The Development of

a Rural ACO Model: The Taos

Experience

Taos, NM

Jemery Kaufman, MD Internist, Taos Medical Group

Erin Doherty, MD Internist/Hospitalist Holy Cross Hospital

Michael Kaufman, MDInternist, Taos Medical Group

No Disclosures

The Background

• Taos County:– Population 30,000– ¼ Medicaid– ¼ Medicare– ¼ Comercial– ¼ Uninsured

The Background

• PHO with long standing vision for integrated healthcare system

• Some systems in place:– Innovative integrated programs

designed to serve ambulatory and home bound patients in place

– Several practices now using same EMR interfaced with hospital

Why Change

• Vision to provide integrated care constrained

• Private practices struggling with Medicare cuts, recruitment

• Hospital scheduled for funding cuts at every level

• Pt's and businesses unable to afford insurance

Catalyst: High Value Healthcare

• Affordable care act – Patient Centered Medical home and

Accountable care organization models

• Approached by outside organizations • AAAH, HTI, private payors

Catalyst: High Value Healthcare

Best clinical outcome+high pt satisfaction/low cost

• “Current payment systems have driven primary care into decline and stifled reform. Primary care is central to managing costs and delivering quality, but has become fiscally and politically impotent, dissatisfying to all and unattractive to new physicians.”

Catalyst: High Value Healthcare

Catylist: High Value Healthcare

• Many existing models– Caremore

Common DenominatorIntergration

• Grand Junction

Catalyst: High Value Healtcare

Cost curve

Catalyst-High Value Healthcare

• Opportunity seen– Get out from under strict fee for service

payment scheme to more directly address key patient needs/innovate

– Patient centered– Draw emphasis back to primary care– Furthered vision for integration– Get paid for something only we can

generate, high value care– Get off sinking ship

Current and Future Issues

• Objectives:– Review Cost Approaches– Organizational Structures– Data Issues-what’s relevant?– Rural Issues

Initial Steps

• Approach– High capital outlay/rapid community

wide transformationVs

– Low capital outlay/incremental implementation

Recent Literature

Iglehart JK. Assessing an ACO prototype — Medicare’s Physician Group Practice demonstration. N Engl J Med 2011;364:198-200

• All 10 groups met 29/32 quality goals• 6/10 demonstrated cost savings by

year three….• No return on investment!

Recent Information

CMS/Don Berwick: March 31,2011

• Start up organizations– Bonus if goals achieved in first 2 years– No penalty if not achieved

• Larger organizations– Bear some of the financial risk in exchange for

modestly higher bonuses if they succeed.

Road Ahead- Data

• Know thyself– Patient/resident specific demographics

& health status– Standardized risk assessment of each pt– Heat map high cost/risk patients

• per practice• per diagnosis• for hospital• for payors

Data

• You have to know where you are starting from…

…to know where you are going!

• Extensive inpatient and outpatient cost analyses

• Get an EMR with good data management…and manage your own data

Patient Care Programs=where money is saved

• Chronic Care Disease Management Initiatives

• Community-Wide Wellness initiatives• Palliative Care Integration• Patient centered model• Hospital Care Program

• End of Life Care=Greatest Cost Savings Opportunity

How do we move forward?

• Taos Care Plan Committee– Key physician leaders, primary care– Home Health– Hospital – Pharmacy– Current Disease Management

Programs; CATCH

How do we move forward?

• Separate legal entity• Determine corporate structure

– Identify equity holders, interests– Identify directors

• IT implementation and coordination plan

• Plan for data reporting requirements

ACO Agreements

• Underlying participant contracts– Physicians, hospital, ancillary services

• Bonus Compensation Provisions– Metrics– Reporting– Performance measures/analysis– Calculation of Allocation

Legal Issues

• Assess federal, state law compliance, certification issues

• NM regulations relating to insurance• HIPPA/privacy concerns• Anti-trust issues

– Fee negotiations, market allocation, exclusivity

Anti-trust Issues

• FTC/DOJ position paper April, 2011– No anticompetitive behavior– Market share < 30%– Exception for rural areas

• May exceed 50% of market share

Paul Krugman, NYT 4/21/11

“How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.”

Conclusions

• Determine community’s risk tolerance-both with investment in structure and agreements with payors

• Determine appropriate structure, physician leadership

• Beware anti-trust issues--the free market prevails!

Mountain Home Health Care

• Who• What• Why• How

Who

• Nine member board• Non-profit• Professional advisory committee• Serving Taos County ~32,000

people

Home health/hospice

• Staff – 7 RNs– 1 MSW– 4 Physical Therapists– 2 CNAs– 6 administration

• 499 patients

PCO C-Waiver Program/Chronic Disease Management

• Staff– 1 RN– 1 Case manager– 122 homemakers

What

How do we define home health?– Traditional– Future/new definition

• Medical home• Virtual integrated community• Project ECHO• Accountable Care Organization

Why

• It is what we do• Can we do it better?• Business decision

– Present system is failing– Several hundred paying clients now– Several thousand paying clients future

• If we can add value to the system

Why (cont’d)

• Annals: Oct 2010 “Diabetes Control with Reciprocal Peer

Support Versus Nurse Care Management”

• Conclusion “Improved glycemic control and other

key outcomes more than nurse care management alone”

Why (cont’d)

Editorial: “Although many unanswered questions

remain about payment, standards for training laypeople to help others manage disease, and the long-term outcomes of such programs, …evidence that we need to move outside our often-isolated medical practices and partner with the community to improve health outcomes of persons with poorly controlled chronic diseases.”

How

• Collaboration with medical community

• Identify resources– Project ECHO– Community college (UNM Taos)– Health extension agent– CATCH (same protocols)– HTI

How (cont’d)

• Training of 120+ homemakers– (3 hour course – UNM Taos)– Chronic Disease Management

(diabetes)– Diet– Exercise– Blood glucose interpretation– Physician comunication

How (cont’d)

• Pilot project– 2 CHW’s– 10 Homemakers/patients– Outcomes

• Communication/Literacy• BG Monitoring• Hypoglycemia• Nutrition• Activity• Self Management/Health Goals• HbA1C

– What can we learn?

Challenges

• Integration with rest of Health Care community– Information Technology– Other technology– Finances– Other chronic disease models

Home Health Care

• Who• What• Why• How• Challenges

Thank You!