wouldn't it be nice... 21apr12
DESCRIPTION
Presented at the 35th Annual ABQAURP meeting, Atlanta 21APR12TRANSCRIPT
wouldn’t itbe nice...wayne pan, mdmbapacifcpartners
to have a great healthcare delivery system?
but we don’t.
whynot?
some learnings from a commercial ACO...
who am i &how did i gethere?
orthopedichandsurgeon
medicaidmedicarehealth plans
ipa/msocommercialmedicareaco/ppo
healthcarewarrior
how aboutyou?
we are allhealthcarewarriors
who are we fighting for?
the patient.
why?
i knowwhat you’re
thinking
takeaways
LISTEN TO THE CHILDWITHIN YOU
WWABD?
HAVE FUN
discipleof
nancyduarte
bjfogg, phdstanford
rogermartinrotman, toronto
2 businessprocesses:
2 businessprocesses:reliability
2 businessprocesses:validity
have to do both
have to do bothsustainable
have to do bothobsolete
why?
From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
?From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all
insanity: doing the
same thing over and over
and expecting different
results
somebasics
humannature
humannaturelazy
humannaturesocial
humannaturecreaturesofhabit
humannaturenotgood@change
lazysocialhabit
humannaturesocialnorms
lazysocialhabit
humannaturestatusquo
lazysocialhabit
humannaturesocialnorms
lazysocialhabit
doctornature
doctornaturecompetitive
doctornatureindependent
doctornaturecurious
doctornatureformsilos
competitiveindependentcurious
doctornaturenotgood@cooperation
competitiveindependentcurious
doctornaturenotgood@collaboration
competitiveindependentcurious
doctornaturecurious
competitiveindependentcurious
doctornaturecompetitive
competitiveindependentcurious
doctornaturecompetence
competitiveindependentcurious
leverageour nature
leverageour nature4 behavior change
michaelvandurenmdmbasutterhealth
michaelvandurenmdmbavariationreduction
WWABD?
leverageour naturesocialnorms
leverageour naturecurious
leverageour naturecompetitive
leverageour naturecompetence
easy
easyaccessible
easyaccessibledesign for failure
easyaccessibledesign for failureachievement
easyaccessibledesign for failureachievementfeedback
marshall goldsmith
what got us here
what got us here
won't get us there
marshall goldsmith
behavior change
from: A Gawande, “The Checklist,” The New Yorker (2007) (Artist: Yan Nascimbene)
from: A Gawande, “The Checklist,” The New Yorker (2007) (Artist: Yan Nascimbene)
© all rights reservedby garyhymes
beware of shortcuts
remember who & why
better for patients?
easier for patients?
?
Who is?
Individual Practice Association Medical Group of
Santa Clara County
Individual Practice Association Medical Group of
Santa Clara County
SCCIPA
largest IPA in Santa Clara County
Santa Clara Countysize 1,304.01 sqmilespop 1,781,642 (2010)
medianincome $74,335
SAND HILL ROAD
the Mississippi River
INFINITE LOOP
VIEW FROM THE VALLEYTHE
ATLANTIC OCEAN
ENGLANDEUROPE
MEXICOCAN
ADA
RUSSIA
ILLINOIS
FB CREDITSPrice 75Apr 21,2012
APPALACHIACLEVELAND
NEW YORK CITY FLORIDA
5 PCP80 Specialists
57 PCP104 Specialists
173 PCP343 Specialists
11 PCP30 Specialists
SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)Anthem Commercial ACO pilot (2011)
SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)Anthem Commercial ACO pilot (2011)
urban/suburban
rural
25,000 commercialACO
40,000 commercialHMO
5,000 MedicareHMO
nooriginal Medicare,
Medi-Cal,CHIP, uninsured
= managementservicesorganization
casemanagementmedicalmanagementnetworkmanagement
qualityimprovement
grievance&appeals
clinicaldataanalytics&reporting
compliance&auditing
claims&encounterprocessing
providercontracting
credentialingmemberservices
marketingoutreach
ITservicesfinance&riskmanagement
partialrisk
managingD ROF
Divisionfinancial esponsibilityR
OF
outpatientservices
inpatientservices
capitatepcps
specialistspaidffs
performancebonus
IHAP4P&HCC
IPAcitizenship
roughroad
roughroad4x4 healthcare
4processes
4dimensionaldata
x
4processes
communication
collaboration
coordination
PCPs
Specialists
Patients
CaseManagers
anticipation
4dimensionaldata
financial
administrative
clinical
retrospectiveretrospective
reactivecare
$$$$$$
behavioral+
predictive
proactivecare
provideactionabledata
@pointofcare
@home
thecareteam
thecarecontinuum
peopleprocessesplatform
peopleprocessesplatform
hospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP
peopleprocesses
SNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
peopleprocesses
onsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs
peopleprocesses
complex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks
peopleprocesses
utilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement
peopleprocesses
primary care physiciansspecialistsancillary providers
people:physicians/staff
primary care physiciansspecialistsancillary providersfront office staff
people:physicians/staff
case managersdisease managersmember outreachbenefit design
people:plan staff
communicatecollaboratecoordinateanticipate
peopleprocessesplatform
peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedback
peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own data
peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback/enter their own data
ourresults
> commercial admits/1000
40
50
60
70
80
JAN10
APR10JU
L10
OCT10
JAN11
APR11JU
L11
40
50
60
70
80
OCT11
Milliman - Well-Managed
Milliman - Moderately-Managed
Milliman - Loosely-Managed
SCCIPA
> commercial bed days/1000
150
175
200
225
250
275
JAN10
APR10JU
L10
OCT10
JAN11
APR11JU
L11
OCT11
Milliman - Well-Managed
Milliman - Moderately-Managed
Milliman - Loosely-Managed
SCCIPA
> commercial average length of stay
2.5
3.0
3.5
4.0
4.5
JAN10
APR10JU
L10
OCT10
JAN11
APR11JU
L11
OCT11
Milliman - Well-Managed
Milliman - Moderately-Managed
Milliman - Loosely-Managed
SCCIPA
> medicare admits/1000
200
250
300
350
400
JAN10
APR10JU
L10
OCT10
JAN11
APR11JU
L11
OCT11
Milliman - Well-Managed
Milliman - Moderately-Managed
Milliman - Loosely-Managed
SCCIPA
> medicare bed days/1000
1,000
1,200
1,400
1,600
1,800
2,000
2,200
JAN10
APR10JU
L10
OCT10
JAN11
APR11JU
L11
OCT11
Milliman - Well-Managed
Milliman - Moderately-Managed
Milliman - Loosely-Managed
SCCIPA
> medicare average length of stay
4.0
4.5
5.0
5.5
6.0
JAN10
APR10JU
L10
OCT10
JAN11
APR11JU
L11
OCT11
Milliman - Well-Managed
Milliman - Moderately-Managed
Milliman - Loosely-Managed
SCCIPA
managingACOpatientsinafee4serviceworld
challenge#1 managingproviderbehavior
challenge#2 managingpatientbehavior
challenge#3 alignincentives
HMOworld
patientsassignedPCP
PCPmanagesreferrals
patientsstayinnetwork
ACOworld
patientsnotassigned
physiciansendspatient
notrestrictedtonetwork
whataboutquality?
whoisaccountable?
carecoordination?
oursolution
make the newway...
feel just like the oldway
trackingauths
> using the same auth system, have providers enter in tracking auths for aco patients
1
keepspatientinnetwork
providerselectiontool
> when selecting “referred to” providers, these providers are listed in descending order of quality, efficiency, satisfaction
2
promotesquality
promotesefficiency
promotessatisfaction
rewardaccountability
> referring physicians can be tracked to incentivize use of provider network
3
checkinbutton
> allows for real-time patient tracking, provides opportunity for care coodination efforts
4
automatedtracking
alertingcasemanager
nocheck-inby_________
requestimmediatehelp
qualityreminders
> @every encounter with the healthcare delivery system, quality is reinforced
5
entireteamisaccountable
virtualpcmhmodel
airtrafffic control
for patients
ibelieve...
asknot...
cultural revolution
thinkdifferent
LISTEN TO THE CHILDWITHIN YOU
WWABD?
HAVE FUN
welcome tohealthcare2.0
