Regional Networks for Time-Critical Diagnoses: Developing Turbo-Charged Accountable Care Organizations (Turbo-ACOs)

Transcription

1 Regional Networks for Time-Critical Diagnoses: Developing Turbo-Charged Accountable Care Organizations (Turbo-ACOs) Chair: Ivan Rokos MD (No relevant financial disclosures)

2 Wash DC Science & Health Policy Lectures on Time- Critical Diagnoses am STEMI Ivan Rokos MD Stroke Ralph Sacco MD Sudden Cardiac Arrest Benjamin Abella MD Discussion on Health Policy (Turbo-ACOs) 1130am -12pm Panelists Brendan Carr MD Jeptha Curtis MD Mr. Sean Cavanaugh

3 Hot topics in Health Policy

4 Medicare in the Spotlight Apr NEJM Times Square August, 1945 Baby 1946 Births 2011 Retirement Medicare population 2011 = 44 million million

5 Perspective High Altitude Fasten your seatbelts we may encounter unexpected turbulence in the Wash DC Jet Stream. The BIG federal deficit $14 Trillion+ Partisan Politics Election cycles Hungry 24-hour Media Complex American Psyche

6 Perspective Modest Altitude ACA Obama s Affordable Care Act Law March 23, 2010 ACO Accountable Care Organizations 2012 implementation Majestic summertime view

7 Four Key Articles NEJM Health Policy & Reform Section

8 NEJM Apr Accountable Care Organizations (ACO) Built on a strong foundation of primary care Group of providers held clinically and financially accountable for the full continuum of care for 5,000 Medicare beneficiaries Clinical Quality 32 process measures Prevention, vaccination, cancer screening, fall risk Chronic care DM, HTN, CAD, CHF, COPD

9 Oct Drs. Lee, Casalino, Fisher, and Wilensky Debated ACO implementation Organizational issues Legal issues Physician buy-in Patient acceptance Financial Incentives via Shared Savings Plan

10 NEJM Jan

11 Dr. Elliot Fisher 3 key ACO attributes Organized Care Performance Measurement Payment Reform ALL aligned to the greatest degree possible

12 NEJM Mar Accountable care is not a panacea but rather one of a number of complementary initiatives chartered by the ACA to help achieve the three-part goal of lower costs, improved care, and better health. The Center for Medicare and Medicaid Innovation is also now exploring ways to test alternative models of ACOs that differ from the models specified in the proposed rule.

13 Turbo-ACO Idea Time-Critical Diagnoses STEMI Stroke Sudden Cardiac Arrest (Trauma) Turbo Metaphor Power and speed of a standard engine

14 Complementary Portfolio of ACO models Standard ACOs Primary and Chronic Care focus VOLUME Huge volume of care at moderate speed Turbo-ACOs Time-Critical Diagnoses focus SPEED Modest volume of care at very high speed

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16 Optimizing Regional STEMI System Networks via Turbo-ACOs Ivan C. Rokos, MD, FACEP, FAHA, (FACC) Emergency Physician in Los Angeles, CA Asst. Clinical Professor, UCLA Staff Physician, Olive View-UCLA Staff Physician, Huntington Hospital Staff Physician, Arcadia Methodist Hospital (No relevant financial disclosures)

17 The STEMI heart attack Plaque Rupture Blockage

18 Ideal STEMI Treatment Synergistic effects Skilled Interventionalist and Cath Lab team Best devices Best drugs Fastest time

19 Time to Treatment in PCI Adjusted for pt s symptom delay & baseline risk (N=29,222 from NRMI registry) (Nallamothu 2007 NEJM 357:1631) Beyond a D2B 90 Minutes Every 15-minutes of Delay Mortality

20 National trend in median doorto-balloon time, Door-to-balloon time (minutes) min. Jan 99 Jul 00 Jan 02 Jul 03 Month McNamara et al., JACC, 2006

21 PPCI for STEMI heart attacks (Rokos et al, 2009 JaccIntv 2:339) Primary Percutaneous Coronary Intervention (PPCI) is the most complex, multi-disciplinary, and time-sensitive therapeutic intervention in the world of medicine. Our process is measured in Minutes Our outcomes are measured in terms of Mortality Teamwork and smooth Transitions are essential

22 Convergence of Solutions (2006 AHJ,152:661) American College of Cardiology (Nov-06) Intra-hospital focus American Heart Association (May-07) Inter- and Pre-hospital

23 STEMI Systems Applying 3 Core ACO Principles 1. Organized Care 2. Performance Measurement 3. Payment Reform

24 JACC CV Interventions, April 2009; 2:339-46

25 Map of 10 STEMI Networks (Rokos et al, 2009 JACC Intv., 2:339) PDF

26 Demographic Summary for 10-regions 20+ million citizens 5,000+ paramedics 166 hospitals Paramedic Receiving Centers 72 hospitals STEMI Receiving Centers D2B Data spans: Unique start date for each region End August 31, 2007 Includes ALL consecutive patients

27 D2B Pooled Analysis N = 2,053 for 10 SRC networks combined 86% rate of D2B 90 Minutes Inclusions: ALL consecutive PH-ECG (+) and PPCI (+) Exclusions: No self-transport patients No inter-hospital transfer patients

28 Secondary Endpoints: N=2,053 with D2B Time 50% rate of D2B 60 Minutes (N=1,031) 25% rate of D2B 45 Minutes (N=517) 8% rate of D2B 30 Minutes (N=155)

29 E2B EMS-to-Balloon time EMS = Emergency Medical Services Time Zero = Date and Time auto-stamped on first PH-ECG diagnostic of STEMI 68% rate of E2B 90 minutes

30 Key Point The integration of Pre-hospital ECGs with organized STEMI networks consistently provide very fast reperfusion

31 SPEED Deficiency Nationally, <30% rate of Transfer-D2B 90 minutes

32 The Vision Every US hospital can be a STEMI-hospital STEMI Receiving Center (SRC) with Cath Lab STEMI Referral Facility (SRF) without Cath Lab with rapid transfer protocol to SRC Direct Transfer PCI Pharmaco-Invasive strategy with fibrinolytics

33 45 STEMI Receiving Centers: Ventura, Los Angeles, & Orange Counties (California) 64 in So. Cal: 19 more SRCs San Diego, Riverside, San Bernadino Counties.

34 Geospatial Information System (GIS) Maps Coming soon via AHA Mission: Lifeline Nationally standardized regional GIS maps Demonstrate the STEMI system structure across regions, states, and the nation STEMI receiving centers STEMI referral facilities And also identify non-designated hospitals

35 STEMI Systems Applying 3 Core ACO Principles 1. Organized Care 2. Performance Measurement 3. Payment Reform

36 National QA/QI Registries (Started by ACC, now in collaboration with AHA) Voluntary Participation by US hospitals Cath-PCI >10 million patient records Primary focus Cath Lab interventions ACTION Registry-GWTG >250,000 submitted cases Primary focus The overall STEMI system

37 Existing National QA/QI Registries Process Measurements Door-to-ECG in the Emergency Dept. Door-to-balloon (D2B) Transfer-D2B EMS-to-Balloon (E2B) for patients

38 Mortality stratified by System Delay (Western Denmark, Terkelsen 2010 JAMA 304:763) N=6,209 >180min <60min

39 National QA/QI Registries (Cath-PCI & ACTION-GWTG) Outcome Measurements Risk-standardized mortality rates (RSMR) Extensively validated models Calculated from clinical data, not claims data Track other clinical events Recurrent MI, bleeding, shock, CHF, etc.

40 Swedish National STEMI Registry (Jernberg 2011 JAMA 305:1677) RIKS-HIA database All patient for 12 years National death registry Encourage regional systems of care All 72 hospitals Demonstrates strong association between improved process and improved outcomes

41 AR-G Regional Reports Coming soon via AHA Mission: Lifeline Nationally standardized regional reports Structure Process Outcomes QA/QI for cities, counties, or states QA/QI of Turbo ACO

42 STEMI Systems Applying 3 Core ACO Principles 1. Organized Care 2. Performance Measurement 3. Payment Reform

43 (2009 BMC Cardiovascular Disorders 9:32) Pre- vs. Post-Intervention design Pre = Oct-04 to Aug05 Started evidence-based interventions to D2B Post = Sep-05 to Jun-06 Median D2B times Pre-intervention = 113 minutes (N = 52) Post-intervention = 75 minutes (N = 80)

44 Insurance payments pre/post $35,000 to $25,000 (approximate) Hospital Costs pre/post $28,000 to $18,000 (approximate) (2009 BMC Cardiovascular Disorders 9:32) Payers saved $10k, hospital = same income DRG relative weight (3.74 to 2.97) Outlier payments >$100,000 (7.7% to 0%) At one year, savings totaled >$14,000 per pt.

45 Minnesota 2 Pioneering STEMI networks hospital re-admissions, recurrent MI need for implantable cardiac defibrillators cardiac mortality across the state

46 Projected savings of $5.5 billion annually If all hospitals performed as well as top 25% Quality Resource Efficiency Save 33,800 lives and 24,800 Re-admits Save $7,200 per admit (775,000 in USA) $20,800 average hospital cost, vs. $13,600 for high-performing hospitals

47 Initial Turbo-ACO Proposal Turbo-ACO region >500,000 residents 100x bigger than a standard ACO Payment reform promotes: Hospital collaboration, not competition Small% pay to all hospital when network created Value over volume Larger% pay if all regional hospitals meet QA/QI benchmarks (process and outcomes) Simplicity continue direct payments by CMS

48 Conclusion STEMI Systems Turbo-ACOs 1. Organized Care 2. Performance Measurement 3. Payment Reform We have built the STEMI Systems engine We need the Feds to help turbo-charge our efforts