1. Bending the Cost Curve and Improving
Quality in One of America’s Poorest
Cities
Jeffrey Brenner, MD
Executive Director/Medical Director

2. Long-term Federal Debt
!

3. 7/20/12 3

4. 7/20/12 4

6. 7/20/12 6

8. You are cordially invited to the first
Camden City Healthcare Providers’
Breakfast
History of
CCHP"
Join fellow clinicians to get acquainted, and to share strategies, resources, and
ideas on providing health care to Camden City residents.
!
Thursday, January 24, 2002
7:30 – 9:00 am
At the Rutgers University Octagon Room,
Camden Campus Center, North Third Street
Sponsored by the Center for Strategic Urban Community Leadership at
Rutgers University, Division of Urban Health in the Department of Family
Medicine at Cooper Hospital, and the Camden Area Health Education Center
Please RSVP to Daria Chacón at 856-963-2432 x218 by Friday, January 11.

9. Camden Health Data!
n 2002 – 2011 with Lourdes, Cooper, Virtua data!
n 500,000+ records with 98,000 patients!
n 50 % population use ER/hospital in one year!
n Leading ED/hospital utilizers citywide!
n 324 visits in 5 years!
n 113 visits in 1 year!
n Total revenue to hospitals for Camden
residents $100 million per year!
n Most expensive patient $3.5 million!
n 30% costs = 1% patients!
n 80% costs = 13% patients!
n 90% costs = 20% patients!

10. Top 10 ER Diagnosis 2002-2007 (317,791 visits)!
465.9
ACUTE UPPER RESPIRATORY 12,549
INFECTION (head cold)
382.9
OTITIS MEDIA NOS (ear infx)
7,638
079.99
VIRAL INFECTION NOS
7,577
462
ACUTE PHARYNGITIS (sore throat)
6,195
493.92
ASTHMA NOS W/ EXACER
5,393
558.9
NONINF GASTROENTERI (stomach virus)
5,037
789.09
ABDOMINAL PAIN-SITE NEC
4,773
780.6
FEVER
4,219
786.59
CHEST PAIN NEC
3,711
784.0
HEADACHE
3,248

12. Trenton Health Team
Hospital Utilization Analysis
St Francis and Capital Health
2010 - 2011
Ewing Royal Health Gate Nursing & Rehab
1314 Brunswick Ave
Trenton Housing Authority 1,834 episodes
237 Oakland St
1,354 episodes
Providence Nursing & Rehabilitation Center
439 Bellevue Ave
1,174 episodes
^
Rowan Tower
620 W State St ^
1,065 episodes
Luther Towers
489 W State St
^
^^
1,551 episodes
^ ^
333 W State St
1,042 episodes ^
^
Rescue Mission of Trenton Trenton
98 Carroll St
2,315 episodes
Trent Center West
465 Greenwood Ave
1,335 episodes Trenton Center Apartments
511 Greenwood Ave
1,700 episodes
12

13. Newark Beth Israel Hotspot Analysis (2010) Total Receipts by Zip Code
07112 $24,079,842
Total Costs per 07108 $16,553,538
Census Block (deciles) 07103 $14,181,330
$0 07106 $11,788,444
$1 - $1,097 07104 $7,022,274
$1,098 - $4,955 07114 $6,440,656
07107 $5,594,552
$4,956 - $10,700 07104 07105 $5,498,100
$10,701 - $18,685 07102 $4,206,927
$18,686 - $31,353 07107
$31,354 - $54,230
$54,231 - $88,719 1060 Broad St
$88,720 - $167,531 (1 Building)
$167,532 - $1,793,955 87 Patients
Hotspot 198 ER & Inpatient Visits
^ (>$200k in receipts
$993 thousand in receipts
and >50 patients)
07106
07103
^
^ 07102
^
07108
^ 07105
Mt Vernon and Manor Dr 07112 Elizabeth Ave
High Rises (4 Buildings)
^^ High Rises (6 Buildings)
272 Patients 774 Patients
379 ER & Inpatient Visits 07114 1,390 ER & Inpatient Visits
$1.11 million in receipts ^ $2.0 million in receipts
SAINT BARNABAS
HEALTH CARE SYSTEM
13
Newark Beth Israel Medical Center

14. £
¤
1
MaineCare Hotspot Analysis: Penobscot County
§
¨
¦
95
7/1/2008 - 6/30/2010 Mount Chase
Patten
Stacyville Aroostook
£
¤
2
North Penobscot
Piscataquis Millinocket East Millinocket
Medway Drew
Kingman
£
¤
201
Mattawamkeag
High utilizer density Woodville £
¤
1
High Prentiss
Webster
§ Chester
¨
¦
95 Winn
Penobscot Carroll
Seboeis Springfield
Somerset Low
Lincoln
Lee
Penobscot Indian Island
Maxfield Lakeville Whitney
What is a hot spot? Enfield Twombly Ridge
A hot spot is any geography where a
Howland 95
§
¨
¦ Burlington
Lowell
large number of high utilizers reside. Passadumkeag
LagrangeEdinburg
High Utilizers are defined as any
individual with 3 or more hospital East Central Penobscot
Bradford
admissions or 6 or more ER visits ArgyleGreenbush Washington
GarlandCharleston Alton
within 2 years. Hot spots range from Dexter
blue (no hot spot) to red (intense hot Corinth
Hudson
Milford
spot) Corinna
Exeter
Old Town
KenduskeagGlenburn
Stetson Levant Orono Bradley Hancock
Newport
Veazie
Bangor
Franklin Hermon Eddington
Clifton
Carmel
£§
¤¨
¦
Etna 395 Brewer
Plymouth 202
Holden
£
¤
201
£
¤
202 Hampden
Newburgh Orrington
£
¤
2 Clinton
Dixmont 1£
¤ ¤
Unity
Waldo
Oxford Vienna
Rome
Oakland £
¤
201 Benton
£ £
¤ ¤
1 1

15. £
¤ £
¤
201
§
¨
¦
95
MaineCare Hot Spot Analysis: Kennebec County 201
Plymouth
Etna
7/1/2008 - 6/30/2010
Newburgh
Franklin Somerset §
¨
¦
95 Dixmont
Clinton
£
¤
201
Unity
Benton
£
¤
2
Rome
Oakland
Vienna
Waterville
Winslow
Albion
Belgrade Waldo
Mount Vernon
Sidney
Fayette
Vassalboro
China
Oxford Readfield
What is a hot spot?
£
¤
201
A hot spot is any geography where a
Wayne
Manchester Augusta £
¤
202 large number of high utilizers reside.
High Utilizers are defined as any
Winthrop £
¤
201 Windsor
individual with 3 or more hospital
Hallowell
admissions or 6 or more ER visits
Androscoggin £
¤
202
Chelsea within 2 years. Hot spots range from
Farmingdale
201£
¤ blue (no hot spot) to red (intense hot
Monmouth
West Gardiner
Randolph spot)
§
¨
¦495
Gardiner
Pittston Knox
High utilizer density Litchfield
High
Lincoln
Lincoln
c
§
¨
¦495
£
¤
1
Low £ £
¤ ¤
1
Sagadahoc
New Gloucester

16. Overview of the Coalition!
- 20 member board, incorporated non-profit!
- Foundation and hospital support!
- Structure of the Coalition:!
- Operations!
- Health Information Exchange!
- Research/Data/Evaluation!
- Finance/Admin/Legal!
- Programming!
- Citywide Care Management Project!
- Camden Chronic Disease/Primary Care Collaborative!
- Community-based Patient Engagement Strategies!

17. Care Continuum Model!
Hospital • Mul.disciplinary
care
management
outreach
Admission • Pa.ents
with
history
of
ED
visits/hospital
admissions
and
readmissions
(4
admits
w/in
6
mos.);
social
s Data! complexi.es
• Average
6-­‐8
month
engagement
Inclusion! CCHP Outreach! Medical Home!
Triage!
High
Risk
Care
Coordina.on
Health
Coaching
Intermediate
Risk
Data
driven
care
mgt.
Pa.ent
Engagement
• Nurse
driven
care
transi.on
• Pa.ents
with
history
of
ED
visits/hospital
admissions
and
readmissions
(2+
admits
w/in
6
mos.);
socially
stable
• Average
6-­‐8
week
engagement

18. Utilization typology
Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
0 0 1,293 57 4 1
1 26,128 2,075 117 7 0
2 to 3 13,390 1,842 373 68 3
4 to 5 3,216 666 223 118 15
6 to 7 1,020 251 106 84 24
8 to 9 386 112 39 41 11
10 + 339 96 70 65 62

19. Utilization typology
Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
0
1 Normal Range of Utilization
2 to 3
Potential High
Inpatient
4 to 5 Utilizers
High Utilizers
6 to 7
Emergency
Potential High
Department
Utilizers
High Utilizers
8 to 9
10 +

20. Utilization matrix
Inpatient visits, 2011
ED visits, 2011 0 1 2 3 to 4 5+
0
44,728 (85%) patients
5,210 Inpatient visits
63,489 ED visits
1
$28,000,000 (50%) IP payment
$25,800,000 (59%) ED payment
2 to 3 985 (2%) patients
1,856 IP visits 503 (1%) patients
4,129 ED visits 2,026 Inpatient Visits
4,144 ED Visits
4 to 5 $10,000,000 (17%) IP
1,563 (3%) patients
payment $10,900,000 (20%) in IP payment
1,239 IP visits
4,961(9%) patients 6,962 ED visits $1,700,000 (4%) ED $1,700,000 (4%)in ED payment
6 to 7 payments
28,447 ED visits
$6,700,000 (18%) in IP
$11,500,000 (27%) in payment
8 to 9 ED payment $2,800,000 (6%) in ED
payment
10 +

21. Patient A
Es.mated
2011
Payment
ED:
$38,000
to
$76,000
(93
visits)
IP:
$65,000
to
$130,000
(12
visits)
Total:
$103,000
to
$206,000
Saving
Es.mates
30%
reduc.on
in
u.liza.on
:
ED:
-­‐28;
-­‐$11,000
to
-­‐$22,000
IP:
-­‐
4;
-­‐$19,000
to
-­‐$38,000

22. Train local residents to
participate in decision-
making over health care
resources!

23. Promote collaboration
among providers and
between providers and the
community!

25. Comparing Emergency Room High Utilizers in
Camden, Trenton, and Newark!
Emergency Department High Utilizers Top 1% 2007
Camden
Patients 386
Visits 5169
Visits/Patient 13.4
% visiting more than one hospital 80.6%
Trenton
Patients 504
Visits 7616
Visits/Patient 15.1
% visiting more than one hospital 78.2%
Newark
Patients 928
Visits 14367
Visits/Patient 15.5
% visiting more than one hospital 71.1%

26. SENATE, No. 2443
STATE OF NEW JERSEY
214th LEGISLATURE
INTRODUCED DECEMBER 6, 2010
Sponsored by:
Senator JOSEPH F. VITALE
District 19 (Middlesex)
SYNOPSIS
Establishes Medicaid Accountable Care Organization Demonstration Project
in DHS.
CURRENT VERSION OF TEXT
As introduced.

27. The
Plan:
Compe1ng
ACOs
Lourdes
ACO
Cooper
ACO
Virtua
ACO

28. A
Different
ACO
Model
for
Camden

29. Camden cost savings strategies
!
1. Nurse practitioner led clinics in high cost
buildings!
2. More high utilizer outreach teams!
3. Medical home-based nurse care
coordination!
4. More same day appointments (open
access scheduling)!

30. Lessons from Camden!
n Strategic ability to filter, focus, and segment!
n Comfort with ambiguity and willingness to
tinker!
n Adaptive challenge not a technical challenge!
n Passion for moving towards standardization
and efficiency when the time is right!
n Meaningful solutions are local, gradual, and
require chunking!