Acma presentation april 2013 4.8.13 sf

Central Texas Health Care

in 2013: Organizing Our Delivery System

ACMA MeetingApril 2013

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Why Reform the Delivery System?

• There are 50 million uninsured Americans• Health care costs are a factor in 55% of personal

bankruptcies.• Health care costs have been growing at 2-3 times

the rate of inflation for 3 decades.• Quality and safety rankings are below most

developed and industrialized nations.• Medicare and Medicaid costs “unsustainable.”• Health care continues to consume a larger

proportion of our nation’s GDP (currently 18%)

Unsustainable

Unsustainable

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Unsustainable

Follow the Money

• 1% of the population accounts for 25% of health costs;

• 10% of the population accounts for 70% of health costs;

• 78% of national health care expenditures can be attributed to chronic illness.

On order of $2 trillion.

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Enter Insurance Reform (ACA)

• Expansion of insurance coverage– Medicaid expansion (not in Texas)– Employer mandate; small business tax credit– Individual mandate ($95/1% $695/2.5%)– Insurance Exchanges (2014) and tax credit (400% FPL)

• Insurance Regulation and Reform– Do away with lifetime maximums– Do away with pre-existing conditions– Do away with rescissions (being dropped once you’re sick)– Guaranteed deductible-free preventive care– Minimum Medical Loss Ratio (MLR)

HMMMM….

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• Quality & Safety– Pay for value programs to turn focus toward quality

improvement.– Encourage and reward use of information technology.– Research to support “evidence based care.”

• Cost Efficiency– Emphasis of preventative & chronic condition management

to reduce downstream costs.– Accountable Care Organizations (ACOs) - pay for value not

for volume.• ACO concept is now new. Examples of Clinically Integrated

Networks: Advocate Physician Partners; Kaiser Permanente; Cleveland Clinic.

Enter Insurance Reform (ACA)

Volume Based System• Proprietary Pricing• Broad Payer Networks• Episodic Patient Care• Disparate Providers• Hospital Focus• Practice Pattern

Variation• Provider Centered Care• Fragmented Hospital IT

Value Based System• Transparent Pricing• Performance Based

Networks• Cross-Continuum of Care• Clinically Integrated

Providers• Health System Focus• Evidence Based Care• Person Centered Care• Cross-Continuum Based

IT

Delivery System Transformation

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Volume Based Reimbursement

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• Real change will require us to fundamentally change the way care is delivered.– Aligned Incentives– Enhanced communication and managed transitions– Risk-stratified interventions – getting the most

resources to the sickest patients– Organized care

The Right Care at the Right Place at

the Right Time

Value Based Care

Key Attributes of a Clinically Integrated Network Physician Driven and Governed

Structured Quality Initiatives

IT Infrastructure for Quality Data Measurement and Reporting

Incentive payments

CLINICAL INTEGRATION

A network of physicians willing to demonstrate a high degree of interdependence and cooperation through a program of initiatives designed to control costs and ensure quality, which is supported by an infrastructure that allows the physicians to evaluate and modify practice patterns.

-- Hogan Marren, Ltd.

Defining Clinical Integration

Key Attributes of an ACO• Person Centered Care

• Physician Driven

• Coordinated Care Across the Continuum

• Practice Consistent Evidence Based Medicine (Clinical Integration)

• Responsible for Cost and Quality of a Population

• Rewarded, financially, for Performance

ACCOUNTABLE CARE

ORGANIZATION

A network of physicians,

hospitals and ancillary providers that share clinical

and financial responsibility for providing care to

patients across the continuum.

Defining ACO

Seton Healthcare

Family

Seton Health Alliance

Community Physicians

• Building clinically integrated network of health care

providers

• Selected as one of 32 Pioneer ACOs in 2012

• Commericial ACO contracts begining in 2013

Seton Health Alliance ACO

• 1-5% of Population• Advanced Care Coordination Clinic

(ACCC) High Risk Chronic

• 10-15% of Population• Embedded Nurse

Navigator-PCP Care Coordination

Moderate Risk Chronic

• Estimated 80% of Population

• Care Gap Management

Healthy and Low Risk

Tran

siti

on

s (1

0%)

Ho

me

& P

ost

Acu

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Em

erg

ency

Dep

artm

ent

Pre

ven

t In

pat

ien

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dm

its

En

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f L

ife

(5%

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allia

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Car

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rog

ram

Risk Stratified Interventions

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• 10,397 active patients• 200+ participating

providers• 30+ facility and agency

partners• 36 locations• 9 cities• 11 counties• 14,000 square miles

Seton Health Alliance ACO

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Transitions & Post Acute Network

Goals:• Improve transitions and handoffs across the continuum;• Strengthen provider-provider communication across the

continuum;• Reduce preventable readmissions.

Process: Utilized Request for Information; Grow network of physician groups and facilities/agencies aligned with mission and objectives

Current Network:• 5 Physician Practices (hospitalist/post acute)• 18 Skilled Nursing Facilities• 3 Rehabilitation Hospitals• 12 Home Health Agencies• 1 Physician Home Service Provider

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Charting the Journey

Plan well before you take the journey.

Remember the carpenter’s rule:

measure twice, cut once.

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Meredith Duncan

Director of Operations, Seton Health Alliance

[email protected]

Contact Information