Bending the Cost Curve and Improving Quality in One of America’s Poorest Cities Jeffrey Brenner, MD Executive Director/Medical Director.

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Presentation transcript:

Bending the Cost Curve and Improving Quality in One of America’s Poorest Cities Jeffrey Brenner, MD Executive Director/Medical Director

Primary care practice opened in January 2003.

Long-term Federal Debt

Dartmouth Atlas #1 Source: Dartmouth Atlas of Healthcare. 2006. Inpatient and Part B spending per decedent during last 2 years of life Source: Dartmouth Atlas of Healthcare. 2006.

Source: Dartmouth Atlas

More Specialty Care is Not Better Care - 180 patients randomized to sham arthroscopy vs real arthroscopy with no difference in outcomes - 650,000 arthroscopies/year

More Specialty Care is Not Better Care Study of 2,287 patients with CAD randomized to angioplasty or medication with no difference in outcomes 1,000,000/yr stents placed

Disruptive Change- Patient Centered Medical Home Geisinger Demo- 18% reduction hospitalization, 36% reduction in 30 day readmissions

Disruptive Change- Patient Centered Medical Home Group Health Demo- 29% reduction ER visits, 6% reduction in hospitalization

Camden Health Data 2002 – 2009 with Lourdes, Cooper, Virtua data 480,000 records with 98,000 patients 50 % population use ER/hospital in one year Leading ED/hospital utilizers citywide 324 visits in 5 years 113 visits in 1 year Total revenue to hospitals for Camden residents $100 million per year Most expensive patient $3.5 million 30% costs = 1% patients 80% costs = 13% patients 90% costs = 20% patients

Top 10 ER Diagnosis 2002-2007 (317,791 visits) 465.9 ACUTE UPPER RESPIRATORY INFECTION (head cold) 12,549 382.9 OTITIS MEDIA NOS (ear infx) 7,638 079.99 VIRAL INFECTION NOS 7,577 462 ACUTE PHARYNGITIS (sore throat) 6,195 493.92 ASTHMA NOS W/ EXACER 5,393 558.9 NONINF GASTROENTERI (stomach virus) 5,037 789.09 ABDOMINAL PAIN-SITE NEC 4,773 780.6 FEVER 4,219 786.59 CHEST PAIN NEC 3,711 784.0 HEADACHE 3,248

Overview of the Coalition 20 member board, incorporated non-profit Foundation and hospital support Structure of the Coalition: Operations Health Information Exchange Research/Data/Evaluation Finance/Admin/Legal Programming Citywide Care Management Project Camden Chronic Disease/Primary Care Collaborative Community-based Patient Engagement Strategies

Case Management- Experience Thus Far Over 5 year period: Most expensive patient $4,973,811 charges $661,155 receipts Visits 1,663 with average 38.67 visits/patient 37% visits are inpatient Total 43 patients $25,598,615 charges $2,995,080 receipts

Train local residents to participate in decision-making over health care resources

Promote collaboration among providers and between providers and the community

Comparing Emergency Room High Utilizers in Camden, Trenton, and Newark Emergency Department High Utilizers Top 1% 2007 Camden Patients 386 Visits 5169 Visits/Patient 13.4 % visiting more than one hospital 80.6% Trenton 504 7616 15.1 78.2% Newark 928 14367 15.5 71.1%

The Plan: Competing ACOs Lourdes ACO Cooper ACO Virtua ACO

A Different ACO Model for Camden

Camden cost savings strategies Nurse practitioner led clinics in high cost buildings More high utilizer outreach teams Medical home-based nurse care coordination More same day appointments (open access scheduling)

Lessons from Camden Strategic ability to filter, focus, and segment Comfort with ambiguity and willingness to tinker Adaptive challenge not a technical challenge Passion for moving towards standardization and efficiency when the time is right Meaningful solutions are local, gradual, and require chunking