Current Medicare ACO Model Based on staff model HMOs Greater medical staff Move towards risk- bearing Compete with other ACOs
The Plan: Competing ACOs Cooper ACO Lourdes ACO Virtua ACO
The Unique Challenges We’re Facing in Camden “Where there is no vision, the people will perish”
Camden challenges/opportunities $100 million per year in hospital/ER spending 50% of population uses an ER/hospital in 1 yr #1 dx for ER visits- head colds (12,000/5 yrs Costs highly concentrated: – 30% costs = 1% of the patients – 90% costs = 20% of the patients – Individual buildings Northgate 2- $12 million/5 yrs for 600 pts Abigail- $15 million/5 yrs for 300 pts
Emergency Department High UtilizersTop 1% 2007 Camden Patients386 Visits5169 Visits/Patient13.4 % visiting more than one hospital80.6% Trenton Patients504 Visits7616 Visits/Patient15.1 % visiting more than one hospital78.2% Newark Patients928 Visits14367 Visits/Patient15.5 % visiting more than one hospital71.1% Additional challenge….
Hospitals Primary care providers Behavioral health providers Patients Social service agencies Public health organizations Housing providers
Differing ACO Visions No riskRisk-bearing Shared savingsCapitation Geographic attributionMedical staff attribution Open networkClosed network Learning collaborative Insurance product/Mini HMO Community- based/Primary care focused Hospital-centric
A Camden ACO Vision…. The City of Camden will be the first city in the country to dramatically improve healthcare and reduce costs through collaboration.
Building Blocks for a Camden ACO 1.High Utilizer Teams 2.Primary Care Medical Homes 3.Target High Cost Buildings 4.Open Access Scheduling & Panelizing Practices
Disruptive Change- Patient Centered Medical Home Geisinger Demo- 18% reduction hospitalization, 36% reduction in 30 day readmissions
Patient Centered Medical Home Practice Management Acute Care Current ModelNew Model Quality Improvement Care Coordination Patient Engagement
Patient Centered Medical Home Daily hospital census New embedded staff – Program assistant – RN/LPN care coordinator – Patient advocate – AmeriCorp health coach Weekly in-office case conference Group visits, EHR, registries, specialty support, staff training
The ACO Life Cycle Certification Certification Establish organizational capacity Establish organizational capacity Gainsharing Plan Gainsharing Plan Present implementation plan Present implementation plan Prove financial and clinical readiness Prove financial and clinical readiness Engage the public Engage the public Annual Review Annual Review Demonstrate effectiveness Demonstrate effectiveness
Certification Purpose Purpose Define coverage area Define coverage area Confirm governing structure Confirm governing structure Evidence provider support & program commitment Evidence provider support & program commitment State Action State Action Review application Review application Written approval / denial Written approval / denial Assist with reconsideration Assist with reconsideration Make all documents available Make all documents available
The Gainsharing Plan Purpose Purpose Explain implementation plan Explain implementation plan Provide opportunity for public input Provide opportunity for public input Explain use and distribution of savings Explain use and distribution of savings Define patient safety and quality programs Define patient safety and quality programs State action State action Review, analyze and verify the plan Review, analyze and verify the plan Written approval / denial Written approval / denial Assist with reconsideration Assist with reconsideration Manage amendments Manage amendments Make all documents available Make all documents available
NJ’s ACO – The Importance of Quality The NJ ACO law provides the opportunity to share savings The NJ ACO law provides the opportunity to share savings In exchange, NJ ACOs have the responsibility to provide quality care In exchange, NJ ACOs have the responsibility to provide quality care Federal laws also require quality Federal laws also require quality Protect patients ability to access medically necessary care Protect patients ability to access medically necessary care Prevent providers from denying care to save money Prevent providers from denying care to save money Important elements to protecting quality Important elements to protecting quality Meaningful ways for patients to provide feedback Meaningful ways for patients to provide feedback Consistent monitoring of care Consistent monitoring of care