3. “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
4. “He who rejects change is the architect
of decay”
Harold Wilson
10. Most widely documented ambulatory errors
Prescriptions for incorrect drugs or incorrect dosages
Missed, delayed and wrong diagnoses
Missed and delayed tests as well as errors in patient
follow-up on test results
Doctor-patient communication errors, doctor-doctor
communication errors or other miscommunications
between parties
Errors in scheduling appointments and managing
patient records
11. Effect of improvement efforts
Inappropriate use and dissemination of
knowledge
Waste
Inappropriate priorities
We 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
12. 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
Cash
27. So, then, what is an ACO?
Voluntary group of physicians and care facilities
Minimum 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 leadership
Defined processes to promote evidence-based
medicine, report on quality and cost measures, and
coordinate care
Delver care in a patient-centered manner
28. ACO
Invisible Enrollment
Not formally enrolled, not required to obtain services through the
ACO, and might not even know the ACO existed
Performance 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
32. 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”
39. 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
40. 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
41. 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
42. 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
44. Physician specific quality markers
Infection Prevention Practices
Infection Indicators
Compliance with Medicare CORE Measures
Medical Record and Operating Room Dictation
Completion
Patient Complaints
Mortality Rates
Readmission Rates
Other Quality Initiatives
45. What can you do today in the hospital?
Focus on detail/accuracy and timeliness of
documentation
Attention to discharge planning
Difficult discharges prior to noon and increase
discharges on weekends
Get a handle on implant costs and implementation of
demand matching
Decrease time between request for consultation and
occurrence of consultation
Earlier transition from ICU to standard acute floor
46. 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
47. Conclusions
We need much better customer service than we
currently provide is urgent
Pay attention to changes in care delivery payment
such as ACOs and bundled care is urgently needed
Clearly people are voting with their feet
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...
48. Conclusions
Despite noise
Volume payments will be cut by all payers
Market demand for value, transparency is increasing
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.
Delivering quality, evidence based care is a core competency
The value of efficiency cannot be overestimated
Chronic Disease Management
ICU care
End-of-life care
Hospitalization becomes avoidable expense
Risk shifts from payer to physician/provider/system
