anne bracken univ of south al - aco rural health

ALLEN PERKINS, MD, MPHPROFESSOR AND CHAIR, FAMILY

MEDICINEUNIVERSITY OF SOUTH ALABAMA

Accountable Care Organizations

Disclosure

None – except for being a tax payer

“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

Utilization will decline, so a smaller pool

of specialists will need to serve a broader

population.

“He who rejects change is the architect of decay”

Harold Wilson

Incremental efforts to change hospital care

Ineffe

ctive

Not limited to hospitals

Most widely documented ambulatory errors

Prescriptions for incorrect drugs or incorrect dosages

Missed, delayed and wrong diagnosesMissed and delayed tests as well as errors in

patient follow-up on test resultsDoctor-patient communication errors, doctor-

doctor communication errors or other miscommunications between parties

Errors in scheduling appointments and managing patient records

Effect of improvement efforts

Inappropriate use and dissemination of knowledge

WasteInappropriate prioritiesWe 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

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

CashFee-fo

r-serv

ice

Triple Aim

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)

Payers want to pay for value

The world of the possible

Phase 2

Volume based practice - inpatient

Transitional payment

Transitioning to what?

How bundled payments work

Encouraging efficiency

Volume based practice-outpatient

Transitional payment

Transitioning to what?

So, then, what is an ACO?

Voluntary group of physicians and care facilitiesMinimum 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 leadershipDefined processes to promote evidence-based medicine,

report on quality and cost measures, and coordinate careDelver care in a patient-centered manner

ACO

Invisible Enrollment Not formally enrolled, not required to obtain services through

the ACO, and might not even know the ACO existedPerformance 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

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)

428 in 30 m

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4 mill

ion enro

lled

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”

Impossib

le with

out HIT

Is it working?

Medicare spending growth in excess of GDP growth

Where does the money go?

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

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

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

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

Pondering your future, yet?

Physician specific quality markers

Infection Prevention PracticesInfection IndicatorsCompliance with Medicare CORE MeasuresMedical Record and Operating Room

Dictation CompletionPatient ComplaintsMortality RatesReadmission RatesOther Quality Initiatives

What can you do today in the hospital?

Focus on detail/accuracy and timeliness of documentation

Attention to discharge planningDifficult discharges prior to noon and increase

discharges on weekendsGet a handle on implant costs and

implementation of demand matchingDecrease time between request for consultation

and occurrence of consultation Earlier transition from ICU to standard acute

floor

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

Conclusions

We need much better customer service than we currently provide is urgent

Clearly people are voting with their feet Pay attention to changes in care delivery

payment such as ACOs and bundled care is urgently needed

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...

Conclusions

Despite noise Volume payments will be cut by all payers Market demand for value, transparency is increasing

Delivering quality, evidence based care is a core competency The value of efficiency cannot be overestimated

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. Chronic Disease Management ICU care End-of-life care

Hospitalization becomes avoidable expense Risk shifts from payer to physician/provider/system

Questions?