Anne Bracken Univ of South AL - aco rural health

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Anne Bracken Univ of South AL - aco rural health

  1. 1. Accountable Care Organizations ALLEN PERKINS, MD, MPH PROFESSOR AND CHAIR, FAMILY MEDICINE UNIVERSITY OF SOUTH ALABAMA
  2. 2. Disclosure  None – except for being a tax payer
  3. 3.  “Eventually, effective ACOs will hand-pick specialists to become integrated into their provider networks. There will certainly be winners and losers as specialists compete for referrals based on cost, quality and service. Utilization will decline, so a smaller pool of specialists will need to serve a broader population.” Terry Spoleti, president of Glenridge HealthCare Solutions, 2012
  4. 4. “He who rejects change is the architect of decay” Harold Wilson
  5. 5. Incremental efforts to change hospital care
  6. 6. Not limited to hospitals
  7. 7. Most widely documented ambulatory errors  Prescriptions for incorrect drugs or incorrect dosages  Missed, delayed and wrong diagnoses  Missed and delayed tests as well as errors in patient follow-up on test results  Doctor-patient communication errors, doctor-doctor communication errors or other miscommunications between parties  Errors in scheduling appointments and managing patient records
  8. 8. Effect of improvement efforts  Inappropriate use and dissemination of knowledge  Waste  Inappropriate priorities  We need to develop guidelines to support health care business leaders to transition from a business model wherein a filled hospital bed is the pinnacle of efficiency to a model that rewards an empty hospital bed. Don Berwick, December 2012
  9. 9. Why are we so slow to change?  Center for Medicare and Medicaid Services  Medicare  Medicaid  Other Government payers  Tricare  VA  Commercial carriers  BC/BS  Other  Cash
  10. 10. Triple Aim
  11. 11. CMS Priorities  High impact conditions  Heart disease (Coronary Artery Disease and Congestive Heart Failure)  Diabetes  Joint disease/Arthritis  Cancer  Renal disease  Pneumonia and Influenza  Chronic Obstructive Pulmonary Disease  Accounted for $123 Billion (44% of cost)
  12. 12. Payers want to pay for value
  13. 13. The world of the possible
  14. 14. Phase 2
  15. 15. Volume based practice - inpatient
  16. 16. Transitional payment
  17. 17. Transitioning to what?
  18. 18. How bundled payments work
  19. 19. Encouraging efficiency
  20. 20. Volume based practice-outpatient
  21. 21. Transitional payment
  22. 22. Transitioning to what?
  23. 23. So, then, what is an ACO?  Voluntary group of physicians and care facilities  Minimum requires sufficient primary care professionals     necessary to treat a beneficiary population (minimum of 5,000 beneficiaries) Sufficient information about the participating health care professionals to support beneficiary assignment and for the determination of payments for shared savings Physician leadership Defined processes to promote evidence-based medicine, report on quality and cost measures, and coordinate care Delver care in a patient-centered manner
  24. 24. ACO  Invisible Enrollment  Not formally enrolled, not required to obtain services through the ACO, and might not even know the ACO existed  Performance Measurement  Data on utilization and costs for the ACO population and on measures of quality of care and population health, emphasis on quality, and mechanisms to improve  Shared Savings  If the ACO was found to have saved money, it would receive some share of the savings as compared to historical data or community comparison  Evolution Toward Stronger Incentives  Inclusion of downside risk
  25. 25. Initial quality measures  Patient/caregiver experience (7 measures)  Care coordination/patient safety (6 measures)  Preventive health (8 measures)  At-risk population:  Diabetes (6 measures)  Hypertension (1 measure)  Ischemic Vascular Disease (2 measures)  Heart Failure (1 measure)  Coronary Artery Disease (2 measures)
  26. 26. Organizational Capabilities Needed  Manage Risk.  Use of Electronic Health     Records. Performance measures tracking. Implement standardized care management protocols Sufficiently engage patients in self-care management and self-determination. Integrate beyond the structural level.  Balance the interests of hospitals, primary care physicians, and specialists in creating governance and management processes to adjudicate differences  Make contractual relationships with the most cost-effective specialists.  Navigate the new regulatory and legal environment  Recognize the interdependencies and avoid “race to the bottom”
  27. 27. Is it working? Medicare spending growth in excess of GDP growth
  28. 28. Where does the money go?
  29. 29. AHA must-do strategies  Must-must do  Aligning hospitals, physicians, and other providers across continuum of care  Utilize evidence based practices to improve quality and safety  Improve efficiency through productivity and financial management  Develop integrated information systems
  30. 30. American Hospital Association  Kinda-must do  Joining and growing integrated provider networks and systems  Create physician and employee leaders  Reinvest using strengthened finances  Partner with payers  Advance organization through scenario-based strategic, financial, and operational planning  Seek population health improvement
  31. 31. Why not Alabama (yet)  Blue Cross of Alabama (analysis of University Health Plan)   Has 90% of market BC/BS only pays 53% of charges and only 30% of hospital outpatient charges    Encourages volume to overcome reduction in per patient revenue Still on per diem for hospital charges (one of few in country) Available data difficult to analyze
  32. 32. United HealthCare  Aggressive transformation of provider network beginning in 2012  expected to reach 50% to 70% of market by 2015.  Currently 10% of Alabama market  Exchanges are a game changer
  33. 33. Pondering your future, yet?
  34. 34. Physician specific quality markers  Infection Prevention Practices  Infection Indicators  Compliance with Medicare CORE Measures  Medical Record and Operating Room Dictation     Completion Patient Complaints Mortality Rates Readmission Rates Other Quality Initiatives
  35. 35. What can you do today in the hospital?  Focus on detail/accuracy and timeliness of      documentation Attention to discharge planning Difficult discharges prior to noon and increase discharges on weekends Get a handle on implant costs and implementation of demand matching Decrease time between request for consultation and occurrence of consultation Earlier transition from ICU to standard acute floor
  36. 36. Improving transitions  Experts noted that, as a first step, hospitals must  Inform PCPs when their patients have been hospitalized  Let them know when patients are discharged  Provide copies of the discharge status and plans  Facilitate post discharge medication management
  37. 37. Conclusions  We need much better customer service than we currently provide is urgent   Pay attention to changes in care delivery payment such as ACOs and bundled care is urgently needed    Clearly people are voting with their feet Our major payers are moving rapidly in this direction Quality trumps volume in the NWO Teaching is no longer an acceptable excuse for inefficiency  We need to change how we work...work smarter not harder...
  38. 38. Conclusions  Despite noise  Volume payments will be cut by all payers  Market demand for value, transparency is increasing    Push for innovation in care delivery        Work smarter, not harder Leverage technology Understand what contributes to costs in your setting Focus on primary care and controlling high-cost acute care utilization.   Delivering quality, evidence based care is a core competency The value of efficiency cannot be overestimated Chronic Disease Management ICU care End-of-life care Hospitalization becomes avoidable expense Risk shifts from payer to physician/provider/system
  39. 39. Questions?

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