Restructuring Healthcare The Role of Technology

Transcription

1 Restructuring Healthcare The Role of Technology Philip Gaziano, MD October 11, 2012

2 2 Physician Owned & Lead Organizations Accountable Care Associates, LLC (ACA): Founded in 2010, it is physician owned and operated, and a provider MCO to support and partner with physicians and hospitals in managed healthcare delivery. Philip Gaziano, M.D. is Chairman and CEO, and he helped develop some of ACA s services from 1998 to 2010 in Hampden County Physicians Associates, a Massachusetts based multi-specialty physician practice now served by ACA. ACA Provides: Contracting, Consulting, Care Coordination, Reinsurance, Coding, Clinical Rounding, Provider Educational, Chart Auditing, Risk Adjustment, Compliance, Quality Measures Management, Custom Work Flow Design, and Other Provider MSO Services for Managed Healthcare Delivery. Quality Health Ideas, LLC (QHI): Founded in 2002, it is an IT and Data Management Company, that is physician owned and operated by Philip Gaziano, M.D. and Felicitas Thurmayr, M.D. Ph.D. QHI Builds and Provides: Data Management, Quality Registry, Decision Support, EMR/EHR Integration, HIE Integration, and Web Integration Tools and Services.

3 Physician Perspectives 1. Change is hard, (and only done if no other option) 2. Choices: independence vs. practice aggregation 3. Job satisfaction comes from quality, control, & comp. 4. All care delivery changes require more data 5. Too much data, or confusing & wrong data is worse 6. Need to improve providers work flows with tools 7. Infrastructure and starting cost must be low 8. Risks (financial & legal) must be low 9. A great need exists for help, guidance, and support (Who to call?, and who to partner with?)

4 Why Will Reforms and New Systems be Provider Driven? In 4 Massachusetts counties served by ACA physician networks this pen can order either $4,000,000,000 of health care, or $3,500,000,000, and give higher quality care.

5 New ACO Type Global Delivery & Payment Systems Vs. Older HMO Systems, and Other Non-Global Systems

6 New ACO Type Global Delivery & Payment Systems Medicare Advantage (including SNP & other) Dual eligible (SCO, PACE, & other) Commercial (Blue Cross AQC & other) Medicare ACOs (pioneer and shared savings) State ACOs and some pilot programs Some (but not all) HMOs None Depend on the Federal Affordable Care Act

7 Reducing Downside Financial Risk with Global Delivery Medicare shared savings ACOs (track 1) have: No downside financial risk Other shared savings have upside potential only Data infrastructure can identify and reduce risk Partner with others to reduce and share risk Reinsurance is always available

8 Real World Experience From ACA, QHI, and Our Providers

9 Our Consistent Savings Can (And Has Since 1998) Paid for Our Nurse, Physician, Admin, & Data Infrastructure And Has Contributed to Increased Physician Compensations

10 Physician % of Medicare Budgets Specialists Specialists Including Specialists Including Phys. Managers Including Phys. Managers & Hospitalists Phys. Managers & Hospitalists 11% & Hospitalists 9.5% 9% Office PCPs Office PCPs Office PCPs 4.0% 6% 3% Medicare Medicare Well Run Fee-For-Service Share Savings Medicare ACO Advantage (Our ACA Model) (Our ACA Model) (2012 Applications) (Run Since 1998)

11 Our ACA & QHI Growth HCPA 1996 ACA 2010 January 2012 By Mid 2013 Total PCPs Served: >500 Total Network Docs: 250 2,000 5,000 >15,000 Managed Members: ,000 34, ,000 Our Employees: >100 Counties / States: 1 / 1 3 / 1 4 / 1 25 / 7 Care Managed ($Million/yr.): >$2 Billion We are Adding 6 New Federal ACOs in 7 States for Jan. 2013

12 Our ACA & QHI Growth ACA Managed Members ACA Managed in All of Massachusetts ACA Managed Outside of Massachusetts All ACA Managed Members in the US Managed Medicaid & Commercial 20,000 10,000 30,000 Medicare Advantage: 15, Medicare Shared Savings ACOs: 30,000 60,000 90,000 All Managed Medicare: 45,000 60, ,000 Total Managed Members: 65,000 70, ,900 Healthcare $/Managed/Year: $600 Million $700 Million $1.3 Billion Contracted so Far for Jan. 2013

13 Our Massachusetts Diversity We Serve 250 PCPs + >5000 Specialists With 10 Hospitals in 4 counties (2 = Home/Partners) 50% of PCPs are in practice groups of 3 or fewer 20% of PCPs still use paper charts 11 different PCP EMRs that do not share data Hospitals have different EHRs, not connected to PCPs They are Not Integrated Other Than by Our Tools

14 Our Groups Performances: Since 2002 we added 56 different groups, in 4 counties, of different makeups, from solo practices to 100 provider groups, under 12 managed different contracts. All these groups improved in both quality and efficiency. Many came with no global-payment experience. Our newest groups now perform best (in only 3 months). We have never had a deficit year with any group. Efficiency and quality increase in only 3 6 months. All quality measures and all providers improved. Groups report no barriers to starting, and satisfaction due to the physician lead processes.

15 A Deloitte Review of 8 MA Organizations Powered by ACA & QHI CareScreen TM Leading Practice Due to Our: Costs, Outcomes, & Our Unique Approach. Our Tool Integration Helps Our Groups Consistently Perform Well, and Also Makes our Tools and Services Cost Less

16 MA Budget Savings Breakdown Medicare Members Ranked by % of Total Annual Expenses % of Total Care Budget Used Not ACA Managed Managed $ Million in 2011 For 6,300 Members Not ACA Managed Managed Top 3% 50% 42% Next 17% 30% 34% Next 30% 10% 12% Lower 50% 10% 12% Total: 100% 100% And Quality Improved

17 A Look at Our 3.5 Year BCBS-Mass.- AQC Experiences: Could Our Consistent Outcomes in Medicare Advantage Since 1998 Be Duplicated in the: (New in 2009) Commercial Global Payment AQC?

18 Our 3 Year AQC Outcomes 7.9% 5.5% 2.4% 2009, 2010, and 2011 (& %) = Real Savings & Both Quality and Satisfaction Improved

19 Our Quality Improvements (Medicare and BCBS-AQC) All measures improved All practitioners improved Practice cultures are changing Members noticed and satisfaction The plans and employers noticed Our MA plans ranked #2 & #4 in US

20 Our Risk Reduction Best practice activities increased Test tracking = better than EMR alone Malpractice cases reduced Malpractice premiums decreased Utilization and financial modeling Satisfaction improved for all Practitioner work flow redesigns When done well, global delivery systems reduce risk

21 CareScreen TM A Look at the Tools and Service

22 CareScreen HCC Trending and Comparison Report

23 CareScreen RAF Adjustments by Tool Usage Rates 50% rise in RAF ( ) from low to High users.

24 CareScreen Quality Registry & P4P Summary & Dashboards

25 CareScreen Quality Registry & P4P Member Reports

26 CareScreen Quality Registry & P4P Summary Report Cards Measure Process/Outcome Min TH Upr TH Breast Cancer Screening P Cervical Cancer Screening P Colorectal Cancer Screening P DM: LDL-C P DM: LDL-C Control (<100 mg/dl) O DM: HbA1C P DM: HbA1C Control (>9.0% = Poor Control) O DM: Blood Pressure (<140/80) O DM: Eye Exams P DM: Nephropathy P HTN: Controlling High Blood Pressure (<140/90) O Cholesterol Mgmt for CV Conditions P Cholesterol Mgmt Control (<100 mg/dl) O Well Child < 15 Months P Well Child 3 to 6 Years P Adolescent Well Care P Appropriate Testing for Pharyngitis P Appropriate Treatment for URI P Chlamydia Screening in Women 16 to 20 Years P Chlamydia Screening in Women 21 to 24 Years P

27 Building and Using Managed Care Infrastructure Infrastructure for global payment and delivery systems can also work well for all other payment and delivery systems EMRs, EHRs, & HIEs are not the only answer and may even create barriers of their own Correctly done, costs are low, & satisfaction is high Physician compensation must be maintained or increased, but comp. formulas must change Delaying does not help (providers are ready)

28 Improving Chances for Success Data Must Provide Actionable Information (not merely raw data which can actually cause more harm, confusion, and noncompliance) Add Provided Decision Support with Tools Add Care Coordination, Training, & Incentives Add Clinician Care Delivery Programs (For PCPs & Specialists Physicians, NPs, PAs & Nurses) Add Leadership, Guidance, & Vision (Medical Directors, Managers, Data Staff)