Mayo Health System Overview

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2 2005 Mayo Health System Overview Confidential Internal Use Only Letter of Introduction I. MHS Overview Vision, Values and Principles Vision... 1 Values... 2 Principles of Affiliation... 3 Summary of MHS Finance Model... 4 MHS Governance and Operations Mayo Reserved Powers...5 MHS Governance...6 MHS Board...7 Administration...8 Organizations Map...9 Dates of Affiliation...10 Communities and Facilities...11 MHS Staffing and Bed Summary...12 AMGA Acclaim Award...13 II. MHS Staffing Physician Staff Summary (by site)...14 Associate Provider Summary (by site)...15 MHS Physician and Associate Provider Summary (by specialty)...16, 17, 18 III. Service Activity Measures Mayo Clinic Outreach Services (by site) Mayo Clinic Outreach Activity Consultant FTEs MCR Patients From Counties Within 120 Miles MHS Physician Referral Requests to MCR Hospital Discharge Maps Hospital Discharge Data for MHS Communities Hospital Discharge Data for MHS and Other Selected Communities Hospital Discharge Change 2002 to 2003 for MHS Communities Hospital Discharge Change 2002 to 2003 for MHS and Other Selected Communities Hospital Discharge Change 1999 to 2003 for MHS and Other Selected Communities MHS Annual % Growth in FTE and Patient Volumes i (MHS Overview continued See next page)

3 2005 Mayo Health System Overview Confidential Internal Use Only IV. Clinical Quality Measures MHS Quality Committee Clinical Quality Dashboard... 31, 32 Disease Management Strategies in MHS , 34, 35 Patient Satisfaction MHS Patient Safety Committee Patient Safety JCAHO Surveys/Results MHS Sites V. MHS Strategic Plan Strategic Plan Mayo Clinic Rochester/Mayo Health System Shared Vision for Regional Care Delivery... 41, 42 MHS Business Products Improvement Steering Committee MCR/MHS Common Patient Standards Workgroup MHS Unintended Variations Tactics and Success Measures Appropriate Care Seamless Care... 47, 48 Effective Governance and Management... 49, 50, 51 Leadership Development Sustain and Provide for Growth of the Practice... 53, 54, 55 Employer of Choice... 56, 57, 58 Enhanced Value and Patient Safety... 59, 60, 61, 62, 63, 64, 65 Future Opportunities and Risk... 66, 67, 68, 69 Information Technology Strategy (See Section VIII) VI. MHS Financial Performance MHS Growth in Physicians and Operating Revenue...70 MHS as % of Mayo Patient Care MHS Net Operating Income and Margin...72 MHS Capital: VII. Future Capital Projects Capital Appropriation Requests 2005 Actual 2009 Projected...74, 75 (MHS Administration 2005 Operations Plan See next page) ii

4 2005 Mayo Health System Overview Confidential Internal Use Only VIII. MHS System-wide Projects and Initiatives (2005) Communications...76 Contracting and Payor Relations...77 Development...78 Disease Management Strategies...79 EnhanceMed...80 Facilities...81 Finance and Accounting...82 Health Insurance Portability and Accountability Act of 1996 (HIPAA)...83 Human Resources...84, 85, 86 Information Technology...87, 88 Leadership Education and Development...89 Marketing...90 Patient Financial Services and Compliance...91, 92 Performance Excellence...93 MHS Performance Assessment Category Teams...94 Physician Recruitment...95, 96 Planning Services...97 Supply Expense Management...98 Systems and Procedures...99, 100 IX. MHS Administration Resource Plan (2005) Department Plan Top Level Summary Cost Center/Activity Responsibility List , 103 MHS Program and Administrative Expense as Percent of MHS Total Operating Expense X. MHS Scholarly Activity and Societal Contributions Presentations and Publications MHS Administration Societal Contributions iii

5 May 2005 Dear Colleague, We are pleased to provide the attached update of Mayo Health System s activities, progress toward core goal initiatives, and financial performance in Mayo Health System continues to be cited as one of the few successful integrated networks in the healthcare industry. We now have 661 physicians supported by 11,715 allied health staff providing care to patients in 64 communities. In addition, Mayo Health System owns 15 hospitals, 9 nursing homes and contract manages 2 additional hospitals and 1 nursing home. Over 25% of Mayo Foundation s total patient care activities occur in Mayo Health System. We have developed a new shared vision with Mayo Clinic Rochester that MCR and MHS together will build Mayo s integrated healthcare delivery system to best serve the healthcare needs of our region; at any entry point, patients will experience a single healthcare system; and our staffs will work as partners and respected colleagues. We have begun to address the strategic priorities to achieve this vision. We have also committed as a system to eliminate unintended variation from our clinical practice. In 2004 we also began our journey to align our practice using the Malcolm Baldrige performance excellence criteria. Growth and access implications for both Rochester and Mayo Health System continue to be a primary emphasis within the plan. Tactics are in place to pursue our goals related to staff recruitment and retention, patient safety, seamless care and financial success. We continue to receive regional and national recognition for our continuous improvement efforts in open access, disease management, preventive services, quality, patient safety and service. Net operating income reached $46.6 million, $17.3 million greater than plan and $4.6 million greater than This resulted in a 4% operating margin for the system on net revenue of $1.05 billion. We continue to strive toward our goal of achieving a 5% margin to sustain and grow the practice. Yes, Mayo Health System is strong and getting stronger. We may well be the most successful system in the country, but we cannot rest on our laurels as there is much to do to truly achieve the highest standards for medical care and health improvement in the communities in which we live and work. We are proud of our excellent progress and success of this fine system. Dr. Peter W. Carryer, Chair Mayo Health System Board Mr. Gregory J. Thomas, Chair Mayo Health System Administration

6 Mayo Health System Vision Selected community clinics and hospitals within the geographic region of Rochester are affiliated with Mayo Clinic to form Mayo Health System. Our vision is: To achieve the highest standards for medical care and health improvement in the communities in which we live and work. To accomplish this, Mayo Health System will link the expertise of Mayo Clinic in practice, education and research with the health-delivery systems of our communities. We will combine the finest Mayo Clinic care for complex, serious illnesses with the finest community care. Ours will become a model for the high quality, innovative and cost-effective approach to the full spectrum of health improvement and patient care. 1

7 Mayo Health System Values The needs of the patient come first. Practice Practice medicine as a multidisciplinary team of professionals. Education Provide high-quality health information for our communities, and educate physicians and allied health professionals. Research Foster innovative programs to improve patient care and health services in our communities. Physician Leadership Assure dedication to the needs of the patient through physician leadership. Mutual Respect Respect and value the diversity of our patients, our staff and our communities. Continuous Improvement Continuously improve all processes and services that support the care of our patients and communities. Work Environment Foster teamwork, integrity, personal responsibility, innovation, trust and communication throughout our system. Stewardship Operate in a manner that permits a financial return sufficient to meet present and future requirements but not for the purpose of accumulating wealth. System Focus Allocate resources to serve the best interest of Mayo Clinic and the regional health system rather than its individual entities. 2

8 Mayo Health System Principles of Affiliation In an attempt to develop a philosophy to guide Mayo Health System affiliations, the following statements have been agreed upon: The ultimate goal is a healthcare system which respects the long and honorable traditions of each institution. Within the system, the physician will always be the patient's advocate. The right of the patient to choose his or her physician inside or outside the system will be respected. With excellent patient care available at all levels (i.e., primary, secondary and tertiary care) and the system's built-in efficiencies, it is anticipated that the majority of patients, once they access the system, will receive all their care therein. However, exceptions will occur based on individual physician referral decisions or on patient choice. Not all referrals can be expected to go to either party. The governance structure will enable as many local decisions as possible. There will be a clear commitment made to continuous quality improvement. All components of the system are expected to attain economic self sufficiency. The constituencies of both organizations should view the affiliation as fair and having potential for each organization. 3

9 Mayo Health System Summary of MHS Finance Model Purpose: To codify current financial processes and to establish a workable framework for future MHS financial operations and capital planning Summary Guidelines: General Accounting, Cash and Debt: 1) Accounting will remain separate and distinct for each MHS entity. 2) Model begins with January 1, 2003 balances. 3) MHS entities will bank with Mayo. MHS balances will be identified as designated when consolidated. 4) Liquidity expectations will be implemented. Base liquidity balances will earn money market rate of interest. Larger balances may be invested for higher return. 5) Mayo will assume bonded debt and convert to inter-entity debt payable to Mayo. Summary Guidelines: Expense Transfers and Fees 6) MHS Program and Administrative expense (including allocations from MCR and MF) will be billed to MHS entities to appropriately reflect overhead costs in the entity s net operating income and cash. 7) A process and funding mechanism to allow investment in programs and projects that enhance integration among and between MHS entities and MCR will be developed. Incorporate a routine entity fee paid by the entities to begin in Funds will be under the direction of the MHS Board of Directors. Summary Guidelines: Capital Budget and Funding 8) Generally, the aggregate MHS cash flow will be the primary determinant of the maximum MHS capital budget for the following year. Single annual amount (with carryover provision) Formula driven (evolve to 3-year average) 9) Periodically, a significant strategic project will come along that cannot be accommodated within the MHS Model. In that event, MHS will demonstrate that the project is strategic for Mayo Clinic and MHS and pursue incremental budget approval and funding, e.g. MHS non-recourse debt, Mayo-invested equity, etc.. 10) Each MHS business plan will identify a funding source for the requested capital budget. Funding may come from current operations, entity cash reserves, local development, a Mayo sponsored loan program or in rare instances, additional Mayo-contributed equity. Positive elements of the MHS Finance Model: A. Extends focus beyond NOI B. Promotes system thinking C. Understandable link to financial performance D. Accountable E. Predictable F. Self regulating G. Acknowledges legal corporate structure of MHS Each MHS entity is a distinct not-for-profit entity with a Board of Directors H. Accommodates diversity of MHS entities 4 Implemented January 2004

10 Mayo Health System Reserved Powers The powers reserved by the MCR Board of Governors in the governing documents of each MHS site (the "Reserved Powers") generally include the following items. Most of these powers have been delegated to the MHS Board of Directors: Delegated (Reserved Powers delegated to the MHS Board) (1) Bylaw Amendment: Amendment of the Bylaws or Articles of Incorporation of any MHS corporation or of any subsidiary. (2) Merger: Merger, consolidations, and reorganizations involving an MHS corporation, or sale or transfer of assets other than in the ordinary course of business. (3) Annual Budget, Fee Schedules, MD Staff Requests: Adoption and implementation of annual operating and capital budgets by an MHS corporation, fee schedules, and physician staff requests (other than specialty staff). (4) MD Compensation and all Benefits: Annual physician compensation which will be reviewed to determine that it is reasonable as to each physician and complies with tax exemption and other regulatory requirements; establishment, change, or discontinuance of physician compensation or any employee benefits in a manner that deviates materially from the physician compensation system established in the annual operating budget or from any existing benefits. (5) Capital Expenditures over Specified Limits: Capital expenditures or contracts committing to expenditures that exceed a threshold amount stipulated by the MCR Board of Governors. (6) Fundamental Changes: Changes in the fundamental nature or principal mission of any MHS corporation. (7) Change of Name: Alteration of names used with respect to the health care facilities operated by any MHS corporation. (8) General Matters Affecting Mayo: Matters, activities and events undertaken or encountered by any MHS corporation which could impact MCR or affiliated corporations with respect to legal, tax exemption, business, or reputational matters. (9) Appoint/remove Local Site Board Members: Approval of local MHS Board members to the extent MCR has the ability to elect, appoint, approve or to remove them pursuant to the local MHS site governing documents. Non-delegated (Reserved Powers retained by the Mayo Clinic Rochester Board) (1) Debt: Incurrence of debt by any MHS site. (2) New MHS Services/Strategic Plan: Adoption of strategic plan provisions not within the scope of mutually agreed upon, predetermined guidelines; establishment of new programs or services and discontinuance of existing programs and services. (3) Specialty MD Staff Requests 5

11 Mayo Health System Governance MCR Board of Governors FSPA MHS Board of Directors FSH Corporate Members Forum MHS Management Committee MHS Employer of Choice Committee MHS Finance Committee MHS Medical Directors Committee MHS Strategic Planning Committee MHS Local Boards FSH MHS Quality Committee MHS Patient Safety Committee 6 MHS Governance 2005.ppt 6

12 Mayo Health System Board Peter W. Carryer, M.D., Chair Mayo Clinic Rochester David M. Beckmann, M.D. Cannon Valley Clinic David W. Berg Owatonna Clinic Terrence L. Cascino, M.D. Mayo Clinic Rochester Glenn S. Forbes, M.D. Mayo Clinic Rochester DuWayne A. Hansen, M.D. Fairmont Medical Center Timothy J. Johnson, M.D. Austin Medical Center Cheri A. Kramer Lake City Medical Center/Wabasha Clinic Randall L. Linton, M.D. Luther Midelfort Robert H. Lohr, M.D. Mayo Clinic Rochester James T. McCarthy, M.D. Mayo Clinic Rochester Dawn S. Milliner, M.D., Mayo Clinic Rochester Robert E. Nesse, M.D. Franciscan Skemp Healthcare William C. Rupp, M.D. Immanuel St. Joseph s Alan R. Schilmoeller Mayo Clinic Rochester Gregory J. Thomas Mayo Clinic Rochester Julie S. Hansen Mayo Clinic Rochester Margaret P. Dougherty Mayo Clinic Rochester 7

13 Mayo Health System Administration Chair - Dr. Peter Carryer Mayo Health System Board Vice Chair - Dr. Robert Lohr Mayo Health System Operations Vice Chair - Dr. William Rupp Mayo Health System Planning Administrative Functions - Communications - Contracting and Payor Relations - Development - Facilities - Finance and Patient Financial Services - Human Resources - Information Technology & Systems - Leadership Development - Marketing - MHSA Support Staff - Performance Excellence - Physician and Administrator Liaisons - Physician Recruitment - Planning Services - Systems and Procedures Chair - Gregory Thomas MHS Administration Dept. MHS Programs - Disease Management Strategies - Documentation and Coding - EnhanceMed - Mayo Regional Medical Plan - Supply Expense Management Rev

14 Mayo Health System Luther Midelfort Eau Claire, Wisconsin Decorah Clinic, Decorah, Iowa Wabasha Clinic Wabasha, Minnesota New Hampton Clinic New Hampton, Iowa Fairmont Medical Center Fairmont, Minnesota Albert Lea Medical Center Albert Lea, Minnesota Red Cedar Medical Center Menomonie,, Wisconsin Austin Medical Center Austin, Minnesota Franciscan Skemp Healthcare La Crosse, Wisconsin Cannon Valley Clinic Faribault, Minnesota Immanuel St. Joseph's Mankato, Minnesota Owatonna Clinic Owatonna, Minnesota Lake City Medical Center Lake City, Minnesota Lamberton Springfield Madelia St. James Truman Fairmont Sherburn Armstrong St. Peter Minnesota Mankato Lake Crystal Waseca New Richland Wells Kiester Le Sueur Northfield Waterville Janesville Lake Mills Faribault Owatonna Blooming Prairie Alden Albert Lea Austin Charles City Prairie Farm Glenwood City Elmwood Barron Menomonie Rochester Grand Meadow Adams LeRoy Iowa Lake City Plainview Colfax Mondovi Decorah New Hampton Cameron Wabasha Alma Chetek Bloomer Chippewa Falls Eau Claire Arcadia Osseo Galesville Holmen Onalaska La Crescent Houston Caledonia Mabel Waukon Wisconsin Sparta Tomah West Salem La Crosse Prairie du Chien Clinics Hospitals Hospitals (Management Contract) CP

15 Mayo Health System Dates of Affiliation/Opening Organization Location Dates Affiliation Decorah Clinic Decorah, IA 2/4/92 Luther Midelfort Eau Claire, WI 10/1/92 Wabasha Clinic Wabasha, MN 6/2/93 New Hampton Clinic New Hampton, IA 7/1/94 Fairmont Clinic Fairmont, MN 9/1/94 Albert Lea Clinic Albert Lea, MN 1/1/95 Austin Medical Center Austin, MN 1/1/95 Franciscan Skemp Healthcare La Crosse, WI 7/1/95 Red Cedar Clinic Menomonie, WI 7/1/95 Naeve Hospital Albert Lea, MN 1/1/96 Myrtle Werth Hospital Menomonie, WI 3/1/96 Immanuel St. Joseph s Mankato, MN 3/1/96 Owatonna Clinic Owatonna, MN 3/1/97 Lake City Clinic Lake City, MN 4/1/97 LeRoy Clinic LeRoy, MN 7/1/97 Waseca Medical Center Waseca, MN 1/1/98 Springfield Medical Center Springfield, MN 1/1/98 Barron Hospital Barron, WI 4/1/98 Lake City Hospital Lake City, MN 8/1/98 Bloomer Community Memorial Hospital Bloomer, WI 9/1/98 Midelfort Clinic Bloomer Bloomer, WI 1/1/99 Madelia Clinic Madelia, MN 7/1/99 Parkview Clinic Lake Crystal, MN 7/1/99 Janesville Clinic Janesville, MN 7/1/99 ISJ Clinic-NorthRidge North Mankato, MN 1/1/01 Fairmont Community Hospital Fairmont, MN 10/1/01 St. Peter Clinic St. Peter, MN 10/14/02 Le Sueur Clinic Le Sueur, MN 10/14/02 Mabel Clinic Mabel, MN 7/8/02 Cannon Valley Clinic Northfield Northfield, MN 4/7/03 Osseo Area Medical Center Osseo, WI 01/01/04 De novo Cannon Valley Clinic Faribault, MN 9/6/95 Prairie du Chien Clinic Prairie du Chien, WI 9/29/99 10

16 MAYO HEALTH SYSTEM COMMUNITIES AND FACILITIES AS OF JANUARY 2005 SUMMARY Organizations - 13 Mayo Owned Hospitals - 15 Mayo Owned Nursing Homes - 9 Hospital Service Agreement - 2 Nursing Home Service Agreement - 1 Communities - 64 Physicians (FTE) Allied Health Staff (FTE) - 9,842 Organization (Primary) Regional Clinics Hospitals Nursing Hospital Service Nursing Home Homes Agreement Service Agreement Albert Lea Medical Center Alden, MN New Richland, MN Albert Lea, MN Wells, MN Albert Lea, MN Kiester, MN Wells, MN Albert Lea Clinic (1/95) Lake Mills, IA Naeve Hospital (1/96) Austin Medical Center (1/95) Adams, MN LeRoy, MN (7/97) Austin, MN Austin, MN Blooming Prairie, MN Austin Clinic Grand Meadow, MN St. Olaf Hospital Cannon Valley Clinic (9/95) Northfield, MN (4/03) Faribault, MN Decorah Clinic (2/92) Mabel, MN (7/02) Decorah, IA Fairmont Medical Center Armstrong, IA Truman, MN (7/97) Fairmont, MN Sherburn, MN (2/97) Fairmont Clinic (9/94) Fairmont Community Hospital (10/01) Fairmont, MN Fairmont, MN Franciscan Skemp Healthcare (7/95) Arcadia, WI Onalaska, WI LaCrosse, WI LaCrosse, WI Lansing, IA LaCrosse, WI Caledonia, MN Prairie du Chien (9/99) Arcadia, WI Arcadia, WI St. Francis Hospital Galesville, WI Sparta, WI Sparta, WI Sparta, WI Skemp Clinic Houston, MN (4/97) Tomah, WI Holmen, WI Waukon, IA LaCrescent, MN West Salem,WI Immanuel St. Joseph's (1/96) Janesville, MN (7/99) NorthRidge-Mankato, MN(1/01) Mankato, MN St. James, MN Mankato, MN Lake Crystal, MN (6/99) St. Peter (10/14/02) (10/00) Springfield Medical Center (1/98) Lamberton, MN Springfield, MN Springfield, MN Waseca Medical Center (1/98) Le Sueur, MN (10/14/02) Waseca, MN Waseca, MN Madelia, MN (6/99) Waterville, MN Lake City Medical Center Lake City, MN Lake City, MN Lake City, MN Lake City Clinic (4/97) Lake City Hosp & Nrsg Home (8/98) Luther Midelfort (10/92) Barron, WI Colfax, WI (1/99) Eau Claire, WI Barron, WI Eau Claire, WI Bloomer, WI (1/99) Mondovi, WI (1/97) Barron, WI (4/98) Bloomer, WI Luther Hospital Cameron, WI Osseo, WI (8/95) Bloomer, WI (9/98) Osseo, WI (1/04) Midelfort Clinic Chetek, WI Prairie Farm, WI (11/94) Osseo, WI (1/04) Chippewa Falls, WI Red Cedar Medical Center Elmwood, WI Menomonie, WI Menomonie, WI Glenwood City, WI Red Cedar Clinic (7/95) Myrtle Werth Hospital (3/96) New Hampton Clinic (7/94) New Hampton, IA Owatonna Clinic (3/97) Owatonna, MN Wabasha Clinic (6/93) Wabasha, MN Alma, WI Plainview, MN Floyd County Memorial Hospital, Charles City, IA (2/94) Charles City, IA 11 DHB/K:/RPA/Forms-Labels-reports/11COMM~1.XLS/UPDATEJANUARY2005

17 MAYO FOUNDATION MAYO HEALTH SYSTEM STAFFING AND BED SUMMARY As of 12/31/2004 Total Number of Number Annual / year ended 12/31/2004 Physician Allied Number of Hospital Merger Providers Health of Beds Beds Patient Admissions ALOS Organizations (primary) Date (FTEs) (FTEs) (staffed/open) * (licensed) * Days Decorah Clinic 2/1/ Luther / Midelfort (Eau Claire) 10/1/ , ,365 9, Barron Medical Center 4/1/98 # incl above incl above , Bloomer Community Memorial 9/1/98 # incl above incl above Osseo Medical Center 1/1/04 # incl above incl above Wabasha Clinic 6/2/ New Hampton Clinic 7/1/ Fairmont Medical Center (merged 12/15/2004) ,208 2, Fairmont Clinic 9/1/1994 Fairmont Community Hospital 10/1/2001 Albert Lea Medical Center ** ,640 3, Clinic 1/1/1995 Naeve Hospital 1/1/1996 Austin Medical Center 1/1/ ,417 3, Franciscan Skemp Healthcare 7/1/ ,224 Hospitals LaCrosse ,652 7, Arcadia # Sparta # , Menomonie Medical Center ,921 1, Red Cedar Clinic 7/1/95 Myrtle Werth Hospital 3/1/1996 # Cannon Valley Clinic (Faribault) 9/6/ Immanuel St. Joseph's (Mankato) 1/1/ , ,257 9, Springfield Medical Center 1/1/1998 # , Waseca Medical Center 1/1/1998 # , Owatonna Clinic 3/1/ Lake City Medical Center Clinic 4/1/ Lake City Hospital/NH 8/1/98 # , Total 659 9, , ,695 39, Hospital Management Service Contracts Floyd County Memorial Hospital, Charles City, IA St. James Medical Center, MN (10/00) # Nursing Home Management Service Contract Lansing, IA # = Critical Access Hospitals (Springfield became CAH eff: 2/1/04, and Myrtle Werth eff: 7/1/04) 12 MAYO HEALTH SYSTEM ADMINISTRATION DHB/BJF/ACZ 4/13/2005 K:\RPA\FORMS-LABELS-REPORTS\12MHSS~1.XLS\Thru

18 2004 AMGA Acclaim Award Luther Midelfort Selected as Acclaim Honoree Luther Midelfort received a 2004 for their quality initiatives concerning the IOM s six aims. This is Luther Midelfort s second Acclaim Award and the fifth year running that a Mayo Health System site has received the award. The Acclaim Award is the American Medical Group Association s (AMGA) most prestigious quality award, honoring physician-directed organizations that bring the American healthcare system closer to a delivery model in which patients experience care that is safer, more reliable, more responsive, more integrated, and more readily available. The 2004 AMGA Acclaim Award rewards medical groups who are transforming their organizations to incorporate the Institute of Medicine (IOM) aims of providing care that is safe, effective, patient centered, timely, efficient and equitable. The award recognizes organizations that are successfully integrating the IOM aims into their strategy for improvement. Luther Midelfort has been selected as an honoree and was presented with an award and $10,000 on October 21 at the annual AMGA meeting. 13

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24 Mayo Outreach January 2005 Non-Internal Medicine Outreach Neurology Adult Neurology Peds Dialysis Unit Oncology Ophthalmology Pediatric CV Pediatric Ortho PM&R Internal Medicine Outreach Cardiology Endocrinology Gastroenterology Nephrology Preventive Medicine Rheumatology Springfield Mankato Madelia Fairmont Owatonna Waseca Albert Lea Duluth Grand Forks St. Cloud Bismarck Faribault Mason City Osage Austin Barron Chippewa Falls Menomonie Lake City Rochester Cresco Charles City Durand Wabasha Spring Valley Decorah Eau Claire Winona New Hampton La Crosse Elmhurst IL CP

25 Rochester Management Accounting Sue Graff L:\dept\skg\Outreach\20 Outreach Cons FTEs 2005.xls 4/13/2005 MCR Outreach Activity Consultant FTE's Dec 2000 Dec 2001 Dec 2002 Dec 2003 Dec 2004 Department/Division YTD YTD YTD YTD YTD Anesthesiology Otorhinolaryngology Ophthalmology Neurologic Surgery Obstetrics and Gynecology Orthopedics Urology Dermatology Medical Genetics Neurology Family Medicine Pediatrics Physical Medicine and Rehab Psychiatry and Psychology Diagnostic Radiology Oncology Lab Medicine Misc Patient Care-Related Non-Internal Medicine Sub-Total Allergy Cardiovascular Diseases Endocrinology Gastroenterology Hematology Infectious Disease Nephrology Rheumatology Pulmonary and Critical Care Preventive Medicine Cardiac Cath Lab Internal Medicine Sub-Total Total Outreach Consultant FTE's

26 Mayo Health System MCR Patients from Counties within 120 miles , Growth Rate Primary MHS Site -0.2% Secondary MHS Site -0.4% Rest of 120 Miles 1.9% 36,714 37,808 38,814 43,036 40,994 43,615 44,225 43,914 43,827 Patients ,439 26,557 26,863 20,734 21,581 22,518 23,510 23,91524,57725,41525,557 21,090 22,242 20,252 27,434 26,329 27,346 26,313 27,233 26, Primary MHS Site (12) Secondary MHS Site (15) Rest of 120 Miles (47) Note: Excludes Twin Cities, Olmsted County and Dodge County. 21

27 Mayo Health System Physician Referral Requests to MCR 19,000 17,000 15,000 13,000 11,000 11,558 13,269 13,845 14,911 14,710 16,987 9,000 7,000 5,000 7,014 7,860 8,734 9,871 3, % change from previous year 12% 11% 13% 17% 15% 4% 6% 1% 14% Prior year data updated to include historical referral data for all MHS sites prior to their affiliation date with Mayo. Volumes exclude all referrals by MCR physicians. 22

28 2003 Hospital Discharge Maps The following maps are provided for your information 2003 Hospital Discharge Data for MHS Communities 2003 Hospital Discharge Data for MHS and Other Selected Communities Hospital Discharge Change 2002 to 2003 for MHS Communities Hospital Discharge Change 2002 to 2003 for MHS and Other Selected Communities Explanation of Data: For each zip code in the 120-mile radius surrounding Rochester, the hospital with the highest percent of expected inpatient discharges was assigned that zip code. Zip codes where no hospital had more than 10% of expected discharges were not assigned. The MHS Community Maps compare hospital discharges for hospitals in communities where MHS sites are located. Faribault, MN and Owatonna, MN data was not available. The MHS and Other Selected Community Maps compare combined discharges for MCR and MHS hospitals with discharges from the Twin Cities area hospitals as well as other major hospitals in the region. Data sources include the Solucient database (WI and IA discharges), Minnesota Hospital Association (MN discharges), Decision Support System (for MCR), and MHS hospitals located in Minnesota. Highlights for 2003: MHS Community Maps: Outside of the Southeast Minnesota area, MCR continues to dominate in northern Iowa and western Faribault County. Compared to 2002, 94% of the zips remained the same from 2002 to % changed (1/3 to MCR, 1/3 to no winner, and 1/3 to other MHS hospitals). Lake City Hospital had the majority of discharges to Lake City (43%), although MCR discharge volumes continue to be very close (42%). St. Elizabeth s hospital in Wabasha had the majority of discharges to Wabasha in 2003 (31%), changing from a majority by MCR/MHS in This area has continued to switch between MCR/MHS and St. Elizabeth s as winners over the past few years. MHS and Other Selected Community Maps: Although the majority of discharges to Rice county (Faribault City area) were from SE MN hospitals, Twin Cities hospitals continue to have dominance over MCR for the county (23% vs.12%) and for the city of Faribault (22% vs. 17%). The Winona area had the most discharges from SE MN hospitals, not from Mayo or Gundersen. Mayo and Gundersen discharges were both 11% of expected discharges for Winona (zip code 55987). In 2002, Gundersen had slightly more discharges (13%) than MCR/MHS (11%). Eau Claire, Wisconsin continues to be very close between Mayo and Sacred Heart in Eau Claire. However, Sacred Heart had more discharges (35%) for the county than MCR/MHS (32%). 23

29 2003 Hospital Discharge Data for MHS Communities Minneapolis Menomonie Eau Claire Northfield Faribault Lake City Wabasha Marshfield Mankato Owatonna Rochester La Crosse Fairmont Albert Lea Austin Decorah Mason City New Hampton Waterloo Notes: 1. Hospital discharges by zip, unadjusted for mix, were compared against other MHS sites. Hospital with largest volume was given credit for that zip. 2. Zips where no hospital had more than 10% market presence were excluded. 3. Data doesn't include discharges from other hospitals in the region (i.e., Twin Cities, Lutheran-La Crosse). 4. Data was not available for Faribault Hospital or Owatonna Hospital. * Hospital discharge data is updated annually and has a lag time of approximately one year discharge data was not available at the time of this printing. (Plng Srvs\Mkt Penet\2003 Data\DischargeMapFiles\MHSHospDisch2003.w or) 11/23/04 FSH-LaCrosse (29) Luther Midelfort-Eau Claire (34) Mercy-New Hampton (3) Winneshiek County-Decorah (14) MCR Hospitals (117) ISJ-Mankato (36) Naeve-Albert Lea (19) St. Olaf-Austin (8) St. Elizabeth's-Wabasha (4) Fairmont Hospital (17) Lake City Hospital (2) 24

30 2003 Hospital Discharge Data for MHS and Other Selected Communities Minneapolis Menomonie Eau Claire Marshfield Mankato Northfie ld Faribault Owatonna Lake City Wabasha Roche s te r La Crosse Fairm ont Austin Albert Lea De corah Mason City Ne w Ham pton Waterloo Notes: 1. Hospital discharges by zip, unadjusted for mix, w ere compared against each other. Hospital w ith largest volume w as given credit for that zip. 2. Zips w here no hospital had more than 10% market presence w ere excluded. 3. Data w as not available for Faribault or Ow atonna Hospitals. 4. Other includes: IA Luth & Broadlaw ns-des Moines, Mercy-Iow a City, Mercy-Cedar Rapids & Des Moines, Mercy-Janesville, St. Michaels-Stevens Point, Meriter Hospital-Madison, Prairie du Chien Memorial Hospital. 5. Tw in Cities includes all 7 county metro hospitals. * Hospital discharge data is updated annually and has a lag time of approximately one year discharge data was not available at the time of this printing. PlngSrvs\MktPenet\2003 Data\DischargeMapFiles\AllCommunDischarge03.w or 11/23/04 25 Tw in Cities Hospitals (222) Sacred Heart Hospital-Eau Claire (5) Lutheran Hospital-LaCrosse (33) St. Mary's Hospital-Madison (4) Univ of Wisc Hospital-Madison (5) St. Joseph's Hospital-Marshfield (33) Covenant Medical Center-Waterloo (21) Univ of Iow a Hospital-Iow a City (3) Mercy Medical Center-North Iow a (61) Mercy Medical Cetner-Dubuque (24) Allen Memorial Hospital-Waterloo (28) MCR/MHS (221) Other Hospitals (13) Mary Greeley Medical Center-Ames (10) St. Luke's Hospital-Cedar Rapids (12) Trinity Regional Hospital-Fort Dodge (16) St. Joseph's Hospital-Chippew a Falls (6) Central Minnesota Hospitals (21) SE Minnesota Hospitals (36) SW Minnesota Hospitals (22)

31 Hospital Discharge Change 2002 to 2003 for MHS Communities (Areas Where a Different MHS Hospital Held Greatest Market Penetration in 2003 vs. 2002: 2003 Hospital Shown) Minneapolis Menomonie Eau Claire Marshfield Mankato Northfield Faribault Owatonna Lake City Rochester Wabasha La Crosse Fairmont Austin Albert Lea Decorah Mason City New Hampton Waterloo Notes: 1. Hospital discharges by zip, unadjusted for mix, w ere compared against other MHS sites. Hospital w ith largest volume w as given credit for that zip. 2. Zips w here no hospital had more than 10% market presence w ere excluded. 3. Data doesn't include discharges from other hospitals in the region (i.e., Tw in Cities, Lutheran-LaCrosse). 4. Data w as not available for Faribault Hospital or Ow atonna Hospital. * Hospital discharge data is updated annually and has a lag time of approximately one year discharge data was not available at the time of this printing. (PlngSrvs\Mkt Penet\2003 Data\DischargeMapFiles\MHSChange02-03.wor) 11/29/04 26 FSH-LaCrosse (2) Luther Midelfort-Eau Claire (1) Mercy-New Hampton (1) Winneshiek County-Decorah (4) MCR Hospitals (20) ISJ-Mankato (2) Naeve-Albert Lea (1) St. Olaf-Austin (3) St. Elizabeth's-Wabasha (3) Fairmont Hospital (2) Lake City Hospital (1) No MHS Site w ith > 10% share in 02 or 03 (680) No MHS site w ith > 10% share in 2003 (20) No Change from 02 (243) New Zip Code (2)

32 Hospital Discharge Change 2002 to 2003 for MHS and Other Selected Communities (Areas Where a Different Hospital Held Greatest Market Penetration in 2003 vs. 2002: 2003 Hospital Shown) Minneapolis Menomonie Eau Claire Marshfield Mankato Northfield Faribault Owatonna Lake City Wabasha Rochester La Crosse Fairmont Austin Albert Lea Decorah Mason City New Hampton Waterloo Notes: 1. Hospital discharges by zip, unadjusted for mix, w ere compared against each other. Hospital w ith largest volume w as given credit for that zip in their service area. 2. Zips in w hich all hospitals had less than 10% market presence w ere left unshaded. 3. MHS includes MCR Hospitals. 4. Data w as not available for Faribault and Ow atonna Hospitals. 5. Other includes: IA Luth & Broadlaw ns-des Moines, Mercy-Iow a City, Mercy-Cedar Rapids & Des Moines, Mercy-Janesville, St. Michaels-Stevens Point, Meriter Hospital-Madison, Prairie du Chien Memorial Hospital. 6. Tw in Cities includes all 7 county metro hospitals. * Hospital discharge data is updated annually and has a lag time of approximately one year discharge data was not available at the time of this printing. PlngSrvs\Mkt Penet\2003 Data\DischargeMapFiles\AllCommunChange02-03.w or 11/23/04 Tw in Cities Hospitals (13) Lutheran Hospital-LaCrosse (5) Univ of Wisc Hospital-Madison (5) St. Joseph's Hospital-Marshfield (1) Covenant Medical Center-Waterloo (7) Univ of Iow a Hospital-Iow a City (3) Mercy Medical Center-Dubuque (4) Allen Memorial Hospital-Waterloo (4) MCR/MHS (22) Other Hospitals (1) Mary Greeley Medical Center-Ames (3) St. Luke's Hospital-Cedar Rapids (3) Trinity Regional Hospital-Fort Dodge (2) Central Minnesota Hospitals (1) SE Minnesota Hospitals (6) SW Minnesota Hospitals (4) No site w ith >10% share in 02 or 03 (170) No Change (710) No hosp w ith > 10% share in 03 (change from 02) (19) New Zip Code (2) 27

33 Hospital Discharge Change 1999 to 2003 for MHS and Other Selected Communities (Areas Where a Different Hospital Held Greatest Market Penetration in 2003 vs. 1999: 2003 Hospital Shown) Minneapolis Menomonie Eau Claire Marshfield Mankato Northfield Faribault Owatonna Lake City Wabasha Rochester La Crosse Fairmont Austin Albert Lea Decorah Mason City New Hampton Waterloo Notes: 1. Hospital discharges by zip, unadjusted for mix, w ere compared against each other. Hospital w ith largest volume w as given credit for that zip in their service area. 2. Zips in w hich all hospitals had less than 10% market presence w ere left unshaded. 3. MHS includes MCR Hospitals. 4. Data w as not available for Faribault and Ow atonna Hospitals. 5. Other includes: IA Luth & Broadlaw ns-des Moines, Mercy-Iow a City, Mercy-Cedar Rapids & Des Moines, Mercy-Janesville, St. Michaels-Stevens Point, Meriter Hospital-Madison, Prairie du Chien Memorial Hospital. 6. Tw in Cities includes all 7 county metro hospitals. * Hospital discharge data is updated annually and has a lag time of approximately one year discharge data was not available at the time of this printing. PlngSrvs\Mkt Penet\2003 Data\DischargeMapFiles\AllCommunChange99-03.w or 11/29/04 Tw in Cities Hospitals (6) Sacred Heart Hospital-Eau Claire (2) Lutheran Hospital-LaCrosse (7) St. Mary's Hospital-Madison (1) Univ of Wisc Hospital-Madison (4) St. Joseph's Hospital-Marshfield (3) Covenant Medical Center-Waterloo (6) Univ of Iow a Hospital-Iow a City (3) Mercy Medical Center-North Iow a (2) Mercy Medical Center-Dubuque (5) Allen Memorial Hospital-Waterloo (4) MCR/MHS (22) Other Hospitals (9) Mary Greeley Medical Center-Ames (4) St. Luke's Hospital-Cedar Rapids (5) Trinity Regional Hospital-Fort Dodge (3) Central MN Hospitals (21) SE MN Hospitals (36) SW MN Hospitals (22) No site w ith >10% share in 99 or 03 (63) No Change (610) No hosp w ith > 10% share in 03 (change from 99) (30) New Zip Code (117) 28

34 Mayo Health System Annual % Growth in FTE and Patient Volumes 10.0% 8.0% Pt Care Consultants Admissions Patient Visits Surgical Pts 6.0% 4.0% 2.0% 0.0% (2.0%) (4.0%)

35 Mayo Health System Quality Committee Charge: The Mayo Health System (MHS) Quality Committee is appointed by and reports to the MHS Board through the MHS Medical Directors Committee. The MHS Quality Committee supports the MHS Board through the following duties: Monitor industry trends and activities to measure and improve the quality of patient care and service. Recommend system-wide quality initiatives and priorities to the MHS Board. Provide support for system-wide quality initiatives as directed by the MHS Board. Define metrics to monitor quality and provide progress reports to the MHS Board. Recommend infrastructure resources required to measure, monitor and improve quality to the MHS Board Membership: Terrance R. Borman, M.D., Chair Luther Midelfort Christopher D. Rustad, Secretary Mayo Health System Administration Gregory L. Angstman, M.D. Lake City Medical Center/Wabasha Clinic Mark Deyo-Svendsen, M.D. Red Cedar Medical Center Cynthia M. Dube, M.D. Austin Medical Center Robert T. Holt, R.Ph. Austin Medical Center Robert H. Lohr, M.D. MHS Administration; Chair, Medical Directors Committee James M. Naessens Mayo Clinic Rochester Mark A. Nyman, M.D. Mayo Clinic Rochester Joseph P. O Keefe Mayo Clinic Rochester Steven E. Parnell, M.D. Fairmont Medical Center Guillermo M. Pons, M.D. Immanuel St. Joseph s P. Stephen Shultz, M.D. Franciscan Skemp Healthcare Darlene A. Vsetecka Decorah Clinic Peter W. Carryer, M.D. Mayo Health System Administration William Unverzagt Mayo Health System Administration 2005 Meeting Schedule: January 19, 2005 February 16, 2005 March 16, 2005 April 20, 2005 May 18, 2005 June 15, 2005 July 20, 2005 August 17, 2005 September 21, 2005 October 19, 2005 November 16, 2005 December 21, :00 5:00 PM third Wednesday of each month. Rochester location: 201 Building (1-03). Videoconference provided to MHS sites (Austin and Decorah). 30

36 Mayo Health System Clinical Quality Dashboard The Mayo Health System clinical quality dashboard is a set of quality measurements that reflect the services provided across all MHS organizations. Measurement is a basic element of quality improvement and health care purchasers are rapidly gaining expertise in measuring health care quality. In response to these observations, the MHS Quality and Patient Safety Committees have developed a clinical quality dashboard which is a work in progress organized around the Six Aims from the Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century. The MHS Quality and Patient Safety Committees are charged with three of the six aims: safe, effective and patient centeredness. The MHS Medical Directors Committee is charged with the remaining three aims: equity, efficient and timely. CARE IS SAFE Define the elements of a culture of safety. Develop measurement. Measurement of adverse events. Confirmation of compliance with JCAHO national patient safety goals. CARE IS EFFECTIVE Measures Mortality - Hospitalization for Community-Acquired Pneumonia Quality Indicator Project - Hospitalization for Congestive Heart Failure Quality Indicator Project Readmission - Hospitalization for Community-Acquired Pneumonia Quality Indicator Project - Hospitalization for Congestive Heart Failure Quality Indicator Project Medicare Provider Analysis and Review (MEDPAR) JCAHO Core Measures - Congestive Heart Failure - Acute MI - Community-Acquired Pneumonia - Pregnancy-related conditions Surgical Measures - Gallbladder surgery Measures being done are bold. 31

37 Measures (cont) Adult Preventive Services - BP screening - Total and HDL cholesterol - Immunizations Tetanus Influenza Pneumonia - Colorectal screening - Pap smear - Mammogram - Tobacco documentation - Advising smokers to quit Adult Diabetes Measures - Percent of patients with glycosated hemoglobin/a1c in the last 6 months - Percent of patients with HbA1c<7% - Percent of patients with LDL in last 12 months - Percent of patients with LDL<=100mg/dl - Percent of patients with BP<130/80 CARE IS PATIENT CENTERED Mayo Foundation Patient Satisfaction Survey Inpatient MHS Provider-Specific Patient Satisfaction Survey Outpatient Patient Access Initiatives 32

38 Disease Management Strategies in Mayo Health System 2004 The mission of disease management strategies (DMS) is to identify, promote and support the implementation of high value, evidence-based best practices to maximize the quality of care at the Mayo Health System (MHS) sites for patient populations. At the local level, a multidisciplinary team led by a physician and facilitated by a DMS Coordinator performs problem analysis and implement changes to improve the process of patient care. The DMS coordinator has extensive knowledge about continuous improvement tools and measurement that provides the process expertise to the team. The MHS DMS teams are partnering with insurance companies through pilots of care for diabetes and other chronic diseases. Local awards have been obtained to assist in educating their patients and offer community opportunities about tobacco cessation, preventive screening and wellness. Preventive Services Various implementation activities occurred at MHS sites to meet and exceed Preventive Service standards. The types of activities used to promote Preventive Service care continues to increase at the sites and within the communities. Implementation Activities include: Pre-visit planning is done with use of flow sheet to review and prepare medical records for a clinic visit and highlight or flag for the patient care team the particular service that needs to be addressed at the patient visit. Stamps to prepare the medical record for visits were created to allow for information collection at the visit for vital signs, allergy review, immunizations, or other preventive service screening. Nursing protocols have been developed to enhance efficiency of service delivery for immunizations. Wellness programs and women s health were provided by a number of sites as an effort to educate their patients and public about appropriate preventive services, tobacco cessation, walking campaigns, diet, stress, and other topics. Additional types of public awareness were promoted at some sites through screening clinics and flu clinics. Measurement: Goal: Achieve a goal of 90% in implementation of all Preventive Services. A total of 18 sites report quarterly using a web-based tool to collect medical record information using a random sample methodology. The population measured at each of the sites is defined as a random sample of 30 patients, age 18-80, who had a clinic/site visit. The measures for preventive services include: Cardiovascular Screening Tobacco Prevention and Cessation - documentation of tobacco use and advise to quit Lipid Screening - screening for women age and men age every 5 years Blood Pressure Check - measured at every visit Immunizations Tetanus vaccination every 10 years Influenza annual vaccination in the autumn recommended for patients age 50 and older, and any high risk patient Pneumococcal vaccination recommended for patients who are 65 and older, and any high risk patient. Cancer Screening Colorectal Cancer examination every 5 years after age 50 Cervical Pap Smear obtained every 3 years for women age

39 Breast Cancer - measurement in 2004 included women age years. Recommended screening includes annual mammography for women age 40 and older. Diabetes Implementation Activities A web-based sample tool assists sites to collect medical record data for sites that do not have a diabetes registry. The diabetes registry has a report that is used as a tool to provide a patient summary sheet which is used by the physician, nurse, and care teams in pre-visit planning and discussion of follow up goals with patients at the time of the visit. Diabetes flow sheets were developed and inserted into charts for patients with diabetes at some sites and preventive services information is incorporated in the diabetic flow sheets. A specific color tag or sticker on the outside of charts is used to identify medical records for patients with diabetes at some sites. Patients are sent reminder letters, indicating the need to come for a follow up appointment for their diabetes or notifying them of educational sessions. Sites developed a mechanism with local ophthalmology and optometrists to forward results of patient eye exams to the clinic to include in the patient medical records. Group educational visits were started or continued at a number of MHS sites. Community efforts to provide diabetes support groups or group education were implemented in a number of sites. Several MHS sites have been recognized by the ADA for physician excellence and/or for ADA certified diabetes education programs. Measurement Goal: Complete diabetes implementation activities and increase defined diabetes measures 5% above baseline. A random sample of adult patients with diabetes ages 18 and 80 with an ICD-9 code of is utilized for measurement. These patients have at least one visit coded for diabetes at the site in the months prior to the service date. Data collection includes a random sample of 20 patients with a visit per month. The measures established for ongoing quarterly reporting include: HbA1c level measured every six months % of patients with a HbA1c level less than 7% LDL cholesterol level measured every 12 months % of patients with a LDL level less than 100 mg/dl % of patients with a blood pressure measurement less than 130/80 34

40 Preventive Services - MHS S ervices C om plete - G oal 90 % ,753 patients , patients ,081 2, patients patients sites sites 6 sites sites sites sites sites sites sites sites sites sites Percentage Percentage of of appropriate appropriate (age (age and and sex sex defined)) defined)) services services for for the the population population which which were were completed completed Confidential Confidential Review Review - - Organization Organization Data Data Mayo Health System Preventive Services Tetanus Tetanus Influenza Influenza Pneum Pneum Colorectal Colorectal Mammogram Mammogram Cervical Pap Cervical Pap Tobacco Use Tobacco Use Tobacco Advice quit Tobacco Advice quit Lipid Lipid BP BP All Services All Services Percentage of of appropriate (age (age and and sex sex defined) services for for the thepopulation which which were were completed Confidential Confidential Review Review Organization Organization Data Data 35

41 PATIENT SATISFACTION Patient satisfaction is an on-going measurement at all MHS organizations. The intent of these surveys is to provide departments and individual practitioners with feedback regarding their interactions with patients while also providing a snapshot of performance to the leadership of MHS and individual MHS organizations. We have focused on reporting the percent excellent response for questions, as it identifies loyal patients and shows the potential for the highest level of performance. There are two system-level patient satisfaction surveys, the Mayo Foundation Survey for inpatients, and the MHS Provider-Specific Patient Satisfaction Survey for outpatients. The Mayo Foundation Patient Satisfaction Survey is a phone survey with the goal of 400 interviews per MHS hospital per year. This is not always an attainable goal since some of the hospitals do not have sufficient admissions in a year. In addition to all MHS hospitals, Decorah Clinic patients admitted to Winneshiek County Hospital (not part of MHS) are also surveyed. The survey year for the hospital patients is October to the following September. The MHS Provider-Specific Patient Satisfaction Survey is a mail survey in which 100 patient surveys are sent out per provider. Each MHS provider's patients are surveyed once a year, with three to four organizations participating in the survey per quarter. Each MHS organization receives an annual report. System-level reporting is done on a rolling-fourquarters basis. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Mayo Foundation Patient Satisfaction Survey MHS Hospital Patient Survey 10/00-9/01 (n=2,951) 10/01-9/02 (n=3,026) 10/02-9/03 (n=3,060) 10/03-9/04 (n=3,217) 48% 44% 45% 46% Physician 43% 41% 43% 41% 39% 37% 38% 38% Nurses/Allied Health Staff Practice Support 73% 63% 64% 61% Advocation Categories: Physician: overall MD care, listening, thoroughness, explanation;. Nurses/AHS: overall nurses care, responsiveness, explanation, overall AHS care. Practice Support: efficiency, information re. tests, cleanliness, discharge, billing. Advocation: overall care, willingness to return, recommend and brag.* Fairmont Comm. Hosp. was added to MHS in 2002 *Willingness to brag question removed in 2003 Mayo Health System Provider-Specific Survey Trends in % Excellent for Key Questions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% (n=19,142) (n=26,482) (n=25,091) (n=39,616) 55% 56% 57% 58% 49% 46% 47% 49% 46% 48% 49% 51% Overall MD Care Overall Care Recommend 36

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