Mark A. Smith, MD, FACSMay 17, 2012

CAMSS Annual Meeting

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Marcelo W. Hinojosa, MDUniversity of California, Irvine Medical Center

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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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

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

In short, a MESS! Raises a number of Issues

Rising costs Decreased reimbursements Lack of access Shortage of healthcare providers Legal liabilities

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).

    AUS CAN GER NETH NZ UK US

OVERALL RANKING (2010) 3 6 4 1 5 2 7

Quality Care 4 7 5 2 1 3 6

Effective Care 2 7 6 3 5 1 4

Safe Care 6 5 3 1 4 2 7

Coordinated Care 4 5 7 2 1 3 6

Patient-Centered Care 2 5 3 6 1 7 4

Access 6.5 5 3 1 4 2 6.5

Cost-Related Problem 6 3.5 3.5 2 5 1 7

Timeliness of Care 6 7 2 1 3 4 5

Efficiency 2 6 5 3 4 1 7

Equity 4 5 3 1 6 2 7

Long, Healthy, Productive Lives 1 2 3 4 5 6 7

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

Note: $US PPP = purchasing power parity.Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

Average spending on healthper capita ($US PPP)

Total expenditures on healthas percent of GDP

$7,290

$2,454

16%

8%

Too costly- $2.3 Trillion in 2009, 17.3% of GDP

Lack of Access- 40-55 Million Uninsured

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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

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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

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

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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

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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

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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

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Individual Responsibility Purchase health insurance if not qualified

for a government plan or pay penalty Dependents can remain on parent policy

until 26th birthday Will have access to more information on

both quality and pricing

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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

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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

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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

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Funding Tax on high income taxpayers Annual fee on Health insurers Increased fee on drug and device

manufacturers Other sources to be named later

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Who knows what will remain and what will be removed?

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Healthcare Reform Act will result in:1. 60% will restrict access to patients2. 59% will spend less time with individual

patients3. 10% see increased quality; 56% see

diminished quality4. 67% had a negative or very negative

reaction to the reform bill5. 40% anticipate leaving medicine within 3

yrs.

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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

The primary independent Organized Medical Staff of today is a dinosaur

New hybrid models will need to take the changes discussed into consideration

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

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

Quality Performance Data collection and

Interpretation Management of Performance deficiencies

Human Resource Practice management Recruitment

Strategic Planning and Implementation

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