Making Medicaid More Sustainable Creation of an Urban ACO November 11, 2010 From Vision to Reality State Strategies for Health Reform Implementation Washington, D.C. NJ Consumer Voices for Coverage

The Problem - Camden, A Very Challenging Environment on Every Level, including Healthcare One of the poorest cities in the country, it is perhaps best known for its struggles with urban dysfunction. In 2005, more than 57% of Camdens children lived in poverty. 2 out of every five adults live in poverty. In 2009 Camden had the highest crime rate in the US Three Camden mayors have been jailed for corruption Until recently the school system, police department and city government were in state takeover No history of cooperation between local healthcare stakeholders

Camden Health Data New Data Set ,000 records with 98,000 patients Leading utilizer came 324 visits Most expensive patient $3.5 million Total revenue to hospitals for Camden residents $460,000,000 + charity care 80% costs = 13% patients 90% costs = 20% patients

Top 10 ED Diagnosis (317,791 Total Number of Visits) ACUTE URI NOS 12,549 OTITIS MEDIA NOS 7,638 INFECTION NOS 7,577 ACUTE PHARYNGITIS 6,195 ASTHMA NOS W/ EXACER 5,393 NONINF GASTROENTERIT NEC 5,037 ABDOMINAL PAIN-SITE NEC 4,773 FEVER 4,219 CHEST PAIN NEC 3,711 HEADACHE 3,248

Top 1% of Utilizers ( ) 1,035 patients with 39,056 visits Between 24 and 324 visits Total charges $375 million Total receipts $46 million + charity care Enough $$ to fund 50 family physicians or 100 nurse practitioners

A Cry for Change - A Solution for Camden – Local Doc, Jeffrey Brenner, forms the Camden Coalition of Health Care Providers. Seeks to improve the health status of Camden City residents through: collaboration data sharing education improvements in service delivery

A proposal for an Urban Medicaid Accountable Care Organization (ACO) An ACO demonstration project focused exclusively on urban, underserved community is easier to launch, more likely to succeed, and a good place to start in NJ: The public through Medicaid is the primary payers in underserved marketplaces which simplifies the implementation and management of an ACO pilot. Easier to get the cooperation of hospitals and providers to improve coordination of care, expand access, and reduce cost in underserved communities than in suburban communities where they vigorously compete for more patients. A successful ACO in a poor, underserved community can provide an important example for implementing similar ideas in the wider healthcare system.

Proposed Legislation Non-profit, must be certified by state Department of Health Eligible for Medicaid reimbursement in designated urban area Mission to improve the quality, capacity, and accessibility of the local health care system Participation of local hospitals, clinics, FQHCs, private practitioners and public health agencies ACO would receive funding based on the savings generated from the integration and efficiency of care – gainsharing Academic Research Center (Rutgers) provides assistance to oversee the project and calculate/verify the gainsharing calculations.

Mandates Consumer Representation and Transparency The ACOs governing board shall include individuals representing the interests of health care providers patients, and other social service agencies or organizations located in the designated urban area. The ACOs governing board shall include voting representation from at least two consumer organizations capable of advocating on behalf of patients living within the designated urban area of the ACO. At least one of the organizations must have extensive leadership involvement by individuals residing within the designated urban area of the ACO, and must have a physical location within the designated urban area. Additionally, at least one of the consumer organization board seats must be occupied by an individual who resides within the designated urban area served by the ACO; The ACO must have a process for engaging members of the community and for receiving public comments with respect to its gainsharing plan;

Campaign Opportunities for Grassroots Education, Engagement and Coalition Building PICO/Camden Churches Organized for People conducting grassroots education campaign – the ACO Game NJ for Healthcare develops and reaches consensus on 12 Patient Priorities

Campaign Opportunities for Grassroots Education, Engagement and Coalition Building ACO campaign includes broad spectrum of stakeholders: Local Providers Hospital Association NJ Chamber of Commerce Academics and Policy Institutes Consumer Advocates Local Grassroots Leaders State Funders Policy Makers and Political Leaders including the Governor

Whats Next for Urban ACOs in NJ Legislation being finalized Introduction in January, 2011 Passage by mid year, 2011 Start with up to five urban ACO demonstration projects. Collaborative work has already begun in two other urban areas – Trenton and Newark, NJ