1. Eric Montion Vi Tran Natalie Whitlock

2. January 26 th - “Hospital in Turmoil” January 26 th - “Hospital Announces Big Payroll Cuts” February 18 th - “In a Financial Pinch” March 13 th - “Tulare Hospital Bond Ratings Downgraded”

3. Community Outreach and Market Share Hospital Rebranding Regaining Market Share Physician-Hospital Alignment Physician Recruitment Physician Integration Healthcare Reform Impact on Rural Facilities Payment Reform Delivery System Reform

4. Tulare Medical FoundationTulare Regional Medical Center Evolution’s Fitness and Wellness Center (4+1) Rural Health Clinics Federally Qualified Health Clinic 120+ Physicians on Staff TRMC Lab and Diagnostic Tulare’s Pharmacy Family X-Ray Tulare Community Health Clinic

5. Service Area: In 2010 Kaweah Delta District Hospital was the leader followed by Tulare District Hospital Service Line: Highest percentage of services are obstetrics, followed by general medicine -Behavioral health is only at 5%

6. Population: 2016 projection: 9.3% increase – Over 50% of service area is of Hispanic ethnicity – The percentage of adults over the age of 65 is expected to grow about 21% by the year 2016 Payer Mix: Mostly Medicare and Medi-Cal

7. Problems Layoffs Public Perception Lack of public donations

8. Build up the current workforce Involve the community Improve employee satisfaction Improve patient satisfaction Develop new patient care programs Provide integrated and coordinated care Solutions

9. Increase market share in behavioral health – There is a lack of a system of care – Excessive use of emergency rooms for behavioral health patients – Create a culturally competent workforce

10. Age Adjusted Percentage of People with Chronic Conditions in 2009 American Hospital Association. MSA is metropolitan statistical area. Large MSAs have a population of 1 million or more; small MSAs have a population of less than 1 million

11. Focus on primary care and preventative care – Chronic disease management – Need to develop programs and provide resources to ensure sustained disease management – Need to address the negative health behaviors Smoking Obesity Binge drinking STDs

12. Goals – Address the needs of the community – Deliver quality care through the continuum of care – Increase market share in Tulare’s service area and beyond – Improve revenue through volume and reimbursement

13. Employment – Strongest type of physician alignment – Difficult to revert or disband the relationship – Compensation made up of (80%) Salary plus (20%) Cost Saving Sharing

14. Management Services Organization (MSO) – Provide administrative services for the physician group – By sharing cost, equipment, and EMR/EHR – Establish relationship for the MSO to refer business to the hospital – MSO ties the physician to the success of the hospital

15. Employment (0 to 1 Year) – Establish a Tulare Medical Foundation – Physician recruitment Start communicating with the physicians on staff (120+) Conduct surveys to understand the needs and wants of the providers Understand why some physicians are not referring patients to TRMC

16. MSO (0 to 1 Year) – Identify the Potential IPAs and Solo Practitioners – Setup MSO model Cost, Legal, Contract, Reimbursement, Referral – Train middle management to be ready to take on MSO Lean Health Management

17. Governance – Tulare Medical Foundation Board Will need a strong involvement by physician Give an active role to retiring physician on the board Each large MSO should have a physician representative

18. Employment (Year 1 to 4) Start recruiting physicians to the Tulare Medical Foundation Address the current physician gaps Primary Care Providers (PCP) Aging physicians in physician pool Service lines needed by the community

19. MSO (Year 1 to 4) – Contract with IPA to establish MSO Five Year MSO contract Six-month back-out clause – Continue to Improve on Quality and Increase Efficiency to create cost saving

20. The Shift (Year 4 and Beyond) – MSO to Employees Create a stronger alignment – Start creating more value for the MSO to be employees

21. Challenges Dependence on governmental payers Disadvantaged in negotiating contracts due to size and volumes Increase in self-pay, charity care, and bad- debt

22. Federally Qualified Health Clinic (FQHC) Free Standing Cost-Based Reimbursement= $109/visit Annual Visits in 2010=90,571 Est. Annual Visits Currently=100,000 Provider Cost-Based Reimbursement=$149/visit $149 X 100,000=$14.9 Million New Revenue

23. Program SolutionGoalCost Savings Reduce Bad Debt Charges25%$500,000 Increase Cash Collections15%$120,000 Decrease uncompensated charges15%$432,000 Discounted Bill Program100%$480,000 Reduce “Discharge not final billed”<5 days A/R Days40 Days Days Cash on Hand80 Days Total Revenue Cycle ImprovementsFY13$1,532,000

24. Program SolutionGoalCost Savings Behavioral Health Enrollment15%$75,000 Da Vinci/Surgical Procedures20%$800,000 OB Procedures20%$250,000 Readmissions15%$100,000 ED Wait Times20% Total SavingsFY13$1,225,000

25. Program SolutionGoalCost Savings Disease Management Programs 500 Persons$500,000 Community Health Fairs 10,000 Persons Increase in Donations 10% Increase$500,000 Total Outreach Savings$1,000,000

26. Tulare Medical FoundationTulare Regional Medical Center Evolution’s Fitness and Wellness Center (4+1) Rural Health Clinics Federally Qualified Health Clinic 120+ Physicians on Staff TRMC Lab and Diagnostic Tulare’s Pharmacy Family X-Ray Tulare Community Health Clinic