I’m going to give you a little different talk today than you’re used to in this symposium.  And when you try to talk about quality you have to make sure you don’t put the audience to sleep first of all. This has been a totally neglect area of medicine as you will see.   However, over the last ten years and particularly over the last two or three years with some changes in legislation I really think that this is going to change the paradigm in medicine.  I believe within the next 5 to 10 years we will see a dramatic shift from volume based, volume driven healthcare to one of quality metrics and cost and value.  

So I always like to show this slide that the transparency train is coming.  And I really think that the train has arrived. So the things that we used to say, my patients are sicker, my patients are noncompliant, my demographics are bad, my patients are at high risk, I  have elderly people, it’s not fair to compare me to other  people.  I practice at Presbyterian, high cost, quaternary care center, it’s not going to work.  The government doesn’t care, this push to get to the electronic record is a way to get to looking at our quality and to have a totally transparent care system in the United States. Employers are asking for it, patients are asking for it.   So the message I’m going to give to you today is to be prepared and to try to get prepared for the choo-choo train that’s coming.  So you’ve got to know the environment, you’ve got to know what’s out there, it’s not going to be fair, there’s huge challenges to try to risk adjust anybody’s data and lastly as they say in the ‘burgh, it is what it is. 

So there’s a few things in the environment that are happening, certainly consumerism is spreading to medicine.  I can tell you that I have never had a patient ever go to WebMD or HealthGrades to look up a specialty referral that I sent them to.  I actually had a patient call me back and said they looked on WebMD about the physician I had sent him to, he didn’t like the report and basically wasn’t going to go see that physician, he picked his own person from WebMD.  Also what’s happening is employer groups because of double digit inflation in insurance are actually looking for solutions in terms of how to find transparency. Right now we have very wide networks, you see Highmark with their boulevard you can anybody you want until next year.  However, there’s going to be more narrow networks as we move in to the next 5 to 10 years, it just has to be that way because there’s just too much variability. And these are a list of some of the things that are out there that are profiling you and I whether you know it or not. 

In Pittsburgh, Highmark profiles us as a star rating on diabetes care and women care profiling. So they look at whether you do A1Cs, LDLs, your microalbumin and eye exams, that’s how they determine you’re a three star rated doctor versus a two star rated doctor.  As you know Hospital Compare started in 2004 where Medicare started looking at certain core measured diseases and putting them on the website and actually there are financial penalties for those who are poor performing hospitals and most recently last year Physician Compare was introduced.  We’re also in this boondoggle of meaningful use right now but there’s a lot of things that are going on which are driving this transparency unit.

And these are just some examples of what’s out there, this is a report on stroke for hospital care, this is a report on stroke by PHC4.  This is my Hospital Compare.  So it tells you where I went to medical school, whether I participated in the Physician Quality Reporting System, it doesn’t tell you my results yet and basically it says I accept Medicare patients which is what they’re really interested in.

In Cleveland, if you lived in Cleveland there’s an alliance for improved health where there’s total transparency. So if you went to Cleveland you could go to the website and actually look at physicians’ performance results there in diabetes care, hypertension care and congestive heart failure. So you know this movement is really happening, I hate, you know, I want everybody to know that the train is here, it’s arrived,  people are going to these websites and one of the biggest challenges is, the information is not very good.  A lot of this is claims-based driven, it comes from hospital centric focus, there’s not a whole lot in the ambulatory setting right now. Believe it or not most of our insurers don’t get lab data from the labs that they pay for lab data is for their patients. UPMC Health Plan does.  So they can tell you how you’re doing with diabetes care for their patients, they know what the A1Cs are, they know what the LDLs are, your microalbumins, they know claims based data for ace inhibitors, statin use, etc.  So there are parts of the country now where patients are being shifted. There are parts of the country now where you can go for cardiac care and basically the insurers will waive your deductibles, they’ll even put you up in nice hotels if you don’t happen to live in that geographic area because there are outcomes for high quality and low cost surgical interventions.  As I mentioned employers are asking for profiling information, the company store is starting to come back again.   Some of the big companies are offering a clinic now where patients can go, employees can stay on the job so they can keep them at work and control costs. 

So what do you need to do as clinicians?  So this is a wonderful slide of my children and this represents the triple AIM.  Happy, satisfied patients, healthy, this is my daughter Rachel who’s a marathon runner.  Low cost.  This is my son Dave, as you can see he has a little Izod, he drives a BMW, low cost not.  But this is where the Institute for Healthcare Improvement is trying to get us to go. We need to get away from looking at individual patients and focus on populations of patients.  I’m always amazed when I ask new recruits to UPMC, how many patients you have as a primary care doctor.  Anybody want to take a guess what the answer is?  Ten thousand, everyone has 10,000 patients, standard answer.  The average primary care person has 2500 patients that they really care for.  So most people don’t even know how many patients they have let alone how many diabetics, how many patients with coronary disease, how many patients with heart failure, how many patients that have had colonoscopies, etc.  So you need to start to focus on knowing your population, knowing how you’re doing with them. 

The other triple AIM is the enhanced patient experience of care, quality, access and reliability.  Reliability is a thing I’ve been hung up on for many years. I lose sleep over reliability in terms of how our doctors perform their task and the variability that comes as a result of not performing their task. 

So lastly the triple AIM is to reduce costs and everybody has heard the term value based care. So value based care is basically looking at outcomes versus cost.  Now I will tell you most of our outcomes are what I call surrogate markers.  So they’re really process measures. So if you look at say coronary disease, managing LDL cholesterol to goal, it’s really a process measure that should be linked to outcome.  But where we need to go is truly outcome measures.  When you go to your orthopedic surgeon and get a knee replacement you want to know in a year, five years, ten years, are you going to walk  and be back to work.  That’s what you want to know.  You don’t want to know whether, you want to know if you’re going to die in the hospital but you don’t want to know infection rates, mortality, readmission rates, short term goals. You want to know long terms goals on outcome. And in diabetes we want to know how our patients are doing in the areas of microvascular and macrovascular events. So we really want to get to an outcomes based phenomenon in the area of quality. 

So this is the Institute of Medicine definition of quality and as you can see it really hits on the triple AIM managing populations to get the desired outcome and basically using evidence-based medicine is the other mantra of this.  So why has quality in medicine been neglected for all these years?  We’ve always assumed that quality was good since you’re dealing with professionals. We have the brightest, the top of the class here, who went to medical school.  Unfortunately in medicine we never measured it, industry is much farther ahead than we are in terms of measuring quality.  Collecting data remains a challenge even if you have an electronic record because a lot of data and most of the data is in unstructured notes so you need data mining tools to pull that out.   Unfortunately our variability remains tremendous.  And I always tell people when I give a quality talk, if I can get rid of the variability and bring the standard deviation curve together like this, I could, I wouldn’t be as gray as I am and I would sleep a lot better.

But most of my best work gets done in the middle of the night, worrying about this stuff.  Also deciding what to measure has been challenging. We’re fortunate in primary care that there’s a lot of nice data looking at process measures and outcome measures.  And there’s very good correlation in the academic literature.  But when we go to our speciality colleagues and try to find things that are evidence-based, there’s very little out there, so all the spine surgery we do, there’s only two surgical procedures on the spine that are evidence-based and I’m not sure that’s even true. Cervical stenosis and lumbar stenosis is the only evidence-base surgical procedures of the spine that we have that actually shows it does some good in the long run believe it or not.  And there are some papers in the literature in the New England Journal that says physical therapy is just as good for spinal stenosis as surgery.   So we’re struggling in our specialty areas.  And as I mentioned to you we really want to look at process measures and link it to true outcomes rather than using process measures as a surrogate marker.  So quality is a relatively new science. 

If we want to look at this, I did an interesting thing the other night, this was last year when I gave this talk, I went into the New England Journal from 1812 when it started to 1954 when I was born.  So this is 142 years and I just put in quality outcomes in medicine.  As you can see there were 445 articles written. I went in over the last ten years and you can see there’s almost as many articles written in the last ten years as there was in 142 years.  So quality is finally getting some recognized respect as Rodney Dangerfield would say.  So I’m going to scare you now, you know when I gave a talk similar to this at Shadyside, Fred Reuben said it was the Bejeesus talk, you scared the bejeesus out of me.  I like that Fred. 

So this is not meant to scare you but it’s meant to show you what’s really happening around you.  I’m going to go through some of the hospital landscape and then I’m going to talk a little bit about what’s happening in the ambulatory environment, we’ll talk about meaningful use and then a little bit about ACOs.  So most of you who work in the hospital setting know about CMS Hospital Compare, Community acquired pneumonia, heart failure, acute MI, surgical care improvement project and now patient satisfaction or HCAHPS.  So this is UPMC dashboard and I’m actually obligated by contract to put this up here to show how our quaternary care at Presbyterian Shadyside Hospitals does but as you can see we’re very green here, even at Passavant and McKeesport and if you look at academic institutions across the country the only one that’s green like that is Duke believe it or not, of all the hospitals that we compete with in U.S. News and World Report. 

So I’m not going to spend a whole lot of time on going through these metrics, they’re in your, in your share point, you’re little jump drive if you want to look at these but I do want to make a few comments.  So these were the original measures that CMS started with and as you can see now they’re starting to look at 30 day mortality and 30 day readmission rate. In 2012 the government will stop paying for unnecessary readmissions.  It’s unclear how they’re going to define that but for all of these core measures if you get readmitted within 30 days and it’s felt to be an unnecessary admission, the hospital will not get paid for this.  So for once in our life primary care and our hospitals will be aligned.  This is how we do in acute MI and this is what they call the bundled measure score for each of our hospitals. 

And I’m not going to bore you because we’re doing really good now but the secret to success in all this thing is infrastructure and teamwork.  None of those things do we have in our small practices for the most part.  We have very little resources as primary care, most of us are running on a shoestring even in the organization I run on we have I think 2.7 FDEs per  doctor. We have no care managers we have no behavioral health people, no have new nutritionists.  So it’s a big challenge to do this in your ambulatory setting. As you can see hospitals have lots of resources, they’re really good at putting a team together to do this, send you emails when there’s gaps in care. 

Now some of the good news in Western Pennsylvania is UPMC Health Plan is actually putting some care managers in to both private practices as well as physician practices to help manage our patients.  This is the heart failure metrics, we’re doing good in heart failure. This is the community acquired pneumonia one, they got rid of oxygen assessments since it was 100 percent over the last 5 years.  And once  again you can see readmissions and 30 day mortalities on there.  Once again we’re doing good, surgical care.

And this started out with just these three measures and as you can see over the last several years has really grown exponentially.  These are putting more and more burdens on the hospitals and I will tell you that this antibiotic measure across the country has done one damn thing to reduce wound infections.  We’re still not washing our hands, we’re still  having residents come in, go  patient to patient without even a hand wash, without even putting a glove on, even attendings are doing that I might have to say.  So wound infections will  not change until we can get surgeons to take care of their hands and wash their hands and use gloves before and after  patients. 

And this is how we’re doing in SCIP – so you can see we’re doing really well.  This is an area where most hospitals are not doing very well.  This is the HCAHPS survey and patient satisfaction and this will be as significant impact on hospitals from a financial perspective where they can actually lose money if they don’t score very well here. So as you can see just to make a couple points, communication with nurses, communication with doctors, I will tell you that in all the UPMC hospitals, they love us. So we don’t have to worry about us, it’s everybody else up here.  It’s responsive of the hospital staff, pain management is pretty terrible, when somebody rings the bell they need a pill, the response rates are not great.   Having gone through a temporary colostomy in Venice, Italy last year and then a reversal here, I can tell pain management when I range that bell in Italy, those Italians were right on it.  But I also told them I was in the Mafia.  Yeah my name is Solano. 

I’ll tell you a funny story, I went in there with an acute diverticular perforation, I had a heck of a time getting through the ER. I finally had to pull my VISA card out to get a CT scan.  So after I got my CT scan the surgeons came running and then we have a partner in Palermo who runs our transplant unit,  a guy named  Bruno Verdelli, the name is enough obviously.  So Bruno calls the mentor of these surgeons who operate on me and said you know you should take, this guy is one of our UPMC hotshots, whatever.  So Monday morning the surgeons walks in and he  looks at me and he says who the hell are you?  Because he went, he actually trained in Nebraska even though he was Italian.  I said what do you mean?  He said I’ve had more phone calls about you over the weekend than any other patient and I just looked at him straight faced and said I’m in the mob, don’t mess with me.

So anyway that’s one way to get good service in Italy, it didn’t work in the United States though, it didn’t work at all. But you can see talking to patients about medicines and what they’re for, cleanliness is a big problem we have, I can tell you the Italian hospital was spotless, even though nobody knew what to do with me.  Quietness in the hospital is a huge problem, hospital noise, alarms all night long.  Transition to care is a big thing that CMS is focusing on particularly in their accountable care things and basically willingness to recommend.  So you can see these are big challenges for a lot of hospitals.

This is just another look at other external measures.  So you can see the list is growing and growing and growing about all these external agencies that are putting more and more reporting requirements on patients. And the SDA, surgery data base now, you can go into Consumer Reports and look and see how your hospitals are doing, you can go into PHC4 database and look and see by surgeon how they’re doing with some of these key metrics as well as mortality readmission rates and complication rates. 

So the number of things that our hospitals are forced to do is just unbelievable and here’s just a laundry list of things that CMS is actually looking at as well in addition to the core measures.  Falls continue to be a big problem for us.  These are some of the AHRQ indicators and some of the  never events as well.  And in Pennsylvania we have to report hospital acquired infections and we have to notify patients if they get a hospital acquired infection.  In all of our stroke centers and we use Telestroke throughout our system we are using get with the guidelines and these are all the metrics we have to look at.  All of our hospitals are going through Meaningful Use Stage 1, VTE prophylaxis is a Highmark incentive as well as a national incentive, the Surgical Safety List, the Care Transitions, End of Life Care, appropriate pain management. 

So if you are a hospital CEO you’d be a lot grayer and balder than I am right now probably.  We’re approaching about 150 metrics now. So this is where the hospital  is and I can tell you that we’re going to be there soon.  It’s not going to be far.  And the biggest challenge is, I don’t know if any of you heard Brent James when he was here about two weeks ago to talk on quality but if you look at where the debt is in the United States, two-thirds of the debt that we have is in the Medicare population, they have to do something to stop the rise in the Medicare population and it’s going to fall on providers backs.

Now the good news is, in the newest law primary care people got a 10 percent raise, the 30 percent raise or 27 percent raise that was in the proposal that just got pushed off a few months ago by Congress is very real for our specialty colleagues and certainly there are proposals to cut hospital reimbursement.  I suspect that we will  have a lot of small community hospitals go out of business because the margins for losing revenue for some of the HCAHPS surveys, the infections that are occurring, never events, now we have these bounty hunters out there looking for dollars as well.  And now readmission rates where you don’t get paid for readmission rates, all this is going to dramatic impact the landscape.  They got to cut dollars and basically Medicare is the biggest target.

So I don’t know if I should talk about Meaningful Usefulness.  Meaningful Use, so everybody heard the term meaningful use.  Everybody knows exactly what it is right?  So Congress passed the high tech act in 2009, last summer the regulations came out about what you had to do for meaningful use, I can tell  you that we spend probably hundreds of thousands of dollars with our lobbyists in Washington  still trying to figure out what this Bill means and what we have to do.  It was well-intentioned, it was intentioned to actually give  physicians some dollars to implement and electronic record.  Not only implement but use it. And I always, you know, I have a bugaboo about the electronic record. Everybody thinks the electronic record is going to bring up to Nirvana.  Not.  Just like we did in the paper world, remember in the paper world we used to have problem lists, meds, allergies, health maintenance sheets.  I can tell you when we acquired our 450 doctors, probably about a third of them used that.  When we implemented the electronic record, probably about a third of them used the tools in the electronic record. So the records, the e-record is never going to bring us to where we need to be unless we use the tools.  We’re going to be forced to use the tools.  Because if you fall off the transparency platform, you’re going to be thrown out of networks, you’re not going to have access to patients.  Now we may be in such a physician shortage with the chronic disease that they’ll let somebody see somebody but you probably won’t get paid as well as some of the other people.  So to be in meaningful use compliance CMS has setup 15 objective measures and you have to meet 6 of 10 clinical quality measures, and over 5 years you can get $44,000 per provider if you succeed in the ambulatory setting, which if you are in private practice that’s a reasonable amount of money to help you implement, it certainly won’t cover all the costs.

If you want to read a very nice short article read Blumenthal’s Review in the New England Journal from last August. Some of it’s not totally up to date but it will give you a great feel for where the law is taking us, and these are a laundry list of the measures.  Computerized physician order entry, one of the caveats of this is that it’s only for Medicare fee for service patients, it’s not for your managed care patients or your other patients. So basically looking at the problem list, making that you marked as reviewed, using e-prescribing, med list, maintenance, allergies and you can read all of these things here.  Making sure your e-record has decision support, drug allergy checking, drug-drug checking, being able to give patients after visit summaries, being able to give them access to their records and being able to exchange key information electronically. 

You may have heard Steve Shapiro talk about Health Information Exchanges which we’ve developed with about 9 of our ring hospitals here in Pittsburgh so that we can actually exchange information on patients electronically. And these are some of the other metrics that are out there, you’ve got to look at your labs, they have to be integrated, be able to send patients reminders and provide education resources, reconciliation of medicines and basically a summary of care upon a transition of care. So this is going to be a challenge, but I would tell you for most primary care providers if you have an electronic record you are probably doing most of these things.  Your electronic record has to be a certified vendor to be able to qualify for meaningful use, so you want to pick an electronic record that actually has met meaningful use criterion.

I would tell you the quality measures in this bill are crap, to be honest with you, they are extremely rudimentary. I think they are just a little bogus look at quality in a fly by.  I think what CMS is really trying to do is to get into our databases and really find out how we are taking care of patients, but I – you know I’m not paranoid at all, I used to be a right wing Republican, now I’m a moderate Democrat, but seriously the quality metrics are very rudimentary. So hypertension control, they want to know what percentage of your patients are at 140/90, they even want to know what percentage of the plastic surgeon, ophthalmologist patients are at 140/90.  So I don’t know what that means. When we asked them if they took blood pressures it was a real challenge.  Now they want to know what we do when the blood pressure is high. So I’m not convinced that all of these things that they are asking us to do are really quality metrics.

Smoking cessation and intervention, you heard Dr. Wilson say the most powerful thing we can do is tell your patient to stop smoking, that’s got about a 7% change of getting them to stop smoking. And then if you really get them to engage and use some of the drugs you may get a 30 or 40% rate of at least immediate intervention. 

There are some good things, if you look at preventive scare - care immunizations, scare, yeah I said that.  BMI assessment and counseling, another thing that’s very useful in terms of you heard the bariatric talk yesterday was all focused on surgical intervention, not lifestyle intervention.  Until we take the McDonald’s look-alikes out of the schools, get our kids to walk and exercise on a regular basis we’re not going to have a chance on this. And then when they go home they  just can’t eat a Big Mac and fried every night, not to pick on McDonald’s.  Disclaimer, I have no stock in McDonald’s.

So this is what our report looks like, it’s a readiness report, in terms of this comes right out of EpicCare, which is our electronic record and it basically tells you whether you are green, red or yellow.  To get the dollars you’ve got to be green in everything, there is no strike 1, strike 2, strike 3, you’ve got to be 100%. When is the last time you guys had to have 100% before you got anything?  I don’t remember that.  The government is pretty tough. I wish they graded themselves at 100%, especially on budgetary management or we wouldn’t be in this pickle we are in.

So where are we headed in quality?  There is no question in my mind that the only way to improve the health of our population in the United States is to really take a serious look at quality, not a cursory rudimentary look but a deep dive at quality.  The electronic records will become a mandate because if you don’t do an electronic record you are actually going to have part of your Medicare money taken away, and I guarantee you that the commercial insurers will follow. Highmark actually put that in their pay for performance program that you have to meet meaningful use, not for your practice, every doctor in your practice.  They are being just like the government, you’ve got to have 100% of your doctors. So I bring in a new doctor, he doesn’t even quality for meaningful use, we get penalized. Anyway don’t get me on my tirades here.

Preventive medicine will certainly have a more important role. I think there will be more dollars linked to performance and all the pay for performance and all the reimbursement schemes are going to get rid of what I would call the fee for service, do more is better phenomenon.  I think the new models of care where you will have a dollar and it will be divided up between hospital and providers is probably what’s going to happen. We are all going to have to go at risk.  The only way to go at risk and succeed, and I’m not even sure this is true yet, is to really practice good medicine.  We’ve done some projects over the years where we focused just on quality metrics, we didn’t say a word about utilization, we didn’t say a word about cost and when we improved quality we reduced costs by about 7%. And this was in a Medicare population, that’s quite an astounding figure when you look at Medicare’s average rate of 12% a year in terms of its performance.  So we are going at sometime, within the next 5 to 10 years I think the hospitals will be getting away from this thing called volume, volume, volume and we will be going more towards appropriate care, what’s needed care.

One of the problems about evidence based medicine as you know only probably 10 to 15% of what we do has really evidence based metrics that are out there.  I’m hopefully that at some point process will be linked to outcome as well.   So we will hopefully with this advent of the chronic care and everybody recognizing that primary care is crucial to the survival of this country we will hopefully get some needed help.  I think the government is starting to realize that team based care is the only way we can get a handle on chronic disease, we’re going to have to start using better risk adjusted metrics, we are going to have to have population management and registries of patients so that we can follow patients longitudinally. I think we will have predictive modeling and targeted interventions for our high risk patients and all of this hopefully will drive what drives me crazy, this practice variability and provider variability away. We are already starting to look at performance based credentialing which is what JCAHO is actually mandating for a lot of hospitals. And ultimately we’ll have outcome metrics that show that we are accountable providers, we can provide efficient care across the continuum. 

And there will be total transparency.  In UPMC we can look up everybody’s results, there are no secrets at UPMC.  We publish ranking reports on key performance metrics in our primary care provider practices, on diabetes, cardiac care, anticoagulation management, preventive care, and we actually rank the practices based on how their performance is.  We have to put a lot of disclaimers so I don’t get sued or shot, but these kinds of tools actually help everybody understand what they need to do.  And this is going to happen, I guarantee you. In Cleveland you can go look at it, it’s very buried to try to find it, but there is a little section on that Cleveland Accountable Care Place that ays practice quality metrics.  And lastly, patient satisfaction is going to be a huge thing for the Federal Government to look at in terms of how we get paid.

So I just wanted to give you an idea of what a future diabetic report card may look at, and basically this is the number of patients who get an A1C, how they are managed, LDL management, whether you look for nephropathy, whether you do blood pressure management, influenza, smoking cessation, but the bottom of this is very interesting and I know it’s hard to read but where we need to go is what kind of macrovascular events.  I can tell you I have 140 diabetic patients, 25 of them have either had a bypass or an intervention from, from one of our cardiologists.  I can tell you how many have retinopathy, I can tell you two have had transplantation and that about 4 have renal insufficiency. So it’s really important that all of us learn to know what’s happening with our patient populations.

The other thing that I think is really beautiful in the setting of being in an academic environment is that this longitudinal data, so we have right now 30,000 patients within our electronic record where we have codified information on many of these metrics. We can now look at what I call real world science.  You know Steve Shapiro alluded to my distaste for some of the clinical trials out there, so if you look at the Jupiter Trial they screened 90,000 people to find 30,000 patients.  You look at the Claridge Trial, they looked at 25,000 patients to find close to 9,000 patients.  These trials are absolutely biased, not anything that we see and when we go out and practice and we start seeing what happens to patients that’s exactly different than what  happens in these clinical trials.   So I think our electronic record will bring us science that’s based on  our community patients, not based on a biased population.  And I think that’s the beauty of these electronic records, we will have longitudinal followup on a population of 30,000  patients with diabetes, 20,000 patients will coronary  disease. We’ve got 4000 patients with heart failure.  Can you imagine the power of doing science for that.  And our e-prescribing tool even tells us who’s compliant with their medicines or not.  This is a phenomenal place for academic science to blend with the community in our community medicine practice and actually come up with some legitimate science that’s really applicable to our patient population.

So I’m very excited about the future because I really think that we’re going to be able to practice better. So the  last few minutes I just want to talk about accountable care organizations, you probably heard a lot about this.  But basically in the new healthcare law there is a proposed rule which is almost 700 pages if you’d  like to try to read it.  I have tried to read it, I read the original one last year, then I read the other one the other night and unfortunately I fell asleep even with NoDoz.  So the biggest question is, how are we going to align incentives across providers and insurers.  If you look at accountable care, there’s money to be taken out of the system.   I think every one would agree there’s probably 20 to 30 percent waste in the system, duplication of testing, unnecessary testing,  not following guidelines, not doing the right thing. 

So who’s going to lose money?  No question, hospitals and our specialty colleagues.  So somebody is going to lose.  So how do you get these teams of people together to align the incentives. I don’t think anyone has figured that out yet. What they have tried to do, CMS and I hate to say this, is once again pit primary care against speciality because if you look at the Bill,  it’s designed only to reward primary care specialists.  There’s no rewards for specialists, there’s not rewards for hospitals. 

The other  question is with our aging population and the shift of more chronic diseases keeping more people alive, are we realistic about improving quality is going to improve cost and  I’m not sure of that to be honest with you. Because I think what will happen is we’ll just have higher volumes of patients who have diabetes, heart failure, hypertension, renal failure, etc.  So we may save a cost per case but in terms of the volume, the volume will drive us, continue to drive us into bankruptcy. 

I talked about who gets the money, how’s it divided, as I mentioned it’s focused for primary care and then what happens if cost is really reduced, what’s going to happen year after year because you’re only going to  hit a plateau after some  point and who will survive this mess after it’s all  over. So the original Bill had 65 quality metrics, it’s down to 33 now. And they’re in the area of patient care giver experience or patient satisfaction.  Spending a lot of time on care coordination particularly with transitions of care, you know, readmission rates for some of these chronic diseases are in the 22 to 30 percent and that’s at 30 days.  We didn’t even talk about 6 months which can be double that.  So care coordination is on their docket and those of you who work in UPMC hospitals are probably fed up with the Cerner discharge process but it will get better, we will  make it better.  But the reason that as built was to improve care coordination for patients and hopefully stop readmissions. 

Patient safety is another critical.  Preventive health and looking at at-risk populations particularly the frail elderly.  So to get money before – so say you save money, you have to meet all of these 33 measures plus you have to have meaningful use.  If you miss any of those measures and  you save a million dollars, you don’t get anything.  Okay?  Still pretty onerous. 

There is a nice move to patient-centered care.  One of the issues that people have with this, it’s only in Medicare fee for service.  And  you have to notify that the patients, that they’re in this project and that your practice is participating and you have to put signage in that you’re trying to reduce costs off their backs.  They’re going to really want to be in this practice.

They can move in and out of your group so if somebody doesn’t like me and I’m managing their costs well and they want to go to a high cost provider, they can leave.  It’s still a mess to be honest with you and I don’t want to say too much but it really is a mess.  I’ll  hold back.

So these are some of the other things, they have some good points, they want to focus on patient satisfaction.  Patients need to be involved in the governance.  You need to set up a whole  infrastructure with the Board, sometimes a separate tax ID number so you can bill for this, in this accountable care environment.  And basically you have to look at the unique needs of your patients whatever that means.  You have to develop care plans for your high risk patients and how you document that, how Medicare is going to know you document that, is beyond me. 

Coordination of care is a good thing, communication of evidence-based medicine to beneficiaries, like sliced bread you can’t say that’s bad either.  Patient engagement and shared decision making, these are all components of the medical home, giving patients access to records and  lastly measurement of physician  performance on these quality metrics and these  other things.

So to be an ACO you have to have a minimum of 5000 fee for service Medicare patients, follow them over 3 years, we talked about some of the infrastructure requirements.  So you can, if you’re a private person, private doctor, you combine with some of your friends to get the magic number of 5000 patients but you’ll need to set up a separate tax ID number, probably to form this little group practice. So  you can do it by individual practices, you can partner with hospitals and even hospitals can actually be the impetus for this as well.  So there will be public reporting on this and governance issues as well. 

So you will need a lawyer and accountant to help figure this out I guarantee you.  So I’m almost at my last slide, so what can  you do as provider, I like this slide if I can get it to work.  Get engaged.  Don’t procrastinate any longer.  I told you the train’s here, make sure your patients get the care they need, start to look at your populations of patients and all the chronic diseases.  Start to look at your screening rates, look at evidence-based metrics and look at outcomes about how you’re doing.  Start looking at your hospital metrics, opportunity areas, coordinate care with your specialty colleagues and most importantly get a team-based approach.  Use your medical home to get that team-based care, please if you’re going to use the electronic record, use the tools in it,  otherwise you’ll fail and you go to align with somebody either your partners, your peer group, insurance, hospitals or a system, you’re not going to make it alone.

So the final goal is the right care at the right time for every patient.   I hope I’ve given you a little different perspective than the typical didactic talk we’ve had here.  I’m not sure I have any time for questions but I’ll be around all day if you need to talk to me.