Innovations and the Affordable Care Act Tammi Pollum, BSN, MBA VP, Care Coordination Detroit Area Agency on Aging 1-A Suzanne White, MD, MBA, FACEP, FACMT Chief Medical Officer Detroit Medical Center
Affordable Care Act High quality health care does not necessarily mean the most expensive health care. It means safe care, free from medical injuries, errors and infections; it means reliable care, based on the best available science; it means person-centered care, in which each patient is treated with dignity and respect for his or her own unique preference. Donald Berwick, MD, MPP, Administrator, Centers for Medicare and Medicaid Services, February, 2011, Committee on Ways and Means, U.S. House of Representatives
Affordable Care Act Key Concepts - Consumer Stronger Consumer Rights and Protections More Affordable Coverage Better Access to Care Stronger and More Sustainable Medicare
Affordable Care Act Key Concepts Health Care Sector Increased focus on Quality Reforming the Delivery System Modernizing the Payment System Decreasing Waste, Fraud and Abuse Stronger and More Sustainable Medicare
Affordable Care Act 6
Affordable Care Act Help for Medicare Beneficiaries Access to life-saving medicines Increase support for Primary Care Increased access to preventive care Tools and authorities to fight fraud High quality Medicare Advantage benefits
Coordination and Access The Center for Medicare and Medicaid Innovation Work with Federal agencies, clinical and analytical experts Work with local, national and regional providers Test and study the most promising innovative payment and service delivery models
Coordination and Access Federal Coordinated Health Care Office Dual Eligibles 15% of Medicaid enrollees, 39% of expenditures 16% of Medicare enrollees, 27% of expenditures Beneficiaries historically needed to navigate two separate systems New Office will work to better streamline care
Coordination and Access Additional funding for Community Health Centers Increase services Improve facilities Train and support more health care professionals
Improving Health Care Delivery Providing better care Effective, patient centered, timely, equitable Assuring better health for populations Addressing underlying causes of poor health Reducing costs Improving care, eliminating waste, reducing complications, coordinating care
Improving Health Care Delivery Improving Care for Individuals Value-Based Purchasing Reducing Unnecessary Hospital Readmissions Future: SNF Medical Homes Accountable Care Organizations
Improving Health Care Delivery Post-Acute Care Largest spending increases for: Heart attack, CHF, Hip fracture New readmission measures Hip, Knee and COPD ED: Growing Medicare Volume Home Health Under-utilized
Improving Health Care Delivery Research into Health Care Models Post-Acute Care, Dementia Agency for Healthcare Research and Quality (AHRQ) Institute for Healthcare Improvement (IHI) Center for Healthcare Research & Transformation National Institute for Health CMS Local Universities
Building Successful Partnerships Impact on Community-Based Organizations Care transitions Chronic disease management Medication management Nutrition Transportation Home and family assessments Health benefits counseling Caregiver support
Building Successful Partnerships Articulating strengths Align core competencies Developing new competencies Modify strategies
Building Successful Partnerships Community Based Organizations Services that create value CBOs are the most cost effective entities to provide these services CBOs supportive services could be part of a ACO/ MCO service portfolio
Leadership Competencies Key Competencies Strategic orientation Innovative thinking Relationship building and maintenance Building enthusiasm and overcoming resistance to change Analytical, data driven Communication skills
Building Successful Partnerships Positioned to exploit the new market opportunities created by the ACA Medicare populations Certification Experience Care-delivery models Linkage to the community Trained staff
Building Successful Partnerships AAAs benefit: New, reliable funding sources Long term financial sustainability Build management and leader capabilities Added impact on persons served
May 10, 2013
CASE STUDY Detroit Medical Center 2900 medical staff members Largely private physicians Prior to 2010, no integrated ambulatory delivery system 22
Clinical Integra4on: Cri4cal Need and Alignment method PGIP? PCMH? Meaningful Use? Which vendor? Cri4cal Ques4ons How can we connect specialists? How can we get quality or claims data? 2010 DMC PHO now over 1000 members 2012 Michigan Pioneer ACO 23
Michigan Pioneer ACO Providers Primary Care Physicians 169 Specialists 55 Total ACO Physicians 224 Type of PracRce Private Physicians 142 Faculty 53 Employed 14 VisiRng Physician 15 Total 224 Medicare adributed 19,700 covered lives to the Michigan Pioneer ACO 24
Detroit Medical Center s Priority: THE TRIPLE AIM BeWer health for the community BeWer healthcare quality Lower cost 25
Michigan Pioneer ACO Beneficiary Profile Current ComparaRve Costs for DMC ACO Medicare PaRents Average Per- pa4ent Annual Medicare Expenditure US $12,245 Michigan Pioneer A $18,664 26
Michigan Pioneer ACO Beneficiary Profile Hierarchical Condi4on Categories NaRonal 1.0 Michigan 1.04 Detroit 1.21 Michigan Pioneer ACO 2.269 Death rate for seniors in Detroit 60% higher & hospitalizaron rate 43% higher than rest of the State Average disease burden >3 chronic illnesses 27
Detroit is a Primary Care Desert 500,000 (65%) of Detroiters live in a MUA 300,000 below the poverty line 245,000 uninsured Wayne County Rank (of 82) Health Outcomes 81 Mortality, i.e. premature death 80 Morbidity, e.g. poor or fair health; poor mental health days, low birthweight 80 Health Factors 82 Health Behaviors, e.g. smoking, obesity, alcohol, auto fatalires, STDs, teen birthrate 70 Clinical Care, e.g. uninsured, PCPs, avoidable hospitalizaron, diabetes and mammography screening 67 Social & Economic Factors, e.g. HS graduaron, employment, children in poverty, low social support, violent crime 81 Source: hwp://www.countyhealthrankings.org Physical Environment, e.g. air polluron, access to recrearon, access to healthy food. 77 28
Our Mo4va4on Safety Net Ins4tu4on Using the ACO to accelerate our learning Building a risk pladorm 29
Our Priori4es Align physicians around quality Even before CMS shared savings are realized Evidence- based pladorm EMR Registry ReporRng on Quality Metrics 30
AMBULATORY PREVENTION & CHRONIC DISEASE MANAGEMENT WEIGHTING = 1/3 QUALITY-SAFETY BONUS POOL 0 1 2 DM-1 HbA1c - Good Control < 8 % < 40% 40 and < 70% 70% Compliance % diabetics w/ HbAIc <8% from most recent office visit this quarter DM-2 Blood Pressure Management < 40% 40 and < 70% 70% Compliance % diabetics with BP < 140/90 from most recent office visit this quarter DM-3 Lipid Control LDL < 100 < 40% 40 and < 70% 70% Compliance % diabetics with LDL < 100 from most recent office visit this quarter DM-4 Aspirin Use < 40% 40 and < 70% 70% Compliance % diabetics with ischemic vascular disease taking daily aspirin from most recent office visit this quarter DM-5 Tobacco Non Use < 40% 40 and < 70% 70% Compliance % diabetics who are tobacco nonusers from most recent office visit this quarter HTN-1 Blood Pressure Control- (140/90) < 40% 40 and < 70% 70% Compliance % hypertensives with systolic BP < 140 and diastolic BP < 90 mmhg from most recent office visit this quarter Influenza Vaccination < 40% 40 and < 70% 70% Compliance % patients >50 years who received influenza vaccination Sept-Feb of the year prior to the measurement period Pneumococcal Vaccination > 65 yrs. and at risk populations < 40% 40 and < 70% 70% Compliance % patients 65 years who ever received a pneumococcal vaccination Provider Total Points < 8 8 and < 16 16 Provider Payment 0 50% 100% 31
HOSPITAL CARE TRANSITION WEIGHTING = 2/3 QUALITY-SAFETY BONUS POOL 0 1 2 Post-discharge Visit Within 7 Days January 1, 2012- June 30, 2012 July 1, 2012- December 31, 2012 Medication Reconciliation at Discharge < 40% 40 and < 60% 60% Compliance < 60% 60 and < 80% 80% Compliance < 70% 70 and < 90% 90% Compliance % patients 65 years discharge from any inpatient facility and seen within 60 days in the office by the PCP who had a reconciliation of the discharge meds with current meds documented Re-admission Rate % decrease from baseline rate < 10% 10 and < 15% 15% Compliance OR OR Baseline Performance Percentile 75th Percentile Provider Total Points < 4 4 and < 8 8 Provider Payment 0 50% 100% 32
Our Strategies Muffling the Variability 33
Our Strategies Have decreased in network re- admission rate by 30% 34
Our Strategies CreaRng Our Own Risk/ConRngency Arrangements Community Partners DAAA Personalized Care at Home 35
Our Strategies Understanding the boundaries of risk sharing Despite elegant agreements, must have a boots on the ground approach 36
Our Partners Care TransiRons Partnerships 37
Transi4on Coaching: Partnership with DAAA 38
Transi4on Coaching: Partnership with DAAA 39
Transi4on Coaching: Partnership with DAAA 40
Our 2013 Strategies: Physician Quality Performance Metrics Readmission Rates Patient Notice DMC PowerPlan Use Electronic Quality Reporting Office Access for ASC Advance Directives CMS Quality Measures 41
Our 2013 Strategies: ACO Preferred Home Health Providers How ohen the HHA began parents' care in a Rmely manner How ohen the HHA taught parents (or their family caregivers) about their meds How ohen parents got bewer at taking their meds correctly How ohen parents needed any UC/ED care How ohen parents had to be admiwed to the hospital How ohen the HHA gave care in a professional way How well HHA communicated with parents Did the HHA discuss medicarons, pain, and home safety with parents? PaRents rarng of the overall care from the HHA Likelihood to recommend HHA to friends and family 42
Our Challenges Our demographic Physician behavior: FFS versus Quality IncenRves Out of network spend AnalyRcal tools Data lag & data warehouse CompeRRon from shared savings ACOs Loss of beneficiaries 43
Key Messages Achieving the TRIPLE AIM is dependent on effecrve networks. It requires new, non- tradironal collaborarons across the community. We need to develop different types of parent, physician and other community partner collaborarons that are built on trust and long term commitments by all parres. There is substanral infrastructure required to be able to create the necessary capability that allows us to share data, informaron, and knowledge. Since we have not done this before, each endeavor will be a learning experience. 44