ALLEN PERKINS, MD, MPH PROFESSOR AND CHAIR, FAMILY MEDICINE UNIVERSITY OF SOUTH ALABAMA Accountable Care Organizations
Jun 13, 2015
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
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
onthd
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?