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Value is a Prescription for SuccessSteve Hester, MD, MBA
Senior Vice President and Chief Medical Officer
Integrated Delivery Network of Five Not-for-Profit Hospitals
15 Out-patient Centers
1.6 Million yearly patient encounters$1.7 Billion yearly revenue
12,000 Employees600 Employed Providers
2,000 Physician Medical Staff1,857 Licensed Beds
60,000 Admissions/year
Norton Healthcare
ACO Current State
• Accountability is an Action… Not an Organization
• ACA has pushed organizations to compete on quality and price rather than fee-for-service.
• Currently 5% of Medicare Beneficiaries in an “ACO”
• 89 initial CMS approved ACOs – only five with both upside and downside risk
ACCOUNTABLE CARE ORGANIZATION
Manage population health
Patient attributionCommunity outreachTraining and educationBehavior and change
managementSegmentation and risk
factor capabilitiesMarketing
Cost and Efficiencies
Effective Health
Management
Coordinate Items and Services
Manage to Quality
Standards
Manage Costs and Efficiencies
Manage to Quality StandardsCoordinate Items and Services
Components of an ACO
Quality management (definition by population, not event or episode-driven)
Quality standards reporting
Disease managementData management and
analyticsBusiness intelligence
management of clinical, operational and financial data
Effective Health Management
Risk managementFinance and accountingDisease managementMeasurement of clinical,
operational and financial key performance indicators
Preventive careMedical managementTelemedicineFunding administrationSupply chainParticipation in Health
Information Exchanges (HIEs)
EmployersPatientsHospitalsAcute, sub-acute and
long-term care providers Ambulatory care centersPharmaceutical
companiesMedical device
manufacturersCare Givers (physicians,
nurses, home health, clinical social worker, clinical psychologist, and other ancillary providers)
PayorsFederal government
The Players
Used with Permission KPMG HEALTHCARE
• Initiated as part of Brookings – Dartmouth Commercial Pilot in 2009
• Future plans for other manage care providers as model develops.
• Patient population – 1.24 million in community
• Current included groups: NHC employees/Humana employees – 10,000
• Approximately 300 physicians included
— Primary Care and Specialists
• Consideration to expand into other reimbursement partnerships
— Bundled Payment
— Shared Risk (smaller employers)
Journey for Accountable Care
Strategy for Success
• Accountability is an Action
• Manage the Patient Through the Care Continuum
• Patient and Community Engagement and Accountability
• Transparency
• Data Infrastructure Management and EMR
• Patient, Provider, Payer, and Employer Partnerships
• Change is Hard
• Decrease Variation – Increase Personalization
Learning
ImprovingPredicting
Evolution of Analytics
WHAT happened?
WHY it happened?
WHAT WILL happen and
WHEN?
Year 1 Financial Data
Norton Year 2 1.7% Reduction below target PMPMHumana Year 2 14.9% Reduction below target PMPM
Norton Healthcare – Humana Accountability Pilot
Clinical Results: Aggregated Commercial ACO-Utilization/Quality/Overuse Metrics
Inpatient days/1000 Down 29%
ER visits/1000 Down 46%
Physician visit within 7 days discharge Up 14.6%
Diabetes A1c testing Up 6.1%
Cholesterol Management - Diabetes Up 8.6%
Appropriate Imaging – Low Back Pain Up 13.9%
Avoidance of Antibiotics w/Acute Bronchitis Up 32%
Norton Healthcare Accountability Pilot
15
Dartmouth – Brookings ACO Pilot Performance
Measurement
Quality Measure(for all, higher %s represent better performance)
2009 HEDIS PPO
Norton Baseline
NortonYear 1 Change
Diabetes – A1c Management (testing) 83.3% 87.7% 93.4% 5.6%
Diabetes – Cholesterol Management (testing) 78.6% 83.9% 91.8% 7.9%
Use of Appropriate Medications for People with Asthma 92.8% 96.2% 82.8% -13.4%
Cholesterol Management for Patient with Cardiovascular Conditions (testing) 80.2% 88.9% 89.5% 0.6%
Use of Imaging Studies for Low Back Pain 72.7% 65.2% 56.3% -8.8%
Avoidance of Antibiotic Treatment for Adults with Bronchitis 22.6% 12.2% 16.7% 4.5%
Persistence of Beta Blocker Treatment After Heart Attack 69.6%
Cervical Cancer Screening 74.6% 77.9% 78.2% 0.3%
Breast Cancer Screening 67.1% 79.9% 81.6% 1.7%
Annual Monitoring for Patients on Persistent Medications 77.0% 83.7% 88.6% 4.9%
Too few eligible cases.
Anti-Infective Purchasing/QTR/Patient Day
Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012
1 1
0.86
0.98
0.90
0.730.75
0.68
Miscellaneous Beta-Lactams
Macrolides
Miscellaneous
Aminoglycosides
Antivirals
Quinolones
Antifungals
Tetracyclines
Anti-Pseudomonal Beta-Lactams
Anti-MRSA
Dol
lars
Per
Pati
ent D
ay
Total Joint Replacement(Per Case)
Absolute Impact % Impact
Direct Variable Cost ($665) -8.0%Length of Stay (0.27) -9.5%
COPD Initiative(Per Case)
Absolute Impact % Impact
Direct Variable Cost ($400) -13.1%
Length of Stay (0.37) -7.5%
CHF Initiative(Per Case)
Absolute Impact % Impact
Direct Variable Cost ($243) -6.8%
Length of Stay (0.01) -0.2%
Clinical Effectiveness
ESRD Initiative(Per Case)
Absolute Impact % Impact
Direct Variable Cost ($1094) -9.4%
Length of Stay (0.75) -8.7%
The Future of Clinical Re-Engineering
• Improved care coordination and communication
• Improved access – physician extenders – email – phone call etc.
• Prevention and early diagnosis
• ED and Immediate Care Center visits
• Increase generic medication utilization
• Hospital re-admissions and multiple ED visits
• Improved management of complex patients – Manage the Top 100
– Care Coordination and High Resource Utilizers
Think Differently – Treat DifferentlyFuture of Healthcare
*The Volume-To-Value Revolution. Oliver Wyman
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