LEADING HEALTH CARE TOMORROW…

SUSTAINABILITY, PROFITABILITY, SURVIVAL

David Jacofsky, MD

"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.

THE INVERSE RELATIONSHIP

WE MAY BE GOOD…BUT WE COULD BE BETTER!

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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.

INDUSTRY DYNAMICS

Changing Payment Systems

Efficiency Pressures

Lack of Physician Alignment

Decreasing Margins &

Quality

SUCCESS REQUIRES ASERVICE 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

KEY COMPONENTSData

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.

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…”

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”

WHAT TO EXPECT IN HEALTHCARE SHOULD BE ANALOGOUS TO THE PATH

SEEN IN OTHER INDUSTRIES…

5 PHASES OF INDUSTRY DEVELOPMENT

• Craft/Art• Rules plus Instruments• Standardized Procedures• Automation• Computer Integration

EXAMPLES OF SOME INDUSTRIES

• Airlines• Firearms Safety• Manufacturing• Communications• Finance• National Security

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”

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

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

FROM ANNALS OF INTERNAL MEDICINE

“We believe that to achieve the next increase in safety levels, healthcare professionals must face a very difficult transition: abandoning their status

and self-image as craftsmen and instead adopting a position that valuesequivalence among their ranks. For example, a commercial airline passenger

usually neither knows nor cares who the pilot or the copilot flying theirplane 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 excellentapproximation, equivalent to one another in their skills. Patients have a

similar attitude toward anesthesiologists when they face surgery. In bothcases, the practice is highly standardized, and the professionals involvedhave, in essence, renounced their individuality in the service of a reliable

standard of excellent care. They sell a service instead of an individual identity.”

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

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

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

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

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

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)

AVIATION IS A SYSTEM AND FLYING IS WHAT A PILOT

DOES…

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

HISTORY OF ALMOST EVERY INDUSTRY AND EVERY

EXPERT WOULD SAY THAT HEALTHCARE WILL FOLLOW

THE SAME PATH…

HEALTHCARE IS BETWEEN STAGE 2 AND 3…

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 costso Reduced pricingo Reduced Utilizationo Improved quality outcomeso Accountable providers across the continuum

Population Health Management

INCENTIVE = VALUE

FUTURE PAYER REFORM ALIGNMENT STRATEGIES

HEALTHCARE REFORM

NEW PAYMENT MODELSCost, 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

MUST MANAGE ENTIRE THE CONTINUUM!

KEY COMPONENTSData

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.

Execute. Transform. Succeed.

STAKEHOLDER ALIGNMENT

& CARE REDESIGN

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

QUALITY INFRASTRUCTUREQuality

Committee

Service ExcellencePeer Review Committee

Surgical case reporting

M &M

Compliance

Risk management

Audits

FPPE/OPPE

MACRA work group

Provider Clinical Manage

mentArizona

• East Valley• West

Valley• Central

Valley

Michigan• Novi• Southfield• Brighton

CORE Analytics

TeamComplications

reporting

Provider Dashboard

Patient reported outcomes

Patient complaint system

Continuous patient monitoring system

Service Line

Management

BDWMC

BDMC

BTMC

BEMC

BUMCP

BBWMC

BBMC

BCGMC

CARE REDESIGN SUMMARYStakeholder 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

Execute. Transform. Succeed.

DATA ANALYSIS( AND PROBLEMS WITH BIG DATA)

PROVIDER CONNECT

DOCUMENTS ON PROVIDER CONNECT

E-FACE SHEET /REGISTRY

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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/EFaceV2/

PROBLEMS WITH BIG DATA AND PUBLIC OUTCOMES…

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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

TKA COMPLICATIONS

Further drill done by procedure can be done

TKA related complications sorted in descending order

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

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OVERALL FINDINGS FROM THE AUDIT

% Indica

tion Documented

% Algorit

hm/ Pro

tocol Fo

llowed

% Imag

ing/ Documen

tation Complet

e

% Technique W

ithin St

andard

s

% Complications R

ecogn

ized an

d Man

aged*

% Procedure

Follo

w Up Occu

rred

% Post Pro

c Imag

ing Complet

e &Revi

ewed

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Provider A Provider B Provider C Provider D Provider E Provider F

ADHERENCE TO PROTOCOL

Provider A Provider B Provider C Provider D Provider E Provider F0

2

4

6

8

10

Algorithm/ Protocol Not Followed Algorithm/ Protocol Followed

YOU MUST DRIVE EVIDENCE BASED BEHAVIORS TO HELP

PHYSICIANS BE SUCCESSFUL!

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.

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.

• 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

CUSTOM PRO

PRO CONTINUED

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PRO CONTINUED

57

PATIENT CLICK SUBMITS AND RETURN TABLET TO STAFF

PRE-OP PREDICTIVE SCORING (POPS)®

Development And Deployment

SYSTEMS AND PROGRAMS SCALABLE TO ANY HOSPITAL,

INSURANCE PROGRAM, OR PHYSICIAN GROUP!

Jan

Feb

Mar Ap

rM

ay Jun Jul

Aug

Sep

Oct

Nov De

cJa

nFe

bM

ar Apr

May Jun Jul

Aug

Sep

Oct

Nov De

cJa

nFe

bM

ar Apr

May Jun Jul

Aug

Sep

Oct

Nov De

cJa

nFe

bM

ar Apr

May Jun Jul

Aug

Sep

Oct

Nov De

cJa

nFe

bM

ar Apr

May Jun Jul

2012 2013 2014 2015 2016

0%

10%

20%

30%

40%

50%

60%

70%

80%

Routine DC Linear (Routine DC) SNFLinear (SNF) DC to Home Health Linear (DC to Home Health)

POST ACUTE USAGE

Home w/ OP PT

LENGTH OF STAY

Jan-11

Mar-11

May-11

July-11

Sep-11

Nov-11

Jan-12

Mar-12

May-12

Jul-12Sep

-12

Nov-12

Jan-13

Mar-13

May-13

Jul-13Sep

-13

Nov-13

Jan-14

Mar-14

May-14

Jul-14Sep

-14

Nov-14

Jan-15

Mar-15

May-15

Jul-15Sep

-15

Nov-15

Jan-16

Mar-16

May-16

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

Total Hips LOS Total Knees LOS

POPULATION HEALTH CAPITATED RISK

EMPLOYER NETWORKS

FFS RISK

MUST MANAGE ENTIRE THE CONTINUUM!

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)

POPULATION HEALTH – THE ORTHOPEDIC CONTEXT

1 Risk infrastructureBasic organizational foundations to manage at-risk contracts

2 Episode EfficiencyUnderstanding how to maintain or improve quality across an episode while reducing total costs

3 Appropriate UtilizationUnderstand type and cause of orthopedic utilization by putting the patient at the center of this approach

4 Prevention and WellnessUnderstand 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

Episode

Efficiency

Appropriate

Utilization

Prevention and Wellness

PATH TO POPULATION HEALTH SOLUTIONS…

THE FUTURE IS ABOUT…

• Leverage and Scale• Population Health• Clinically Integrated Networks• Technology to manage costs, behaviors, and

improve outcomes• “Winners” and “Losers”

Be Bold. Lead.

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

QUESTIONS?