Mark A. Smith, MD, FACS May 17, 2012 CAMSS Annual Meeting 1

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Marcelo W. Hinojosa, MD University of California, Irvine Medical Center

 What do we have today?  What I know (with uncertainty) for the near future?  How will this impact the Organized Medical Staff?

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 Structure today a result of two parallel lines of development  Legal  Regulatory- CMS, The Joint Commission, HFAP, DNV  Independent Governance  Responsibilities delegated from and reports to a Board

 Primary Responsibilities  Credentialing and Privileging- Competency Determination  Peer Review for Individual quality  Secondary Responsibilities  System Quality  Core Measures  Patient Safety  Strategic Planning and Implementation  Organizational Leadership

 In short, a MESS!  Raises a number of Issues  Rising costs  Decreased reimbursements  Lack of access  Shortage of healthcare providers  Legal liabilities

Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009). AUSCANGERNETHNZUKUS OVERALL RANKING (2010) Quality Care Effective Care Safe Care Coordinated Care Patient-Centered Care Access Cost-Related Problem Timeliness of Care Efficiency Equity Long, Healthy, Productive Lives Health Expenditures/Capita, 2007$3,357$3,895$3,588$3,837*$2,454$2,992$7,290 Country Rankings 1.00– – –7.00

Note: $US PPP = purchasing power parity. Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009). Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP $7,290 $2,454 16% 8%

 Too costly- $2.3 Trillion in 2009, 17.3% of GDP  Lack of Access Million Uninsured

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 AAMC (American Association of Medical Colleges) in April, 2010  Total Physicians- 954,000  Primary Care- 352, 908  Need 45,000 more by 2020  Estimated total shortage 150,000 by 2025 Wall Street Journal April 12,

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 Independent medical practice as a model format is dead!  >90% of new physicians are employed immediately  In addition to direct employment (in California, it is the foundation model), hospitals are pursuing other directed physician-hospital entities

 Market forces outside of Governmental healthcare reform  Move from volume to value (quality) based system  Curb overall costs of healthcare  Create a safe healthcare system  Government Healthcare Reform  Pre-Obama Changes  Patient Protection and Affordable Care Act- PPACA 22

 Decreased reimbursements on a per event basis  Increased fraud monitoring  Acute Care Episode (ACE) pilots by CMS- bundling hospital and physician service payments for certain orthopedic and cardiovascular care- hospital controls payment distribution  Increased never events- non-payment  PQRI- Physician Quality Reporting Initiative 23

 Access- designed to cover 32 million of 56 million uninsured  Individual mandate- anyone not already covered needs to get insurance or pay a penalty  Expand Medicaid/Medicare coverage  Low Income above Medicaid offered subsidies 24

 Health Insurance Rules  Health Insurance Exchanges- State bourse  Guaranteed Issue- must offer same premium  Essential benefits package- eliminates copayments, deductibles for certain basics  Pre-existing conditions disappear  Must spend a certain amount on medical care improvement  Insurers must reveal more information about their pricing and have an appeals process 25

 Individual Responsibility  Purchase health insurance if not qualified for a government plan or pay penalty  Dependents can remain on parent policy until 26 th birthday  Will have access to more information on both quality and pricing 26

 Business Responsibility  Large businesses (employ 50 or more) must provide health insurance or pay subsidies  Smaller businesses eligible for subsidies if purchase insurance through an exchange  Must disclose value of benefits provided  Change in tax reporting 27

 Government Responsibility  States must develop Health Insurance Exchanges or opt out with an approved equivalent plan  Create a government independent Outcomes Research Institute  Develop a National Prevention and Public Health Strategy  Increased fraud and abuse monitoring  Develop an Independent Payment Advisory Council  Develop ACO rules and implementation pathways 28

 Provider Responsibility  Participate in providing care for increased numbers of patients  Adopt EMR (Actually mandated elsewhere but continued support)  Participate in expanded PQRI  Encouraged to join ACO  More transparency in performance data 29

 Funding  Tax on high income taxpayers  Annual fee on Health insurers  Increased fee on drug and device manufacturers  Other sources to be named later 30

 Who knows what will remain and what will be removed? 31

Healthcare Reform Act will result in: 1. 60% will restrict access to patients 2. 59% will spend less time with individual patients 3. 10% see increased quality; 56% see diminished quality 4. 67% had a negative or very negative reaction to the reform bill 5. 40% anticipate leaving medicine within 3 yrs. 32

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 Issues  Governance- for parallel organizations?  Less emphasis on traditional credentialing; more emphasis on competency determinations  Need to collect performance data to support the above  Rise in specialty and sub-specialty work within a hospital setting

 The primary independent Organized Medical Staff of today is a dinosaur  New hybrid models will need to take the changes discussed into consideration

 Reduce duplication of management services between medical staff and physician practice groups by taking on Human Resource duties  Medical Staff will assume even greater responsibility for both defining and interpreting individual quality performance measures  Medical Staff will have a greater responsibility for ambulatory or outpatient care physicians

 No change  Eliminated- Functions absorbed by a totally new organization  Becomes a more Quality oriented organization  Becomes a more Human Resource oriented organization  Combo- Quality + Human Resource  Something else

 Quality  Performance Data collection and Interpretation  Management of Performance deficiencies  Human Resource  Practice management  Recruitment  Strategic Planning and Implementation

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