A Demonstration Project to Build Medicaid Accountable Care Organizations (ACOs) in New Jersey Jeffrey Brenner, MD Executive Director/Medical Director

Long-term Federal Debt 2

Dartmouth Atlas Source: Dartmouth Atlas of Healthcare Inpatient and Part B spending per decedent during last 2 years of life #1 3

Camden Health Data 2002 – 2009 with Lourdes, Cooper, Virtua data 2002 – 2009 with Lourdes, Cooper, Virtua data 480,000 records with 98,000 patients 480,000 records with 98,000 patients 50 % population use ER/hospital in one year 50 % population use ER/hospital in one year Leading ED/hospital utilizers citywide Leading ED/hospital utilizers citywide 324 visits in 5 years 324 visits in 5 years 113 visits in 1 year 113 visits in 1 year Total revenue to hospitals for Camden residents $460,000,000 + charity care Total revenue to hospitals for Camden residents $460,000,000 + charity care Most expensive patient $3.5 million Most expensive patient $3.5 million 30% costs = 1% patients 30% costs = 1% patients 80% costs = 13% patients 80% costs = 13% patients 90% costs = 20% patients 90% costs = 20% patients 4

Top 10 ER Diagnosis (317,791 visits) 465.9ACUTE UPPER RESPIRATORY INFECTION (head cold) 12, OTITIS MEDIA NOS (ear infx)7, VIRAL INFECTION NOS7, ACUTE PHARYNGITIS (sore throat)6, ASTHMA NOS W/ EXACER5, NONINF GASTROENTERI (stomach virus)5, ABDOMINAL PAIN-SITE NEC4, FEVER4, CHEST PAIN NEC3, HEADACHE3,248 5

Northgate I public housing Primary Diagnosis RankEDInpatient 1 abdominal pain (789.0) live birth (V3X.0) 2 acute URI NOS (465.9) chest pain (786.5) 3 congestive heart failure NOS (428.0)

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Overview of the Coalition - 20 member board, incorporated non-profit - Foundation and hospital support - Projects- - Camden Health Database - Citywide Care Management Project - Camden Diabetes Collaborative - Camden Health Information Exchange - Citywide Violence Intervention 8

Emergency Department High UtilizersTop 1% 2007 Camden Patients386 Visits5169 Visits/Patient13.4 % visiting more than one hospital80.6% Trenton Patients504 Visits7616 Visits/Patient15.1 % visiting more than one hospital78.2% Newark Patients928 Visits14367 Visits/Patient15.5 % visiting more than one hospital71.1% Comparing Emergency Room High Utilizers in Camden, Trenton, and Newark 9

Patient Primary Care Medical Home Hospital s Specialists Community-based Accountable Care Organization NJ Medicaid Medicaid HMOs Behavioral Health Social Service Providers

NJ Medicaid ACO Pilots Community-based non-profit Community-based non-profit Geographic Collaboration Geographic Collaboration 100% inpatient hospitals 100% inpatient hospitals 75% of primary care providers 75% of primary care providers At least 4 behavioral health providers At least 4 behavioral health providers Payer participation Payer participation Mandatory Medicaid FFS Mandatory Medicaid FFS Optional Medicaid HMOs Optional Medicaid HMOs 11

NJ Medicaid ACO Pilots Gainsharing or shared savings model Gainsharing or shared savings model No change in current mode of payment No change in current mode of payment State plays the role of intermediary State plays the role of intermediary Recognizing ACOs Recognizing ACOs Ensures appropriate use of gainsharing funds Ensures appropriate use of gainsharing funds Rutgers State Center for Health Policy Rutgers State Center for Health Policy Helps calculate gainsharing payments Helps calculate gainsharing payments Three cities ready (Camden, Trenton, Newark) Three cities ready (Camden, Trenton, Newark) 12

ACO Pilot Form ACO Board Apply for ACO Certification Board governance Resident participation Submit Gainsharing Plan Outcomes based plan State approval Bend the Cost Curve Improve quality Improve access Reduce cost 13

Camden cost savings strategies 1. Nurse practitioner led clinics in high cost buildings (at least 5 total) 2. Additional high utilizer outreach teams (at least 5 total) 3. Embedded nurse care manager (12 primary care offices) 4. More same day appointments (open access scheduling) 14

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