0
wouldn’t itbe pan, mdmbawayne      nice...pacifcpartners
to have a greathealthcaredeliverysystem     ?
but wedon’t.
whynot?
some learnings from a commercial ACO...
who am i &how did i gethere?
orthopedichandsurgeon
medicaidmedicarehealthplans
ipa/msocommercialmedicareaco/ppo
healthcarewarrior
how aboutyou?
we are allhealthcarewarriors
who arewefightingfor?
the patient.
why?
i knowwhat you’re   thinking
takeaways
LISTEN TOTHE CHILDWITHINYOU
WWABD?
HAVE FUN
discipleof
nancyduarte
bjfogg, phd   stanford
rogermartinrotman, toronto
2 businessprocesses:
2 businessprocesses:reliability
2 businessprocesses:validity
have to doboth
have to dobothsustainable
have to dobothobsolete
why?
From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
?From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
insanity: doing the     samething over and over       andexpecting  different    results
somebasics
humannature
humannaturelazy
humannaturesocial
humannaturecreaturesofhabit
human      lazy           socialnature     habitnotgood@change
human    lazy         socialnature   habitsocialnorms
human       lazy            socialnature      habitstatusquo
human    lazy         socialnature   habitsocialnorms
doctornature
doctornaturecompetitive
doctornatureindependent
doctornaturecurious
doctor      competitivenature            independent            curiousformsilos
doctor   competitivenature         independent         curiousnotgood@cooperation
doctor    competitivenature          independent          curiousnotgood@collaboration
doctor    competitivenature          independent          curiouscurious
doctor   competitivenature         independent         curiouscompetitive
doctor   competitivenature         independent         curiouscompetence
leverageour nature
leverageour nature4 behaviorchange
michaelvandurenmdmbasutterhealth
michaelvandurenmdmbavariationreduction
WWABD?
leverageour naturesocialnorms
leverageour naturecurious
leverageour naturecompetitive
leverageour naturecompetence
easy
easyaccessible
easyaccessibledesign for failure
easyaccessibledesign for failureachievement
easyaccessibledesign for failureachievementfeedback
what got us here        marshall goldsmith
wont get us there what got us here          marshall goldsmith
behaviorchange
from: A Gawande, “The Checklist,” The New Yorker (2007) (Artist: Yan Nascimbene)
from: A Gawande, “The Checklist,” The New Yorker (2007) (Artist: Yan Nascimbene)
© all rights reservedby garyhymes
beware ofshortcuts
rememberwho & why
better forpatients?
easier forpatients?
?
Who is         ?
Individual Practice Association        Medical Group of      Santa Clara County
Individual Practice Association        Medical Group of      Santa Clara County
SCCIPA
largest IPA in Santa Clara County
Santa Clara Countysize 1,304.01 sqmiles pop 1,781,642 (2010)medianincome $74,335
THEApr 21,2012    Price 75 FB C                                     REDITSVIEW FROM THE VALLEY        EUROPE              ...
5 PCP 80 Specialists                                           173 PCP                                           343 Speci...
urban/                    suburban                                             ruralSCCIPA founded in 1986 physician-owned...
25,000commercialACO
40,000commercialHMO
5,000MedicareHMO
nooriginal Medicare,    Medi-Cal, CHIP, uninsured
= managementservicesorganization  medicalmanagement  casemanagement  networkmanagement  providercontracting  qualityimprov...
partialrisk
managingDOFR
DivisionOfF inancialResponsibility
outpatientservices
inpatientservices
capitatepcps
specialistspaidffs
performancebonus
IHAP4P&HCC
IPAcitizenship
roughroad
roughroad 4x4   healthcare
4processes x4dimensionaldata
4processes
communication
collaboration
Case           ManagersPatients              PCPs           Specialists     coordination
anticipation
4dimensionaldata
financial
administrative
clinical
retrospective   retrospective
reactivecare
$$$$$$
+   behavioral
predictive
proactivecare
provideactionabledata
@pointofcare
@home
thecareteam
thecarecontinuum
peopleprocessesplatform
peopleprocessesplatform
peopleprocesseshospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observati...
peopleprocessesSNFistsongoing evaluation of patients to reduce   rehospitalizationnotification of PCP of admission/discharg...
peopleprocessesonsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge p...
peopleprocessescomplex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist  ...
peopleprocessesutilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with...
people:physicians/staffprimary care physiciansspecialistsancillary providers
people:physicians/staffprimary care physiciansspecialistsancillary providersfront office staff
people:plan staffcase managersdisease managersmember outreachbenefit design
peopleprocessesplatform     communicate      collaborate      coordinate       anticipate
peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management o...
peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management o...
peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management o...
ourresults
80                                               Milliman - Loosely-Managed70                                            M...
275                                                Milliman - Loosely-Managed250225                                       ...
4.5 4.0                                                            Milliman - Loosely-Managed 3.5            Milliman - Mo...
400        Milliman - Loosely-Managed350        Milliman - Moderately-Managed300           Milliman - Well-Managed        ...
2,2002,000    Milliman - Loosely-Managed1,8001,600         Milliman - Moderately-Managed1,400                             ...
6.0 5.5         Milliman - Loosely-Managed 5.0         Milliman - Moderately-Managed 4.5                                  ...
managingACOpatientsinafee4serviceworld
challenge#1managingproviderbehavior
challenge#2managingpatientbehavior
challenge#3alignincentives
HMOworld
patientsassignedPCP
PCPmanagesreferrals
patientsstayinnetwork
ACOworld
patientsnotassigned
physiciansendspatient
notrestrictedtonetwork
whataboutquality?
whoisaccountable?
carecoordination?
oursolution
make the newway...
feel just like the oldway
1trackingauths> using the same auth system, have providers enter in  tracking auths for aco patients
keepspatientinnetwork
2providerselectiontool> when selecting “referred to” providers, these providers are  listed in descending order of quality...
promotesquality
promotesefficiency
promotessatisfaction
3rewardaccountability> referring physicians can be tracked to incentivize use of  provider network
4checkinbutton> allows for real-time patient tracking, provides opportunity  for care coodination efforts
automatedtracking
alertingcasemanager
nocheck-inby_________
requestimmediatehelp
5qualityreminders> @every encounter with the healthcare delivery system,  quality is reinforced
entireteamisaccountable
virtualpcmhmodel
air     trafffic     controlfor patients
ibelieve...
asknot...
culturalrevolution
thinkdifferent
LISTEN TOTHE CHILDWITHINYOU
WWABD?
HAVE FUN
welcome tohealthcare2.0
Thank you!  wpan@ppmsi.com  slideshare.net/bonedoc97WWW.SNOOPY.COM
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
Wouldn't it be nice... 21APR12
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Wouldn't it be nice... 21APR12

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Presented at the 35th Annual ABQAURP meeting, Atlanta 21APR12

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Transcript of "Wouldn't it be nice... 21APR12"

  1. 1. wouldn’t itbe pan, mdmbawayne nice...pacifcpartners
  2. 2. to have a greathealthcaredeliverysystem ?
  3. 3. but wedon’t.
  4. 4. whynot?
  5. 5. some learnings from a commercial ACO...
  6. 6. who am i &how did i gethere?
  7. 7. orthopedichandsurgeon
  8. 8. medicaidmedicarehealthplans
  9. 9. ipa/msocommercialmedicareaco/ppo
  10. 10. healthcarewarrior
  11. 11. how aboutyou?
  12. 12. we are allhealthcarewarriors
  13. 13. who arewefightingfor?
  14. 14. the patient.
  15. 15. why?
  16. 16. i knowwhat you’re thinking
  17. 17. takeaways
  18. 18. LISTEN TOTHE CHILDWITHINYOU
  19. 19. WWABD?
  20. 20. HAVE FUN
  21. 21. discipleof
  22. 22. nancyduarte
  23. 23. bjfogg, phd stanford
  24. 24. rogermartinrotman, toronto
  25. 25. 2 businessprocesses:
  26. 26. 2 businessprocesses:reliability
  27. 27. 2 businessprocesses:validity
  28. 28. have to doboth
  29. 29. have to dobothsustainable
  30. 30. have to dobothobsolete
  31. 31. why?
  32. 32. From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
  33. 33. From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
  34. 34. ?From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
  35. 35. insanity: doing the samething over and over andexpecting different results
  36. 36. somebasics
  37. 37. humannature
  38. 38. humannaturelazy
  39. 39. humannaturesocial
  40. 40. humannaturecreaturesofhabit
  41. 41. human lazy socialnature habitnotgood@change
  42. 42. human lazy socialnature habitsocialnorms
  43. 43. human lazy socialnature habitstatusquo
  44. 44. human lazy socialnature habitsocialnorms
  45. 45. doctornature
  46. 46. doctornaturecompetitive
  47. 47. doctornatureindependent
  48. 48. doctornaturecurious
  49. 49. doctor competitivenature independent curiousformsilos
  50. 50. doctor competitivenature independent curiousnotgood@cooperation
  51. 51. doctor competitivenature independent curiousnotgood@collaboration
  52. 52. doctor competitivenature independent curiouscurious
  53. 53. doctor competitivenature independent curiouscompetitive
  54. 54. doctor competitivenature independent curiouscompetence
  55. 55. leverageour nature
  56. 56. leverageour nature4 behaviorchange
  57. 57. michaelvandurenmdmbasutterhealth
  58. 58. michaelvandurenmdmbavariationreduction
  59. 59. WWABD?
  60. 60. leverageour naturesocialnorms
  61. 61. leverageour naturecurious
  62. 62. leverageour naturecompetitive
  63. 63. leverageour naturecompetence
  64. 64. easy
  65. 65. easyaccessible
  66. 66. easyaccessibledesign for failure
  67. 67. easyaccessibledesign for failureachievement
  68. 68. easyaccessibledesign for failureachievementfeedback
  69. 69. what got us here marshall goldsmith
  70. 70. wont get us there what got us here marshall goldsmith
  71. 71. behaviorchange
  72. 72. from: A Gawande, “The Checklist,” The New Yorker (2007) (Artist: Yan Nascimbene)
  73. 73. from: A Gawande, “The Checklist,” The New Yorker (2007) (Artist: Yan Nascimbene)
  74. 74. © all rights reservedby garyhymes
  75. 75. beware ofshortcuts
  76. 76. rememberwho & why
  77. 77. better forpatients?
  78. 78. easier forpatients?
  79. 79. ?
  80. 80. Who is ?
  81. 81. Individual Practice Association Medical Group of Santa Clara County
  82. 82. Individual Practice Association Medical Group of Santa Clara County
  83. 83. SCCIPA
  84. 84. largest IPA in Santa Clara County
  85. 85. Santa Clara Countysize 1,304.01 sqmiles pop 1,781,642 (2010)medianincome $74,335
  86. 86. THEApr 21,2012 Price 75 FB C REDITSVIEW FROM THE VALLEY EUROPE ENGLAND RUSSIA ATLANTIC OCEAN NEW YORK CITY FLORIDA M DA EX NA ICCA CLEVELAND APPALACHIA O ILLINOIS the Mississippi River INFINITE LOOP SAND HILL ROAD
  87. 87. 5 PCP 80 Specialists 173 PCP 343 Specialists 57 PCP 104 Specialists 11 PCP 30 SpecialistsSCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage) Anthem Commercial ACO pilot (2011)
  88. 88. urban/ suburban ruralSCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage) Anthem Commercial ACO pilot (2011)
  89. 89. 25,000commercialACO
  90. 90. 40,000commercialHMO
  91. 91. 5,000MedicareHMO
  92. 92. nooriginal Medicare, Medi-Cal, CHIP, uninsured
  93. 93. = managementservicesorganization medicalmanagement casemanagement networkmanagement providercontracting qualityimprovement credentialing memberservices claims&encounterprocessing clinicaldataanalytics&reporting marketingoutreach grievance&appeals compliance&auditing ITservices finance&riskmanagement
  94. 94. partialrisk
  95. 95. managingDOFR
  96. 96. DivisionOfF inancialResponsibility
  97. 97. outpatientservices
  98. 98. inpatientservices
  99. 99. capitatepcps
  100. 100. specialistspaidffs
  101. 101. performancebonus
  102. 102. IHAP4P&HCC
  103. 103. IPAcitizenship
  104. 104. roughroad
  105. 105. roughroad 4x4 healthcare
  106. 106. 4processes x4dimensionaldata
  107. 107. 4processes
  108. 108. communication
  109. 109. collaboration
  110. 110. Case ManagersPatients PCPs Specialists coordination
  111. 111. anticipation
  112. 112. 4dimensionaldata
  113. 113. financial
  114. 114. administrative
  115. 115. clinical
  116. 116. retrospective retrospective
  117. 117. reactivecare
  118. 118. $$$$$$
  119. 119. + behavioral
  120. 120. predictive
  121. 121. proactivecare
  122. 122. provideactionabledata
  123. 123. @pointofcare
  124. 124. @home
  125. 125. thecareteam
  126. 126. thecarecontinuum
  127. 127. peopleprocessesplatform
  128. 128. peopleprocessesplatform
  129. 129. peopleprocesseshospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP
  130. 130. peopleprocessesSNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
  131. 131. peopleprocessesonsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs
  132. 132. peopleprocessescomplex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks
  133. 133. peopleprocessesutilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement
  134. 134. people:physicians/staffprimary care physiciansspecialistsancillary providers
  135. 135. people:physicians/staffprimary care physiciansspecialistsancillary providersfront office staff
  136. 136. people:plan staffcase managersdisease managersmember outreachbenefit design
  137. 137. peopleprocessesplatform communicate collaborate coordinate anticipate
  138. 138. peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedback
  139. 139. peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own data
  140. 140. peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback/enter their own data
  141. 141. ourresults
  142. 142. 80 Milliman - Loosely-Managed70 Milliman - Moderately-Managed60 Milliman - Well-Managed50 SCCIPA40 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> commercial admits/1000
  143. 143. 275 Milliman - Loosely-Managed250225 Milliman - Moderately-Managed200 SCCIPA175 Milliman - Well-Managed150 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> commercial bed days/1000
  144. 144. 4.5 4.0 Milliman - Loosely-Managed 3.5 Milliman - Moderately-Managed SCCIPA 3.0 Milliman - Well-Managed 2.5 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> commercial average length of stay
  145. 145. 400 Milliman - Loosely-Managed350 Milliman - Moderately-Managed300 Milliman - Well-Managed SCCIPA250200 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> medicare admits/1000
  146. 146. 2,2002,000 Milliman - Loosely-Managed1,8001,600 Milliman - Moderately-Managed1,400 SCCIPA1,200 Milliman - Well-Managed1,000 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> medicare bed days/1000
  147. 147. 6.0 5.5 Milliman - Loosely-Managed 5.0 Milliman - Moderately-Managed 4.5 SCCIPA Milliman - Well-Managed 4.0 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O> medicare average length of stay
  148. 148. managingACOpatientsinafee4serviceworld
  149. 149. challenge#1managingproviderbehavior
  150. 150. challenge#2managingpatientbehavior
  151. 151. challenge#3alignincentives
  152. 152. HMOworld
  153. 153. patientsassignedPCP
  154. 154. PCPmanagesreferrals
  155. 155. patientsstayinnetwork
  156. 156. ACOworld
  157. 157. patientsnotassigned
  158. 158. physiciansendspatient
  159. 159. notrestrictedtonetwork
  160. 160. whataboutquality?
  161. 161. whoisaccountable?
  162. 162. carecoordination?
  163. 163. oursolution
  164. 164. make the newway...
  165. 165. feel just like the oldway
  166. 166. 1trackingauths> using the same auth system, have providers enter in tracking auths for aco patients
  167. 167. keepspatientinnetwork
  168. 168. 2providerselectiontool> when selecting “referred to” providers, these providers are listed in descending order of quality, efficiency, satisfaction
  169. 169. promotesquality
  170. 170. promotesefficiency
  171. 171. promotessatisfaction
  172. 172. 3rewardaccountability> referring physicians can be tracked to incentivize use of provider network
  173. 173. 4checkinbutton> allows for real-time patient tracking, provides opportunity for care coodination efforts
  174. 174. automatedtracking
  175. 175. alertingcasemanager
  176. 176. nocheck-inby_________
  177. 177. requestimmediatehelp
  178. 178. 5qualityreminders> @every encounter with the healthcare delivery system, quality is reinforced
  179. 179. entireteamisaccountable
  180. 180. virtualpcmhmodel
  181. 181. air trafffic controlfor patients
  182. 182. ibelieve...
  183. 183. asknot...
  184. 184. culturalrevolution
  185. 185. thinkdifferent
  186. 186. LISTEN TOTHE CHILDWITHINYOU
  187. 187. WWABD?
  188. 188. HAVE FUN
  189. 189. welcome tohealthcare2.0
  190. 190. Thank you! wpan@ppmsi.com slideshare.net/bonedoc97WWW.SNOOPY.COM
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