Susan Nedza MD, MBA FACEP Vice President, Strategic Clinical Solutions HealthCircles™

1. Health System Reform: Five Strategic Questions For Emergency Medicine Susan Nedza MD, MBA FACEP Vice President, Strategic Clinical Solutions HealthCircles™ June 23, 2010

2. Five Strategic Questions • What will be the impact of technology on emergency care? • What will be the impact of regionalization efforts on emergency care? • What will be the impact of Accountable Care Organization (ACO) payment on emergency care? • What will be the impact on group models in emergency care? • Where does the ED begin and end? CONFIDENTIAL

3. My Challenge:Brevity and Clarity CONFIDENTIAL

4. Your Challenge: Objectivity

5. I. What will be the Impact of Health Information Technology on Emergency Care? .

6. American Recovery and Reinvestment Act Of 2009 .

7. Meaningful Use of HIT:National Goals • Improve quality, safety, efficiency, and reduce health disparities • Provide patients and families with timely access to data, knowledge and tools to make informed decisions and to manage their health • Improve care coordination • Communicate with public health agencies • Ensure adequate privacy and security protection for personal health information CONFIDENTIAL

8. Meaningful Impact of HIT • Supports the ability of physicians and members of the care team to provide safe, high quality, efficient, patient-centered care • Strengthens the physician-patient relationship • Empowers patients to participate in their care • Provides a sustainable, economic benefit for physicians and the systems in which they provide care HIT Must: • Lessen the burden of disease and improve the health of communities CONFIDENTIAL

9. Meaningful Impact: e-Health Enabled Transformation of Care Delivery • Improve Access to Care- Scale the Care Team • Manage Risk-Impact Defensive Medicine • Utilize Exception Management Systems- Support New Payment Models CONFIDENTIAL

10. Access to Care • Access in all Communities • Access to Specialty Services • Access to a Healthcare Home • Access to services that improve health and are cost effective CONFIDENTIAL

11. Emergency Medicine Risk Management • Access to information to support informed decision making • Access to information to minimize the practice of defensive medicine( $$$) • Access to follow up care in an appropriate setting CONFIDENTIAL

12. Utilize Exception Management Systems: Support New Payment Models • Provide the right care, to the right patient, at the right time, in the right setting • Utilize technology to maximize physician time • Incorporate clinical guidelines and performance measures that reward the appropriate use of resources • Enable quality improvement activities as the goal of performance measurement. CONFIDENTIAL

13. II. What will be the Impact of Regionalization on Emergency Care? .

14. Regionalization of Emergency Care • Future of Emergency Care- 2006 • Regionalization of Emergency Care 2009 • Centralization vs. Regionalization • Mandates or Markets? • Role of Health Information Infrastructure CONFIDENTIAL

15. Institute of MedicineFuture of Emergency Medicine- 2006 • Many Emergency Departments and Trauma Centers are Overcrowded • Emergency Care is Highly Fragmented • Critical specialists are often unavailable to provide emergency and trauma care • The emergency care system is ill-prepared to handle a major disaster • EMS and EDs are ill-equipped to handle pediatric care CONFIDENTIAL

16. Future of Emergency CareRecommendations • Create a coordinated, regionalized accountable system • Create a lead agency • End ED boarding and diversion • Increase funding for emergency care • Enhance emergency care research • Promote EMS workforce standards • Enhance pediatric presence throughout emergency care CONFIDENTIAL

17. Regional Perspective: Adapting the Trauma System Model “As we go forward and begin to expand the regionalization model to other time-sensitive illnesses and injuries, if there is not a governmental authority to provide leadership, the result will be chaos. The effort will be driven by the profit motive and the institutions that are able to cobble together a sustainable business model, rather than by the best evidence and the best medicine.” John Fildes, MD CONFIDENTIAL

18. Centralization Perspective “Informal regionalization has been the norm in the United States for the simple reason that there is no health care system. If you’re going to have formal regionalization, you have to have a system of care.” Ken Kizer, MD CONFIDENTIAL

19. The Neurologist Will See You Now

20. The Surgeon will Operate on You Now..

21. Patient Protection and Affordable Care Act Of 2010 .

22. Immediate Effect • Leaves intact most of the existing infrastructure through which health care is delivered and paid. • Most Americans will continue to receive health benefits through commercial insurance products offered by their employers. • Most health care providers will continue to be reimbursed under the current general payment structures (that is, through private insurers or government health plans). • The existing fragmented delivery and financing system, will not change immediately CONFIDENTIAL

23. Innovation in Health Care Delivery and Payment Policyin PPACA How many times are the words “demonstration” and “pilot” mentioned in the newly passed Federal healthcare reform legislation — the Patient Protection and Affordable Care Act (PPACA)? Answer: 312 and 80 CONFIDENTIAL

24. Section 3504: Design and Implementation of Regional Systems for Emergency Care • Appropriation of 120 million dollars over four years • Design and implementation of regionalized systems for emergency care. • Provides funding to the Assistant Secretary for Preparedness and Response to support pilot projects that design, implement, and evaluate innovative models of regionalized, comprehensive, and accountable emergency care and trauma systems. • Requires the HHS Secretary to support emergency medicine research, including pediatric emergency medical research. CONFIDENTIAL

25. III. What will be the Impact of Accountable Care Organization Payment on Emergency Medicine? .

26. Center for Medicare and Medicaid Innovation • Section 3021 of the enabling legislation also establishes the Center for Medicare and Medicaid Innovation within CMS. • The purpose of the Center will be to research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care provided to patients in each program. Dedicated funding is provided to allow for testing of models that require benefits not currently covered by Medicare. Successful models can be expanded nationally. CONFIDENTIAL

27. Potential Pilots • Supporting care coordination for chronically ill  individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology. • Varying payment to physicians who order advanced diagnostic imaging services • Utilizing medication therapy management services CONFIDENTIAL

28. Quality of Care For Care Transitions .

29. Hospitals Risk Readmission Payments for Heart Failure Patients • In 2012, Medicare will stop paying hospitals for preventable readmissions tied to health conditions such as heart failure or pneumonia. In 2014, HHS will expand that policy to cover four additional health conditions. • Beginning in 2012, hospitals will be paid commensurate to their performance scores for patient satisfaction and care quality tied to treatment of conditions such as heart failure, pneumonia and hospital-borne infections. CONFIDENTIAL

30. Hospitals Risk Readmission Payments for Heart Failure Patients • Heart failure patients who return to a provider for a simple follow-up visit within seven days of hospital discharge are 15 percent less likely to be readmitted CONFIDENTIAL

31. Hospital Readmission’s for Heart Failure "Patients are no longer under 24-hour hospital supervision. They may or may not have picked up their medications or they may not have followed-up on a test. Early evaluation should include a review of therapeutic changes and a thorough assessment of the patient's clinical status outside of the highly structured hospital setting," he said. CONFIDENTIAL

32. Care Transition Measures • Developed by AMA convened Physician Consortium for Performance Improvement, Society for Hospital Medicine, ABIM Foundation • Based upon Dr. Eric Coleman’s work in care transitions • Endorsed by National Quality Forum (NQF) CONFIDENTIAL

33. Quality of Post-Acute Care Transitions • Reconciled medication list received by discharged patients. • Transition record with specified elements received by discharged patients. • Timely transmission of transition record (to facility or primary physician for follow-up care). • Transition record with specified elements received by discharged patients in the emergency department. • Discharge planning/post-discharge support for heart failure patients. CONFIDENTIAL

34. Care Transition Metrics- Policy Goals • Reduction in adverse drug events • Reduction in patient harm related to errors in omission • Reduction in unnecessary healthcare encounters (30 day readmissions) • Reduction in redundant testing and procedures • Achievement of patients goals and preferences • Achievement of patient understanding of and and adherence to treatment plan CONFIDENTIAL

35. Medicare Payment Policy and Care Transitions • Public Reporting of Readmission Rates • Market-basket update requires reporting • Medicare Value-Based Reimbursement System • Decreased Payments for Re-admission within 30 days* *This will have a profound impact on ED boarding CONFIDENTIAL

36. Centers for MEDICAID and Medicare Services CONFIDENTIAL

37. IV. What will be the Impact on the Group Practice Model of Emergency Medicine? .

38. Impact on Group Practice:A Shifting Paradigm • Positive Impact? • Opportunities for process redesign in hospital system • Opportunities to implement connected care models • New models for reimbursement for physicians • Telehealth services • Negative Impact? • Can you redesign care only at the ED level • ED chart disconnected • Are RVUs a good model for rewarding doctors? • Pressure to discharge patients will increase • Volumes will drop

39. A Shift in Culture • How will the next generation of emergency physicians be trained? • Continued debt • Technologically savvy • Gender balance • Risk management CONFIDENTIAL

41. V. Where Does the Emergency Department Begin and End? .

42. Flu Information Care System (FICS) Coalition Disruptive Collaboration • American Medical Association • Microsoft • Merck • CVS • TeamHealth • The Schumacher Group • WorldDoc • ECI CONFIDENTIAL

43. Connected Health Platform AMAfluhelp.org is currently connected to Microsoft Health Vault, Google Connection is shown for example only. CONFIDENTIAL

44. CONFIDENTIAL

45. Health Session Programs have branching tree rules-logic and color-coded alert levels CONFIDENTIAL

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48. The Infrastructure for Connected Care • Connecting patients, physicians, hospitals and caregivers together • Providing appropriate information to support shared-decision making • Linking the pre-hospital setting to the ED (long-term care, home health, FQHC, medical home) • Linking the ED to the post-discharge network CONFIDENTIAL

49. Meaningful Impact of HITEmergency Medicine • Improve quality, safety, efficiency, and reduce health disparities • Provide patients and families with timely access to data, knowledge and tools to make informed decisions and to manage their health • Improve care coordination • Communicate with public health agencies • Ensure adequate privacy and security protection for personal health information CONFIDENTIAL

50. ConclusionThe Setting: Health System Reform Aligned Incentives for Leadership • Feeling of Impotence • Imperative for Sharing Information • Imperative for Action • Infrastructure in Place • Aligned Incentives • Engaged Leadership across Industry CONFIDENTIAL