1. Funded by HRSA HIV/AIDS Bureau Making the Business Case for Quality in Healthcare? December 11, 2008 Roger Chaufournier Kathy Reims, M.D. NQC Consultant

2. National Quality Center (NQC) Presentation Overview The Environment Lessons from Health Care Transformation High Leverage Change Concepts Impact on Finances Dialogue

3. National Quality Center (NQC) The Environment HRSA Core Measures Washington Post October 9, 2006 A Prescription for Worker’s Health: Employers Open In- House Clinics to trim Costs and Boost Preventive Care

4. National Quality Center (NQC) Results from Quality Improvement… Opened 2 additional clinical sites without federal funding Added 2 Pharmacies Added services  2 DSME Programs  Literacy Program  RSVP Developed 2 Wellness Centers Developed Community Initiatives Each Owner received a $1000 Holiday Bonus Increased Cash Reserves - 200 days  $100,000 to over $3M Implemented enterprise-wide EHR billable services increasing by 36% even though the number of encounters increased by only 8%. Self-pay collections increased from 42% to 77% in two months Billing rejections decreased from 95% to 5% Insurance aging >120 days was 44%, now is 13% Source: Greg Wolverton; WRRHC

5. National Quality Center (NQC) The Potential-The Pioneers Time with doctor has gone from 8.2 minutes to 12.5 minutes Total visit time has gone from 90 minutes to 47 minute average HbA1c for their population of focus came down from 11 to 8 Encounters and revenue for behavioral health services skyrocketed (in Medicaid cost based reimbursed and Medicare is 60% of the cap for behavioral counseling services) There are several key clinical indicators where they have reversed the health disparities and outcomes for minority populations are better Third available appointment has gone from 140 to 0 days Went from breakeven/deficit spending to 7% positive margin Total average aggregate costs of care for people with Diabetes 30-70% less than all other providers CareSouth Carolina Source: Ann Lewis, CEO CareSouth Carolina

6. National Quality Center (NQC) Medical All Family HomePractice (CareSouth)Physicians Median Average Total Annual Payment $1,340$1,778 Per patient Annual drug payments per $502 $576 patient Average office visit payment $441 $168 Average Inpatient Hospitalization $172 $634 Average ER Payment $15 $22 Source: South Carolina Office of Budget and Control 2004 Cost based Reimbursed as FQHC. Still did better 25% less Total costs To the State Why are payers interested?

7. National Quality Center (NQC) Delays & Waits for access 1-12 weeks 3:1 Staffing Ratio THE PREVALENT SYSTEM OF CARE DELIVERY 20%-55% Compliance with guidelines Less than 18%-24% use IT for patient care 40% waste & inefficiency 45% Internet traffic is patients seeking self management info Practice working in a vacuum

8. National Quality Center (NQC) OPTIMIZING MARGIN IS A COMPLEX PUZZLE

9. National Quality Center (NQC) Optimizing Your Margin is A Complex Puzzle Prod uctivi ty Charges Collections Demand No Show Rate Lean Design Planned Care Throughput Productivity Work Environment Facility Materials Revenue Drivers Expense Drivers

10. National Quality Center (NQC) Driving the Business Case Lessons from the Field IHI Idealized Practice Redesign lessons HRSA Collaboratives pilots Lean Applications In Health Care High Leverage Drivers: Advanced Access Optimize Care Team Lean-Continuous flow/ Cycle time reduction Planned Care Registries for Master Scheduling Revenue Optimization + IMPROVED OUTCOMES

11. National Quality Center (NQC) Planned Care Use of a proactive care model such as the Wagner Care Model Registries used for master scheduling Population and patient level care

12. National Quality Center (NQC) Informed, Activated Patient ProductiveInteractions: Evidence-based clinical management Collaborative treatment plan Effective therapies Self-management support Sustained follow-up Prepared, Proactive Practice Team Functional and Clinical Outcomes Health System Resources and Policies Community Organization of Health Care Self-Mgt Support Delivery System Design Decision support Clinical Information Systems

13. National Quality Center (NQC) PLANNED CARE IN THE NEW ENVIRONMENT N.P. N.P. R.N. R.N. M.D. M.A. DIETICIAN EXTERNAL TEAM Expanded Care Team Guidelines In exam room with PDAs/registry reminders Open access: No shows decrease to 2-5% DIGMA’s &Group visits used 25% Reimbursement aligned to support planned care Medical Home P4P, P4Play, P4Q Continuous flow minimizes on-site time Community resources part of care team DOH, Disease Vendors EMR: eliminate all paper 17% visits by Email Registry used for master scheduling and outreach

14. National Quality Center (NQC) Advanced Access Majority of appointments held for today’s and yesterday’s patients Planned visits scheduled Today’s work done today Max packing of visits Managing demand through alternative models (e.g. Group visits/Electronic visits)

15. National Quality Center (NQC) What happens in Open Access? Example of Nurse Triage 1. Call answered by a receptionist, message taken, or appointment booked without further discussion (1-3 minutes) 2. The chart is pulled and a message attached (2 minutes) 3. If no appointment made, patient chart and message reviewed and prioritized prior to call back (4 minutes) 4. A call back is placed. More information obtained and then appointment made, referral made or a physician consult is required before resolution (5 minutes: Note not all callbacks are reached on a first attempt) 5. An additional call back to patient after a physician or nurse consult (2 minutes) 6. Receptionist asked to schedule an appointment, complete a managed care referral form or call a script to a pharmacy (3-5 minutes) 7. An entry into patient’s chart is made (3 minutes) 8. The chart is refilled (2 minutes) Total Staff Time: 24 minutes @ an average cost of $14/hr Total annual dollar impact: 10 calls a day; 200 days; $11,200 in staff time annually Source: Case study from NCQA Web site

16. National Quality Center (NQC) Source: Marjorie Godfrey; Dartmouth Hitchcock

17. National Quality Center (NQC) Optimizing the Care Team Expanded roles  Deploying highest level of skill to lowest level of licensure allowed by the state Team based model Care coordination across the continuum; Medical Home Model

18. National Quality Center (NQC) Source: MGMA data Profitability by Full-time Support Staff

19. National Quality Center (NQC) Applying Lean Process Mapping to identify bottlenecks and waste Applying 7 forms of Waste to the clinic Optimizing flow and cycle time Purposeful design Implementing highly reliable systems

20. National Quality Center (NQC) Revenue Optimization Coding Charge Capture Compliance with the evidence base Negotiating new lines of revenue

21. National Quality Center (NQC) White River RedeFin Measures

22. National Quality Center (NQC) The Pioneers-Mercy Campus, Iowa IHI Impact Wellmark Collaboration on Quality Initiative Used SECAT Registry Tested Health Coach Model Tested Transparency of provider group internal to the system Implemented Advanced Access

23. National Quality Center (NQC) Diabetes Outcome Measures October 2005 – September 2006 All MCI diabetes patients n = 8631

24. National Quality Center (NQC) CMS Profit = $8.00 / test Yields $100,000 / yr.

25. National Quality Center (NQC) Dialogue? Questions? Reflections

26. National Quality Center (NQC) Contact Information Roger Chaufournier Chief Executive Officer CSI Solutions, LLC rchaufournier@spreadinnovation.com 301-529-7858 Kathy Reims, M.D. Chief Medical Officer CSI Solutions, LLC kreims@spreadinnovation.com 720-890-8614