1. Mark A. Smith, MD, FACS May 17, 2012 CAMSS Annual Meeting 1

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4. Marcelo W. Hinojosa, MD University of California, Irvine Medical Center

5.  What do we have today?  What I know (with uncertainty) for the near future?  How will this impact the Organized Medical Staff?

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7.  Structure today a result of two parallel lines of development  Legal  Regulatory- CMS, The Joint Commission, HFAP, DNV  Independent Governance  Responsibilities delegated from and reports to a Board

8.  Primary Responsibilities  Credentialing and Privileging- Competency Determination  Peer Review for Individual quality  Secondary Responsibilities  System Quality  Core Measures  Patient Safety  Strategic Planning and Implementation  Organizational Leadership

9.  In short, a MESS!  Raises a number of Issues  Rising costs  Decreased reimbursements  Lack of access  Shortage of healthcare providers  Legal liabilities

10. Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009). AUSCANGERNETHNZUKUS OVERALL RANKING (2010)3641527 Quality Care4752136 Effective Care2763514 Safe Care6531427 Coordinated Care4572136 Patient-Centered Care2536174 Access6.553142 Cost-Related Problem63.5 2517 Timeliness of Care6721345 Efficiency2653417 Equity4531627 Long, Healthy, Productive Lives1234567 Health Expenditures/Capita, 2007$3,357$3,895$3,588$3,837*$2,454$2,992$7,290 Country Rankings 1.00–2.33 2.34–4.66 4.67–7.00

11. Note: $US PPP = purchasing power parity. Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009). Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP $7,290 $2,454 16% 8%

12.  Too costly- $2.3 Trillion in 2009, 17.3% of GDP  Lack of Access- 40-55 Million Uninsured

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19.  AAMC (American Association of Medical Colleges) in April, 2010  Total Physicians- 954,000  Primary Care- 352, 908  Need 45,000 more by 2020  Estimated total shortage 150,000 by 2025 Wall Street Journal April 12, 2010 19

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21.  Independent medical practice as a model format is dead!  >90% of new physicians are employed immediately  In addition to direct employment (in California, it is the foundation model), hospitals are pursuing other directed physician-hospital entities

22.  Market forces outside of Governmental healthcare reform  Move from volume to value (quality) based system  Curb overall costs of healthcare  Create a safe healthcare system  Government Healthcare Reform  Pre-Obama Changes  Patient Protection and Affordable Care Act- PPACA 22

23.  Decreased reimbursements on a per event basis  Increased fraud monitoring  Acute Care Episode (ACE) pilots by CMS- bundling hospital and physician service payments for certain orthopedic and cardiovascular care- hospital controls payment distribution  Increased never events- non-payment  PQRI- Physician Quality Reporting Initiative 23

24.  Access- designed to cover 32 million of 56 million uninsured  Individual mandate- anyone not already covered needs to get insurance or pay a penalty  Expand Medicaid/Medicare coverage  Low Income above Medicaid offered subsidies 24

25.  Health Insurance Rules  Health Insurance Exchanges- State bourse  Guaranteed Issue- must offer same premium  Essential benefits package- eliminates copayments, deductibles for certain basics  Pre-existing conditions disappear  Must spend a certain amount on medical care improvement  Insurers must reveal more information about their pricing and have an appeals process 25

26.  Individual Responsibility  Purchase health insurance if not qualified for a government plan or pay penalty  Dependents can remain on parent policy until 26 th birthday  Will have access to more information on both quality and pricing 26

27.  Business Responsibility  Large businesses (employ 50 or more) must provide health insurance or pay subsidies  Smaller businesses eligible for subsidies if purchase insurance through an exchange  Must disclose value of benefits provided  Change in tax reporting 27

28.  Government Responsibility  States must develop Health Insurance Exchanges or opt out with an approved equivalent plan  Create a government independent Outcomes Research Institute  Develop a National Prevention and Public Health Strategy  Increased fraud and abuse monitoring  Develop an Independent Payment Advisory Council  Develop ACO rules and implementation pathways 28

29.  Provider Responsibility  Participate in providing care for increased numbers of patients  Adopt EMR (Actually mandated elsewhere but continued support)  Participate in expanded PQRI  Encouraged to join ACO  More transparency in performance data 29

30.  Funding  Tax on high income taxpayers  Annual fee on Health insurers  Increased fee on drug and device manufacturers  Other sources to be named later 30

31.  Who knows what will remain and what will be removed? 31

32. Healthcare Reform Act will result in: 1. 60% will restrict access to patients 2. 59% will spend less time with individual patients 3. 10% see increased quality; 56% see diminished quality 4. 67% had a negative or very negative reaction to the reform bill 5. 40% anticipate leaving medicine within 3 yrs. 32

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47.  Issues  Governance- for parallel organizations?  Less emphasis on traditional credentialing; more emphasis on competency determinations  Need to collect performance data to support the above  Rise in specialty and sub-specialty work within a hospital setting

48.  The primary independent Organized Medical Staff of today is a dinosaur  New hybrid models will need to take the changes discussed into consideration

49.  Reduce duplication of management services between medical staff and physician practice groups by taking on Human Resource duties  Medical Staff will assume even greater responsibility for both defining and interpreting individual quality performance measures  Medical Staff will have a greater responsibility for ambulatory or outpatient care physicians

50.  No change  Eliminated- Functions absorbed by a totally new organization  Becomes a more Quality oriented organization  Becomes a more Human Resource oriented organization  Combo- Quality + Human Resource  Something else

51.  Quality  Performance Data collection and Interpretation  Management of Performance deficiencies  Human Resource  Practice management  Recruitment  Strategic Planning and Implementation

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