Pilgrimage Healthcare
Patients Deserve More Options…
Norton Healthcare
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 Employees
600 Employed Providers
2,000 Physician Medical Staff
1,857 Licensed Beds
60,000 Admissions/year
Who is Accountable for Care?
Autonomy
versus
Paternalism
“Flu Shot”
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
Components of an ACO
Effective Health Management
The Players

Manage population health
 Patient attribution
 Community outreach
 Training and education
 Behavior and change
management
 Segmentation and risk factor
capabilities
 Marketing




Manage to
Quality
Standards
Effective
Health
Management
Coordinate
Items and
Services




Cost and
Efficiencies


Employers
Patients
Hospitals
Acute, sub-acute and longterm care providers
Ambulatory care centers
Pharmaceutical companies
Medical device manufacturers
Care Givers (physicians,
nurses, home health, clinical
social worker, clinical
psychologist, and other
ancillary providers)
Payors
Federal government
Manage to Quality Standards
Coordinate Items and Services
Quality management
(definition by population, not
event or episode-driven)
 Quality standards reporting
 Disease management
 Data management and
analytics
 Business intelligence
management of clinical,
operational and financial data

Manage Costs and Efficiencies
Risk management
Finance and accounting
 Disease management
 Measurement of clinical, operational and
financial key performance indicators


Used with Permission KPMG
HEALTHCARE
Preventive care
 Medical management
 Telemedicine
 Funding administration
 Supply chain
 Participation in Health
Information Exchanges (HIEs)

Journey for Accountable Care
• 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)
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
Evolution of Analytics
WHAT WILL
happen and
WHEN?
WHY it happened?
WHAT happened?
Learning
Improving
Predicting
Norton Healthcare – Humana Accountability Pilot
Year 1 Financial Data
Norton Year 2
1.7% Reduction below target PMPM
Humana Year 2
14.9% Reduction below target PMPM
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
Dartmouth – Brookings ACO Pilot Performance Measurement
2009
HEDIS
PPO
Norton
Baseline
Norton
Year 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%15
Quality Measure
(for all, higher %s represent better performance)
Too few eligible cases.
Anti-Infective Purchasing/QTR/Patient Day
1
1
0.98
Miscellaneous BetaLactams
0.90
0.86
Macrolides
0.73
0.75
Miscellaneous
Dollars
Per Patient Day
0.68
Aminoglycosides
Antivirals
Quinolones
Antifungals
Tetracyclines
Anti-Pseudomonal
Beta-Lactams
Anti-MRSA
Q1 2011
Q2 2011
Q3 2011
Q4 2011
Q1 2012
Q2 2012
Q3 2012
Q4 2012
Clinical Effectiveness
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%
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
Evidence or Bias?
Disruptive Innovation
Future of Healthcare
Think Differently – Treat Differently
Future of Healthcare
*The Volume-To-Value Revolution. Oliver Wyman
Resource Management
Questions
Steve.Hester@NortonHealthcare.org