The document discusses leading health care by focusing on sustainability, profitability, and survival. It notes that health care is currently between the standardized procedures and automation phases of industry development seen in other sectors like aviation. Successful management requires data analysis, stakeholder alignment, and care redesign to improve outcomes, reduce costs, and manage utilization across the care continuum.

1. LEADING HEALTH CARE
TOMORROW…
SUSTAINABILITY, PROFITABILITY, SURVIVAL
David Jacofsky, MD

3. "The concept is interesting and well-
formed, but in order to earn better than
a 'C', the idea must be feasible”
A Yale University management professor in
response to Fred Smith's paper proposing
reliable overnight delivery service.

5. THE INVERSE RELATIONSHIP

6. WE MAY BE GOOD…BUT WE COULD BE
BETTER!
1278

7. AVERAGE HOSPITAL INPATIENT CHARGES:
MS-DRG 470 IN 2011
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-05-08.html
2011 National Average: $50,116
Despite clear evidence that orthopedic conditions can be improved significantly
with standardized care, measured outcomes, and unique payment models, there is
still wide variation in orthopedic care patterns.

8. INDUSTRY DYNAMICS
Changing
Payment
Systems
Efficiency
Pressures
Lack of
Physician
Alignment
Decreasing
Margins &
Quality

9. SUCCESS REQUIRES A
SERVICE LINE MANAGEMENT PLATFORM
Must develop an outcomes management
platform proven to:
– Improve outcomes
– Reduce the cost of care
– Manage post-acute utilization
– Improve provider compliance with quality metrics
– Integrate physicians and hospital partners across
the continuum of musculoskeletal care
– Ultimately cannibalize your own volume

10. KEY COMPONENTS
Data
Analysis
• Leading indicators
• Outcomes Metrics
• Understanding CMS Data
• Data analysis
• Alignment structure/strategy in
place and working
• Physicians, post-acute
providers, consultants, etc.
• Assessment of current
process
• Development of new
process
• Implementation and
sustaining care continuum
Stakeholder
Alignment
Care
Redesign
The most successful care management programs
will have all three foundational components.

11. TO SURVIVE AS A COMPANY…
“…requires a part R&D and a part fortune teller.
Companies that survive predict what consumers
will want or need a full 3 years before consumers
realize it…”

12. GERARD J. TELLIS
• Unrelenting Innovation
– “Organizations are in greatest danger of failing when they’re at the peak of their success”
– “Market dominance can be a curse that blinds companies to the next big innovation or process change
on the horizon.”
• Studied 770 companies across 15 countries
• Research found that success over the long haul is NOT related to:
– Size
– Number of patents
– Dollars invested into R&D
• Research found that success over the long haul IS related to:
– A “culture of innovation”
– An appetite for risk
– Reward for radical and fresh thinking
– A focus on the future, not the past
– Willingness to put current business at risk
“Creating a culture designed to cannibalize currently successful products is
the only way to go. Trying to buy that kind of culture usually doesn’t work”

13. WHAT TO EXPECT IN
HEALTHCARE SHOULD BE
ANALOGOUS TO THE PATH SEEN
IN OTHER INDUSTRIES…

14. 5 PHASES OF INDUSTRY DEVELOPMENT
• Craft/Art
• Rules plus Instruments
• Standardized Procedures
• Automation
• Computer Integration

15. EXAMPLES OF SOME INDUSTRIES
• Airlines
• Firearms Safety
• Manufacturing
• Communications
• Finance
• National Security

16. AVIATION AS AN EXAMPLE
• Failures are defined by complications called crashes
• Began in 1903 – Wright Brothers
• Between 1930 and 2010 accident risk decreased by
over 6 orders of magnitude (1,000,000 fold)
• During the same period, infant mortality rates
decreased by only 30 fold
• When the Army Air Corps took over flying the airmail
in 1934, in 78 days of operation it had 66 accidents and
12 fatalities
• Experts believe that up to 80% is due to a shift from
“art to science” and “intuition to real time data”

17. EARLY FLIGHT
• Early pilots used their senses and muscles to control an
airplane very directly
• Open cockpits allowed them to directly feel and hear the
engine, aircraft, and environment
• Maneuvering required physical strength to move the
controls, and they could not take their hands off the controls
• Instruments were basic
• Navigation was based on visual landmarks such as
following roads and railroads
• Decisions on whether to take off in bad weather were based
purely based on judgment.
• Each pilot flew differently, with idiosyncratic results

18. MODERN AVIATION
• Flying is mostly engineering science
• Very little is left to chance or human error
• The role of the human pilot is radically different, with
their senses replaced by digital readouts, and muscles
replaced by computer-controlled motors and other
actuators
• Computers do the actual flying, while the pilots
monitor and direct the computers
• Pilots have discretion to override the computers, but
virtually never need it
– Most often due to other human errors requiring a change

19. FROM ANNALS OF INTERNAL
MEDICINE
“We believe that to achieve the next increase in safety levels, health
care professionals must face a very difficult transition: abandoning their status
and self-image as craftsmen and instead adopting a position that values
equivalence among their ranks. For example, a commercial airline passenger
usually neither knows nor cares who the pilot or the copilot flying their
plane is; a last-minute change of captain is not a concern to passengers, as
people have grown accustomed to the notion that all pilots are, to an excellent
approximation, equivalent to one another in their skills. Patients have a
similar attitude toward anesthesiologists when they face surgery. In both
cases, the practice is highly standardized, and the professionals involved
have, in essence, renounced their individuality in the service of a reliable
standard of excellent care. They sell a service instead of an individual identity.”

20. ART VS. SCIENCE
• Surgery remains a craftsmen market
• Patients believe outcomes are based on their
surgeon because high variation exists and
preventable complications are rampant (1 in
7000 admissions leads to a preventable death)
• Where on the spectrum an industry falls is
based squarely on the available technologies to
move an art to a predictable science

21. AVIATION PHASE 1
“PURE ART/CRAFT”
• Pilots were revered and flying was an art
• The best pilots felt gauges were slower then their hands
and minds and were a non-proven distraction
• Standard definitions didn’t even exist making it
difficult to compare safety records of aircraft or pilots
• Certain activities were near impossible due to loss of
visual landmarks and lack of certain technologies
– Flying above the clouds
• Navigation Method: Railways and landmarks

22. AVIATION PHASE 2
“INSTRUMENTS AND RULES”
• Instruments are born
• Able to fly above clouds
• Instruments superior to human senses
– Even though many state they disagree
• Navigation Method: Gyroscopes and Maps

23. AVIATION PHASE 3
“STANDARD PROCEDURES”
• Checklists begin to be used by some
– Others resist, many of them the most famous pilots
• Human errors minimized
• Navigation Method: Celestial Navigation and
Gyrocompass

24. AVIATION PHASE 4
“AUTOMATION”
• Jets require faster reflexes and calculations
become too complex for pilots to perform in
real time
• Best pilots who weren’t trained on newer
systems almost immediately become obsolete
– Easier to retire than retrain at a certain point
• Younger pilots trained to rely on systems
promote rapidly
• Navigation Method: Automated Radio Paths

25. AVIATION PHASE 5
“COMPUTER INTEGRATION”
• Super-human responsiveness for certain functions
• Goal oriented targeting
– Craft can hit an altitude and speed and 3D position more
accurately, more quickly than any human
– AND do so while calculating the most fuel efficient manner
to get there based on air speed, wind speed, humidity, and
weight distribution
• Navigation Method: Integrated navigation systems
including GPS, 4D, gravitational field, and inertial
systems
• We still need pilots for the most complex of situations
(e.g. choosing the landing site on the Hudson River
after bird impacts into engines)

26. AVIATION IS A SYSTEM AND
FLYING IS WHAT A PILOT DOES…

27. ISN’T ANYTHING AN ART THOUGH?
• Today there now are mathematical models that
are proven predictors of success for both
movies and hit songs…
– Are used to suggest modifications to make them
more successful and desirable to consumers

28. HISTORY OF ALMOST EVERY
INDUSTRY AND EVERY EXPERT
WOULD SAY THAT HEALTHCARE
WILL FOLLOW THE SAME
PATH…

29. HEALTHCARE IS BETWEEN
STAGE 2 AND 3…

30. THE TRANSITION TO RISK: INEVITABLE
The shift from Volume to Value is already underway, so that inaction is not an option
Fee for Service
INCENTIVE = VOLUME
Drivers of Change:
• The recent Presidential election has cemented the
implementation of the ACA
• Healthcare remains focus of budgetary political
activity (e.g. tax cuts, SGR, Sequestration, Debt Ceiling)
• Demand by patients and payors for transparency and
demonstrable value of care by providers:
o Reduced costs
o Reduced pricing
o Reduced Utilization
o Improved quality outcomes
o Accountable providers across the continuum
Population Health
Management
INCENTIVE = VALUE

31. FUTURE PAYER REFORM ALIGNMENT
STRATEGIES

32. HEALTHCARE REFORM

33. NEW PAYMENT MODELS
Cost, Quality, Experience
• Population Health
• Bundled Pricing
– BPCI
– CJR
• Shared Savings
– Pioneer ACO Program
– Commercial ACO Contracts
– Gain-sharing
• Pay-for-Performance
– Readmissions Penalties
– Quality-Based Commercial Contracts
– Value-Based Purchasing

34. MUST MANAGE ENTIRE THE
CONTINUUM!

35. KEY COMPONENTS
Data
Analysis
• Leading indicators
• Outcomes Metrics
• Understanding CMS Data
• Data analysis
• Alignment structure/strategy in
place and working
• Physicians, post-acute
providers, consultants, etc.
• Assessment of current
process
• Development of new
process
• Implementation and
sustaining care continuum
Stakeholder
Alignment
Care
Redesign
The most successful care management programs
will have all three foundational components.

36. Execute. Transform. Succeed.
STAKEHOLDER
ALIGNMENT
&
CARE REDESIGN

37. Service Line
Management
Bundled
Payments
Shared structural
components
Generally service line
focused
Infrastructure to ID &
support quality
improvement targets
Physician incentives
BUNDLED PAYMENTS & SERVICE LINE
OPTIMIZATION

38. QUALITY INFRASTRUCTURE
Quality
Committee
Service Excellence
Peer Review Committee
Surgical case reporting
M &M
Compliance
Risk management
Audits
FPPE/OPPE
MACRA work group
Provider
Clinical
Management
Arizona
• East Valley
• West Valley
• Central Valley
Michigan
• Novi
• Southfield
• Brighton
CORE
Analytics
Team
Complications reporting
Provider Dashboard
Patient reported
outcomes
Patient complaint system
Continuous patient
monitoring system
Service Line
Management
BDWMC
BDMC
BTMC
BEMC
BUMCP
BBWMC
BBMC
BCGMC

39. CARE REDESIGN SUMMARY
Stakeholder Alignment
• Infrastructure and platform
engages physicians in a
different way
• 1:1 surgeon to surgeon
coaching
• Incentive structure beyond
gain sharing
Care Redesign
• Pathways, protocols and order
sets
• Presurgery education (Clinic &
Hospital)
• Standard reports
• Key performance indicators
• Daily monitoring of outcomes
and readjusting
• Project management

40. Execute. Transform. Succeed.
DATAANALYSIS
( AND PROBLEMS
WITH BIG DATA)

41. PROVIDER CONNECT

42. DOCUMENTS ON PROVIDER CONNECT

43. E-FACE SHEET /REGISTRY
42
Here’s a link to EFaceV2 in the
development environment
(only accessible from within
the CORE network):
http://core-dev/EFaceV2/
Here’s a link to EFaceV2 in the
live production environment:
https://www.coreqit.com/EFac
eV2/

44. PROBLEMS WITH BIG DATAAND
PUBLIC OUTCOMES…
43

45. INTERNAL QUALITY MEASURES
• Weekly Case Reporting
• Surgical Case Reporting Committee
– Monthly review of case reporting
– Cases selected for Peer Review Committee and
M&M Conference
– Review any new or potential legal cases
– Protected under Peer Review

46. TKA COMPLICATIONS
Further drill done by procedure can be done
TKA related complications
sorted in descending order

48. FOCUSED PROVIDER PRACTICE
EVALUATION
• Historically used in hospitals to check requested
clinical privileges against actual performance
• At CORE, we use it at 60 and 120 days from start
of clinical practice. We review against 5
parameters:
– Culture and organizational fit
– Understanding of productivity and revenue
– Attitude toward Quality metrics
– Understanding and practice of standardization and
Evidence Based Medicine
– Perception survey completed by staff
47

49. OVERALL FINDINGS FROM THE AUDIT
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Indication
Documented
% Algorithm/ Protocol
Followed
% Imaging/
Documentation
Complete
% Technique Within
Standards
% Complications
Recognized and
Managed*
% Procedure Follow Up
Occurred
% Post Proc Imaging
Complete &Reviewed
Provider A Provider B Provider C Provider D Provider E Provider F

50. ADHERENCE TO PROTOCOL
0
2
4
6
8
10
Provider A Provider B Provider C Provider D Provider E Provider F
Algorithm/ Protocol Not Followed Algorithm/ Protocol Followed

51. YOU MUST DRIVE EVIDENCE
BASED BEHAVIORS TO HELP
PHYSICIANS BE SUCCESSFUL!

52. OSTEOPOROSIS SCREENING, DEXA
ORDERING, & COMMUNICATION
• From the Office Visit Note, in the Past Medical History or due to diagnosis,
the Medical Assistant will indicate if the patient has a history of
osteoporosis. This information will translate into the DEXA Screening
section for the provider.

53. OSTEOPOROSIS SCREENING, DEXA
ORDERING, & COMMUNICATION
• The Provider will select the bright green DEXA Screen button. This
DEXA Screen button will only appear for eligible patients based on data
entered for DOB, insurance, and/or fracture diagnosis.

54. • The DEXA Screen dialog box will open prepopulated based on the osteoporosis
past medical history entered and previous orders. Select the appropriate action from
the action list, and then select Log Action and Return to A/P.
OSTEOPOROSIS SCREENING, DEXA
ORDERING, & COMMUNICATION

55. CUSTOM PRO

56. PRO CONTINUED
55

57. PRO CONTINUED
56

58. PATIENT CLICK SUBMITS AND RETURN
TABLET TO STAFF

59. PRE-OP PREDICTIVE SCORING
(POPS)®
Development And Deployment

65. SYSTEMS AND PROGRAMS
SCALABLE TO ANY HOSPITAL,
INSURANCE PROGRAM, OR
PHYSICIAN GROUP!

66. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
2012 2013 2014 2015 2016
Routine DC SNF DC to Home Health Linear (Routine DC) Linear (SNF) Linear (DC to Home Health)
POST ACUTE USAGE
Home w/ OP PT

67. LENGTH OF STAY
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
Total Hips LOS Total Knees LOS

68. POPULATION HEALTH
CAPITATED RISK

69. EMPLOYER NETWORKS

71. MUST MANAGE ENTIRE THE
CONTINUUM!

72. PAYMENT STRUCTURE SHOULD INCENTIVIZE
OPTIMAL SITE OF SERVICE
ASC
Acute Care Hospital
• Most patients for high acuity surgery (e.g., joints)
• High risk patients for inpatient and outpatient surgery
Surgical Hospital
• Select patients for high acuity surgery (e.g., joints)

73. POPULATION HEALTH – THE ORTHOPEDIC CONTEXT
Risk infrastructure
Basic organizational foundations to manage at-risk
contracts
Episode Efficiency
Understanding how to maintain or improve quality
across an episode while reducing total costs
Appropriate Utilization
Understand type and cause of orthopedic utilization by
putting the patient at the center of this approach
Prevention and Wellness
Understand sources of claims in the population and
identifying what claims can be prevented through
education, coordinated care, and prevention
Taking a Population Health approach to orthopedics requires the surgeon to take a view
beyond the operating suite in considering the total impact and need for orthopedic care.
Risk
Infrastructure

74. PATH TO POPULATION HEALTH
SOLUTIONS…

76. THE FUTURE IS ABOUT…
• Leverage and Scale
• Population Health
• Clinically Integrated Networks
• Technology to manage costs, behaviors, and improve
outcomes
• “Winners” and “Losers”

77. QUESTIONS?
“... it ought to be remembered that there is
nothing more difficult to take in hand,
more perilous to conduct,
or more uncertain in its success,
than to take the lead in the introduction of
a new order of things.”
Nicolo Machiavelli, The Prince
1515

78. QUESTIONS?