Development of a Rural ACO Model: The Taos Experience

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Barrie Cunningham
8 years ago
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1 Development of a Rural ACO Model: The Taos Experience What Who Why Where How Michael Kaufman, MD Jemery Kaufman, MD

2 Our Definition: ACO Care - Patient centered and specific Organized Innovative and Evidence based Across the community Accountable - Data driven and transparent The right patient getting the right care in the right place at the right time by the right clinician on time every time

driven and transparent The right patient getting the right care in

3 Overview: Taos Taos County 31,000 residents Only 19% of the employer market insures employees 50% of the market is divided between MCD and Uninsured 50-60% of billed charges for adult Primary Care is Medicare Healthcare spending estimated at $100MM annually Distribution: Commercial (9,991) Medicaid (6,792) Medicare (5,946) Uninsured (8,817) ~$100MM local healthcare market

Primary Care is Medicare Healthcare spending estimated at $100MM annually Distribution:

4 Overview: Taos PHO with long standing vision for integrated healthcare 50/50 split Neutral Some integrated systems in place CATCH: Diabetes/nutrition/pharmaceutical/patient assistance/smoking cessation/coumadin clinic First Steps

5 Why Change? The current system is broken and designed to produce low value care Pays to do things, not for outcomes There is a better option

6 Paradigm Shift High Value Health Care = Good Outcomes + Patient Satisfaction Low Cost

7 Paradigm Shift Healthcare begins in the patient's home Patient centered, patient specific and out of necessity, innovative and local Provided by an integrated team Organized across the community Physician led/primary care centric Evidence based Data, cost and outcome driven Funded through savings

integrated team Organized across the community Physician led/primary care

8 Bending the Curve

9 VA Study on Home Based Primary Care (HBPC) Costs of Chronic Disease: 68% of Medicare $ for 20% with 5+ chronic conditions 75% of health expenditures for chronic disease (CDC) In VA: 2% of Veterans account for 36% of the cost; Focus: 9% accounts for 52% of the cost. 50% accounts for 4% of the cost Pushing Boundaries with Home Based Primary Care Thomas Edes, MD, MS U.S. Department of Veterans Affairs January 2011

for 36% of the cost; Focus: 9% accounts for 52% of the cost.

10 Costs of Care Before vs During HBPC for 2002 (per patient per year) *includes HBPC cost Total Cost of VA Care Before HBPC During HBPC Change $38,168 $29,036* - 24% P < Hospital $18,868 $ % Nursing home $10,382 $ % Outpatient $6490 $ % All home care $2488 $13,588* + 460% 10

11 How We Got Started Chose to integrate Determined working together in best interest For patient/community/practitioner/hospital Invested Purchased same outpatient EHR Physician led, broad based/multidisciplinary Physician buy in Decision made to start small Well advised

Invested Purchased same outpatient EHR Physician led, broad

12 Where We Are Headed: You cannot manage what you cannot measure - Need patient level data - For complete picture, need data from multiple sources (Diagnosis+Utilization+Financials) Collaborative approach to data management Risk stratify High risk/high utilization: Individualized care plan Predictive modeling: Anticipate crisis Healthy population: Preventive care

Collaborative approach to data management Risk stratify High risk/high utilization:

13 Progress Last Year/Lessons Learned 1. Electronic health record 2. Home Health 3. Substance abuse/pharmaceutical care

14 Electronic Health Record Went live community wide November 2 nd A day that will live in infamy Lessons Practice now submitted for meaningful use Anticipate mining of data Better prepared for go-live 3 months before volumes recovered Interfaces expensive Pt's tolerant, inconvenience offset by perks

meaningful use Anticipate mining of data Better prepared for go-live 3

15 Home Health Non-profit home health agency Rethinking mission statement/business plan Working with Project Echo, UNM Taos and County Health Extension Agent Training and implementing Community Health Workers Lessons: Leverage resources Don't have to wait for investors/write grants, resources available now at multiple levels

Training and implementing Community Health Workers Lessons: Leverage resources

16 Progress/Lessons Learned: Addiction: Building local and state wide coalition Promote integration Leverage resources to broaden treatment options Pharmaceutical care: Proposal to establish clinical consensus on best practice medications Comparative effectiveness research

treatment options Pharmaceutical care: Proposal to establish

17 Payors Payors are interested in purchasing high value healthcare Contracted with two payors Collaborative data management Case management Share savings Are good at contracting...the old way Conversion from adversarial to collaborative relationship Lessons: Start small

management Share savings Are good at contracting.

18 Data Started with hospital No cost accounting system Initial data low quality / Concern over possible expense Restructured Now in early states of analysis Lessons: Meaningful data elusive Need to build capacity and infrastructure Leverage resources Start small

Now in early states of analysis Lessons: Meaningful data elusive

19 Summary Reclaim healthcare for our patients, communities and ourselves...accountable organized care is the future Integrate, collaborate and innovate Data, Data, Data: You cannot manage what you cannot measure Financially feasible High value health care puts the patient first

Impact of VA Home Based Primary Care: Access, Quality and Cost National Health Policy Forum

Impact of VA Home Based Primary Care: Access, Quality and Cost National Health Policy Forum Thomas Edes, MD, MS Director, Geriatrics and Extended Care Office of Clinical Operations U.S. Department of Veterans