Capitalizing on Change:
Improving Value and Community Health
HFMA HSCRC Workshop
January 31, 2014
Who We Are
Western
Maryland
Health System
Cumberland,
MD
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275-bed hospital located in Western Maryland
opened in 2009
Consolidated two campuses into a new
“greenfield” site
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Located in one of the
poorest counties in one of
the nation’s richest states
Skilled nursing facility with
88 beds
Region’s largest employer
with 2,200 employees
Other
14%
SelfPay
5%
Commercial
12%
Payor
Mix
Medicar
e
56%
Medicaid
13%
•
250 physicians on staff
•
1of 9 Trauma Centers in Maryland and the only
Open Heart Surgery program west of Baltimore
•
Part of a newly formed three health system group
in Western Maryland called Alliance Health
Facts About WMHS
• $330 Million in operating revenues
• 14,000 admissions per year (projecting an ½ %
increase over last year)
• 50,000 ED visits per year
• 1,100 deliveries per year
• Over $300 million
economic impact on the
region annually
• Community Benefit of
$48 for FY2013
Service Area
What is Total Patient Revenue
 Originally one of 10 Maryland hospitals as part of a
demonstration project
 A shift from volume-based care delivery to value
based
 Encourages wellness and cost effective delivery of
care instead of caring for the ill and maximizing
volumes
 Revenue is 100% fixed; no change based on
fluctuations in volume or changes in service
 Providing care in the most appropriate
setting/location
 Previous competitors become partners with aligned
objectives
Transitioning to TPR
Initial Reasons
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Aging and declining population in our region
Volume changes
Payment cuts
Economic incentives offered by the HSCRC
Opportunity to jump on the learning curve
Triple aim of health care reform
Future of health care delivery
How Has the Focus of Planning Changed?
Typical Strategic Plan
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•
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FOCUS: Fee for serviceMore is Better
Grow Revenue
Grow Market Share
Increase Volumes
– Sell More
– Do More
Improve Quality
WMHS Strategic Plan
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•
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FOCUS: Deliver Care
Differently
Care Delivery
Physician Collaboration
Patient Engagement
Business Model
– Cost Management
– Partnerships
– Unregulated Services
What Do We Need to Do to Be Successful?
Think
Innovatively
Redesign
Care
Reduce
Costs
Success
Focus on
Market
Competition
Collaborate
with TPR
Hospitals
Align the
Hospital and
Physicians
Managing Under TPR
Keys to Success
• Shift emphasis from
volume to value
• Reduce admissions & readmissions
• Provide care in the most
appropriate location
• Create stronger patient
engagement
• Reduce variation in quality
• Improve payment
alignment with physicians
• Re-invest savings
• Work collaboratively with
community partners
• Focus on better community
access
• Increase health & wellness
activities on a regional basis
• Reduce utilization rates in
ED, inpatient, observation
and ancillary
• Improve chronic care
delivery
Our Challenge
“Reorganizing the delivery system
is unbelievably resource intensive
and fraught with unintended consequences.”
Dr. Robert Galvin, Blackstone Consulting
(former Chief Medical Officer for General Electric)
TPR Collaborative
• The 10 hospitals under TPR formed a Collaborative
in year one of our agreement
• Opportunity to exchange ideas & learn from each
other by sharing best practices
• CEOs, CFOs, COOs meet monthly along with CMOs
and Care Coordinators
• Engaged consultants to assist with development of
data & scorecards to track progress, show the
differences between fee for service & TPR and
creating keys to success
• Negotiated the next agreement as a Collaborative
and not individually as was done the first time around
TPR Collaborative Hospitals
Reimbursement in Maryland
Quality Indicators Affect Reimbursement
• Quality Based Reimbursement – based on
improving patient satisfaction and core measure
results (1% of revenue at risk)
• Pay for Performance – based on reducing
potentially preventable conditions (3% of revenue is
at risk)
• Increased focus on hospital-acquired conditions
• Reducing re-admissions – yet to come but an
important component of TPR
QBR for FY 12
Total Lost Revenue: $1.2 Million
Core Measures
-$547,635
Potentially
Preventable
Conditions
-$430,285
Patient Satisfaction
-$234,701
Potentially
Preventable
Readmissions
Impact coming
QBR for FY 13
Positive Swing of $1,422,667
Core Measures
$56,064
Potentially
Preventable
Conditions
$129,954
Patient Satisfaction
$24,028
Potentially
Preventable
Readmissions
Impact Coming
Engaging Physicians
• Created the President’s Clinical Quality Council
- Twelve Physician Leaders/Early Adopters
• Improved the coordination of care, both
internally and externally
• Enhanced the quality of care provided
• Created a Pay-for-Performance initiative
• Used data to improve care
• Focused on issues such as denials, LOS,
PPCs, readmissions and use rates
• Addressed unnecessary inpatient care
Operational Challenges Under TPR
• Address high utilizers with multiple co-morbidities 1972 patients accounted for $140 million of annual
cost
• Maintain market share while reducing admissions
• Expand primary care access
• Focus on unnecessary utilization & appropriateness
of Admissions
• Decide what to do with volume growth programs
• Educate the internal stakeholders on the changes in
care delivery
• Meet the challenge of health care change by
reshaping the community’s approach to seeking care
Successful Strategies Under TPR
Pre-Acute Care Focused
• Added primary care practices where our most
vulnerable patients reside
• Created the Center for Clinical Resources consisting of
a multi-disciplinary team of NPs, RNs, Dieticians,
Pharmacists, Respiratory Therapists & Care
Coordinators
• Partnered with newly opened urgent care centers as
well as previous competitors
• Focused on keeping independent physicians who no
longer admit engaged with the health system
Successful Strategies Under TPR
Acute Care Focused
• Targeted high utilizers of services - 1,972 patients
• Focused on appropriateness of admissions versus
the number of admissions
• Reviewed daily every readmission within 30 days to
determine the reasons for the readmission
• Formed team of clinicians to round daily on patients
with a LOS of 3 days or longer
• Moved to nurses rounding hourly on every patient &
performing shift report at the patient’s bedside
Successful Strategies Under TPR
Acute Care Focused
• Developed team of physicians & nurses to work
with non-compliant physicians related to
readmissions, use rates, denials, LOS & potentially
preventable conditions
• Revamped our patient education program
• Assigned Pharmacy staff to the ED & inpatient units
for medication reconciliation & rounding on patients
• Created a dedicated care coordinator for Behavioral
Health
Successful Strategies Under TPR
Acute Care Focused
• Implemented Clinical Documentation Improvement
program to ensure accurate documentation of
POA conditions
• Started quarterly Hot Topics sessions for
physicians and advanced practice professionals
where focused education is needed and/or
required
• Changed discharge planning process to cover
patients until they see their primary care provider
• Began discharging patients with their medications
Successful Strategies Under TPR
Post-Acute Care Focused
• Established a Care Link Coordination Team that
follows up with all discharged patients with a focus
on frequent utilizers & those over age 62
• Expanded Home Care resources to address a 35%
increase in visits
• Created a team of Community Health Care Workers
• Created Transition Care Coordinators within our own
skilled nursing facility & SNF community partners
• Connected patients to services they will need post
discharge
Outcomes Under TPR & QBR
Process Improvements
• Improved coding accuracy through use of software programs
• Now perform a urinalysis on every patient to identify UTIs
present on admission
• Better connection of patients to services they need post
discharge
• Expanded Care Coordination 24/7 System wide w/
concentration in the ED
• Created more partnerships with our physicians
• Center for Clinical Resources staff visit high risk inpatients prior
to discharge
• Much greater accountability on the part of staff in driving quality
& reducing cost
Outcomes Under TPR & QBR
Improved Community Health
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Decreased tobacco use during pregnancy
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Reduced the rate of Behavioral Health
admissions
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Improved the infant mortality rate
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Experienced improvement in cancer mortality
rate
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Reduced the rate of ED visits for Asthma
Bottom Line
We have moved from a care delivery
standard that emphasized convenience for us
to the gold standard where care is delivered
as we would want it provided to us
and every member of our family.
Results So Far
Inpatient Admissions
32% over 4 years
Readmissions to 9% in FY13 from high of 16.68% in FY11
SNF Readmissions
by 38%
Inpatient Behavioral Readmissions
ED Use Rates
9% = $470K Savings
3% and ED Admissions
Observation Patients
10%
Diabetic Readmissions
CHF Readmissions
Savings
6%
22 % and Diabetic ED Visits
18% and ED Visits
8% = $383K
29 %
Results So Far
Net Revenue Over
Expenses
In FY13
$15.1 Million
or
5% Operating Margin
YTD for FY 14 is $12.1 Million or 8% operating margin
What’s Next
Creating More Value
• Adding community care coordination in primary care
clinics and physician offices
• Using home monitoring technology linked to Meditech
• Expanding SNF Care Transition Coordinator to a SNFist
(Phy/NP) and taking the program to other SNF’s in the
region
• Creating a dedicated Palliative Care program
• Forming a Clinically Integrative Network with our
physicians and other partners, then establishing an ACO
with our Alliance partners
• Expanding the Center for Clinical Resources to include
medication management & high-risk renal patients
What’s Next
Improving Community Health
• Continue to work on Community Health needs:
 Reducing ED visits for hypertension
 Lowering obesity rates for children and adults
 Decreasing tobacco use by adults
 Reducing drug-induced deaths
Successor TPR Agreement
Began as of July 1, 2013
• Continue to control cost;
improve quality; create
greater alignment with
physicians; monitor
utilization & strengthen our
care coordination process
• Continued focus on reducing
all-cause readmissions
• Get unnecessary cost out of
the system / elimination of
waste
• Improve the health status
of the patients we serve
• Develop a scorecard for
TPR hospitals
• Continue to re-invest the
savings under TPR
• Expect to share savings
with the State
Ongoing Challenges
• Use rates are still too high
• LOS has crept back up
• More work needs to be done on PPCs/Hospital-Acquired
Conditions
• Misaligned incentives with physicians
• 30% rate of “no shows” for follow up appointments in the
Center for Clinical Resources
• Although improvements have occurred in the overall
health of our population, work still needs to be done
there, as well in areas such as social & economic needs
• Many social issues exist among our residents and
patients; WMHS has become the safety net for the region
Concluding Thought
In the last three plus years, WMHS has
become a very different organization by
focusing on a value- based care delivery
system and one that has been able to
embrace the components of the triple aim
of health care reform. It wasn’t easy in
the beginning, but we are now much
better positioned for a challenging health
care future.
Questions?