HealthGroup of Alabama

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HealthGroup of Alabama
HealthGroup of Alabama
Preparing for Health Care Reform –
Lessons from the Field
Prepared for HealthGroup of Alabama
May 27, 2011
Page 1
Making Sense of the Cloud
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May 27, 2011
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May 27, 2011
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May 27, 2011
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May 27, 2011
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In Medias Res
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May 27, 2011
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Mark’s Sticky List
• Physician Specific
Value Based
Payments
• Insert a cool graphic
• MAKE THIS
SECTION DIM HERE
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May 27, 2011
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Mark’s Sticky List
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May 27, 2011
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Agenda
Defining
Applied
Healthcare
Reform
Strategic
Alignment
Shared
Accountability
Sustainable
Quality
Shaping Care
Models
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May 27, 2011
Page 10
Hurricane PPACA:
Projecting the Course
Key Provisions
PQRI payment reduction
New Care Models
• Section 3002
• Beginning January 1, 2015
Value Based Purchasing for Hospitals
• Section 3001
• Beginning October 1, 2012
Pilot Program on Payment Bundling
• Section 3023
• January, 1, 2013 for five years
Medicare Shared Savings Program (ACO’s)
• Section 3022
• Begins no later than January, 1, 2012
Center for Medicare and Medicaid Innovation
• Section 3021
• January 1, 2011
Value Based Payment Modifier
• Section 3007
• Measure published no later than January 1, 2012
PPACA
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May 27, 2011
Page 11
Implementation Timeline
2010
2011 &
2012
•Small business tax
credits enacted
•Temporary
reinsurance program
•Coverage denial for
children's preexisting conditions
barred
•Eliminates lifetime
coverage limits
•Extends coverage for
young adults
•Reduces barriers to
HCBS in Medicaid
•Medicaid flexibility
for states
•Primary care 10%
bonus payment for
underserved areas
•CMS demonstration
projects involving
improving healthcare
quality & efficiency
• Community care
program established
• ACO model
becomes eligible
for shared savings
nationwide in 2012
• VBP for Hospitals
in effect 10/1/12
2013
2014
• Financial Incentives
for preventative
based coverage
• 5 yr bundled
payment program
demonstration
project
• Medicaid DSH
payments decrease
• State Medicaid
required to pay PCP
Medicare rates
• Medical device –
excise tax
• Public reporting of
physician
performance
•2014 - Mandatory
Medicaid expansion
– 133% Federal
Poverty Level
•2014 - Quality
reporting for certain
providers
•2015 – Physician
VBP program to
promote quality for
Medicare
beneficiaries; value
not volume
•2017 – 2% decrease
in DRG payments for
VBP
& Beyond
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May 27, 2011
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Times, They Are A-Changin’….
“…. significantly cutting the rate of
growth in health care spending.”
Andrew Dreyfus
CEO, BCBSMA
“….to get any increase, it has to be
earned.”
SOURCE: Weisman, Robert. “Blue Cross CEO says providers must control costs, or else” The Boston Globe. 23 Jan 2011.
SOURCE: Adamy, Janet. “WellPoint Shakes Up Hospital Payments” WSJ. 16 May 2011.
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May 27, 2011
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This may not end well….
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May 27, 2011
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Key Components of Applied
Healthcare Reform
Sustainable
Quality
Strategic
Alignment
Shared
Accountability
Shaping Care
Models
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May 27, 2011
Page 15
Key Components of Applied
Healthcare Reform
Sustainable
Strategic
Quality
Alignment
• Aligning strategies, not just geographies
• Right people, right seat, right bus
• One size does not fit all
Shared
Accountability
• Focus on “A” and “C”
• More than one fish in the sea
System
Integration
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May 27, 2011
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Key Components of Applied
Healthcare Reform
Shared
Sustainable
Accountability
Quality
• The wise man built his house upon the rock
• Data matters
• You get what you pay for
Shaping Care
Models
• It’s not all about the law
• Creativity on the fringes
System
Integration
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May 27, 2011
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Key Components of Applied
Healthcare Reform
Strategic
Alignment
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May 27, 2011
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Strategic Alignment
• Alignment ≠ Employment
• Finding the right dance partner
• Not everyone will get to play
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May 27, 2011
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Alignment Trends
More Common
Physician
Employment
Medical Directorships
Clinical Co-Management
Call
Coverage
Real Estate JV
Equipment JV
Leasing
Models
Clinically Integrated IPA
More Integration
Less Integration
Quality
Incentives
EMR
ACO
MSO
services
Less Common
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May 27, 2011
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Strategic Alignment
Planning &
Partnering
Coordination &
Integration
Management &
Growth
Goals &
Budget
Recruitment
& Alignment
Onboarding
Pre-Alignment
Transaction
Monitoring &
Measurement Continuous
Improvement
Post-Alignment
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May 27, 2011
Page 21
Southeast Hospital:
A Case Study
• Acute care hospital in a regional system in the
Southeast
• Hospital has less than 175 beds
• 71% of patients are Medicare or Medicaid
• Physicians’ express interest to maintain
independence from hospital
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May 27, 2011
Page 22
Primary Care Co-Management
Model
Outpatient Integration Champion
• Quality indicator integration
• Process improvement coordination
Outpatient
• Continue to manage primary
care needs
• Bill for services provided
• Best practice implementation
Primary Care LLC
• Manage primary care needs
• Reimbursed based upon
Medicare rates
• Best practice implementation
• Integration and management of
Readmission Cycle
• Application of Quality Tools
• Management of Benchmark Data
Clinical Champion(s)
• Design and implementation of clinical
guidelines
• Oversight of quality indicators and
measurement
• Coordination between inpatient/outpatient
treatments
Inpatient Integration Champion
• Quality indicator integration
• Process improvement coordination
Integrated Hospitalist
Patient Healthcare Cycle
(Community Gap Care)
• Provided by either primary care
physician or hospitalist
• Hospital bills for services provided
• Best practice implementation
Physician Extender
Physician Supervision
• Participating primary care
physician
Unassigned Patient Care
• Assigned to participating
primary care physicians
• New group structure
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May 27, 2011
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There’s No Place Like Home
• Accreditation vs.
Implementation
• Horizontal vs. Vertical Care
• Directing Care vs. Providing
Care
“Congress has to enact a Medicare physician payment
system that provides greater support for team-based
primary care…”
- Roland Goertz, MD, MBA – President AAFP
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May 27, 2011
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Key Components of Applied
Healthcare Reform
Shared
Accountability
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May 27, 2011
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Shared Accountability
QUALITY
+
COST
=
VALUE
+
EFFICIENCY
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May 27, 2011
Page 27
Patient-Centered Care
Primary Care
Physician
The Triple Aim
• Better care for individuals
• Better health for populations
• Lower growth in expenditures
Shared
Savings
Payment
PatientCentered
Specialist
Hospital
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May 27, 2011
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How does an ACO work?
Defined
spending
benchmark for a
selected patient
population
How does
Payers will
have the ability
to continue a
fee-for-service
model
ACO
Work?
Improvements
in quality can be
shown to be
delivered at a
lower cost
Cost savings
will be shared
among all
participating
providers
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May 27, 2011
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Shared Savings Models
• Savings shared proportionate to performance on all
quality metrics
• Agreements may begin as either a one or two-sided
model
• One-sided model: ACOs share in savings below the
benchmark quality metrics, but not required to repay
losses
• Two-sided model: ACOs share in both savings below
the benchmark quality metrics and accept risk for
losses above the benchmark
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May 27, 2011
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Shared Savings Models
One-Sided Model
(performance years 1 & 2)
Two-Sided Model
Sharing Rate (assuming
maximum performance on
quality measures)
Up to 50%
Up to 60%
FQHC/RHC Participation
Incentives
Up to 2.5 percentage points
Up to 5 percentage points
Maximum Sharing Cap
Payments capped at 7.5% of
ACO's benchmark
Payments capped at 10% of
ACO's benchmark
Shared Losses Cap
N/A
Year 1 - 5%
Year 2 - 7.5%
Year 3 - 10%
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May 27, 2011
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CMS Initiatives to Encourage ACO
Development
Pioneer ACO Model
• Designed for providers experienced in coordinating care for patients
across care settings
• Involves higher levels of shared savings and of risk compared to the
Medicare Shared Savings Program
• Accelerates move to a population based payment model separate from
MSSP
• Expected Medicare cost savings of $430 million over 3 years
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May 27, 2011
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CMS Initiatives to Encourage ACO
Development
Advance Payment ACO Initiative
• Alleviates concerns from organizations regarding large initial capital
investment necessary to create ACO
• Participating organizations can access portion of savings in advance
Accelerated Development Learning Sessions
• Free educational sessions to assist providers to move quickly toward a
more coordinated care delivery model
• Four ADLS offered in 2011 by the Innovation Center
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May 27, 2011
Page 33
Advocate Health Care:
A Case Study in Accountability
• Non-profit integrated healthcare system in Oak
Brook, IL
• System includes: 10 acute care hospitals, 2
integrated children’s hospitals, and 250 outpatient
care sites
• Serves over 1 million patients in Chicago area
• Largest physician network of primary care
physicians, specialists, and subspecialists in Illinois
• 5,700 physicians on staff, 3,800 are Advocate
Physician Partners
Source: Kaufman, Hall & Associates, Pizzo and Grube
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May 27, 2011
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Advocate Health Care:
A Case Study in Accountability
• Aligned physician and hospital objectives
• Recognizing physician leadership
• Advanced user of healthcare information
technology
“It takes a team to care for patients… so practitioners need
to be incented as a team”
-Lee B. Sacks, MD, CEO Advocate Physician Partners
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Primary Care in the Driver Seat?
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May 27, 2011
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At the end of the day….
Prepared for HealthGroup of Alabama
May 27, 2011
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Mark’s Sticky List
• Physician Specific
Value Based
Payments
• Insert a cool graphic
• MAKE THIS
SECTION DIM HERE
Prepared for HealthGroup of Alabama
May 27, 2011
Page 39
Bundle Up
“A payment methodology…shall include payment for the
furnishing of applicable services and other appropriate services,
such as care coordination, medication reconciliation, discharge
planning, transitional care services, and other patient-centered
activities…” -PPACA, Sec. 3023
• Beginning in 2013, a five year voluntary pilot
begins to explore bundled payment
structures around eight distinct conditions
• CMS three year pilot in progress ends in less
than one year
• Private payers already taking the lead
Prepared for HealthGroup of Alabama
May 27, 2011
Page 40
The ACE Demonstration Project:
Who Wins and How
• Patient –Improved quality as well as direct
payment
• Hospital – Improved quality and increased volume
• Physician – Improved quality and potential
increased reimbursement through gainsharing
• CMS – Improved quality, fewer revisions and
readmissions, decreased cost per case
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May 27, 2011
Page 41
Baptist Health System:
A Case Study In Integration
“We wanted to be a part of shaping future policy, as opposed to just taking what is
dealt to us.”
-Michael Zucker, Senior Vice President Baptist Health System, San Antonio
• BHS launched ACE demonstration projects with strong leaders at all
five facilities - 150 affiliated orthopedists and cardiologists participated
• Within 14 months the hospital was experiencing radical changes in
quality outcomes:
• In 2009, BHS saved $800,000 in cardiovascular implants and $1,400,000
in orthopedic implants
• “Compliance with ‘antibiotic discontinuation within 24 hours of orthopedic
surgery’ increased from the 60th percentile range to above the 95 percent”
• Patients DRGs falling within demonstration project show better satisfaction
ratings than those outside of the demonstration
Source: “Baptist Health System’s ACE Experience” HFMA.com; published August 26, 2010
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May 27, 2011
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Baptist Health System:
A Case Study in Integration
• Success defined by the
clinical success
• Individual physician
performance is second to
overall performance of the
hospital
• Both corporate and individual
metrics must be achieved to
receive payment
• Incentives of the facility and
physicians must be aligned
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May 27, 2011
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Clinical Co-Management
Models
Hospital
Hospital
Pays
for:
• Base management fees
• Incentive Compensation
(limited) Including:
- Quality
- Operational
Efficiency
$
Physicians
Management
Company/
LLC/Committee
Physicians
Service Contract
to Manage
Hospital’s
Service Line
Hospital
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May 27, 2011
Page 44
Co-management “Lite”
Chief Medical Officer
Outpatient Integration
Champion
Daily
Reporting
Policy & Procedure
Aggregate
Reporting
Inpatient Integration
Champion
Infrastructure Reporting
Clinical
Champion
Hospital & Medical Staff
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May 27, 2011
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Key Components of Applied
Healthcare Reform
Sustainable
Quality
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May 27, 2011
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May 27, 2011
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Sustainable Quality
• Not just a department
• Reputation is no longer enough
• Data, Data, Data
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May 27, 2011
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Getting to Quality
PHASE III:
Sustaining the Gains
PHASE II:
Differentiating on Quality
PHASE I:
Establishing the Quality Baseline
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May 27, 2011
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How different
are you really?
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May 27, 2011
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Value in the Present Tense
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
AMI-2 Aspirin Prescribed at Discharge
AMI-7 a Fibrinolytic Therapy Received Within 30
Minutes of Hospital Arrival
AMI-8a Primary PCI Received Within 90 Minutes of
Hospital Arrival
HF-1 Discharge Instructions
HF-2 Evaluation of LVS Function
HF-3 ACEI or ARB for LVSD
PN-2 Pneumococcal Vaccination
PN-3b Blood Cultures Performed in the Emergency
Department Prior to Initial Antibiotic Received in
Hospital
PN-6 Initial Antibiotic Selection for CAP in
Immunocompetent Patient
PN-7 Influenza Vaccination
SCIP-Inf-1 Prophylactic Antibiotic Received Within One
Hour Prior to Surgical Incision
SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical
Patients
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within
24 Hours After Surgery End Time
SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6AM
Postoperative Serum Glucose
SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to
Arrival That Received a Beta Blocker During the
Perioperative Period
SCIP-VTE-2 Surgery Patients with Recommended Venous
Thromboembolism Prophylaxis Ordered
SCIP-VTE-2 Surgery Patients Who Received Appropriate
Venous Thromboembolism Prophylaxis Within 24 Hours
Prior to Surgery to 24 Hrs After Surgery
Clinical
Process of
Care
Measures
70%
HCAHPS
30%
1.
Nurse Communication
2.
Doctor Communication
3.
Hospital Staff Responsiveness
4.
Pain Management
5.
Medicine Communication
6.
Hospital Cleanliness & Quietness
7.
Discharge Information
8.
Overall Hospital Rating
Source: CMS Special Open Door Forum: VBP 2/10/2011
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May 27, 2011
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Elevators and
Amusement Parks
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May 27, 2011
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Denver Health:
A Case Study in Quality
• Public academic health system and
Colorado’s principal safety-net institution
• System includes: emergency paramedic,
acute care hospital, 8 federally qualified
health centers, 12 school-based clinics,
Denver’s public health department, an HMO,
a 100-bed non-medical detox unit,
correctional care, and a call center
• System serves 33% of Denver’s adults, 40%
of children
• 50% of system patients are uninsured
• Mortality rate is the lowest in Colorado
Source: Health Affairs 30, No. 4 (2011)
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May 27, 2011
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Denver Health:
A Case Study in Quality
• Structure and Focus
• Dedicated to Integration
• Advanced user of Healthcare Information
Technology
…aspiration alone will not produce excellent patient safety or quality
- Philip S. Mehler, MD , Director of Quality, Denver Health
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May 27, 2011
Page 54
A Study in
Applied Quality
• ED group at large hospital in SE
• Challenges with Patient Satisfaction and Core
Measures
• Physicians receiving long term financial
subsidy based on productivity only
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May 27, 2011
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A Study
in Applied Quality
• Physician leadership positioned to succeed
• Quality and Patient satisfaction shared by
physician
• Developed goals with physicians
• Instituted two tiered system
– Goal measures
– Trigger measures
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May 27, 2011
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Mark’s Sticky List
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May 27, 2011
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Value-Based Payment
Quality/
Efficiency
Productivity
Health Status
Total
“The Secretary shall establish a payment modifier that provides
for differential payment to a physician or a group of physicians
under the fee schedule established under subsection (b) based
upon the quality of care furnished compared to cost …”
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May 27, 2011
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Applied
Value-Based Payment
$40
Productivity
$7
$3
$50
Quality
Clinical
Leadership
Total
Comp per
wRVU
Compensation at risk for both productivity and
outcomes based quality metrics above a
threshold, with or without a trigger
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May 27, 2011
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Key Components of Applied
Healthcare Reform
Shaping Care
Models
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May 27, 2011
Page 60
Prometheus
Payment Approach
• “An evidence-informed
model for payment reform”
focusing on episode-of-care
payment
• Quality Withhold
• Potentially Avoidable
Complications
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May 27, 2011
Page 61
Not Your Father’s
Practice….
Retail Medicine
•
Up to 4,000 clinics by 2015 Merchant Medicine
•
Clinics are exploring new services such as monitoring
chronic diseases in coordination with primary care
physicians source: insure.com
The New House Call
•
Patients are in charge of their own healthcare through
creative use of Internet and social media.
•
Allows doctors and patients to securely instant message,
e-mail, and conduct “video visits” online.
•
40 hellohealth practices nationwide
www.hellohealth.com
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May 27, 2011
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Direct Care Practices
Source: DailyFinance.com, “Concierge Medicine: Patients Pay Up for a Doctor’s Undivided Attention”, Eric Wahlgren, 2010
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May 27, 2011
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The Qliance Model
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May 27, 2011
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When I get home…
• Play to your strengths
– Not everyone can be all
things to all patients
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May 27, 2011
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When I get home…
• Prove your quality
– Don’t measure only what you can measure
– Did I mention Data….?
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May 27, 2011
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When I get home…
• Make quality count
– Introduce risk and reward
– Physicians must lead
– Choose wisely
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May 27, 2011
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When I get home…
“Where a new invention promises to be useful, it ought
to be tried.”
- Thomas Jefferson
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May 27, 2011
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“An amazing invention…”
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May 27, 2011
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And the Winner is…?
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May 27, 2011
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Contact Information
Mark Browne, MD
Principal
(865) 673-0844 ext 172
[email protected]
Twitter – @consultdoc
Blog – healthcare.pyapc.com
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May 27, 2011
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