Oregon CCO’s –
Passing Fad or A Model for the Future
Changing How we Provide Care
David Schlactus, CEO, Hope Orthopedics
David Schlactus - None
CCO’s v. ACO’s
How they Came About
Why CCO’s
A Driving Force for Change?
Preparing for CCO’s
CCO’s in Portland v. other parts of Oregon
A Passing Fad or the Future?
“The definition of insanity is doing the same
thing over and over again and expecting a
different outcome”
- Albert Einstein
“Americans can always be counted on to do the
right thing….after they have exhausted all
other possibilities.”
- Winston Churchill
“In the absence of a compelling reason to
change, people don’t”
- Phillip Kotter, Leading Change
Healthcare on it’s current course is
unsustainable as a percent of the GDP
10,000 baby boomers turn 65 EVERY day
More than 50 million Americans are
uninsured
In short:
More people are without healthcare
The cost curve has not yet been bent
Access to healthcare is rapidly decreasing due
to flatline reimbursement from Medicare &
Medicaid
Conceived by Don Berwick, MD, former head
of CMS:
Improve Access
Decrease Costs
Improve outcomes / patient experience
But seriously - you can’t really do all three
right? Well – maybe we can.
Hello ACO’s – the new Capitation, albeit, “risk
adjusted capitation”
All money for the hospital and physician
component are put in a basket and the
participants fight over who gets how much.
“Quality” must be demonstrated
65 demonstration projects in the US
Coordinated Care Organization
◦ Includes all revenue for:
Hospitals
Physicians
Behavioral / Mental Health
Dental Care
◦ This is NOT a theoretical exercise – they became
effective August 1, 2012
◦ (Mental Health and Dental $$ to be added in 2013
or 2014)
Plan to have 60% of ALL Medicaid / OHP
patients enrolled by January 1, 2013
Plan to add PEBB and OEBB in 2014
Plan to add Healthcare Exchange patients in
2014
By 2014 – could be as many as 25% of ALL
Oregonians in a CCO
As of September 15, 2012
13 CCO’s statewide
75% of all OHP patients enrolled
Over 500,000 Oregonians!
Fixed budget limits upside cost to state
Why this is BAD math?
◦ Medicare
◦ OHP
◦ Commercial
$36
$28 – 30
$60 - $72
CF
CF
CF
◦ PEBB and OEBB =
15% of our volume
◦ Once in the CCO – the CCO will control these funds
– ah, sorry but mental health and dental are
underfunded so we need some of this money
No problem – we just won’t participate
Nope – SB 158 allows a CCO to MANDATE
participation of providers if they provide
critically needed services
Arbitration for reimbursement rates
Who can afford to drop out if it includes
roughly 15% of your best paying commercial
business?
Oh- by the way – did we tell you that OHP
rates are slated to go down by 10% on
January 1, 2013?
What’s a group to do?
Change how care is delivered!
The goal of Hope Orthopedics is to lower the
cost of care (per unit) by 20%.
You can not do this by cutting staff
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Meaningful use
E-Rx
PQRI
QRUR
Etc…..
We have to redefine how care is provided
Two groups working on this:
◦ Physicians and PA’s at Hope Orthopedics
◦ Clinic Administrators in Salem
17 physicians
10 PA’s
17 Therapists
6 ATC’s at 6 local HS
= 42 providers
2 Clinics + 2 Satellites
Staff spread between 4 buildings
Buying 2 more buildings
MRI, Brace Shop, Therapy, DEXA, ASC, ultrasound
coming
Don’t just think outside the box – break the
box
We forced ourselves to think different by
creating wild and crazy scenario’s
Some of our scenarios included:
◦ MA’s are illegal in the state of Oregon – now what?
◦ Each MD gets only ONE room for the entire day
◦ Everything has to be done by the close of day – no
work can be carried over to the next day
◦ Our clinic no longer has a waiting room
◦ Our clinic no longer has any receptionists
Some of our ideas include:
◦ Patients Register from home or on I-pads in the
lobby
◦ Express line for patients who pre-register
◦ MA Swarm
◦ RN triage
◦ Group pre-op classes
◦ Group physical therapy
Some of our ideas include:
◦ New patients seen by a PA first – goal is to keep the
MD in the OR three days a week
◦ Do totals at our ASC’s with same day discharge
(have successfully completed 7 – with 2 more
scheduled)
◦ Rapid Access Clinic run by PA’s and they get 50% of
the net income
1 hospital
1 IPA
450 physicians
1 Main EMR funded by IPA
4 EMR’s total in community
50 Administrators that have known each
other and worked together for as much as 20
years, in short
We have established some trust
Some of our ideas include:
◦ The specialists “stake” the PCP’s with extra $$
◦ The $$ are used to hire navigators who call patients
to insure they take their meds, comply with care
plans and stay out of the ER.
◦ If we save money – savings go 1st to specialists and
then are split in the physician community
Some of our ideas include:
◦ Establish a one day per week afternoon clinic for
low income / high complication patients, staffed by
the PCP’s and PA’s from all the specialists.
◦ Rather than force these people to travel all over
town by bus, they come to one clinic and can see all
of their care providers in one afternoon.
Some of our ideas include:
◦ Pay our patients for compliance / results.
◦ $5 gift cards for showing up to the afternoon care
clinics.
◦ Collaboration between all of the PCP and specialty
clinics.
CCO’s v. ACO’s
How they Came About
Why CCO’s
A Driving Force for Change?
Preparing for CCO’s
CCO’s in Portland v. other parts of Oregon
A Passing Fad or the Future?
Your options:
◦ Put your head in the sand and hope this will all go
away
◦ Retire early – like at 44
◦ Wait until it is forced upon you, i.e., Oregon
◦ Get ahead of the curve
◦ Learn how to change how you deliver care and
reduce your per unit cost now. Experiment with
ideas but don’t make global changes quite yet.
Think of it this way – if you could lower your
cost by 15%, you could afford to:
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see Medicaid patients
see more patients (improve access)
Spend more time with your patients (improve care)
And still make the income you do now
◦ At least that’s our premise and what we at Hope
Orthopedics are striving to achieve
Who knows
But think of it this way – if we succeed and
lower our costs by 15% and the CCO’s fizzle –
have we wasted our time?
But if they are here to stay and we have not
changed how we deliver care, at all……..
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