PYA Principals Scott Clay and J. Michael Keegan, MD, will join forces to present “Hot Topics: Pacing Volume-to-Value Transition” and “The ROI of Avoiding Antibiotic Overuse” at the AlaHA Annual Meeting, June 8-11, 2016. The two-part presentation first will explore volume- to value-based reimbursement, and how the pace of change is unique to each organization. The presentation will introduce a strategic framework to establish and communicate a pace of change befitting various organizations, explaining: How government policies “set the floor” on the degree of change requested. How to determine the pace of change in your market. How to identify your organization’s current position and culture in relation to value-based payment models. How to set and communicate the pace of transition consistent with your market and your organization’s culture. The second portion of the presentation will focus on the importance of antibiotic stewardship programs (ASP) for population health. The presentation will explain: Why the Centers for Medicare & Medicaid Services is proposing a requirement that hospitals implement ASPs to stem the rise of resistant bacteria. Why PYA is invested in offering hospitals a proven program for improving patient safety while saving costs. What constitutes a successful ASP.

1. Scott Clay, Consulting Principal
Alabama Hospital Association
Annual Meeting
June 10, 2016
TIMING IS EVERYTHING
Pacing the Volume-to-Value
Transition

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The Dilemma

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Positioning for Transformation
Timing Is Everything!
Decisions on when and how to change payer contracting strategies and
underlying operational platforms must be informed by four key considerations:
Government Policy Drivers
Local and Regional Market Drivers
The Organization’s Current Position/Profile
with Regard to Value-Based Transition
The Organization’s Strategic Intent for
Adoption of New Care Models

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CMS’ Push to Value-Based Reimbursement
CMS is setting the “floor” on the level and pace of change required.
2016 2018
30%
In alternative payment models,
e.g. ACOs, bundled payments.
50%
In alternative payment models,
e.g. ACOs, bundled payments.
85%
Tied to quality and
efficiency measures.
90%
Medicaid APMs provide opportunity to minimize losses with less downside
risk and provide upside by minimizing use of high-cost services.
Tied to quality and
efficiency measures.

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Five Key Market Drivers
Population Size and Density
Market Costs and Use Rates
Commercial Payer Activity
Employers
Competitors
Even markets with limited local pressure will require change
based on federal and state healthcare programs.

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Knowing Where Your Organization Stands
While there is no “right” answer at any point in time, leaders must
understand and acknowledge where they stand – and why.
Four Current Status Profiles for New Care Models
Watching and Waiting
Beginning the Course
Mid-Course/Into the Corner
In the Final Lap

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Three Important Process Elements
1 Discussions must include broad stakeholder involvement including
“critics” as well as “champions.”
2 The assessment must honestly reflect how the organization really
behaves rather than how it would like to think of itself – or the
image it would like to project.
3 The assessment must include a reflection on what has influenced
the organization to be in this position at the current time.
 Is it strictly a reflection of external factors?
 Does it reflect a risk-averse culture?
 Did historical experiences influence the perspective?

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How does the organization want to be positioned in the future?
What pace of change is required to achieve that goal?
Four Strategic Intent Profiles for New Care Models
Protect and Defend Current Status
Steadily Advance with the Market
Catch Up to the Market
Disrupt the System and the Market

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Closing the Gap
How Much Change is Required to Reach Your Goal?
Degree of Change Required
to Move from Current Profile to Strategic Intent
Strategic Intent
Protect and
Defend Current
Status
Catch Up to the
Market
Steadily
Advance with
the Market
Disrupt the
System and the
Market
CurrentStatus
Watching
and Waiting
Moderate High High Very High
Beginning
the Course
Low Moderate High Very High
Mid-Course/
Into the Corner
N/A Low Moderate High
In the
Final Lap
N/A N/A Low Moderate

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Monitoring Market Movement
Monitor to Determine Optimal Timing for Key Initiatives
Organizations must answer three questions to establish an effective
market monitoring capability:
What are the few strategic-level market metrics needed to
monitor to inform major decisions?
How do these differ based on an organization’s current position
and strategic intent?
What are the “trigger points” that indicate a significant market
shift?
1
2
3

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Monitoring Market Movement
Common Market Metrics to Track Pace of Change
Metrics can serve as trigger points that indicate significant market
shift demanding immediate action.
 Population Size and Density
 Market Costs and Use Rates
 Payer Activity
 Employers
 Competitors

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Across the Finish Line
While the industry continues to evolve to alternative payment
and care models, a more nuanced approach is emerging for
individual systems.
By honestly assessing who they are and where they want to
be positioned in their market, healthcare systems can pace
their change to reflect the reality of their local markets and
proactively manage the risk of transition.

13. PERSHING YOAKLEY & ASSOCIATES, P.C.
800.270.9629 | www.pyapc.com
Scott Clay
Principal
SClay@pyapc.com

14. June 10, 2016
Presented by:
James M. Keegan, MD
ALABAMA HOSPITAL ASSOCIATION
The ROI of Avoiding Antibiotic
Overuse

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Presented by
James M. Keegan, MD
Native Kingsport, Tennessee
Emory University, Atlanta, Georgia
U.S. Air Force, Ellsworth AFB
South Dakota
Commendation: Meritorious Service
Chief of Medical Staff
University of Vermont
Infectious Disease Fellowship
1986-1990 Clinical Practice of Infectious Disease
with Fred Kerns, MD, Charleston WV
1990-2005 Clinical Practice Infectious Disease
1990-Pres Medical Director of Infection Control,
Rapid City
Regional Hospital and Regional Health
(Western SD)
2001-Pres Medical Director
Antibiotic Stewardship,
Rapid City Regional Hospital
2005-2013 Administrative Leadership
in Regional Health
Vice President Quality  Chief Medical Officer
Chief Executive Officer of Regional Health
Physicians  1 of 5 Senior Executive
Team Members

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“Success is walking from failure to failure with no loss of enthusiasm.”

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Winston Churchill

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“He who knows best knows how little he knows.”

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Thomas Jefferson

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“Leadership is about making others better as a result of your
presence and making sure that impact lasts in your absence.”

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Sheryl Sandberg

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The Problem – Antibiotic Resistance
The Global Health Crisis
Each year in the U.S. at least 2-million Americans will become
infected with bacteria that are resistant to antibiotics, and at
least 23,000 die each year as a direct result... CDC
By 2050, more people will die (worldwide) from antibiotic
resistance than from cancer. BBC

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The Problem – Antibiotic Resistance
The Global Health Crisis
…20-50% of all antibiotics prescribed in U.S.
acute care hospitals are either unnecessary or
inappropriate.”
Similar to the findings in hospitals, studies have
shown that 40–75% of antibiotics prescribed in
nursing homes may be unnecessary or
inappropriate.”
“We can either work to improve antibiotic use and prevent infections,
or watch as the clock turns back to a world where simple infections kill people.”
Tom Frieden, CDC

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Historical Prescribing Practices
90-95% of all sinus infections
are viral, yet…”

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Empiric Prescribing and Risks
At community hospitals, ONE of THREE
patients with bloodstream infections given
inappropriate therapy.” Duke University
: Treatment given without knowledge of cause or nature of
disorder and based on experience, rather than logic.
Simple Definition of EMPIRICAL
empirical
adjective | em-pir-i-kuh-l

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The Dilemma for Physicians
Patient Expectations
 Prescribed antibiotic validates
illness
 Antibiotic often considered a
“cure all”
 Patient satisfaction scores
Physicians prescribe how they
have been historically trained
Treating the patient vs. solving
world issues

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Regulatory Environment
Infectious Diseases Society of America (IDSA)
& Society for Healthcare Epidemiology of
America (SHEA) recommend antibiotic
stewardship as a Condition of Participation
by December 2017 to Centers for Medicare &
Medicaid Services (CMS)”
CMS Requirement Immanent?
IDSA and SHEA letter to CMS, March 4, 2014.

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Message Going Mainstream
Growing Public Awareness of the Problem
“USA needs to take
immediate steps to fight
super bugs, experts say.”

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Broad Spectrum Antibiotics
Use by State
Use of Quinolones in 2012
Source: IMS Xponent

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MRSA
Incidence by Region

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There is a disconnect, why?
 Changing clinical behavior is difficult
 Limited Antibiotic Stewardship experience
 Broadcasting the problem does not equate with solving
the problem
 Pharmacy champions and
others may not be
comfortable with task of
changing physician
prescribing behavior

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What We Are Seeing
RESULTS
OBSERVATIONS
30 Hospital Collaborative

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CDC Core Elements
13 Centers for Disease Control and Prevention, CDC, “Core Elements of Hospital Antibiotic Stewardship Programs.”
Leadership
Commitment
Accountability
Need Drug
Expertise
Active
Oversight
Tracking
Reporting
Ongoing
Education
Antibiotic Stewardship

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Our Philosophy
PRIMUM NON NOCERE

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The Role of Diagnostics
 Rapid Diagnostics
 Pay now or pay more later
 Prescribing contingent
upon lab results

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Clostridium difficile (C.difficile)
Thoughts about this HAI
CDC Hazard Level Rank: Urgent Threat Assessment – Highest
level
 DEADLY: “Contracting C. diff drastically reduces your chance of
leaving the hospital alive. If two patients come into the hospital with
the same diagnosis, the one who gets C. difficile is four times more
likely to die.”
 EXPENSIVE: $10K per incidence (national average)
“I know that today I had 3 rooms closed down for C.diff. Meaning the patients
had discharged and the rooms steri-misted. Still have to confirm they're clean
before reopening them to accept patients. Normally takes 72 hours, depending
on when environmental services get there to steri-mist it”

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Valley Hospital ASP Results
C. difficile and ABX Correlation

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Hospital Engagement Sample Results
C. difficile and Antibiotics Correlation

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Penicillin
Allergy
 If you are hospitalized and declare a penicillin allergy,
your mortality risk doubles if you are prescribed an
alternative medication
 Avoiding penicillin means using alternatives that are less
effective, more expensive or have greater side effects
 Add length of stay increase
 Dangers for those /Treatment risk for those who think
they are allergic

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Antibiotic Stewardship Program
Direct and Attributable Financial Benefits
20-50% reduction in total antibiotic expense with
emphasis on broad spectrum antibiotics. Clinical
improvement to more precise prescribing practices.
Reduce expenses associated with antibiotic inventory
and related costs of maintaining inventory
Decrease C. difficile cases - 10% mortality rate and $10K
per incidence cost associated with this HAI (national
average)

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Antibiotic Stewardship Program
Indirect Financial Benefits
Savings and improved outcomes that
influence Value-Based Reimbursements
• Avoids Unnecessary Admissions
• Decreases LOS (Length of Stay)
• Decreases Readmissions
• Reduces risk for HAI (Hospital-Acquired
Infections)
• Improves DRG Sufficiency

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Antibiotic Stewardship Program
Related Benefits
Public Relations and Improved
Perceptions
Better Patient Care
Mitigate Legal Risk
Prepare for impending CMS
Conditions of Participation
related to the adoption of ASPs

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Antibiotic Stewardship equals
Triple Aim
1. Improves Patient
Care and Outcomes
2. Reduces costs
3. Improves Health of a
Community
…and it is Simply the Right Thing to Do.

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Antibiotic Stewardship Program
Selected Programs and Savings
Location/Type of
Facility
Number of
Beds
Cost
Savings/Reductions
AS Team Composition
Monroe, Louisiana
Community Hospital
120 $177,000/ 1 Year ID Specialist, Clinical
Pharmacist
Dallas, Texas LTAC
Hospital
60 $159,580/ 15 Months ID Specialist, Director of
Pharmacy
Dorchester,
Massachusetts
Community Teaching
Hospital
159 $200,000-250,000/ 1
Year
ID Specialist, ID-trained
Pharmacist
Baltimore, MD Large
tertiary care, teaching
medical center
800 $2,949,705/ 3 Years ID Specialist, Clinical
Pharmacist
Winston-Salem, NC
Academic Medical
Center
880 $920,070 to $2,064,441
per year over 11 years
2 ID Specialists, 3 Clinical
Pharmacists

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RCRH Results
Rapid City Regional Hospital
417 Licensed beds
Ernst & Young ~$1 million antibiotic per
year cost savings

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PYA ASP Team
Our Services
 24/7 Access and Support of Infectious Disease Physician and
Team
 20+ Years of ASP Experience with Proven Results
 Train and Empower Physician and Pharmacy Champions
 Concurrent Monitoring of Prescribing Practices
 Ongoing Review and Data Analysis to Ensure Continued
Success
 Transparent Reporting and Outcomes
 Safety Bundle Recommendations

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Public Health Crisis
…resistance to antibiotics has become
a major threat to public health”
World Health Organization

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PYA’s ASP TEAM
Multidisciplinary Expertise

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“The most important weapon in your arsenal will be your ability to
adapt.”

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Batman

51. PERSHING YOAKLEY & ASSOCIATES, P.C.
800.270.9629 | www.pyapc.com
James M. Keegan, MD
mkeegan@pyapc.com
(605) 408-6513