2. Panel Members
Stephen M. Shortell, PhD, MPH, MBA Professor of the Graduate School Distinguished Professor Of Health Policy and Management Emeritus School of Public Health UC-Berkeley John Findley, MD Medical director, ACO Programs, Caravan Health (916) Tim Putnam, DHA, MBA, FACHE President and CEO, Margaret Mary Health in Batesville, Indiana (812) Lynn Barr, MPH/MBA CEO and Founder, Caravan Health (916)

3. Physician Perspective

4. A Acknowledge… the rural crisis is real
If it were not for the practice transformation efforts underway – I experienced first hand what it felt like to step back 20 years – recruitment issues are real!
Each 10 additional primary care physician per 100,000 people was associated with a 51.5 day increase in life expectancy, the study also found. Every 10 extra primary care doctors was also tied to declines of up to 1.4 percent in mortality rates from common causes like cancer, heart disease and respiratory disorders.
A Navigant analysis* of the financial viability (total operating margin, days cash on hand, and debt-to-capitalization ratio) of rural hospitals nationwide shows 21% or 430 hospitals across 43 states are at high risk of closing unless their financial situations improve. These hospitals represent 21,547 staffed beds, 707,000 annual discharges, 150,000 employees, and $21.2 billion total patient revenue. State-by-state data can be found in Figure 1 and Exhibit A.
As of Jan. 2019, 94 rural hospitals have closed since 2010, with more than 120 and counting closed since Right now, 673 additional facilities are vulnerable and could close, representing more than one-third of rural hospitals in the U.S.   The rate of closure has steadily increased since sequestration began and bad debt cuts began to hit rural hospitals, resulting in a rate six times higher in 2015 compared to   It’s clear that cuts in hospital payments have taken their toll, forcing closures and leaving many of our nation's most vulnerable populations without timely access to care.   If Congress doesn't act to stop the bleeding and prevent further rural hospital closures, an estimated 11.7 million patients will lose direct access to care while local economies suffer.

5. B Build… Robust Primary Care
Data Analytics
Workflows
Task Delegation
Quality Reporting
Staff Training and Support

6. C Collaboration… beyond the point of care
ACO Success Demands
Clinical Integration.
It is estimated that 80 percent of serious medical errors involve miscommunication during the hand-off between medical providers.
C Collaboration… beyond the point of care
First must acknowledge that incredible care is provided at individual level by PCP teams every day. The problems arise between episodes of care.
Hx PCP is an acute care or first come first serve model…one that has failed to get to prevention and proactive chronic dz management.
It is estimated that 80 percent of serious medical errors involve miscommunication during the hand-off between medical providers.
Source: Solet DJ, et al: Lost in translation: challenges and opportunities in physician-to-physician communication during patient hand-offs. Academic Medicine, 2005;80:1094-9
A study released in 2016 estimated that communication failures in U.S. hospitals and medical practices were responsible at least in part for 30 percent of all malpractice claims, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years.
Source: Malpractice risk in communication failures; 2015 Annual Benchmarking Report. Boston, Massachusetts: The Risk Management

7. D Data… that is Actionable

8. E Experience Reengineered
Better Outcomes
Better Provider Experience
Lower Costs
Better Patient Experience

9. Hospital CEO Perspective

10. Hancock Regional Health (Greenfield, IN) Suburban Health ACOs
Steve Long, CEO
Collaborative ACOs that are hospital based and focused on building clinically integrated networks and individual community performance
Suburban Health ACO 1 (Hancock Regional), Suburban Health ACO and starts
ACO Investment Model (AIM) funded.
SHO Attribution 14,862. SHO 2 Attribution 8,121
January SHO 1 and SHO 2 combining= 6 primary hospital participants

11. Rural Solutions

12. About Caravan Health
Helping Providers Navigate the Challenges of Value-Based Payments
Practice Transformation
Data and Analytics
Network Development
Accountability and Performance Improvement
Founded by rural providers
17 Accountable Care Organizations ranging from 10,000 to 230,000 attributed lives
CMS Practice Transformation Network
>350 health systems
>14,000 clinicians
>500,000 attributed Medicare lives

13. What Rural Issues We Are Trying to Solve?
RHC payment model encourages urgent care orientation
Get paid the “All Inclusive Rate” no matter how little you do
Typical rates are $200-$300 per visit
New visibility into costs with mandatory deductibles and price transparency
No quality reporting program
Exempt from Medicare meaningful use
9-5 access drives 50% of ED volume
Aging population without children nearby
Few mental health services, yet overcome with depression and substance abuse
Lack of transportation, home health, hospice, palliative care
| Proprietary & Confidential, Not for Distribution

14. Disparities in Life Expectancy Between Rural and Urban are Growing
50,000,000 Rural Americans x 2.4 years lost = 120 million years lost by today’s rural residents.
Rural vs. Urban Death Rate per 100,000
In 1970, rural and urban life expectancy were .4 years apart. Now it is 2.4 years, and the disparity is widening. Most of the country started implementing ambulatory quality programs in the year 2000 in response to the Institute of Medicine’s publication of “To Err is Human” – a wake up call about the quality of care delivered in the United States.

15. What Are the Assets in Rural Health?
#1 - a relationship with the patient
Strong community identity and resources
Primary care focus
Stable population from cradle to grave
Nimble organizations that move quickly
Mission-driven providers
| Proprietary & Confidential, Not for Distribution

16. 2016 vs 2017 Quality Measures Measure 2016 2017
2017 Caravan Health ACOs
2016 to 2017 % Change
PREV-12
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
30th
50th
31.65
57.25
80.89%
MH-1
Depression Remission at Twelve Months *
3.4
6.06
78.34%
CARE-2
Falls: Screening for Future Fall Risk
60th
80th
53.7
75.69
40.95%
DM-7
Diabetes: Eye Exam
39.61
45.71
15.40%
PREV-8
Pneumonia Vaccination Status for Older Adults
70th
66.57
73.36
10.21%
PREV-6
Colorectal Cancer Screening
59.85
64.98
8.56%
PREV-5
Breast Cancer Screening
62.69
67.81
8.17%
PREV-9
Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
64.84
68.76
6.04%
DM-2
Diabetes: Hemoglobin A1c Poor Control
16.78
16.02
4.54%
PREV-13
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
77.78
80.34
3.29%
PREV-7
Preventive Care and Screening: Influenza Immunization
71.6
73.29
2.35%
PREV-10
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
90th
92.97
94.57
1.72%
IVD-2
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
90.85
92.15
1.43%
HTN-2
Controlling High Blood Pressure
69.47
67.82
-2.37%
CARE-1
Medication Reconciliation Post-Discharge
75.87

17. Rural ACOs: 2017 Financial Results

18. Questions?