1. Making the Business Case for Quality in Healthcare?
December 13, 2007
Roger Chaufournier
NQC Consultant

2. Presentation Overview
The Environment
Lessons from Health Care Transformation
High Leverage Change Concepts
Impact on Finances
Dialogue

3. The Environment Washington Post October 9, 2006
HRSA Core Measures
Washington Post October 9, 2006
A Prescription for Worker’s Health: Employers Open In-House Clinics to trim Costs and Boost Preventive Care

4. Peter Drucker
“Every few hundred years in the history of Western society a transformation takes place. The transformation transcends all aspects of society; the government, the schools, the values, religion, culture, etc. The transformation is not sudden, but takes place over a 50 year or more period. The transformation is so profound that the children born in that era can not comprehend the time in which their parents were born and in which their grandparents lived.”
8:01
2.00
Chip
DRUCKER
[Read the quote.]
Wrote a book that captures the epics of management over time.
Described three-four epics in our history representing profound shifts in society. These epics triggered shifts in management practice.

5. What did private industry learn?
Quality as a business strategy
Quality requires an investment…Quality is free
There are models for how to drive organizational change
Improved outcomes does not necessarily mean higher cost! Doing it right the first time costs less!

6. THE PREVALENT SYSTEM OF CARE DELIVERY
20%-55%
Compliance with guidelines
Less than 18%-24% use IT for patient care
40% waste
& inefficiency
45% Internet traffic is patients seeking self management info
Practice
working in a vacuum
3:1 Staffing Ratio
Delays & Waits for access 1-12 weeks

7. Driving the Business Case Lessons from the Field
IHI Idealized Practice
Redesign lessons
HRSA
Collaboratives
pilots
Lean Applications
In Health Care
High Leverage Drivers:
Advanced Access
Optimize Care Team
Lean-Continuous flow/
Cycle time reduction
Planned Care
Registries for Master
Scheduling
Revenue Optimization
IMPROVED
OUTCOMES +

8. PLANNED CARE IN THE NEW ENVIRONMENT
Guidelines
In exam room with PDAs/registry reminders
Open access:
No shows decrease to 2-5%
DIGMA’s &Group visits used 25%
Reimbursement aligned to support planned care
Medical Home
P4P, P4Play, P4Q
Continuous flow minimizes on-site time
Community resources part of care team
DOH, Disease Vendors
EMR: eliminate all paper
17% visits by
Registry used for master scheduling and outreach
Expanded Care Team
N.P N.P R.N R.N M.D M.A DIETICIAN EXTERNAL TEAM

9. Advanced Access
Majority of appointments held for today’s and yesterday’s patients
Planned visits scheduled
Today’s work done today
Max packing of visits
Managing demand through alternative models (e.g. Group visits/Electronic visits)

10. What happens in Open Access? Example of Nurse Triage
1. Call answered by a receptionist, message taken, or appointment booked without further discussion (1-3 minutes)
2. The chart is pulled and a message attached (2 minutes)
3. If no appointment made, patient chart and message reviewed and prioritized prior to call back (4 minutes)
4. A call back is placed. More information obtained and then appointment made, referral made or a physician consult is required before resolution (5 minutes: Note not all callbacks are reached on a first attempt)
5. An additional call back to patient after a physician or nurse consult (2 minutes)
6. Receptionist asked to schedule an appointment, complete a managed care referral form or call a script to a pharmacy (3-5 minutes)
7. An entry into patient’s chart is made (3 minutes)
8. The chart is refilled (2 minutes)
Total Staff Time: 24 an average cost of $14/hr
Total annual dollar impact: 10 calls a day; 200 days; $11,200 in staff time annually
Source: Case study from NCQA Web site

11. Source: Marjorie Godfrey; Dartmouth Hitchcock

12. Optimizing the Care Team
Expanded roles
Deploying highest level of skill to lowest level of licensure allowed by the state
Team based model
Care coordination across the continuum; Medical Home Model

13. Profitability by Full-time Support Staff
Source: MGMA data

14. Applying Lean Process Mapping to identify bottlenecks and waste
Applying 7 forms of Waste to the clinic
Optimizing flow and cycle time
Purposeful design
Implementing highly reliable systems

15. Compliance with the evidence base Negotiating new lines of revenue
Revenue Optimization
Coding
Charge Capture
Compliance with the evidence base
Negotiating new lines of revenue

16. White River RedeFin Measures

17. The Pioneers-Mercy Campus, Iowa
IHI Impact
Wellmark Collaboration on Quality Initiative
Used SECAT Registry
Tested Health Coach Model
Tested Transparency of provider group internal to the system
Implemented Advanced Access

18. Diabetes Outcome Measures October 2005 – September 2006
All MCI diabetes patients n = 8631

19. CMS Profit = $8.00 / test
Yields $100,000 / yr.

20. Use of a proactive care model such as the Wagner Care Model
Planned Care
Use of a proactive care model such as the Wagner Care Model
Registries used for master scheduling
Population and patient level care

21. Productive Interactions:
Health System
Organization of Health Care
Community
Self-Mgt Support
Delivery System Design
Clinical Information Systems
Decision support
Resources and Policies
Productive
Interactions:
Evidence-based clinical management
Collaborative treatment plan
Effective therapies
Self-management support
Sustained follow-up
Informed,
Activated
Patient
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes

22. The Potential-The Pioneers
CareSouth Carolina
Time with doctor has gone from 8.2 minutes to 12.5 minutes
Total visit time has gone from 90 minutes to 47 minute average
HbA1c for their population of focus came down from 11 to 8
Encounters and revenue for behavioral health services skyrocketed (in Medicaid cost based reimbursed and Medicare is 60% of the cap for behavioral counseling services)
There are several key clinical indicators where they have reversed the health disparities and outcomes for minority populations are better
Third available appointment has gone from 140 to 0 days
Went from breakeven/deficit spending to 7% positive margin
Total average aggregate costs of care for people with Diabetes 30-70% less than all other providers
Source: Ann Lewis, CEO CareSouth Carolina

23. Why are payers interested?
Medical All Family
Home Practice
(CareSouth) Physicians
Median
25% less
Total costs
To the State
Average Total Annual Payment $1,340 $1,778
Per patient
Annual drug payments per $ $576
patient
Average office visit payment $ $168
Average Inpatient Hospitalization $ $634
Average ER Payment $ $22
Cost based
Reimbursed as
FQHC. Still did
better
Source: South Carolina Office of Budget and Control 2004

24. Dialogue? Questions? Reflections

25. Contact Information
Roger Chaufournier
Chief Executive Officer
CSI Solutions, LLC