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Medicine in 21st Century USA -- Kent Bottles, MD

The document discusses the Affordable Care Act (ACA), highlighting its significance as a comprehensive healthcare reform aimed at expanding insurance coverage and controlling costs. Key features include the establishment of health insurance exchanges, individual mandates, Medicaid expansion, and measures to regulate health plan coverage. It also addresses the impact of ACA on uninsured rates, hospital services, and the future of healthcare delivery systems in the U.S.

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EmCare Leadership Conference Kent Bottles, MD 610 639 4956 www.kentbottlesmd.com kent@kentbottlesmd.com April 4, 2013 Las Vegas, Nevada
The Affordable Care Act http://www.nytimes.com/2012/04/03/health/policy/the-abcs-of-the-health-care-law-and-its- future.html • Series of policies, regulations, subsidies, and mandates that builds upon the incoherent medical system of public & private insurance • Most important health care law since enactment of Medicaid & Medicare in 1965 • 70,000 pages of guidance from HHS
Affordable Care Act • Medicare, Medicaid, VA, CHIP, FEHIP retained • Employer furnished insurance retained (>50 employees must offer insurance) • Individual mandate • Fed subsidies to those too poor to pay • Insurance exchanges in each state
Two Intertwined Goals Reform the health care delivery and payment system to provide better care in a more cost-efficient manner Goals Make better health insurance coverage more available and affordable for legal residents
In 2009 . . . • 50+ million (about 17%) uninsured • Remaining 254 million – 93 million on government programs o 43 million on Medicare o 48 million on Medicaid – 195 million (56%) have private coverage o 87% through employment o Lowest rate since recordkeeping began o About 10% underinsured
. . . by 2016 • Reduce number of uninsured to 22 million – 2010-2013: no significant change – 2014: down to 34 million – 2015: down to 28 million – 2016: down to 22 million • 1/3 remaining uninsured = undocumented immigrants
Seven-Part Solution Offer incentives to expand coverage Control rising costs Regulate health plan coverage Solution Impose individual mandate Establish health insurance exchanges Impose employer penalties Expand Medicaid
Solution No. 1: Offer Incentives to Expand Coverage • Temporary high-risk pools • Early retiree reinsurance program • Tax credits for small employers – Cover at least 50% of health insurance costs – Fewer than 25 FTEs, average wage less than $50,000 – Credit = up to 35% of costs thru 2013; 50% thereafter
Solution No. 2: Control Rising Costs • State grants for health insurance premium reviews • Cost containment – Medicare savings of $500 billion over 10 years • Comparative effectiveness studies • Voluntary shared savings through ACO • Bundled payment pilots • Reimbursing physicians based on quality performance
Solution No. 3: Regulate Health Plan Coverage All Plans – Now In Effect • No lifetime limits on “essential benefits” • Tighter restrictions on annual limits • No rescission of coverage, except for fraud or intentional misrepresentation • Kids covered through 26th birthday • No pre-existing condition exclusions for kids <19 • Automatic enrollment of full-time employees – 200+ FTE; subject to employee opt-out
Regulate Health Plan Coverage Guarantee Issue and Renewal • Effective January 1, 2014 • Premium costs differ solely based on: – Age (3:1) – Tobacco use (1.5:1) – Family composition – Geographic location
Solution No. 4: Impose Individual Mandate • Maintain “minimum essential coverage” unless… – Coverage costs >8% monthly income – Income below the tax filing threshold – Religious objection – Native American • 3 alternatives – Employer/union-sponsored plan – Purchase individual insurance through exchange – Qualify for federal health care program
Impose Individual Mandate Enforcement • Pay penalty on federal tax return if fail to maintain health insurance for 3+ months • By 2016, penalty = greater of – $695 per person (up to $2,085 per family) – 2.5% of adjusted household income • Failure to pay = lien against future tax refunds – No criminal enforcement – No civil penalties
Solution No. 5: Establish Health Insurance Exchanges • Each state to establish by 2014 (or feds step in) • Individual and small employer market – Expand to larger employers in 2017 • “Essential health benefits package” – Policy must provide essential benefits – Cost-sharing provisions must not exceed HSA out-of- pocket limits (currently, $5,950 single/$11,900 family) – Annual deductible capped at $4,000 family/$2,000 single
Establish Health Insurance Exchanges Individual Tax Credit • May be used only to purchase coverage through Exchange • Qualify if household income is 100-400% of FPL – Unless eligible for Medicaid or employer-sponsored coverage (except if employer pays less than 60% of total benefit costs) – Amount of credit varies with household income and cost of Exchange-provided coverage • Also eligible for cost-sharing reductions • Impact of Medicaid “opt-out”
Solution No. 6: Impose Employer Penalties Source: CRS analysis of P.L. 111-148 and P.L. 111-152.
Solution No. 7: Medicaid Expansion • Starting in 2014, state that expands Medicaid eligibility to 133% FPL will receive higher FMAP for newly eligible – 100% in 2014-16; 95% in 2017; 94% in 2018; 93% in 2019; 90% in 2020+ – Administrative costs still 50/50 • Coverage must be at least as good as the minimum essential health benefits available through Exchanges
Medicaid Expansion Impact on Hospitals • Less-than-expected decline in uncompensated care • Reductions in DSH payments – Medicaid DSH reduced 50% by 2019 o HHS has not yet published methodology – Medicare DSH reduced 75% in 2014 (with some amount returned based on documented uncompensated care)
Medicaid Expansion in PA • Governor Corbett turns down expansion • Will not add 500,000 to Medicaid • Cost to PA of $2.8 billion • $37.8 billion in federal funds refused • Governor Kasich of Ohio is participating in Medicaid expansion
Deloitte Health Care Reform Memo, January 7, 2013 • Implementation of the ACA in 2013 • Clarity • Costs • Compliance • Consolidation • Consumers
Deloitte Health Care Reform Memo, January 7, 2013 • Clarity – SCOTUS affirmed ACA – November election winner Obama – States decide on exchanges – States decide on Medicaid expansion
Deloitte Health Care Reform Memo, January 7, 2013 • Costs ($992 billion in waste; 47%) – Health care costs seen as cause of debt crisis – Failure of care delivery…$154 billion – Failure of coordination.….$45 billion – Overtreatment……………$226 billion – Administration waste…….$389 billion – Pricing failures…….…..…$178 billion – Fraud and abuse………….$272 billion
Bending the Cost Curve through Market-Based Incentives • Medicare premium support replaces defined benefit to be used to purchase insurance • Convert tax subsidy for employer insurance to predetermined refundable credit • Transition from fee for service to bundled payments • High option plan for Medicare
Bending the Cost Curve through Market-Based Incentives • Regional Medicare plans to encourage greater entrepreneurship • Health insurance exchanges without “heavy regulation imposed by ACA”
A Systematic Approach to Containing Health Care Spending • Model of state self regulation with spending targets where public & private payers negotiate payment rates with providers • Replace fee-for-service with bundled and global payments • Medicare competitive bidding for med devices, lab tests, X-rays, etc
A Systematic Approach to Containing Health Care Spending • Insurers should offer tiered plans with lower copays if pt chooses high value providers • Payers & providers electronically exchange eligibility, claims, etc • Single standardized MD credentialing • Price transparency • Non physician providers should practice to full extent of their training
If Consumer Prices Had Risen as Much as Healthcare since 1945 • A dozen eggs would cost $55.00 • A dozen oranges would cost $134.00 • A gallon of milk would cost $48.00
Why Health Care Costs So Much http://www.kaiserhealthnews.org/Stories/2012/October/25/health-care-costs.aspx • FFS payments to doctors, hospitals reward volume rather than value • Demographics: older, sicker, fatter • Pogo: We want new stuff • Tax breaks on health insurance; cost to patient low • Lack of information to become savvy shopper • Hospitals gaining market share; demand higher prices • Supply and demand problems, legal issues make it hard to slow spending
Health Care: The Disquieting Truth • We spend $2.5 trillion on healthcare • Without control, federal budget deficit & national debt will continue to grow • US spends 2.5 times per person what counterparts in Europe spend • We spend more than enough to give good care; the problem is the system not lack of money Arnold Relman, NYRB, September 30, 2010
Ezekiel Emanuel’s $2 Trillion http://blog.lib.umn.edu/schwitz/healthnews/182728.html • 1 million seconds: less than 2 weeks ago • 1 billion seconds: 1974 • 1 trillion seconds: 30,000 BC
White House Sequester Health Cuts • CMS Supplemental Medical Insurance Trust Fund: $5.2 billion • CMS Hospital Ins. Trust Fund: $5.8 billion • CMS Part D: $591 million
White House Sequester Health Cuts • CDC: $464 million • Substance Abuse & Mental Health Services Administration: $275 million • FDA: $318 million • NIH: $2.5 billion • Indian Health Services: $320 million
Deloitte Health Care Reform Memo, January 7, 2013 • Consolidation – Close to 100 hospital acquisitions in 2012 – Medical group deals increased 60% – Physicians fleeing private practice for employment with large ACOS, IDN – “Go big or get out”
Deloitte Health Care Reform Memo, January 7, 2013 • Compliance – US invested $102 million to detect Medicaid fraud – Limit physician self referral – Health plan regulation under the ACA – Clinically unnecessary procedures and tests
Deloitte Health Care Reform Memo, January 7, 2013 • Consumers – Mobile apps enable comparison of treatment options, costs, and providers who adhere EBM – High deductible plans & individual insurance market will drive price & quality sensitivity – Transparency will demand access to performance data from health plans, hospitals, physicians, pharma, long-term care providers
How Will It All Turn Out? • Consumers • Employers • States • Health Care Providers
How Will It All Turn Out? • Consumers – For the 55% with employer insurance & 32% with government program not much changes – Challenge is getting 18 million young adults who don’t have insurance to obtain it. – If young and healthy are not in risk pool the math will not work
How Will It All Turn Out? • Employers – Most will wait and see – Employers with more than 50 workers will have to offer insurance to those working 30 hours a week or more – CBO estimates 8 million fewer workers (5%) will get insurance through employers in 5 years
How Will It All Turn Out? • Employers – Robert Pear, NY Times, Feb 18, 2013, A9 – Companies with young, healthy workers are self-insuring and opting out of regular health insurance market – Could destabilize small group insurance markets and erode protections provided by Affordable Care Act
How Will It All Turn Out? • States – About half of governors will expand Medicaid – About half won’t expand Medicaid
How Will It All Turn Out? • States – Will run exchange: 17 plus DC – Will partner with Feds: 7 – Will let Feds do exchange: 26
How Will It All Turn Out? • Providers – Merge and grow bigger – Integrated delivery systems like Kaiser and Geisinger are seen as models of low cost, high quality health care delivery – Will hospital consolidation reduce costs?
Report Card on Health Care Reform NY Times, March 24, 2013 • 6.6 million aged 19 to 25 insured • 71 million received free preventive service • 17 million kids with pre-existing condition insured • 107,000 adults with pre-existing conditions insured • Policies not canceled due to illness (10,000)
Report Card on Health Care Reform NY Times, March 24, 2013 • $11 billion over 5 years for community health centers • $5 billion reinsurance program to help companies retain retiree coverage • 2012 Insurers paid $1.1 billion in rebates • 6.3 million seniors have saved $6.1 billion on prescription drugs since 2010
Report Card on Health Care Reform NY Times, March 24, 2013 • Medicare Advantage premiums have fallen by 10% and enrollment up 28% since law passed • % Medicare patients being readmitted to hospital within 30 days dropped from 19% over past 5 years to 17.8% in last half of 2012 • Pilot projects
Payment Reform • Boards and Councils – Independent Payment Advisory Board – Federal Coordinating Council of Comparative Effectiveness Research • Health care delivery reform – Center for Medicare and Medicaid Innovation – Comparative effectiveness research panels – Multidisciplinary care teams – Electronic Health Records • Organization of Health Care Reform – ACOs – Medical homes – Baskets of care – Health information exchange • Payment Structure Reform – Bundled payments – Across the board payment reductions – Value based reimbursements
CMS The Physician Feedback/Value-Based Modifier Program • The Physician Quality and Research Use Reports (QRURs) • The Development and implementation of a Value-based Payment Modifier • Allows MD to compare quality and cost of CMS FFS patients’ care with that of other patients in Iowa, Kansas, Missouri, Nebraska
CMS The Physician Feedback/Value-Based Modifier Program • Medicare Improvements for Patients and Providers Act of 2008 • Extended by 2010 Affordable Care Act • CMS will use the value-based payment modifier to adjust CMS FFS payments to physicians based on the quality of care they furnish compared to the costs of such care
CMS The Physician Feedback/Value-Based Modifier Program • HHS Secretary will phase in program over a 2 year period beginning in 2015 • Beginning in 2017 the value based payment modifier will apply to all payments made under Medicare FFS payment schedule
CMS The Physician Feedback/Value-Based Modifier Program • All cost data in your report have been price standardized and risk adjusted to account for differences in patients’ age, gender, Medicaid eligibility, and history of medical conditions so we make apples to apples comparisons
CMS The Physician Feedback/Value-Based Modifier Program • COPD • Diabetes • Bone, joint, muscle • Gyn • Cancer • Heart conditions • HIV • Mental health • Prevention • Medication mangement
CMS The Physician Feedback/Value-Based Modifier Program • Patients whose care you directed: you billed 35% or more of all their outpatient E&M visits • Patients whose care you influenced: you billed less than 35% of outpatient E&M visits but 20% or more of their costs • Patients to whose care you contributed are those you billed less than 35% of visits and less than 20% of their total costs
Alternative Methods of Payment • Fee for service • FFS and shared savings • Episode payment • Partial comprehensive payment and P4P • Comprehensive (Global payment) • Capitation
Reducing Costs Without Rationing Is Also Quality Improvement! Healthy Continued Consumer Health Preventable No Condition Hospitalization Efficient Acute Care Successful Episode Outcome High-Cost Successful Outcome Complications, Infections, Readmissions
“Episode Payments” to Reward Value Within Episodes Healthy Continued Consumer Health Preventable No Condition Hospitalization Efficient Acute Care Successful Episode Outcome $ High-Cost Successful Episode Outcome Payment Complications, A Single Payment Infections, For All Care Needed (“Baskets Readmissions From All Providers in of Care”) the Episode, With a Warranty For Complications
Yes, a Health Care Provider Can Offer a Warranty Geisinger Health System ProvenCare SM – A single payment for an ENTIRE 90 day period including: • ALL related pre-admission care • ALL inpatient physician and hospital services • ALL related post-acute care • ALL care for any related complications or readmissions – Types of conditions/treatments currently offered: • Cardiac Bypass Surgery • Cardiac Stents • Cataract Surgery • Total Hip Replacement • Bariatric Surgery • Perinatal Care • Low Back Pain
Comprehensive Care Payments To Avoid Episodes Healthy Continued Consumer Health Preventable No Condition Hospitalization Efficient Acute Care Successful Episode Outcome $ High-Cost Comprehensive Successful Care Outcome Payment Complications, Infections, A Single or Readmissions Payment “Global” For All Care Payment Needed For A Condition
Isn’t This Capitation? No – It’s Different CAPITATION COMPREHENSIVE (WORST VERSIONS) CARE PAYMENT No Additional Revenue Payment Levels for Taking Sicker Adjusted Based on Patients Patient Conditions Providers Lose Money Limits on Total Risk On Unusually Expensive Providers Accept for Cases Unpredictable Events Providers Are Paid Bonuses/Penalties Regardless of the Quality Based on Quality of Care Measurement Provider Makes Provider Makes More Money If More Money If Patients Patients Stay Well Stay Well Flexibility to Deliver Highest-Value Flexibility to Deliver Services Highest-Value Services
New Roles & Responsibilities • Hospitals/Specialists – Reduce volume – Improve value • Primary care providers – Manage costs – Coordinate patient care • Consumers – Manage health, self care – Choose high-value care
New Roles & Responsibilities • Health plans • Change payment systems • Support providers • Purchasers • Change benefit designs • Pick value-based payers
ACOs: What Do They Mean for Emergency Medicine? http://www.acep.org/ACO/ • Emergency Room Utilization • Care Coordination • Financial Impact • Relationship with the Community
ACOs: What Do They Mean for Emergency Medicine? http://www.acep.org/ACO/ • Emergency Room Utilization – Prudent layperson standard of emergency – ACOs desire decreased inappropriate ED visits – EMTALA vs. ACO – Alternative sites of care will be encouraged
ACOs: What Do They Mean for Emergency Medicine? http://www.acep.org/ACO/ • Care Coordination – Triage systems will become more important – Call centers, telemedicine opportunity for growth? – Alternative sites of care (How to integrate with PC; will increase upfront cost of ACO) • Urgent care • Fast track units • Free standing EDs • Retail minute clinics
ACOs: What Do They Mean for Emergency Medicine? http://www.acep.org/ACO/ • Care Coordination – ED patients who are not admitted to hospital • Observation units • ED-run follow-up clinics • ED-run follow-up call centers • ED-run home health services • Next day community follow-up visits • Accepted community standards for COPD, CHF, cellulitis care
ACOs: What Do They Mean for Emergency Medicine? http://www.acep.org/ACO/ • Financial Impact on Emergency Medicine – Prepaid health plan models of 1980s, 1990s • 23% of premium went to PCP • 56% went to specialists (including EM) • 14% went to ancillary services • 7% went to administration • Emergency care services (facility + professional) less than 4% • Physician PMPM payment $0.44 to $1.50
ACOs: What Do They Mean for Emergency Medicine? http://www.acep.org/ACO/ • Relationship to the community – Small group of frequent flyers – Medical management in partnership with local community providers can decrease ED utilization – Camden, NJ – Henry Ford, Detroit – ED mission creep
EMR for ACOs Need 9 Capabilities Michelle McNicle, Healthcare IT New, 7/11/2012 • Sophisticated pt relationship management • Get data through business intelligence • Data integration for analytics capabilities • Granular clinical data sharing • Payer, billing and pricing data sharing • Aggregate data sharing • Sharing clinical effectiveness evidence • Population management • Change management
Launching ACOs Don Berwick, NEJM, March 31, 2011 • Fragmentation of payment & delivery • Nobody takes full responsibility for health of a patient or a community • Fragmentation leads to waste & duplication and unnecessarily high costs • Section 3022 of the ACA: Medicare Shared Savings Program for ACO as a solution
Pioneer ACO • CMS Innovation Center initiative • Experienced ACOs • More coordinated care/lower cost • Test different payment arrangements
Pioneer ACO • Request for Applications May 2011 • 32 Pioneer ACOs announced Dec 2011
Pioneer ACO • ACO professionals in group practice • Networks of individual practices of ACO professionals • Partnerships or joint ventures between hospitals and ACO professionals • Hospitals employing ACO professionals • Federally Qualified Health Centers
Pioneer ACO • Patients get full benefits under FFS Medicare • Patients have right to go to any provider • Quality measures mirror Shared Savings Program • By end of 2012 Pioneer ACO have at least 50% of PCP have met meaningful use of EHR for receipt of payments through Medicare and Medicaid
Iowa Health System/Wellmark Model • Attribute members to primary care only • Six domains around quality not 33 • Provider quality incentive in addition to shared savings opportunity • Governance much more simple than Medicare ACO
Florida Blue, Baptist Health South Florida, Advanced Medical Specialties • Oncology ACO • Coordinated care approach • Oncologists worried about decreasing reimbursement for cancer drugs from CMS • 500-1000 of Florida Blue’s commercial customers will be involved • Data intensive process • http://www.healthleadersmedia.com/page-1/LED-280059/Florida-Blue-Launches- Oncology-ACO
Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • 68 ACO relationships all over the USA • All are unique • Based on three strategies • Choosing the right partner • Sharing data • Embedding case manager in the practice
Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • Choosing the right partner • Physicians already working on quality and decreasing costs strategies • Chemistry • Large number of PCPs in group
Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • Sharing the data • Concentrate on actionable data • Process measures, outcomes measures, benchmarking information • Case manager is the key conduit for data exchange and use between Aetna and doctors
Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • Embedded case managers • Experienced nurses or social workers • Training in geriatrics, pain management, case management, terminal illness management, cultural sensitivity, patient engagement • Prevent disconnects from happening
Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • Results Aetna/NovaHealth Portland ME • Reduced inpatient days by 50% • Cut hospital admissions by 45% • 99% of patients visit doctor for prevention and follow-up care • Dropped total per member, per month costs by 33%
Kaiser Ids Gaps in MD Readiness for a Reformed Delivery System Crosson, Health Affairs, 2011 • Systems thinking • Leadership and management skills • Continuity of Care • Care coordination • Procedural skills • Office-based practice competencies – Inter-professional team skills – Clinical IT meaningful use skills – Population management skills – Reflective practice and CQI skills
AHA Physician Leadership Forum: Competency Development • Leadership Training • Systems theory and analysis • Use of information technology • Cross-disciplinary training/team building
AHA Physician Leadership Forum: Competency Development • Interpersonal and communication skills – Member of the team – Empathy/customer service – Time management – Conflict management/performance feedback – Cultural and economic diversity – Emotional intelligence • Additional education around – Population health management – End of Life/Palliative care – Resource management – Health policy and regulation
AHA Physician Leadership Forum: Competency Development: Gaps • Systems based practice: cost conscious, effective evidence based medical care • Communication skills: effective information exchange • Systems based practice: Coordinate care with other providers • Communication skills: Work effectively with other team members
AHA Physician Leadership Forum: Competency Development: Missing • Conflict management/performance feedback • End of life/palliative care • Systems theory and analysis • Customer service/patient experience • Use of informatics
The ACO Surprise http://www.oliverwyman.com/the-aco-surprise.htm#.ULTEfqXrWGU • 25 to 31 million get health care from ACOs • 2.4 million in CMS ACOs • 15 million non CMS patients in CMS ACOs • 8 to 14 million in non CMS ACOs • More than 40% live in primary care service areas with at least one ACO
Questions to Ponder in Each Community • Are we going to create an integrated delivery system where physicians, hospitals, long term care, home health, and allied health professionals assume risk for costs and outcomes? • Are we willing to make substantial investments in infrastructure and process work redesign to achieve coordinated, cost-effective, high quality care for our patients?
Questions to Ponder in Each Community • Do we know how to manage population-based outcomes and costs and do we know how to manage risk? • What are our core competencies and what are the core competencies of potential strategic partners? • We should think about which of the CMS initiatives make the most sense for success in our local community.
LarsonAllen Expects 7 Themes • Providers will be asked to accept greater financial risk for outcomes • Operational efficiency will be critical • Collaboration among all providers to survive • Investments in technology will be needed • Increased quality expectations, reporting, and monitoring • Elevated regulatory risk • Increased focus on community-based services and care
Can ACOs Improve Health While Reducing Costs? WSJ, 1/23/2012 • Jeff Goldsmith and Tom Scully • ACO is Exhibit A in yawning disconnect between policy world and the real world • ACO is like asking the hungry horse to guard the granary. To get the savings hospitals and their specialists have to turn their backs on five decades of making more by doing more
Can ACOs Improve Health While Reducing Costs? WSJ, 1/23/2012 • The ACO actually looks like a terrible business deal for providers • The patient’s role is the biggest problem with the ACO – Patients need to be active agents in their health – Patients need to choose to participate – Patients need to be rewarded for healthy actions – In ACOs patients do not choose to participate
Can ACOs Improve Health While Reducing Costs? WSJ, 1/23/2012 • The biggest flaw with ACOs is more power to hospitals, not doctors • Start up cost of ACO is $30 million • Regional hospital based oligopolies – not good for doctors, patients, or saving money
Disease Management Care Blog http://diseasemanagementcareblog.blogspot.com/2013/03/aco-market-dominance-whats- happening-at.html • Jaan Sidorov, MD • FTC & Idaho attorney general file antitrust challenge to unravel 3 month old acquisition of Saltzer Medical Group by St. Lukes • Trinity Health vs. St. Lukes law suit • “The result of the acquisition will be higher prices for the services that those physicians provide.”
Can ACOs Improve Health While Reducing Costs? WSJ, 1/23/2012 • The ACO reminds me of the “backyard steel mill” initiative during Mao’s disastrous Great leap forward during the 1950s…. This effort ignored the scale economies and quality controls required to make steel efficiently. Having each community, large and small, set up its own ACO is like setting up a backyard steel mill.
The Coming Failure of Accountable Care WSJ 2/18/2013 • Clay Christensen, Jeffrey Flier (Dean, Harvard Medical School) • Untenable assumption is ACOs will be successful without major changes in doctors’ behavior • Mistaken assumption is ACOs can succeed without changing patient behavior
The Coming Failure of Accountable Care WSJ 2/18/2013 • Patient behavior – Medicare patients can go where they want – No preferential pricing to steer patients to most effective providers – Patients do not have to comply with recommended treatment or lifestyle changes
The Coming Failure of Accountable Care WSJ 2/18/2013 • Third flawed assumption is ACOs will save money – CBO estimates of full impact of Pioneer ACOs $1.1 billion over five years ($468 billion CMS) – Only 2 of Physicians’ Group Practice from 2005 to 2010 generated savings in all 5 years – Marshfield Clinic ½ total savings for all 10 – Park Nicollet despite 30 years of managed care experience got only a single year of savings
Outpatient Intensivist Medical Teams • University of New Mexico ECHO Project • $8.5 million grant from HHS Innovation • 5000 high cost, high utilization, high severity patients in NM, Washington State • Out patient intensivist teams of nurse practitioners, case managers, counselors, community health workers
California Quality Collaborative Intensive Outpatient Care • Care Manager – Patient panel of 200 – Practice panel of 15 MDs maximum – Primary partner for patient – 24/7 access – Rules-based contacts, bidirectional patient contact at least monthly
California Quality Collaborative Intensive Outpatient Care • Primary care intensivist – Physician – Email/phone access for patients – Same day access for patients
California Quality Collaborative Intensive Outpatient Care • Coordination with ED/Hospital – Same day notification of patients in ED – 48 hour post discharge contact with patient
HHS Care Innovations Summit • Alan Hoops, Chairman and CEO, CareMore • Many frail patients have average of 11 MDs • 20% of frail pop generates 60% of costs • Costs in last year of life increases 7 fold • Low patient compliance with chronic care management protocols
HHS Care Innovations Summit • Frail and Chronically Ill Patients – Strength and training program – Home care – Mental health programs – Social Services – Podiatry – Palliative Care – Wellness
HHS Care Innovations Summit • Speed of action • Intimacy of Contact – Requires constant knowledge of patient’s condition • Proactive intervention – Integration & coordination of care not voluntary
HHS Care Innovations Summit • Frail and Chronically Ill Patients – CareMore Care Center – Case Managers • Results Bed Days Per 1000 – CareMore 2004: 965 – CareMore 2005: 940 – CareMore 2006: 1076 – CareMore 2007: 1085 – Industry Average: 1450

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Medicine in 21st Century USA -- Kent Bottles, MD

  • 1.
    EmCare Leadership Conference Kent Bottles, MD 610 639 4956 www.kentbottlesmd.com kent@kentbottlesmd.com April 4, 2013 Las Vegas, Nevada
  • 2.
    The Affordable CareAct http://www.nytimes.com/2012/04/03/health/policy/the-abcs-of-the-health-care-law-and-its- future.html • Series of policies, regulations, subsidies, and mandates that builds upon the incoherent medical system of public & private insurance • Most important health care law since enactment of Medicaid & Medicare in 1965 • 70,000 pages of guidance from HHS
  • 3.
    Affordable Care Act •Medicare, Medicaid, VA, CHIP, FEHIP retained • Employer furnished insurance retained (>50 employees must offer insurance) • Individual mandate • Fed subsidies to those too poor to pay • Insurance exchanges in each state
  • 4.
    Two Intertwined Goals Reform the health care delivery and payment system to provide better care in a more cost-efficient manner Goals Make better health insurance coverage more available and affordable for legal residents
  • 5.
    In 2009 .. . • 50+ million (about 17%) uninsured • Remaining 254 million – 93 million on government programs o 43 million on Medicare o 48 million on Medicaid – 195 million (56%) have private coverage o 87% through employment o Lowest rate since recordkeeping began o About 10% underinsured
  • 6.
    . . .by 2016 • Reduce number of uninsured to 22 million – 2010-2013: no significant change – 2014: down to 34 million – 2015: down to 28 million – 2016: down to 22 million • 1/3 remaining uninsured = undocumented immigrants
  • 7.
    Seven-Part Solution Offer incentives to expand coverage Control rising costs Regulate health plan coverage Solution Impose individual mandate Establish health insurance exchanges Impose employer penalties Expand Medicaid
  • 8.
    Solution No. 1: OfferIncentives to Expand Coverage • Temporary high-risk pools • Early retiree reinsurance program • Tax credits for small employers – Cover at least 50% of health insurance costs – Fewer than 25 FTEs, average wage less than $50,000 – Credit = up to 35% of costs thru 2013; 50% thereafter
  • 9.
    Solution No. 2: Control Rising Costs • State grants for health insurance premium reviews • Cost containment – Medicare savings of $500 billion over 10 years • Comparative effectiveness studies • Voluntary shared savings through ACO • Bundled payment pilots • Reimbursing physicians based on quality performance
  • 10.
    Solution No. 3:Regulate Health Plan Coverage All Plans – Now In Effect • No lifetime limits on “essential benefits” • Tighter restrictions on annual limits • No rescission of coverage, except for fraud or intentional misrepresentation • Kids covered through 26th birthday • No pre-existing condition exclusions for kids <19 • Automatic enrollment of full-time employees – 200+ FTE; subject to employee opt-out
  • 11.
    Regulate Health PlanCoverage Guarantee Issue and Renewal • Effective January 1, 2014 • Premium costs differ solely based on: – Age (3:1) – Tobacco use (1.5:1) – Family composition – Geographic location
  • 12.
    Solution No. 4: Impose Individual Mandate • Maintain “minimum essential coverage” unless… – Coverage costs >8% monthly income – Income below the tax filing threshold – Religious objection – Native American • 3 alternatives – Employer/union-sponsored plan – Purchase individual insurance through exchange – Qualify for federal health care program
  • 13.
    Impose Individual Mandate Enforcement • Pay penalty on federal tax return if fail to maintain health insurance for 3+ months • By 2016, penalty = greater of – $695 per person (up to $2,085 per family) – 2.5% of adjusted household income • Failure to pay = lien against future tax refunds – No criminal enforcement – No civil penalties
  • 14.
    Solution No. 5: EstablishHealth Insurance Exchanges • Each state to establish by 2014 (or feds step in) • Individual and small employer market – Expand to larger employers in 2017 • “Essential health benefits package” – Policy must provide essential benefits – Cost-sharing provisions must not exceed HSA out-of- pocket limits (currently, $5,950 single/$11,900 family) – Annual deductible capped at $4,000 family/$2,000 single
  • 15.
    Establish Health InsuranceExchanges Individual Tax Credit • May be used only to purchase coverage through Exchange • Qualify if household income is 100-400% of FPL – Unless eligible for Medicaid or employer-sponsored coverage (except if employer pays less than 60% of total benefit costs) – Amount of credit varies with household income and cost of Exchange-provided coverage • Also eligible for cost-sharing reductions • Impact of Medicaid “opt-out”
  • 16.
    Solution No. 6: ImposeEmployer Penalties Source: CRS analysis of P.L. 111-148 and P.L. 111-152.
  • 17.
    Solution No. 7: Medicaid Expansion • Starting in 2014, state that expands Medicaid eligibility to 133% FPL will receive higher FMAP for newly eligible – 100% in 2014-16; 95% in 2017; 94% in 2018; 93% in 2019; 90% in 2020+ – Administrative costs still 50/50 • Coverage must be at least as good as the minimum essential health benefits available through Exchanges
  • 18.
    Medicaid Expansion Impact on Hospitals • Less-than-expected decline in uncompensated care • Reductions in DSH payments – Medicaid DSH reduced 50% by 2019 o HHS has not yet published methodology – Medicare DSH reduced 75% in 2014 (with some amount returned based on documented uncompensated care)
  • 19.
    Medicaid Expansion inPA • Governor Corbett turns down expansion • Will not add 500,000 to Medicaid • Cost to PA of $2.8 billion • $37.8 billion in federal funds refused • Governor Kasich of Ohio is participating in Medicaid expansion
  • 20.
    Deloitte Health CareReform Memo, January 7, 2013 • Implementation of the ACA in 2013 • Clarity • Costs • Compliance • Consolidation • Consumers
  • 21.
    Deloitte Health CareReform Memo, January 7, 2013 • Clarity – SCOTUS affirmed ACA – November election winner Obama – States decide on exchanges – States decide on Medicaid expansion
  • 22.
    Deloitte Health CareReform Memo, January 7, 2013 • Costs ($992 billion in waste; 47%) – Health care costs seen as cause of debt crisis – Failure of care delivery…$154 billion – Failure of coordination.….$45 billion – Overtreatment……………$226 billion – Administration waste…….$389 billion – Pricing failures…….…..…$178 billion – Fraud and abuse………….$272 billion
  • 23.
    Bending the CostCurve through Market-Based Incentives • Medicare premium support replaces defined benefit to be used to purchase insurance • Convert tax subsidy for employer insurance to predetermined refundable credit • Transition from fee for service to bundled payments • High option plan for Medicare
  • 24.
    Bending the CostCurve through Market-Based Incentives • Regional Medicare plans to encourage greater entrepreneurship • Health insurance exchanges without “heavy regulation imposed by ACA”
  • 25.
    A Systematic Approachto Containing Health Care Spending • Model of state self regulation with spending targets where public & private payers negotiate payment rates with providers • Replace fee-for-service with bundled and global payments • Medicare competitive bidding for med devices, lab tests, X-rays, etc
  • 26.
    A Systematic Approachto Containing Health Care Spending • Insurers should offer tiered plans with lower copays if pt chooses high value providers • Payers & providers electronically exchange eligibility, claims, etc • Single standardized MD credentialing • Price transparency • Non physician providers should practice to full extent of their training
  • 27.
    If Consumer PricesHad Risen as Much as Healthcare since 1945 • A dozen eggs would cost $55.00 • A dozen oranges would cost $134.00 • A gallon of milk would cost $48.00
  • 28.
    Why Health CareCosts So Much http://www.kaiserhealthnews.org/Stories/2012/October/25/health-care-costs.aspx • FFS payments to doctors, hospitals reward volume rather than value • Demographics: older, sicker, fatter • Pogo: We want new stuff • Tax breaks on health insurance; cost to patient low • Lack of information to become savvy shopper • Hospitals gaining market share; demand higher prices • Supply and demand problems, legal issues make it hard to slow spending
  • 29.
    Health Care: TheDisquieting Truth • We spend $2.5 trillion on healthcare • Without control, federal budget deficit & national debt will continue to grow • US spends 2.5 times per person what counterparts in Europe spend • We spend more than enough to give good care; the problem is the system not lack of money Arnold Relman, NYRB, September 30, 2010
  • 30.
    Ezekiel Emanuel’s $2Trillion http://blog.lib.umn.edu/schwitz/healthnews/182728.html • 1 million seconds: less than 2 weeks ago • 1 billion seconds: 1974 • 1 trillion seconds: 30,000 BC
  • 31.
    White House SequesterHealth Cuts • CMS Supplemental Medical Insurance Trust Fund: $5.2 billion • CMS Hospital Ins. Trust Fund: $5.8 billion • CMS Part D: $591 million
  • 32.
    White House SequesterHealth Cuts • CDC: $464 million • Substance Abuse & Mental Health Services Administration: $275 million • FDA: $318 million • NIH: $2.5 billion • Indian Health Services: $320 million
  • 33.
    Deloitte Health CareReform Memo, January 7, 2013 • Consolidation – Close to 100 hospital acquisitions in 2012 – Medical group deals increased 60% – Physicians fleeing private practice for employment with large ACOS, IDN – “Go big or get out”
  • 34.
    Deloitte Health CareReform Memo, January 7, 2013 • Compliance – US invested $102 million to detect Medicaid fraud – Limit physician self referral – Health plan regulation under the ACA – Clinically unnecessary procedures and tests
  • 35.
    Deloitte Health CareReform Memo, January 7, 2013 • Consumers – Mobile apps enable comparison of treatment options, costs, and providers who adhere EBM – High deductible plans & individual insurance market will drive price & quality sensitivity – Transparency will demand access to performance data from health plans, hospitals, physicians, pharma, long-term care providers
  • 36.
    How Will ItAll Turn Out? • Consumers • Employers • States • Health Care Providers
  • 37.
    How Will ItAll Turn Out? • Consumers – For the 55% with employer insurance & 32% with government program not much changes – Challenge is getting 18 million young adults who don’t have insurance to obtain it. – If young and healthy are not in risk pool the math will not work
  • 38.
    How Will ItAll Turn Out? • Employers – Most will wait and see – Employers with more than 50 workers will have to offer insurance to those working 30 hours a week or more – CBO estimates 8 million fewer workers (5%) will get insurance through employers in 5 years
  • 39.
    How Will ItAll Turn Out? • Employers – Robert Pear, NY Times, Feb 18, 2013, A9 – Companies with young, healthy workers are self-insuring and opting out of regular health insurance market – Could destabilize small group insurance markets and erode protections provided by Affordable Care Act
  • 40.
    How Will ItAll Turn Out? • States – About half of governors will expand Medicaid – About half won’t expand Medicaid
  • 41.
    How Will ItAll Turn Out? • States – Will run exchange: 17 plus DC – Will partner with Feds: 7 – Will let Feds do exchange: 26
  • 42.
    How Will ItAll Turn Out? • Providers – Merge and grow bigger – Integrated delivery systems like Kaiser and Geisinger are seen as models of low cost, high quality health care delivery – Will hospital consolidation reduce costs?
  • 43.
    Report Card onHealth Care Reform NY Times, March 24, 2013 • 6.6 million aged 19 to 25 insured • 71 million received free preventive service • 17 million kids with pre-existing condition insured • 107,000 adults with pre-existing conditions insured • Policies not canceled due to illness (10,000)
  • 44.
    Report Card onHealth Care Reform NY Times, March 24, 2013 • $11 billion over 5 years for community health centers • $5 billion reinsurance program to help companies retain retiree coverage • 2012 Insurers paid $1.1 billion in rebates • 6.3 million seniors have saved $6.1 billion on prescription drugs since 2010
  • 45.
    Report Card onHealth Care Reform NY Times, March 24, 2013 • Medicare Advantage premiums have fallen by 10% and enrollment up 28% since law passed • % Medicare patients being readmitted to hospital within 30 days dropped from 19% over past 5 years to 17.8% in last half of 2012 • Pilot projects
  • 46.
    Payment Reform • Boards and Councils – Independent Payment Advisory Board – Federal Coordinating Council of Comparative Effectiveness Research • Health care delivery reform – Center for Medicare and Medicaid Innovation – Comparative effectiveness research panels – Multidisciplinary care teams – Electronic Health Records • Organization of Health Care Reform – ACOs – Medical homes – Baskets of care – Health information exchange • Payment Structure Reform – Bundled payments – Across the board payment reductions – Value based reimbursements
  • 47.
    CMS The Physician Feedback/Value-BasedModifier Program • The Physician Quality and Research Use Reports (QRURs) • The Development and implementation of a Value-based Payment Modifier • Allows MD to compare quality and cost of CMS FFS patients’ care with that of other patients in Iowa, Kansas, Missouri, Nebraska
  • 48.
    CMS The Physician Feedback/Value-BasedModifier Program • Medicare Improvements for Patients and Providers Act of 2008 • Extended by 2010 Affordable Care Act • CMS will use the value-based payment modifier to adjust CMS FFS payments to physicians based on the quality of care they furnish compared to the costs of such care
  • 49.
    CMS The Physician Feedback/Value-BasedModifier Program • HHS Secretary will phase in program over a 2 year period beginning in 2015 • Beginning in 2017 the value based payment modifier will apply to all payments made under Medicare FFS payment schedule
  • 50.
    CMS The Physician Feedback/Value-BasedModifier Program • All cost data in your report have been price standardized and risk adjusted to account for differences in patients’ age, gender, Medicaid eligibility, and history of medical conditions so we make apples to apples comparisons
  • 51.
    CMS The Physician Feedback/Value-BasedModifier Program • COPD • Diabetes • Bone, joint, muscle • Gyn • Cancer • Heart conditions • HIV • Mental health • Prevention • Medication mangement
  • 52.
    CMS The Physician Feedback/Value-BasedModifier Program • Patients whose care you directed: you billed 35% or more of all their outpatient E&M visits • Patients whose care you influenced: you billed less than 35% of outpatient E&M visits but 20% or more of their costs • Patients to whose care you contributed are those you billed less than 35% of visits and less than 20% of their total costs
  • 54.
    Alternative Methods ofPayment • Fee for service • FFS and shared savings • Episode payment • Partial comprehensive payment and P4P • Comprehensive (Global payment) • Capitation
  • 55.
    Reducing Costs WithoutRationing Is Also Quality Improvement! Healthy Continued Consumer Health Preventable No Condition Hospitalization Efficient Acute Care Successful Episode Outcome High-Cost Successful Outcome Complications, Infections, Readmissions
  • 56.
    “Episode Payments” toReward Value Within Episodes Healthy Continued Consumer Health Preventable No Condition Hospitalization Efficient Acute Care Successful Episode Outcome $ High-Cost Successful Episode Outcome Payment Complications, A Single Payment Infections, For All Care Needed (“Baskets Readmissions From All Providers in of Care”) the Episode, With a Warranty For Complications
  • 57.
    Yes, a HealthCare Provider Can Offer a Warranty Geisinger Health System ProvenCare SM – A single payment for an ENTIRE 90 day period including: • ALL related pre-admission care • ALL inpatient physician and hospital services • ALL related post-acute care • ALL care for any related complications or readmissions – Types of conditions/treatments currently offered: • Cardiac Bypass Surgery • Cardiac Stents • Cataract Surgery • Total Hip Replacement • Bariatric Surgery • Perinatal Care • Low Back Pain
  • 58.
    Comprehensive Care Payments To Avoid Episodes Healthy Continued Consumer Health Preventable No Condition Hospitalization Efficient Acute Care Successful Episode Outcome $ High-Cost Comprehensive Successful Care Outcome Payment Complications, Infections, A Single or Readmissions Payment “Global” For All Care Payment Needed For A Condition
  • 59.
    Isn’t This Capitation? No – It’s Different CAPITATION COMPREHENSIVE (WORST VERSIONS) CARE PAYMENT No Additional Revenue Payment Levels for Taking Sicker Adjusted Based on Patients Patient Conditions Providers Lose Money Limits on Total Risk On Unusually Expensive Providers Accept for Cases Unpredictable Events Providers Are Paid Bonuses/Penalties Regardless of the Quality Based on Quality of Care Measurement Provider Makes Provider Makes More Money If More Money If Patients Patients Stay Well Stay Well Flexibility to Deliver Highest-Value Flexibility to Deliver Services Highest-Value Services
  • 60.
    New Roles &Responsibilities • Hospitals/Specialists – Reduce volume – Improve value • Primary care providers – Manage costs – Coordinate patient care • Consumers – Manage health, self care – Choose high-value care
  • 61.
    New Roles &Responsibilities • Health plans • Change payment systems • Support providers • Purchasers • Change benefit designs • Pick value-based payers
  • 62.
    ACOs: What DoThey Mean for Emergency Medicine? http://www.acep.org/ACO/ • Emergency Room Utilization • Care Coordination • Financial Impact • Relationship with the Community
  • 63.
    ACOs: What DoThey Mean for Emergency Medicine? http://www.acep.org/ACO/ • Emergency Room Utilization – Prudent layperson standard of emergency – ACOs desire decreased inappropriate ED visits – EMTALA vs. ACO – Alternative sites of care will be encouraged
  • 64.
    ACOs: What DoThey Mean for Emergency Medicine? http://www.acep.org/ACO/ • Care Coordination – Triage systems will become more important – Call centers, telemedicine opportunity for growth? – Alternative sites of care (How to integrate with PC; will increase upfront cost of ACO) • Urgent care • Fast track units • Free standing EDs • Retail minute clinics
  • 65.
    ACOs: What DoThey Mean for Emergency Medicine? http://www.acep.org/ACO/ • Care Coordination – ED patients who are not admitted to hospital • Observation units • ED-run follow-up clinics • ED-run follow-up call centers • ED-run home health services • Next day community follow-up visits • Accepted community standards for COPD, CHF, cellulitis care
  • 66.
    ACOs: What DoThey Mean for Emergency Medicine? http://www.acep.org/ACO/ • Financial Impact on Emergency Medicine – Prepaid health plan models of 1980s, 1990s • 23% of premium went to PCP • 56% went to specialists (including EM) • 14% went to ancillary services • 7% went to administration • Emergency care services (facility + professional) less than 4% • Physician PMPM payment $0.44 to $1.50
  • 67.
    ACOs: What DoThey Mean for Emergency Medicine? http://www.acep.org/ACO/ • Relationship to the community – Small group of frequent flyers – Medical management in partnership with local community providers can decrease ED utilization – Camden, NJ – Henry Ford, Detroit – ED mission creep
  • 68.
    EMR for ACOsNeed 9 Capabilities Michelle McNicle, Healthcare IT New, 7/11/2012 • Sophisticated pt relationship management • Get data through business intelligence • Data integration for analytics capabilities • Granular clinical data sharing • Payer, billing and pricing data sharing • Aggregate data sharing • Sharing clinical effectiveness evidence • Population management • Change management
  • 69.
    Launching ACOs Don Berwick, NEJM, March 31, 2011 • Fragmentation of payment & delivery • Nobody takes full responsibility for health of a patient or a community • Fragmentation leads to waste & duplication and unnecessarily high costs • Section 3022 of the ACA: Medicare Shared Savings Program for ACO as a solution
  • 70.
    Pioneer ACO • CMS Innovation Center initiative • Experienced ACOs • More coordinated care/lower cost • Test different payment arrangements
  • 71.
    Pioneer ACO • Requestfor Applications May 2011 • 32 Pioneer ACOs announced Dec 2011
  • 72.
    Pioneer ACO • ACOprofessionals in group practice • Networks of individual practices of ACO professionals • Partnerships or joint ventures between hospitals and ACO professionals • Hospitals employing ACO professionals • Federally Qualified Health Centers
  • 73.
    Pioneer ACO • Patients get full benefits under FFS Medicare • Patients have right to go to any provider • Quality measures mirror Shared Savings Program • By end of 2012 Pioneer ACO have at least 50% of PCP have met meaningful use of EHR for receipt of payments through Medicare and Medicaid
  • 74.
    Iowa Health System/Wellmark Model • Attribute members to primary care only • Six domains around quality not 33 • Provider quality incentive in addition to shared savings opportunity • Governance much more simple than Medicare ACO
  • 75.
    Florida Blue, BaptistHealth South Florida, Advanced Medical Specialties • Oncology ACO • Coordinated care approach • Oncologists worried about decreasing reimbursement for cancer drugs from CMS • 500-1000 of Florida Blue’s commercial customers will be involved • Data intensive process • http://www.healthleadersmedia.com/page-1/LED-280059/Florida-Blue-Launches- Oncology-ACO
  • 76.
    Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • 68 ACO relationships all over the USA • All are unique • Based on three strategies • Choosing the right partner • Sharing data • Embedding case manager in the practice
  • 77.
    Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • Choosing the right partner • Physicians already working on quality and decreasing costs strategies • Chemistry • Large number of PCPs in group
  • 78.
    Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • Sharing the data • Concentrate on actionable data • Process measures, outcomes measures, benchmarking information • Case manager is the key conduit for data exchange and use between Aetna and doctors
  • 79.
    Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • Embedded case managers • Experienced nurses or social workers • Training in geriatrics, pain management, case management, terminal illness management, cultural sensitivity, patient engagement • Prevent disconnects from happening
  • 80.
    Aetna ACO Strategy http://www.fiercehealthpayer.com/special-reports/3-effective-aetna-aco-strategies?utm_campaign=twitter-Share-NL • Results Aetna/NovaHealth Portland ME • Reduced inpatient days by 50% • Cut hospital admissions by 45% • 99% of patients visit doctor for prevention and follow-up care • Dropped total per member, per month costs by 33%
  • 81.
    Kaiser Ids Gapsin MD Readiness for a Reformed Delivery System Crosson, Health Affairs, 2011 • Systems thinking • Leadership and management skills • Continuity of Care • Care coordination • Procedural skills • Office-based practice competencies – Inter-professional team skills – Clinical IT meaningful use skills – Population management skills – Reflective practice and CQI skills
  • 82.
    AHA Physician LeadershipForum: Competency Development • Leadership Training • Systems theory and analysis • Use of information technology • Cross-disciplinary training/team building
  • 83.
    AHA Physician LeadershipForum: Competency Development • Interpersonal and communication skills – Member of the team – Empathy/customer service – Time management – Conflict management/performance feedback – Cultural and economic diversity – Emotional intelligence • Additional education around – Population health management – End of Life/Palliative care – Resource management – Health policy and regulation
  • 84.
    AHA Physician LeadershipForum: Competency Development: Gaps • Systems based practice: cost conscious, effective evidence based medical care • Communication skills: effective information exchange • Systems based practice: Coordinate care with other providers • Communication skills: Work effectively with other team members
  • 85.
    AHA Physician LeadershipForum: Competency Development: Missing • Conflict management/performance feedback • End of life/palliative care • Systems theory and analysis • Customer service/patient experience • Use of informatics
  • 86.
    The ACO Surprise http://www.oliverwyman.com/the-aco-surprise.htm#.ULTEfqXrWGU • 25 to 31 million get health care from ACOs • 2.4 million in CMS ACOs • 15 million non CMS patients in CMS ACOs • 8 to 14 million in non CMS ACOs • More than 40% live in primary care service areas with at least one ACO
  • 87.
    Questions to Ponderin Each Community • Are we going to create an integrated delivery system where physicians, hospitals, long term care, home health, and allied health professionals assume risk for costs and outcomes? • Are we willing to make substantial investments in infrastructure and process work redesign to achieve coordinated, cost-effective, high quality care for our patients?
  • 88.
    Questions to Ponderin Each Community • Do we know how to manage population-based outcomes and costs and do we know how to manage risk? • What are our core competencies and what are the core competencies of potential strategic partners? • We should think about which of the CMS initiatives make the most sense for success in our local community.
  • 89.
    LarsonAllen Expects 7Themes • Providers will be asked to accept greater financial risk for outcomes • Operational efficiency will be critical • Collaboration among all providers to survive • Investments in technology will be needed • Increased quality expectations, reporting, and monitoring • Elevated regulatory risk • Increased focus on community-based services and care
  • 90.
    Can ACOs ImproveHealth While Reducing Costs? WSJ, 1/23/2012 • Jeff Goldsmith and Tom Scully • ACO is Exhibit A in yawning disconnect between policy world and the real world • ACO is like asking the hungry horse to guard the granary. To get the savings hospitals and their specialists have to turn their backs on five decades of making more by doing more
  • 91.
    Can ACOs ImproveHealth While Reducing Costs? WSJ, 1/23/2012 • The ACO actually looks like a terrible business deal for providers • The patient’s role is the biggest problem with the ACO – Patients need to be active agents in their health – Patients need to choose to participate – Patients need to be rewarded for healthy actions – In ACOs patients do not choose to participate
  • 92.
    Can ACOs ImproveHealth While Reducing Costs? WSJ, 1/23/2012 • The biggest flaw with ACOs is more power to hospitals, not doctors • Start up cost of ACO is $30 million • Regional hospital based oligopolies – not good for doctors, patients, or saving money
  • 93.
    Disease Management CareBlog http://diseasemanagementcareblog.blogspot.com/2013/03/aco-market-dominance-whats- happening-at.html • Jaan Sidorov, MD • FTC & Idaho attorney general file antitrust challenge to unravel 3 month old acquisition of Saltzer Medical Group by St. Lukes • Trinity Health vs. St. Lukes law suit • “The result of the acquisition will be higher prices for the services that those physicians provide.”
  • 94.
    Can ACOs ImproveHealth While Reducing Costs? WSJ, 1/23/2012 • The ACO reminds me of the “backyard steel mill” initiative during Mao’s disastrous Great leap forward during the 1950s…. This effort ignored the scale economies and quality controls required to make steel efficiently. Having each community, large and small, set up its own ACO is like setting up a backyard steel mill.
  • 95.
    The Coming Failureof Accountable Care WSJ 2/18/2013 • Clay Christensen, Jeffrey Flier (Dean, Harvard Medical School) • Untenable assumption is ACOs will be successful without major changes in doctors’ behavior • Mistaken assumption is ACOs can succeed without changing patient behavior
  • 96.
    The Coming Failureof Accountable Care WSJ 2/18/2013 • Patient behavior – Medicare patients can go where they want – No preferential pricing to steer patients to most effective providers – Patients do not have to comply with recommended treatment or lifestyle changes
  • 97.
    The Coming Failureof Accountable Care WSJ 2/18/2013 • Third flawed assumption is ACOs will save money – CBO estimates of full impact of Pioneer ACOs $1.1 billion over five years ($468 billion CMS) – Only 2 of Physicians’ Group Practice from 2005 to 2010 generated savings in all 5 years – Marshfield Clinic ½ total savings for all 10 – Park Nicollet despite 30 years of managed care experience got only a single year of savings
  • 98.
    Outpatient Intensivist Medical Teams • University of New Mexico ECHO Project • $8.5 million grant from HHS Innovation • 5000 high cost, high utilization, high severity patients in NM, Washington State • Out patient intensivist teams of nurse practitioners, case managers, counselors, community health workers
  • 99.
    California Quality Collaborative Intensive Outpatient Care • Care Manager – Patient panel of 200 – Practice panel of 15 MDs maximum – Primary partner for patient – 24/7 access – Rules-based contacts, bidirectional patient contact at least monthly
  • 100.
    California Quality Collaborative Intensive Outpatient Care • Primary care intensivist – Physician – Email/phone access for patients – Same day access for patients
  • 101.
    California Quality Collaborative Intensive Outpatient Care • Coordination with ED/Hospital – Same day notification of patients in ED – 48 hour post discharge contact with patient
  • 102.
    HHS Care InnovationsSummit • Alan Hoops, Chairman and CEO, CareMore • Many frail patients have average of 11 MDs • 20% of frail pop generates 60% of costs • Costs in last year of life increases 7 fold • Low patient compliance with chronic care management protocols
  • 103.
    HHS Care InnovationsSummit • Frail and Chronically Ill Patients – Strength and training program – Home care – Mental health programs – Social Services – Podiatry – Palliative Care – Wellness
  • 104.
    HHS Care InnovationsSummit • Speed of action • Intimacy of Contact – Requires constant knowledge of patient’s condition • Proactive intervention – Integration & coordination of care not voluntary
  • 105.
    HHS Care InnovationsSummit • Frail and Chronically Ill Patients – CareMore Care Center – Case Managers • Results Bed Days Per 1000 – CareMore 2004: 965 – CareMore 2005: 940 – CareMore 2006: 1076 – CareMore 2007: 1085 – Industry Average: 1450