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Miami ExperienceDr Liz SiddonsNHS Leicester City

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Presentation structure

• Purpose of visit

• Overview of US healthcare

• MCCI Company Overview

• What impressed us?

• Clinical Outcomes

• What we could try in Leicester City?

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Purpose of visit

• 3 day study tour focused on MCCI approach to clinical leadership and driving management of patient care, provider behaviour and activity from primary care

• Arranged by Humana’s Commissioning Institute and Medical Care Consortium Inc. (MCCI)

• Attended by c.30 people (PBC GPs, CEs/Directors) inc. Newham, NE Essex, and Sutton & Merton, DH

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Overview of US system

•Complex and multiple funding streams:•Medicare – 65+yrs (Fed)•Medicaid – low income children

and adults (Fed and State)•Tricare – military (Fed)•Commercial – employer/personal

•C.300m population, of which c.46m uninsured

•Inequitable and financially unsustainable

•Health system reform is Obama priority

Commercial17%

Medicare46%

Medicaid37%

Patient Type

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Key differences to NHS

• Insurance based - coverage• Patients select insurer (e.g. Humana) and

provider (e.g. MCCI) every 6mths• Buyers market – 27 hospitals in Broward

county• Consultants freelance – setting less of an

issue• Insurance notification/authorisation drives

patient level accounting• No tariff so price negotiation

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Headquartered in Miami, FloridaOperating since 1988

67 state-of-the-art medical centers in Florida

5,000 to 30,000 square feet

Medical Resources173 physicians

Over 250 specialists

Partnerships with Humana, Coventry, and WellCareProvides healthcare services under global risk contracts

Approximately 140,000 patients

In-house urgent care services

Broad range of full scale medical services

on site

Disease management programs

MCCI Company MCCI Company OverviewOverviewMCCI Company MCCI Company OverviewOverview

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Pharmacy In-house Pharmacy Mail order capability Home delivery available

Transportation Fleet of 46 vans Ensures patients meet appointments Free service offered to patients

Non-medical staff per facility: 1 medical director 1 business administrator 1 hospital coordinator 2-3 case managers

Activity Centre

MCCI Company MCCI Company Overview Overview MCCI Company MCCI Company Overview Overview

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MCCI PatientsMCCI PatientsMCCI PatientsMCCI Patients

Revenue ($ in millions)Revenue ($ in millions)Total MembershipTotal Membership

$243.8 $273.4

$311.3

$416.6

$525.0

58,351

79,578 90,298

108,518

140,000

2005 2006 2007 2008 2009P

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Medical StructureMedical StructureMedical Structure

Chief Medical OfficerEduardo Alarcon, MD

Medical DirectorMiami-Dade County

Medical Director Hillsborough County

Utilization Management Director

Chief Executive Officer:Jose Armas, MD

Case Managers

Medical DirectorBroward County

Medical Director Palm Beach County

Medical Director Orange County

Medical Director Duval County

Hospital Coordinator

Miami-Dade County Hillsborough CountyBroward County Palm Beach County Orange County Duval County

Hospital Coordinator Hospital Coordinator Hospital Coordinator Hospital Coordinator Hospital Coordinator

Lead Physicians

Miami-Dade County Hillsborough CountyBroward County Palm Beach County Orange County Duval County

Lead Physicians Lead Physicians Lead Physicians Lead Physicians Lead Physicians

Medical StructureMedical StructureMedical Structure

Chief Medical OfficerEduardo Alarcon, MD

Medical DirectorMiami-Dade County

Medical Director Hillsborough County

Utilization Management Director

Chief Executive Officer:Jose Armas, MD

Case Managers

Medical DirectorBroward County

Medical Director Palm Beach County

Medical Director Orange County

Medical Director Duval County

Hospital Coordinator

Miami-Dade County Hillsborough CountyBroward County Palm Beach County Orange County Duval County

Hospital Coordinator Hospital Coordinator Hospital Coordinator Hospital Coordinator Hospital Coordinator

Lead Physicians

Miami-Dade County Hillsborough CountyBroward County Palm Beach County Orange County Duval County

Lead Physicians Lead Physicians Lead Physicians Lead Physicians Lead Physicians

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MCCI’sBroad Range of ServicesMCCIMCCI’’ssBroad Range of ServicesBroad Range of Services

DiseaseManagement

In House/Delivery Pharmacy

EKGTesting

DentalServices

Diabetes Education/Nutrition

CaseManagement

Direct Access to Physicians

PacemakerCheck

Eye Care

Family Health Education

Hospitalists

Direct Access to Specialist

X-rayServices

InternalMedicine

Activity Centers

Urgent Care

Direct ReferralAccess

Lab DrawingStations

Physical Therapy

Transportation Services

MCCI’sBroad Range of ServicesMCCIMCCI’’ssBroad Range of ServicesBroad Range of Services

DiseaseManagement

In House/Delivery Pharmacy

EKGTesting

DentalServices

Diabetes Education/Nutrition

CaseManagement

Direct Access to Physicians

PacemakerCheck

Eye Care

Family Health Education

Hospitalists

Direct Access to Specialist

X-rayServices

InternalMedicine

Activity Centers

Urgent Care

Direct ReferralAccess

Lab DrawingStations

Physical Therapy

Transportation Services

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Cardiology

Endocrinology

Gynecology

Optometry

Psychiatry

Dermatology

Gastroenterology

Nephrology

Orthopedics

Rheumatology

Dietician

General Surgery

Ophthalmology

Podiatry

Urology

Oncology Physical Therapy Wound Care

Wide Offering of SpecialtiesWide Offering of SpecialtiesWide Offering of Specialties

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MCCI ApproachMCCI ApproachMCCI ApproachMCCI Approach

Patient is seen within 7 days after assigned to physician

High risk patients may be segregated into an inter-disciplinary approach

Disease management

Social services

Increased frequency of physician-patient interaction

Preventive screening (e.g., mammograms)

MCCI coordinates all referral visits for patients

One hospital coordinator at every medical center

Post-hospitalization follow up within 48 hours

In-house pharmacy in all facilities

Transportation provided to patients

Activity centers available

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What impressed? (1)

Hospital Coordinator• Primary link between GP, hospital physician and

specialist• Initiates discharge planning and outpatient

management post discharge

• Receives list of all admitted patients twice daily

• Gathers information from GP to avoid duplication of tests

• Attends hospital rounds with Attending Physician and processes orders

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What impressed? (2)

Discharge planning:• Begins on the 1st day of admission• Coordinated approach to assess needs• Hospice Care• Rehabilitation• Home Care• Equipment• Psychosocial/counselling• Nutrition• Pharmacy• Transportation• Follow-up within 48 hours of discharge• Disease Management- phone based

• Patient and family education

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What impressed? (3)

Utilisation management:• Dedicated Director appointment• Dedicated central support team• Web-based reporting system with costed

activity drill down by county, centre, physician and patient

• Systematic review of variation• Physician led discussions with clinical

teams (wkly/mthly/qtly)

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Clinical Outcomes

Admissions per ThousandsAdmissions per ThousandsAdmissions per Thousands

2005 2006 2007 2008

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Clinical Outcomes

Re-Admission Rate (7 days or less)ReRe--Admission Rate Admission Rate (7 days or less)(7 days or less)

2005 2006 2007 2008 Industry Avg.

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Clinical Outcomes

Re-Admission Rate (30 days or less)ReRe--Admission Rate Admission Rate (30 days or less)(30 days or less)

2005 2006 2007 2008 Industry Avg.

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What could we try in UK?

• Shifting emphasis to “aggressive management” out of hospital (PBC groups?)

• Greater use of patient pathways (map of medicine?)

• Supporting admission/planned discharge (hospitalist role?)

• Resource utilisation monitoring, analysis and reporting (PBC hub and cassius?)

• Global risk contracting (new practice procurements?)

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Liz SiddonsAssistant Medical DirectorElizabeth.Siddons@LeicesterCity.nhs.uk