Upload
mallory-bulger
View
216
Download
0
Embed Size (px)
Citation preview
2011 Medical Professional Liability Symposium
Chicago, IL ~ March 24 & 25, 2011
EVOLUTION OF HEALTHCARE DELIVERY: ACO’S &
MEDICAL HOMES
EVOLUTION OF HEALTHCARE DELIVERY: ACO’S & MEDICAL HOMES
Moderator:Paul A. Greve, Jr., JD, RPLU, Executive Vice President, Willis Health Care Practice
Panelists:Thomas S. Campenella, Esq., Associate Professor, Health Economics
Baldwin Wallace College; Of Counsel to Baker & Hostetler
Of Counsel, Baker Hostetler
William M. Marella, MBA, Director, Patient Safety Reporting Programs, Risk Management Group, ECRI Institute
Andrew L. Shapiro, JD, Senior Vice President, HealthPro, CNA
• Unlimited financial demands placed on the finite resources available to society
• Medical care must be placed within the context of other goals considered important by society
• To a large extent these are competing priorities
The Financial Challenge Facing Healthcare
Stakeholders
The culmination of healthcare cost, quality and access to care issues:
1. Negative impact on employers
2. Negative impact on Medicare/Medicaid
3. Negative impact on both the “haves and have nots”
4. Which will in turn negatively impact healthcare stakeholders – no longer business as usual
The Financial Challenge Facing Healthcare Stakeholders
• Our healthcare system is shaped by how we pay for services and what we pay for
• Medicare, the primary architect of our healthcare system
• Will there be “real payment” reform of Medicare?
• Remember, healthcare cost is revenue to the healthcare stakeholders
Follow the Money
• Large urban hospital systems
• Rural and independent hospitals
• Physicians
• Managed care organizations
• Long-term care industry
• Free-standing ambulatory provider facilities
How will Healthcare Reform Impact the Stakeholders?
• Accountable Care Organizations are provider groups (e.g. hospitals/physicians) that accept responsibility for the cost and quality of care delivered to a specific population of Medicare patients cared for by the group’s clinicians. ACOs are rewarded in the form of shared savings if the group provides care to beneficiaries for less than the Medicare benchmark cost while meeting criteria for patient service and quality of care.
Healthcare Reform – Large Urban Hospital Systems
Hospital Systems and ACOs• Key to success – aligning incentives• Positive/negative stakeholder impact • The return of the HMO model?• The impact of transparency• Make or buy?• Winners and losers – house of cards?
Healthcare Reform –Large Urban Hospital Systems
What is the future of rural and independent hospitals under health
care reform?
1. Independent physician collaboration
2. Business community collaboration
3. Tertiary centers of excellence collaboration
Healthcare Reform –Rural & Independent Hospitals
• Patient centered medical home (PCMH) - a team based approach to delivering medicine. The PCMH practice is responsible for providing care for all the patient’s health needs or making appropriate arrangements with other quality professionals. This includes the provision of preventive care, treatment of acute chronic illness
Healthcare Reform –Physician Industry
Patient Centered Medical Homes
1. Focus on primary care
2. Can they stand alone?
3. Will payers support them?
What is the future of the independent physician practice?
1. Medicare payment policy
2. Hospital collaboration
Healthcare Reform –Physician Industry
71%
23%
72%
26%
68%
30%
69%
28%
61%
35%
54%
39%
48%50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2002 2003 2004 2005 2006 2007 2008
Doctors
Hospitals
Source: Medical Group Management Association
Percentages of Practices Owned by …
Healthcare Reform –Physician Industry
What is the future of the MCO industry under healthcare reform?
• Insurance reform• Health insurance exchanges• A new role for MCOs?• Increased consolidation?• Winner & losers
Healthcare Reform –Insurance Industry
What is the future of the long-term care industry under healthcare reform?
• Aging baby boomers – a different model• Medicaid financial crisis• The role of long-term care insurance• Winner & losers
Healthcare Reform –Long-term Care Industry
What is the future of free-standing
ambulatory provider facilities?
1. Transparency + prudent purchasers of healthcare services = financial success
2. Medicare payment policies
3. Independent physician collaboration
4. Collaboration with MCOs
Healthcare Reform –Free-standing Ambulatory
Provider Facilities
• Both challenges and opportunities for health care stakeholders
• Those stakeholders that are proactive in addressing these challenges will have the best chance for short and long-term success
The Healthcare Stakeholders’ Challenges/Opportunities
Major Trends in the Landscape
• Declining reimbursement, growth in less profitable populations
• Consolidation of providers• More coverage = more care = more claims• Shifting patients to least costly acceptable
settings Expanded utilization of ASCs and O/P Expansion of patients and procedures in ASCs More home care & tele-health
17
• Exacerbates existing primary care shortage• Increased patient volume• Physicians more pressured for time (dx
error, lack of follow-up on tests)• ACOs: Financial incentive to reduce
utilization• Medical Homes: 24x7 responsibility; what
are they promising?
18
Crunch on Primary Care
• Will physicians push them too far• Level of supervision• Defining scope of practice• Who is reviewing their cases• What standard of care applies• Issues around ostensible agency
19
Expanded Use of Mid-Level Providers
• CMS non-payment for hospital acquired conditions (HACs)
• Medicare payment reduced by 1% for all d/cs for hospitals in the top quartile of HACs (2015)
• Incentive payments for hospitals (Oct 2012) exceeding standards for AMI, heart failure,
pneumonia, surgery, & HAIs
20
Value-Based Purchasing
• 30-day Readmissions payment penalties (Oct 2012)
• Results posted on HospitalCompare and PhysicianCompare
• Changes the ROI calculations for safety improvements
• Liability for failure to adopt specific patient safety practices?
21
Value-Based Purchasing
22
Foreign Object Retained After
SurgeryAir Embolism Blood
Incompatibility Pressure Ulcer Falls & Trauma Catheter Associated UTI
Vascular Catheter
Associated Infection
Poor Glycemic Control
Surgical Site Infection
Orthopedic Procedure &
PE/ DVTTotal
Medicare HACs Reported Using POA Indicator (Numerator)
No HACs Reported
No HACs Reported
No HACs Reported
No HACs Reported 4 3 No HACs
ReportedNo HACs Reported
No HACs Reported 1 8
Medicare Discharges Related to the HAC Category (Denominator) 769 5,832 5,832 5,832 5,832 5,832 5,832 1,561 2 187 5,832
All Surgical Cases All Cases All Cases All Cases All Cases All Cases All Cases All Diabetic CasesCertain Ortho Procedures,
Bariatric Surgery and CABG Cases
Hip and Knee Replacement
CasesAll Cases
Estimated Medicare HAC Rate per 1,000 Discharges 0.00 0.00 0.00 0.00 0.69 0.51 0.00 0.00 0.00 5.35 1.37
Discharges Subject to Reduced Medicare Payment Because the HAC Reported was the Only Qualifying CC/MCC
0 0 0 0 2 0 0 0 0 0 2
Source: Hospital and HealthSystem Association of Pennsylvania
Hospital Acquired Conditions - Sample
• ACOs and Medical Homes will fail without information flow across care settings
• $19B in incentives for EHR adoption in ARRA • Critical that we adopt the EHR, despite the short-
term problems• Many problems are analogous to those with the
paper record Orders & studies posted to wrong chart Inaccurate info charted, failure to chart Wrong box checked, wrong selection chosen from list Privacy concerns/HIPAA
23
EHR is Integral toHealth Reform
• VA terminates access to data from DOD EHR system when entries appear intermittently in wrong patients’ charts (March 2010)
• Selected cases of massive data loss
• First year of HITECH: 166 breaches, 4.9M people affected
24
The Scale ofProblems has Changed
• Technical Learning curve associated with new technology User errors (failure to save entries, connectivity failures) Data corruption, availability Can lead to delay in treatment, misdiagnosis Alert atrophy and alert fatigue
• Legal EHR audit trail of document access, changes made Failure to act on information timely Automation of discovery process in fraud investigations Marginal risk of actively rejecting evidence-based guidelines
25
Some Problems areNew and Unique to HIT
• Data communication/transmission problems and software problems may be less detectable
• Failure of images being transferred to PACS from diagnostic devices (CT, radiography, echocardiography)
• Incorrect processing of information (spatial orientation, patient position, measurements of pathology)
• Missing sections of CT studies, images reconstructed incorrectly
• Some cases of mass data loss
26
The Case of PACS
• In February 2010, MIM Software received FDA marketing clearance for an App for diagnostic viewing of CT, PET, MRI, and SPECT images on iPhone, iPod Touch, & iPad
27
Source: PR Newswire
Get Ready for theGolf Course Diagnosis
• Corporate Form• Leadership Structure• Governance• Providers• Members• Capitalization
Organizational Issues
• Coverage of entity and or providers• Breadth of coverage• Transient nature of insureds• Primary or secondary?• Character of patient population• Financial Risk
Insurance Considerations
• Quality of provider integration• Degree of physician leadership• Quality of systems for coordination of
care• Patient satisfaction monitoring• Progress toward meaningful use
More Insurance Considerations
• Causes of action relative to coordination of care
• Standard of care relative to EMR• Financial risk impact on level of care
decisions
Liability Issues
QUESTIONS?
EVOLUTION OF HEALTHCARE DELIVERY: ACO’S & MEDICAL HOMES
Moderator:Paul A. Greve, Jr., JD, RPLU, Executive Vice President, Willis Health Care Practice
Panelists:Thomas S. Campenella, Esq., Associate Professor, Health Economics
Baldwin Wallace College; Of Counsel to Baker & Hostetler
Of Counsel, Baker Hostetler
William M. Marella, MBA, Director, Patient Safety Reporting Programs, Risk Management Group, ECRI Institute
Andrew L. Shapiro, JD, Senior Vice President, HealthPro, CNA