Why Nurse Practitioners Are More Relevant than Ever in the New World of ACOs. Richard A. Parker, MD

Transcription

1 Why Nurse Practitioners Are More Relevant than Ever in the New World of ACOs Richard A. Parker, MD 22nd Annual Northeast Regional Nurse Practitioner Conference May 6-8, 2015

2 DISCLOSURES There has been no commercial support or sponsorship for this program. The planners and presenters have declared that no conflicts of interest exist. The program co-sponsors do not endorse any products in conjunction with any educational activity.

3 ACCREDITATION Boston College Connell School of Nursing Continuing Education Program is accredited as a provider of continuing nursing education by the American Nurses Association Massachusetts, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation.

4 SESSION OBJECTIVES Describe the differences between the fee for service and global payment financial models. Explain what it takes to form and run a high functioning Accountable Care Organization. Summarize why Nurse Practitioners can play a critical role in fulfilling the needs of patients and practices in the new ACO world. 22nd Annual Northeast Regional Nurse Practitioner Conference May 6-8, 2015

5 Why Nurse Practitioners are More Relevant than Ever in the New World of ACOs Rich Parker, M.D. May 7, 2015 Newton Marriot, Mass

6 Goals for today s talk Understand cost/value problem in U.S. healthcare Understand how an Accountable Care Organization can improve care Understand the vital role Nurse Practitioners play in this changing landscape Feel better when you walk out of my talk!!

7 Added value of the nurse practitioner Skill with the taking of the history and performing the physical exam Recognition of the psychosocial needs of the patient Longitudinal care of the chronically ill Availability for urgent care needs Fill the growing need for primary care that cannot be handled by general internists and family practitioners Team players and team leaders

8 US Healthcare System US population 320 million Medicare 40 million elderly and 8 million disabled Medicaid 58 million Commercial Insurance +/- 200 million 32 million uninsured $9,000/person X 320 million = $2.9 TRILLION

9 100,000 Foot Level $2.9 Trillion dollars spent on healthcare in % of US GDP Median family income in Mass is $61,000 Family healthcare costs -- $24,000 Is something wrong??

10 Mass Healthcare Costs 2000 Medicaid/MassHealth 21% 2013 Increased to 39% of state budget 1.3 million out of 6.6 million residents on Medicaid/MassHealth Eligible if under 133% of Federal poverty level or $29K for family of four. Connector pays full or partial subsidy up to 300% of Federal poverty level.

11 Boston statistics and high deductible plans Spends $270 million on policing Spends $300 million on health care for its employees Next year anticipated rise in health care costs -- $20 million More residents enrolled in high deductible plans/$1000 pp Reduced use of preventive health services

12 $20 billion retiree health tab Boston Globe reports that the 50 largest cities and towns alone face a retiree health care bill of $20 billion over the next 30 years. Mass Taxpayers Foundation no municipality is putting aside nearly enough money. Would have to set aside an additional $1.5 billion per year to cover it. Lawrence FY10 single family tax bill -- $2,374. Increase by $6053 (255% increase) to cover obligations.

13 Asthma Hospital Admission Rates (age 15+, per 100,000 population) Canada 16 Germany 21 France 43 Britain 74 US 121 Source: Commonwealth Fund (wait times); Organization for Economic Cooperation and Development

14 Percent Who Wait Four Weeks or More to See a Specialist Germany 16% US 17% Britain 28% France 47% Canada 56% Source: Commonwealth Fund (wait times); Organization for Economic Cooperation and Development

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17 Charles Parker s sutures V=Q/C??? $118/Suture

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19 Unjustified Price Disparity 15

20 Average Costs Across Public and Private Sectors (in dollars) Britain Canada France Germany USA MRI Scan $187 $304 $398 $632 $1,009 Normal Childbirth $2,792 $2,667 $3,768 2,147 $8,435 Appendectomy $3,456 $3,810 $2,795 $3,285 $13,123 Average Hospital Stay Cataract Surgery Hip Replacement Not Available $7,707 $4,715 $4,718 $14,427 $1,299 $927 $3,352 Not Available $14,764 $9,637 $10,753 $12,629 $15,329 $34,454 Bypass Surgery $13,998 $22,212 $16,325 $27,237 $59,770 Source: International Federation of Health Plans

21 Medicare ACO Utilization Utilization per 1,000 assigned enrollees Minimum Median Maximum Hospitalizations ER department visits ,448 ER visits with hospitalization CT events ,044 MRI events Ambulance events ,851 Source: CMS Fast Facts, March 2013 (220 ACOs serving 3.2 million Medicare enrollees)

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23 Continuum of care Improve access Improve quality EMR PCP Office Specialist Cellulitis, CHF, asthma, DVT-home Social Workers Home Infusion ER Home Hospitals RN NP VNA Care management Community services Hospice and palliative care SNF LTC Post-acute care Discharge planning Decrease utilization lab, radiology, procedures

24 About BIDCO BIDCO is an independent physician and hospital network and an Accountable Care Organization (ACO) Located in Westwood, Massachusetts Employs more than 80 staff members Contracts with 2,200 physicians, including 550 primary care physicians (PCPs) and 1,800 specialists Number of NPs is uncertain Certified by Centers for Medicare and Medicaid Services (CMS) as Pioneer ACO 20

25 Why become a Pioneer ACO? Opportunity to improve care and financial performance Timing is everything take it or lose it opportunity 1 of 5 Pioneer ACOs in Massachusetts 21

26 What it takes to be a Pioneer ACO Coordinating care across care settings Managing at-risk patient populations Providing the right level of care at the right time; avoiding over-treating and under-treating Responsibility for the entire budget 22

27 Care and population management 23

28 Implementing Care Management Services Risk Level Where Provided By Whom Highest In home NPs Medium Telephonic/In home ACO RNs and Clinical Pharmacists Lowest Telephonic/Mail/PCP offices Quality Improvement Coordinators, RNs and practice staff

29 Clinical management programs for high-risk patients NP Housecalls program Nurse care managers Referral to community home care services Disease management programs Clinical pharmacists 25

30 ACO patient risk stratification Dr. Seuss' ACO patients HIC Patient name Gender DOB % Likelihood of admit in next 12 months Address City State Zip xxxxxxxxx Mickey Mouse M 11/10/ Walt Disney Blvd Orlando FLA xxxxxxxxx Daisy Duck F 2/6/ Walt Disney Blvd Orlando FLA xxxxxxxxx Donald Duck M 4/15/ Walt Disney Blvd Orlando FLA xxxxxxxxx Kermit the Frog M 8/4/ Walt Disney Blvd Orlando FLA xxxxxxxxx Minnie Mouse F 4/22/ Walt Disney Blvd Orlando FLA xxxxxxxxx Snow White F 8/23/ Walt Disney Blvd Orlando FLA xxxxxxxxx Sleepy M 9/27/ Walt Disney Blvd Orlando FLA xxxxxxxxx Grumpy M 9/29/ Walt Disney Blvd Orlando FLA xxxxxxxxx Pluto M 7/18/ Walt Disney Blvd Orlando FLA xxxxxxxxx Tinker Bell F 9/28/ Walt Disney Blvd Orlando FLA xxxxxxxxx Peter Pan M 2/29/ Walt Disney Blvd Orlando FLA xxxxxxxxx Buzz Light Year M 7/11/ Walt Disney Blvd Orlando FLA xxxxxxxxx Cinderella F 2/17/ Walt Disney Blvd Orlando FLA xxxxxxxxx Pinocchio M 12/17/ Walt Disney Blvd Orlando FLA xxxxxxxxx Sleeping Beauty F 9/5/ Walt Disney Blvd Orlando FLA xxxxxxxxx Ariel F 8/22/ Walt Disney Blvd Orlando FLA 26

31 Highlighted Top 9% of Patients on a Patient Panel List Member_ ID MemberName DOB IP_Stay_ Probability Street_Address City_State PCP Pod Do you agree that your patient is high risk? Yes or No Jean 90 Anywhere, MA Dr X William 86.3 Anywhere, MA Dr X Barbara 77.1 Anywhere, MA Dr X Lenore 70.8 Anywhere, MA Dr X Reese 43.5 Anywhere, MA Dr X Angela 39.1 Anywhere, MA Dr X Dolores 30.1 Anywhere, MA Dr X Liam 29.9 Anywhere, MA Dr X Would pt benefit from house calls/np /collaborating provider?

32 PCPs and NPs Indicate Preferred Patients to Follow Member_ ID MemberName DOB IP_Stay_ Probability Street_Address City_State PCP Pod Do you agree that your patient is high risk? Yes or No Would pt benefit from house calls/np /collaborating provider? Jean 90 Anywhere, MA Dr X Yes Yes William 86.3 Anywhere, MA Dr X Yes Yes Barbara 77.1 Anywhere, MA Dr X Yes Yes Lenore 70.8 Anywhere, MA Dr X Yes Yes Reese 43.5 Anywhere, MA Dr X Yes No-home health Angela 39.1 Anywhere, MA Dr X Dolores 30.1 Anywhere, MA Dr X Yes Yes Liam 29.9 Anywhere, MA Dr X Yes Work with cardiologist

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34 Patient Identification Exclusion Criteria Practice A Practice B Practice C Practice D Practice E Practice F Practice G

35 (Model 2) Advanced Illness/Palliative Care Levine Prognostication Tool Patients with total score >=4 have 46% chance of death over next 12 months. Levine SK, Sachs GA, Jin L, et al: A prognostic model for 1-year mortality in older adults after hospital discharge. Am J Med 2007, 120:

36 Population management infrastructure Data and analytics to measure and monitor quality and utilization Care coordination among specialists, providers, hospitals Predictive modeling to identify and target high-risk patients Registry to plan and track care, ensure follow up Resources to support patient education and selfmanagement 32

37 Approved SNF Waiver Program Opportunity to directly admit ACO patients to skilled level of care avoiding three-day hospital stay Strict program oversight required by CMS Dedicated RN Care Manager oversees program Goal of 40 patients per month 33

38 Tracking Results How Do We Measure Success? Three sets of patients Identified as high risk, seen by nurse practitioner Not identified as high risk, selected by PCP, seen by nurse practitioner Patients with similar co-morbidities, identified as high risk, patient declined participation in the program Measure before and after program start date Costs pmpm Admits per year Hospice use

39 Other Areas Chief Medical Officer identified 6 areas for disease management Palliative care/end of life care CHF Chronic kidney disease Emphysema Diabetes Behavioral health Overlap of patients across programs

40 What it takes to get the job done Information technology Clinical infrastructure Culture and leadership Physician, nurse practitioner, RN and hospital collaboration 36

41 How BIDCO works with physicians and NPs Pod performance feedback Quality results Utilization data Financial performance Care management programs Monthly PCP Advisory Meeting for Pod Leaders Webinars, training sessions, and online resources Annual physician education conference 37

42 Information technology Management of Quality measures Interoperability for EMRs and data center Risk stratification Efficiency and utilization reporting 38

43 Clinical infrastructure PCPs and NPs serve as the backbone Pod structure based on shared culture and geography Pod Leader training Specialists engagement 39

44 Culture and leadership Leadership buy-in is essential Everyone plays a role; cost-effective care is a shared goal Constant reinforcement of message 40

45 Physician and hospital collaboration Emergency department (ED) engagement Inpatient case management Skilled Nursing Facility (SNF) strategy Post-acute care 41

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53 Treat the patient, not the test!! NPs and MDs feel pressured for time and may order a test rather than do the thorough H&P. Patients (and some providers) have a mythical belief in the power of technology to diagnose illnesses. Tests cause complications and more tests!

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55 Nurse practitioner and RN care management Ongoing counseling and education on self-care, symptom recognition Care coordination with physicians, external facilities, community services, and family Referrals to other services (e.g., social work, pharmacy, disease management) Care transitions hospital to home or SNF or LTC 51

56 Some of the worst experiences in my life never even actually happened! Mark Twain

57 Stoics It is not circumstances that define us; It is our response to circumstances.

58 Managers do things right, Leaders do the right thing.

59 Future trends and challenges Moving more care into patients homes and other non-acute settings Increased patient care self management Ongoing initiatives to reduce excess utilization Constant emphasis on improving quality, and patients and families experience of care Finding innovative ways to increase specialist engagement 55

60 Saving a Life!

61 Added value of the nurse practitioner Skill with the taking of the history and performing the physical exam Recognition of the psychosocial needs of the patient Longitudinal care of the chronically ill Availability for urgent care needs Fill the growing need for primary care that cannot be handled by general internists and family practitioners Team players and team leaders

62 Anything can be accomplished if you don t care who gets the credit! Harry Truman

63 YOUR FUTURE IS BRIGHT!!!!!