Managing the Transition to Accountable Models of Care

1
Managing the Transition to AccountableModels of
Care

• Mark Crockett, MD FACEP

2
Agenda

• Accountable trends in healthcare
• Resource and employment needs in the new model
• HIT
• Analytics
• Staffing
• Future landscape

3
Its hard to argue the case against payment reform

• Rank of US healthcare amongst industrial
  nations - 7 (of 7)
• Rank of US healthcare amongst developed nations
  26 (of 27)
• Spend per capita 2007 7,290
• Spend per capita of 1 ranked country 2007 3,387
  (46)

Source WSJ
4
Where do we spend the money?
5
(No Transcript)
6
(No Transcript)
7
Effect of Healthcare Reform and Aging Population
Source Plunkett Research, Ltd.TM
8
Various estimations of cost growth
9
Enter the ACO

• Made legal under the healthcare reform act
• Final rules expected by the end of the year
• January 1 mandate for CMS to have the structure
  in place
• Represents a bundled payment and cost savings
  model for healthcare

10
How is an ACO reimbursed?
Projected Spending
Target Spending
Shared Savings
Actual Spending
Source Brookings
11
The next few years will be interesting!
Pay for Performance/Accountable Care
Fee for Service
12

ACOs
13
Medicares Idea of an Accountable Care
Organization

• Provider led organization
• ACO is responsible for
• Improved clinical outcomes
• Reduced cost growth
• For a defined population of people
• Organizations that may be treated as an ACO
  include
• Group practices
• Networks of individual practices
• Partnerships or Joint Ventures
• Hospitals employing physicians
• Other groups as determined by the Secretary of HHS

Source The Camden Group
14
How does that currently work?

• ACO reports quality metrics on particular
  patients/situations
• Quality of care must remain high
• Metrics negotiated in advance
• Patient population affected negotiated in advance
• ACO is privy to cost information from payors
• ACO receives and distributes incentive payments
  based on cost containment and shared savings
• Private and now Medicare patients both affected
  in certain markets

15
ACO rules under Medicare

• A 2-year participation contract
• A formal legal structure
• Inclusion of primary care physicians with at
  least 5,000 patients
• A list of primary care physicians and
  subspecialty physicians who are involved provided
  to the Centers for Medicare Medicaid Services
  (CMS)
• Contracts with care groups of specialty
  physicians outside the ACO
• Management and leadership structure for joint
  decision making
• Defined processes for promoting evidence-based
  medicine and reporting on quality, cost reduction
  measures, and coordinated care.

16
The Unicorn
17
The Unicorn

• United Healthcare will have 2 billion in
  providers in an ACO model by 2012 in 8 markets
• Current projects
• Scottsdale health
• AppleCare /Daughters of Charity
• Southwest Medical Associates (SMA)
• Optum Health
• Network contracting based on accountable models
• Other organizations Stanford, Advocate,
  Partners, etc

18
West Side Story

• 2001 Advocate healthcare physician challenge
• 2002 Advocate invests in primary care physicians
• 2003 Cost savings model war
• 2005 New model based on Generic drug benefits
• 2007 Model expanded to 3 insurers, 4 metrics
• 2011 16 metrics, 5 insurers

19
West Side Story The Financials

• 68M dollars to advocate physicians distribution
• 2000 physicians eligible 34,000 per physician
• 4 metrics, then 10, now 24
• 100 CPOE
• Client satisfaction, etc
• Net Effect on Patient Care?
• Sicker ED patients
• 1.5 patients per hour
• Care management focus

20
Services What has value under new models?

• Fee for Service

• Capitated Models

• Expensive Procedures
• Preferably outpatient
• Outpatient urgent care
• Scans of all types
• MRI, CT, Nuc Med
• Billable infusions
• Surgical admissions
• Level 4,5, critical care ED visits

• Preventative care
• Disease surveillance
• Team care (30M new patients coming in)
• Chronic disease management
• Outcomes surveillance

21
Providers What has value under new models?

• Fee for Service

• Capitated Models

• Surgical Subspecialists
• Interventional Cardiologists
• Trauma care
• High referral physicians with sick patients

• Primary Care
• Internal Medicine
• Care Team Management
• Physician extenders
• Care Management
• Pediatrics/Cancer???
• Physicians with good outcomes

22
Patients What has value under new models?

• Fee for Service

• Capitated Models

• Sick patients
• Patients needing high value procedures
• Clumsy patents
• Patients who dont follow instructions

• Well patients
• Patients that take their medicine
• Patients that follow instructions
• Patients that have chronic diseases that are
  manageable

23
Key aspects of the new models

• Capitated payments will increase as a portion of
  total
• Hospitals taking population risk
• Chronic disease management becomes a large focus
• Admissions are the next to worst thing possible.
• Whats the worst thing possible?

24
S.C.R.E.W.E.D (f)

• Someone
• Capturing
• Revenue (our)
• Elsewhere
• When
• Emergency
• Department
• Is full.
• Net bills from other systems are anathema.
  (change in rule?)

25
Employment opportunities in the new models

• IT Current systems woefully inadequate to manage
  outcomes
• Analytics with old systems
• Implementation of new systems.
• Integration strategy
• Healthcare information exchange is no longer nice
  to have
• Coordination of Clinical Care
• Care Teams
• New staffing models
• Clinical Operations
• CMIO, (CNIO?) and staff

26
Why Exchange Care Information?
Source S.E.C.
27
Market Shift Underway - Meaningful Use to
Accountable Care
The market is evolving from a fragmented
ecosystem focused on fee-for-service
reimbursement models to a collaborative network
aligned on outcomes based reimbursement with
shared risk management as a principle
Vision
Accountable Care Management Service Progression
Required Competencies

• Deep clinical expertise solution set in
  addition to revenue cycle leadership
• Clinical informatics and applied business
  intelligence
• Distributed and networked technology architecture
  and applications
• Real time interactive point of care applications
  with integrated workflow
• World class ability to manage risk ability to go
  at risk to deliver outcomes
• Industry leading customer base and distribution
  models in both clinical/revenue cycle sets and
  ambulatory/acute settings

Integrated care/cost management

• Population management
• Chronic disease management
• Distributed disease management
• Risk management

Outcomes Management Focus

• Health risk assessment
• Acuity classification
• Predictive modeling

• Outcomes Management (P4P)
• Patient education and compliance programs
• Care coordination and referral management

Care Coordination
Advanced Health Management
Basic Service
Delivery model sophistication
28
Capabilities To Enable ACO Development
Consulting
Services
Technology Solutions
Ability to Manage Risk
Leverage of Technology
Alignment of Clinical and Business Environments
Integration of Clinical and Financial Systems/Data
29
Who Benefits

• Companies that provide an integrated
  inpatient/outpatient EMR (or have a good story)
• Epic
• Cerner
• Companies that provide the infrastructure for
  same
• Medicity
• Axololtl
• Companies with patient continuity data sets
• Surescripts
• Ingenix

30

Back to The Future

• New capitated models of care are inevitable
• Infrastructure under meaningful use is better
  than it was, but still inadequate
• Clinical Operations is getting better care done
  at less cost
• Integrated care can be done a number of ways, but
  Analytics and Exchange are essential
• Seeing more patients with fewer resources means
  more teams, more coordination
• Expensive inpatient care is less preferable, and
  new models will reward outpatient management