change management

1. Central Texas Health Care
in 2013:
Organizing Our Delivery System
ACMA Meeting
April 2013

2. Why Reform the Delivery
System?
• There are 50 million uninsured Americans
• Health care costs are a factor in 55% of personal
bankruptcies.
• Health care costs have been growing at 2-3 times
the rate of inflation for 3 decades.
• Quality and safety rankings are below most
developed and industrialized nations.
• Medicare and Medicaid costs “unsustainable.”
• Health care continues to consume a larger
proportion of our nation’s GDP (currently 18%)
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3. Unsustainable

4. Unsustainable

5. Unsustainable
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6. Follow the Money
• 1% of the population accounts for 25% of
health costs;
• 10% of the population accounts for 70% of
health costs;
• 78% of national health care expenditures
can be attributed to chronic illness.
On order of $2 trillion.

7. Enter Insurance Reform
(ACA)
• Expansion of insurance coverage
– Medicaid expansion (not in Texas)
– Employer mandate; small business tax credit
– Individual mandate ($95/1%  $695/2.5%)
– Insurance Exchanges (2014) and tax credit (400% FPL)
• Insurance Regulation and Reform
– Do away with lifetime maximums
– Do away with pre-existing conditions
– Do away with rescissions (being dropped once you’re sick)
– Guaranteed deductible-free preventive care
– Minimum Medical Loss Ratio (MLR)
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8. Enter Insurance Reform
(ACA)
• Quality & Safety
– Pay for value programs to turn focus toward quality improvement.
– Encourage and reward use of information technology.
– Research to support “evidence based care.”
• Cost Efficiency
– Emphasis of preventative & chronic condition management to reduce
downstream costs.
– Accountable Care Organizations (ACOs) - pay for value not for
volume.
• ACO concept is now new. Examples of Clinically Integrated Networks:
Advocate Physician Partners; Kaiser Permanente; Cleveland Clinic.
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9. Delivery System
Transformation
Volume Based System Value Based System
• Proprietary Pricing • Transparent Pricing
• Broad Payer Networks • Performance Based Networks
• Episodic Patient Care • Cross-Continuum of Care
• Disparate Providers • Clinically Integrated
• Hospital Focus Providers
• Practice Pattern Variation • Health System Focus
• Provider Centered Care • Evidence Based Care
• Fragmented Hospital IT • Person Centered Care
• Cross-Continuum Based IT

10. Volume Based
Reimbursement
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11. Value Based Care
• Real change will require us to fundamentally
change the way care is delivered.
– Aligned Incentives
– Enhanced communication and managed transitions
– Risk-stratified interventions – getting the most
resources to the sickest patients
– Organized care
The Right Care at the Right
Place at the Right Time 11

12. Defining
Clinical Integration
CLINICAL INTEGRATION
Key Attributes of a
A network of physicians
Clinically Integrated willing to demonstrate a high
Network degree of interdependence
and cooperation through a
 Physician Driven and Governed program of initiatives
designed to control costs and
 Structured Quality Initiatives ensure quality, which is
 IT Infrastructure for Quality Data supported by an
infrastructure that allows the
Measurement and Reporting
physicians to evaluate and
 Incentive payments modify practice patterns.
-- Hogan Marren, Ltd.

13. Defining ACO
ACCOUNTABLE
CARE Key Attributes of an ACO
ORGANIZATION
• Person Centered Care
A network of • Physician Driven
physicians,
hospitals and • Coordinated Care Across the Continuum
ancillary providers • Practice Consistent Evidence Based Medicine
that share clinical (Clinical Integration)
and financial • Responsible for Cost and Quality of a
responsibility for Population
providing care to
• Rewarded, financially, for Performance
patients across the
continuum.

15. Seton Health Alliance ACO
Seton Seton Community
Healthcare Health Physicians
Family Alliance
• Building clinically integrated network of health care providers
• Selected as one of 32 Pioneer ACOs in 2012
• Commericial ACO contracts begining in 2013

16. Risk Stratified
Interventions
• 1-5% of Population
High Risk
• Advanced Care Coordination Clinic
Chronic
Prevent Inpatient Admits
(ACCC)
Palliative Care Program
Emergency Department
Home & Post Acute
Transitions (10%)
End of Life (5%)
• 10-15% of Population
Moderate Risk • Embedded Nurse
Chronic Navigator-PCP Care
Coordination
• Estimated 80% of
Population
Healthy and Low Risk • Care Gap
Management

17. Seton Health Alliance ACO
• 10,397 active patients
• 200+ participating
providers
• 30+ facility and agency
partners
• 36 locations
• 9 cities
• 11 counties
• 14,000 square miles
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18. Transitions & Post Acute
Network
Goals:
• Improve transitions and handoffs across the continuum;
• Strengthen provider-provider communication across the
continuum;
• Reduce preventable readmissions.
Process: Utilized Request for Information; Grow network of physician
groups and facilities/agencies aligned with mission and objectives
Current Network:
• 5 Physician Practices (hospitalist/post acute)
• 18 Skilled Nursing Facilities
• 3 Rehabilitation Hospitals
• 12 Home Health Agencies
• 1 Physician Home Service Provider
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19. Charting the Journey
Plan well before you take
the journey.
Remember the
carpenter’s rule:
measure twice, cut once.
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20. Contact Information
Meredith Duncan
Director of Operations, Seton Health Alliance
mdduncan@seton.org
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