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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