Moving to Accountable Care
Delaware Organization of Nurse Leaders
John Van Gorp, Sr.Vice President
Planning & Business Development
September 2011
The Growing Crisis – How Can Providers Help?
Healthcare expenditures projected to be 17% of GDP in 2010
$2.3 Trillion Health Care Expenditures ‘08
$1.1 Trillion (47%) - Public Payments
Public expenditures for healthcare projected to exceed 50%
of total in 2010!
USA 2007
Healthcare Expenditures
Other HC
Spend
16%
Other
Personal
Health
13%
Homecare
3%
Nursing Homes
6%
Rx Drugs
10%
Hospital
31%
Phys/ Clin
21%
4
US Health Reform 2010
Two-pronged approach to redesign of the US Health Care
System. Who will lead “Delivery System Reform”?
Coverage
Expansion
Insurance
Reform
Individual
Mandate
Medical-Loss
Ratio
US Health Care
Reform
ACO
New Org
Structures
PCMH
Delivery System
Reform
Payment
Reform
• PCMH = Patient Centered Medical Home
• ACO = Accountable Care Organization
Value-Based
Payments
Bundled
Payments
6
Major Payment and Delivery System
Initiatives – ACA 2010
ACA
Roll-out
2011 - Primary Care Pay – 10% bonus for 5 years
Medicaid payment penalty for Hospital Acquired Infections
(HAI)
2012 - Rewards for hospital value-based purchasing (quality
bonus)
Hospital penalty for preventable readmissions
ACO shared savings payment potential
State pilots on acute care bundling
2013 - National voluntary pilot program on bundled payments for
hospital care
2014 - Primary care Medicaid payment increase to Medicare levels
2015 - Value-based payment program for physicians
Hospital Medicare payment penalty for high HAI rates
9
Value Based Reimbursement – in FY 2012
• No reimbursement for several Hospital acquired
events: (Stage III & IV pressure ulcers, catheter associated
UTI’s, central line related infections, surgical infection following
CABG, bariatric surgery and certain orthopedic procedures, hospital
falls with injury, others in an expanding list)
• No reimbursement for “excessive” readmissions
of CHF, AMI or pneumonia pts (currently 1
Delaware Hospital affected).
• Increase/decrease of Medicare payments began
July 1, 2011 based on Patient Satisfaction,
SCIP, tougher AMI, CHF and Pneumonia
measures
CMS ACO Pilot Program
Eligible ACO pilot organizations must be
able to demonstrate the following six
(6) capabilities:
1. Processes to promote care quality, report costs and
coordinate care
2. Management and leadership structure for decision
making
3. Formal legal structure that allows the organization to
receive/ distribute bonuses to participating providers
------------------------------------------------------------------------------4. Include PCPs (5,000 Medicare beneficiaries)
5. Contracts with a core group of specialist physicians
6. Participate for a minimum of three (3) years
13
The Path to the ACO - Delivery System Reform
Integrating the three components of the delivery system into a single entity
FFS
P-4-P, Bundles
Global Cap
H
CIN
P
I
P-4-P
ACO
I
H = Hospital
P = Physicians
I = Insurers
CI = Clinical Integrated Network
ACO = Accountable Care Organization
15
CIN
Clinically Integrated Network
16
FTC
Economic
Integration
• Capitation
• 1990’s
Clinical
Integration
New Model Definitions
A “qualified clinically integrated
arrangement” is an arrangement to
provide physician services in which:
1. All physicians who participate in the arrangement
participate in active and ongoing programs of the
arrangement to evaluate and modify the practice
patterns of physicians and create a high degree of
interdependence and cooperation among these
physicians, in order to control costs and ensure
the quality of services provided through the
arrangement; and
2. Any agreement concerning price or other terms or
conditions of dealing entered into by or within the
arrangement is reasonably necessary to obtain
significant efficiencies through the joint
arrangement.
Source: Statements of Antitrust Enforcement Policy in Health Care by the FTC and the U.S. Department of Justice, Statement 8
17
Clinically Integrated Networks
In a Clinically Integrated Network: “Physicians and Hospitals
cooperate and modify practice patterns in order to control
costs and ensure the quality of services” Definition from
Hosp
Federal Trade Commission
CIN
Phy
P-4-P
I
I
ACO
Health Reform and a Clinically Integrated
Network – What does it mean for you?
• Major focus on measurable outcomes, with Medicare,
Medicaid and soon commercial reimbursement linked to
Patient Service and Clinical results, which means...
• Outcomes matter; from Board goals to your Department,
to individual performance reviews. Pay attention to the
data; focus on specific targets you can influence.
• Better sharing of data and coordination of care across
the Hospital-Community spectrum, with private
physicians, home care and others.
• Change!