital

5. Why Change • Vision to provide integrated care constrained • Private practices struggling with Medicare cuts, recruitment • Hospital scheduled for funding cuts at every level • Pt's and businesses unable to afford insurance

6. Catalyst: High Value Healthcare • Affordable care act • Patient Centered Medical home and Accountable care organization models • Approached by outside organizations • AAAH, HTI, private payors

7. Catalyst: High Value Healthcare Best clinical outcome+high pt satisfaction/low cost

8. Catalyst: High Value Healthcare • “Current payment systems have driven primary care into decline and stifled reform. Primary care is central to managing costs and delivering quality, but has become fiscally and politically impotent, dissatisfying to all and unattractive to new physicians.”

9. Grand Junction Catylist: High Value Healthcare • Many existing models • Caremore Common Denominator Intergration

10. Catalyst: High Value Healtcare Cost curve

11. Catalyst-High Value Healthcare • Opportunity seen • Get out from under strict fee for service payment scheme to more directly address key patient needs/innovate • Patient centered • Draw emphasis back to primary care • Furthered vision for integration • Get paid for something only we can generate, high value care • Get off sinking ship

13. Current and Future Issues • Objectives: • Review Cost Approaches • Organizational Structures • Data Issues-what’s relevant? • Rural Issues

14. Initial Steps • Approach • High capital outlay/rapid community wide transformation Vs • Low capital outlay/incremental implementation

15. Recent Literature Iglehart JK. Assessing an ACO prototype — Medicare’s Physician Group Practice demonstration. N Engl J Med 2011;364:198-200 • All 10 groups met 29/32 quality goals • 6/10 demonstrated cost savings by year three…. • No return on investment!

16. Recent Information CMS/Don Berwick: March 31,2011 • Start up organizations • Bonus if goals achieved in first 2 years • No penalty if not achieved • Larger organizations • Bear some of the financial risk in exchange for modestly higher bonuses if they succeed.

17. Road Ahead- Data • Know thyself • Patient/resident specific demographics & health status • Standardized risk assessment of each pt • Heat map high cost/risk patients • per practice • per diagnosis • for hospital • for payors

18. Data • You have to know where you are starting from… …to know where you are going! • Extensive inpatient and outpatient cost analyses • Get an EMR with good data management…and manage your own data

19. Patient Care Programs=where money is saved • Chronic Care Disease Management Initiatives • Community-Wide Wellness initiatives • Palliative Care Integration • Patient centered model • Hospital Care Program • End of Life Care=Greatest Cost Savings Opportunity

20. How do we move forward? • Taos Care Plan Committee • Key physician leaders, primary care • Home Health • Hospital • Pharmacy • Current Disease Management Programs; CATCH

21. How do we move forward? • Separate legal entity • Determine corporate structure • Identify equity holders, interests • Identify directors • IT implementation and coordination plan • Plan for data reporting requirements

22. ACO Agreements • Underlying participant contracts • Physicians, hospital, ancillary services • Bonus Compensation Provisions • Metrics • Reporting • Performance measures/analysis • Calculation of Allocation

23. Legal Issues • Assess federal, state law compliance, certification issues • NM regulations relating to insurance • HIPPA/privacy concerns • Anti-trust issues • Fee negotiations, market allocation, exclusivity

24. Anti-trust Issues • FTC/DOJ position paper April, 2011 • No anticompetitive behavior • Market share < 30% • Exception for rural areas • May exceed 50% of market share

25. Paul Krugman, NYT 4/21/11 “How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.”

26. Conclusions • Determine community’s risk tolerance-both with investment in structure and agreements with payors • Determine appropriate structure, physician leadership • Beware anti-trust issues--the free market prevails!

28. Mountain Home Health Care • Who • What • Why • How

29. Who • Nine member board • Non-profit • Professional advisory committee • Serving Taos County ~32,000 people

30. Home health/hospice • Staff • 7 RNs • 1 MSW • 4 Physical Therapists • 2 CNAs • 6 administration • 499 patients

31. PCO C-Waiver Program/Chronic Disease Management • Staff • 1 RN • 1 Case manager • 122 homemakers

32. What How do we define home health? • Traditional • Future/new definition • Medical home • Virtual integrated community • Project ECHO • Accountable Care Organization

33. Why • It is what we do • Can we do it better? • Business decision • Present system is failing • Several hundred paying clients now • Several thousand paying clients future • If we can add value to the system

34. Why (cont’d) • Annals: Oct 2010 “Diabetes Control with Reciprocal Peer Support Versus Nurse Care Management” • Conclusion “Improved glycemic control and other key outcomes more than nurse care management alone”

35. Why (cont’d) Editorial: “Although many unanswered questions remain about payment, standards for training laypeople to help others manage disease, and the long-term outcomes of such programs, …evidence that we need to move outside our often-isolated medical practices and partner with the community to improve health outcomes of persons with poorly controlled chronic diseases.”

36. How • Collaboration with medical community • Identify resources • Project ECHO • Community college (UNM Taos) • Health extension agent • CATCH (same protocols) • HTI

37. How (cont’d) • Training of 120+ homemakers • (3 hour course – UNM Taos) • Chronic Disease Management (diabetes) • Diet • Exercise • Blood glucose interpretation • Physician comunication

38. How (cont’d) • Pilot project • 2 CHW’s • 10 Homemakers/patients • Outcomes • Communication/Literacy • BG Monitoring • Hypoglycemia • Nutrition • Activity • Self Management/Health Goals • HbA1C • What can we learn?

39. Challenges • Integration with rest of Health Care community • Information Technology • Other technology • Finances • Other chronic disease models

40. Home Health Care • Who • What • Why • How • Challenges

41. Thank You!