Co-management (Service Line Agreement 2007)

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4 Co-management (Service Line Agreement 2007)

5 Orthopedics Neuroscience Cardiology Cardiovascular Surgery Collaboration on a different level Tactical method of increasing alignment and collaboration Agreement on Standardized quality and performance metrics Fundamentally begins with the assumption that a dollar invested has a positive return

6 Primary Care Discussions United Health Care Western Region Patient Centered Medical Home Pilots Brookings/Dartmouth Collaborative TMC Board Approval Health Information Exchange

7 ACO

8 An ACO is an affiliated group of healthcare providers that assumes the responsibility for increasing quality outcomes for a population within an efficient cost structure. This is now reflected in the CMS Triple Aim developed by CMS Director Donald M. Berwick, MD while at the Institute for Health Improvement: Improve the health of the population; Enhance the patient experience of care (including quality, access, and reliability); and Reduce, or at least control, the per capita cost of care. If successful, the ACO should attain revenue for quality and efficiency results that might not otherwise be available.

9 Successful launch of Service Line Agreements (SLAs) with physicians (Ortho/Neuro, Cardiac); we proved the value of collaboration Successful partnership of Patient Center Medical Home (PCMH) between United healthcare and three aligned NCQA certified practices. The ACO aligned with Tucson Medical Center is the network model ACO pilot chosen by Brookings/Dartmouth among its first three pilot sites.

10 Brookings-Dartmouth and most/all emerging ACO Models are Medicare and Commercial Combined Initiatives Local Accountability Recognize natural local networks and encourage responsibility for population health care costs Standardized Performance Measurement Develop standardized quality, efficiency and communications standards Payment Reform Incent provider collaboration and provide incentives to achieve quality and efficiency outcomes

11 Physician Steering Committee MSO Network Metrics Distributive Model United Health Group Eller College of Management (University of Arizona)

12 [T]he Medicare fund that pays hospital bills for older Americansis expected to run out of money in 2017, two years sooner than projected last year. The Social Security trust fund will be exhausted in 2037, four years earlier than predicted NY Times May 12, 2009

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14 Factors Average life span (post 65) 4 years 20 years Ratio of Taxpayers per Beneficiary 10:1 3:1 Medicare Beneficiaries <10 M 44M Threat of insolvency will force change (Medicare projected to be insolvent by 2017) Provider reform/value Based Purchasing Accountable Care Organization (Provider System reform) Patient Centered Medical Home (Provider Class reform) There will be winners and losers Information technology (IT) adoption

15 On Jan. 1, 2011, Kathy Casey-Kirschling, the first of 78 million baby boomers, turns 65. She will be followed by another boomer every eight seconds, more than 10,000 a day, for the next 18 years. By the time the last boomer turns 65 on Dec. 31, 2029, the size of the 65-plus population will be nearly double what it is today. And by 2050, one person in five will be 65 or older. [AARP]

16 Hospital Names HCI Index Total Medicare spending Inpatient site of care Outpatient site of care Skilled nursing / Long-term care Home health care Cedars Medical Center (Miami, FL) 98.1 $95,901 $55,284 $10,510 $12,814 $5,608 Lake Forest Hospital (Lake Forest, IL) 76.0 $59,212 $30,622 $13,228 $6,234 $3,276 Bayhealth Medical Center (Dover, DE) 75.2 $49,259 $30,012 $7,758 $5,936 $1,779 Decatur Memorial Hospital (Decatur, IL) 46.7 $40,812 $20,726 $9,620 $5,764 $1,100 Rose Medical Center (Denver, CO) 38.1 $55,364 $27,231 $8,462 $10,297 $3,217 Meriter Hospital (Madison, WI) 18.2 $44,455 $24,612 $6,997 $6,848 $1,687 Putnam County Hospital (Greencastle, IN) 13.2 $40,206 $18,876 $5,927 $9,074 $1,066 This data uses Dartmouth s hospital care intensity index, or HCI. The HCI is based on twovariables: the number of days patients spent in the hospital and the number of physician encounters (visits) they experienced as inpatients. It is computed as the age-sex-race-illness standardized ratio of patient days and visits. For each variable, the ratio of a given hospital s utilization rate to the national average was calculated, and these two ratios were averaged to create the index. Definition and Sample report created from : Dartmouth Atlas of Health Care

17 Title III, Subtitle A Transforming the Health Care Delivery System Part III Sec Medicare and Medicaid Innovations Center is established to develop test and expand innovative payment and delivery arrangements to improve quality and reduce cost. Sec National bundled payment pilot, commencing 1/1/2013 a voluntary pilot to encourage physician, hospital and post-acute providers to improve patient care through bundled payment models. Sec Hospital readmission reduction program, Beginning 2012will adjust hospital IPPS payments based on readmission measures of potentially avoidable conditions. Sec Medicare shared savings program, no later than 1/1/2012, organizations qualifying as Accountable Care Organizations become eligible for shared savings bonuses for FFS Medicare.

18 ACO Launched Projected Spending (4.5% inflation) Target Spending (CMS) Shared Savings Expending Actual Spending Year Note: Target Spending is below the projection to avoid random variation

19 Large enough to assume risk of variations in populations (with risk management tools) Sufficient integration to manage care through transitions and across the continuum of care Capable of receiving and internally distributing shared savings with prospective financial planning to sustain accountability

20 Systematic efforts to improve quality and reduce costs across the organization: Using appropriate workforce (increased use of NPs, PAs, NCMs, etc. Improved care coordination Internal process improvement Aligned provider incentives Informed patient choice; health risk assessments Evidence based medicine Point of care reminders and provider-based best-practices Chronic disease management Use data and collaboration to identify and reduce waste (i.e. duplicate testing) Accountability Use systems to produce actionable, timely, objective data to identify high and low performers with ramifications

21 New systems New methods Self assessment Metrics Quality Efficiency Systemness

22 NCQA is a good source of information on metrics embraced by several organizations: Dartmouth CMS HEDIS NQF Cal/IHA: Pay for performance program measures Source = NCQA.org/tabid/1266/default.aspx

23 Quality Percent of diabetic patients who have had a HbA1c in the last 6 months Efficiency Rate of use of advanced imaging studies for low back pain Patient Satisfaction PCP office staff rating: Likhert scale (1-10). % of patients who ranked the physician office staff an 8 or above

24 [Discussion of regulation expected before presentation date]

25 Within Guiding Principles, Health Care Reform will Require Commitment, Investment and Risk. Legislative and/or Administrative Recognition may Bring Legal and Regulatory Relief to Ease the Transformation. Detailed Financial Analysis to Validate the Value of a New Accountable System of Care. An Honest Assessment of the Necessary Investments. New Technologies will make Information and Data available, but New Methods to Analyze, Combine and Use this Information are Critical. In the End, Improving Collaboration, Quality, Efficiency and Patient Informed Choice are Simply the Right Things to Do.

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27 Board Acceptance Address Finance Department Concerns Funding Changing Culture Regulatory Issues Distributive Model

28 CMS HIE Implementation Beneficiary Notification Agreed Upon Quality Metrics Transparency