1. Emergency Medicine and Value-Driven Healthcare Reform
AACEM, April 2013
Brent R. Asplin, MD, MPH
President and Chief Clinical Officer
Fairview Health Services
Minneapolis, MN

2. Goals Drivers of “population health”
Accountable Care Organization (ACO) Perspectives
Strategic Landscape for EM

3. Average Annual Premiums for Single and Family Coverage, 1999-2012
$15,745*
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

4. Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation, and Workers’ Earnings,
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), ; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, (April to April).

5. Mortality Amenable to Health Care—Global
Deaths per 100,000 population*
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. See Appendix B for list of all conditions considered amenable to health care in the analysis. Data: E. Nolte, RAND Europe, and M. McKee, London School of Hygiene and Tropical Medicine, analysis of World Health Organization mortality files and CDC mortality data for U.S. (Nolte and McKee, 2011).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.

6. Paul Starr’s account of the rise of the American medical industry during the 20th century

7. Value Based Purchasing
Pay for performance
PQRS
Value-based Modifier
Episodes of care & bundled payments
Hospital readmissions
Accountable care organizations (ACOs)

8. Accountable Care Organizations
Provider-led organizations with a strong primary care base that take accountability for the full spectrum of healthcare services for a defined population
Financial incentives tied to:
Total cost of care
Quality and patient satisfaction

9. CMS ACO Programs (260 Participating Organizations)
Physician Group Practice Transitions Program
Six organizations (started Jan 2011)
Pioneer ACO Program
32 organizations (started Jan 2012)
Medicare Shared Savings Program
27 organizations began in April 2012
89 organizations began in July 2012
106 organizations announced in Jan 2013

10. Interesting ACOs “Diagnostic Clinic Walgreens Well Network”
All of Florida
“Scott and White Healthcare Walgreens Well Network, LLC”
Texas

11. The Paradox of ACOs
Every dollar of waste in healthcare is somebody’s dollar of revenue
Hospitals stand to lose the most from reductions in TCOC
Admissions for chronic diseases
Readmissions
ED visits

12. Private Exchanges and Narrow Network Products
Don’t underestimate how quickly markets will move toward value-based insurance products
Partnerships between payers and delivery systems
Many of the providers are Independent Practice Associations (IPAs)

13. New payer/provider partnerships are emerging in the Twin Cities market
Providers Relationship Payer
New products
50% ownership;
new products
New product
Merger 13

14. Implications for Emergency Medicine
Reduction of avoidable ED visits is a goal for every one of the 260 ACOs and private insurance products in the US today
Contrary to what you may hear, this is based on sound economics
Every smart ACO should try to partner with EDs to coordinate care and create alternatives to admissions/readmissions

16. ED Acute Care Framework (Peter Smulowitz, MD and colleagues)
Opportunity #1
Opportunity #2
Source: Smulowitz et al. Annals of EM. 2012

17. Marginal Cost of Acute Care for Low Acuity Conditions
Regardless of setting, the marginal cost of producing acute care is relatively low
How expensive is it for you to diagnose acute otitis in your ED?
This is much different than the cost incurred by the payer (i.e. patient, health plan, government)
Widely variable depending on the location

18. Medicare Reimbursement ED vs. Office Visit
Source: Smulowitz et al. Annals of EM (In Press)

20. ED Acute Care Framework (Peter Smulowitz, MD and colleagues)
Opportunity #1
Source: Smulowitz et al. Annals of EM. 2012

21. The Value of Emergency Care
The most expensive routine decision in healthcare
The more “accountability” we take for reducing potentially avoidable admissions and re-admissions, the more “value” we will create for the system

23. Hub of the Enterprise? “Accountability” + “Value” = ?
A new revenue stream for emergency medicine?
Why wouldn’t you become part of risk based products?
Private insurance, ACOs, Medicare Advantage plans, etc….

24. Opportunities for an Emergency Care Hub
Coordination of transitions
Reducing avoidable admissions and readmissions
Rapid complex diagnostic evaluations
Especially for patients with complex conditions
Communication interface with other care delivery hubs
PCMH and geriatrics

25. The Irony of Emergency Medicine and Value Based Healthcare
We are often pushed to the fringe as a provider to avoid rather than pulled into the middle of the operation
Providing better care for complex patients is the answer---won’t happen without better coordination in the ED

26. Hubs for Managing Population Health
Primary Care
Patient-Centered
Medical Home
Geriatric Services Continuum
The Emergency Care System
Behavioral Health Capabilities

27. The market is changing…
Methodologies
Payment
Care Delivery
Population/
Global
Individual/
Discount Fee For Service
Encounter
Episode/Lifetime X
Today
Transition
Market Relevance
Global Adoption
Value
Volume

28. Discussion

30. US Gross HC Spending

31. 2010 Healthcare Spending as a Percent of GDP

32. Variations in practice and spending
14 March, 2001
The Dartmouth Atlas
1. The paradox of plenty
2. What’s going on?
3. What might we do?
4. Is there reason for hope? 32

35. ED Acute Care Framework
Opportunity #2
Source: Smulowitz et al. Annals of EM (In Press)

37. Disrupting Healthcare
A simple question:
Will your economics be disrupted or will you do the disrupting?

38. Acute Unscheduled Care Patient Satisfiers
Biggest drivers of satisfaction for most acute unscheduled conditions:
Timely access
Low cost

39. The Strategic Opportunity
We already know how to deliver acute unscheduled care quickly and at a low marginal cost
Why are we content to do this in an environment that has:
Long waiting times due to hospital boarding; and
High fixed hospital costs that drive a non-competitive business model?

40. Disruptive Alternatives to ED Care
Free-standing centers
Target complexity is above standard urgent care
Rapid throughput and lower cost
Not hospital-based (no EMTALA)

41. Disruptive Alternatives to ED Care

42. Disruptor vs. Disruptee?
We have already solved the most difficult challenge of acute unscheduled care:
The 168 Hour Work-Week!
There are important opportunities to step out of the hospital (literally and virtually) to capture demand for low-cost alternatives to ED care

43. The Cycle of Disruption
Original Provider
Disruptive Alternative
Hospital OR
Inpatient Stay
Surgical Specialists
Specialty Care
Primary Care
Retail Clinics
The Hospital ED
Ambulatory Surgery
ED Observation
Non-Surgical Specialists
Primary Care
Retail Clinics
Virtual Care
Free-Standing EDs plus which of the above???