Cutting the Fat from Your Health Care Bill

Cutting the Fat from Your Health Care BillUtilization ManagementACHSA Conference - November 4, 2011Ricki Barnett, MDGoal- Accessible, quality health care that is cost effective.

Health care costs escalatingSituation in 2008 and nowIssues and how we dealt with them can be extrapolated to other systemsNot exclusive to corrections. Everyone has same problems.

2Status in 2008 vs. 2011Access Challenges

Health Care outcomes

Costs IncreasingMore Bad NewsTransportation, guarding costs risingHospitals full (bed days, ADC)High contract ratesSlow paymentsBegging for specialist, hospital accessNo quality oversightDefensive medical practicesBurdensome peer reviewMultiple external pressuresWhat is constitutional care?Where did we start?Educate leadershipAgree there is a problemGet permission to collect data and informationMake it easy to do the right thing

Health Care Systems The IdealElectronic authorization systemsElectronic claims payment systemsEncounter data capture to assess patient medical acuityEMRElectronic scheduling systemDaily census information for all hospitals and institutional bedsThe MinimumInterQual based volume reportsRetrospective claims based reportsLaboratory resultsPharmacy resultsElectronic daily hospital and institutional censusA scheduling system

Is there any fat to trim, without affecting quality?TRIMTHEFAT!Medical Necessity DefinitionMedically Necessary means health careservices that are determined by the attendingphysician to be reasonable and necessary toprotect life, prevent significant illness ordisability, or alleviate severe pain, and aresupported by health outcome data as beingeffective medical care.

- Title 15 Article 8 Section 3350 (b)(1)

Archives of Internal Medicine / Mt. Sinai School of MedicineBased upon research published in the May 2011Archives of Internal Medicine, researchers at Mt. Sinai Medical School have identified at least $6.7 billion yearly wasted medical expenditures.

The High Cost of Statins & Other DrugsThe October 1, 2011 issue of American Family Physician includes a Cochrane Review that fails to find any benefit from the use of statins in patients with no history of cardiac disease. No reduction of mortality or morbidity could be shown in the use of statins for patients with normal risk factors for heart disease and borderline cholesterol elevations.

Identify cost drivers, manage them.

Top Volume/Cost Specialty ServicesRadiology Orthopedic SurgeryGeneral SurgeryHematology / OncologyCardiology OphthalmologyUrologyTraumaHospital Based Physicians/Attending Staff How many referrals are necessary?Medically Unnecessary CategoriesOrthopedicsPodiatryOncologyNeurologyNeurosurgeryDermatologyImagingCardiology

Specialty Referral ManagementMandatory InterQual useMandatory review of outcomesAggressive goalsAccountability and responsibility stays localEncourage institutions to know their specialists and talk to them

Managing Specialty Referrals with the Primary Care TeamEducateCompare OutcomesMeetFeedbackTrack ResultsManaging Specialists Services with Network SpecialistsCompare OutcomesCommunicate ExpectationsFeedback Regarding Access, Availability, Outcomes, Treatment PhilosophyTop Diagnoses- ER Visits Chest PainTrauma- minor, majorEpilepsyAbdominal PainHeadache

How to Manage Emergency CostsMorning huddlesPrimary care model and moving from line based systems to anticipatory primary care modelReview of all outliersTraining of all staff and outside resources

Top Reasons for Hospital AdmissionsCellulitisChest painG.I. ConditionsHepatic DisordersSeizures, ALOCCancerOrthopedicsTrauma

Managing Hospital ServicesMonitor Daily Discharge Planning Begins on AdmissionMandatory Concurrent RoundsCompare OutcomesInvolve Hospitalists and Institution MDsBe ready to leaveDoes Telemedicine Reduce Cost?Improves accessDecreases transportation and custody costsImproves public safetyCost neutral on clinical costsBest for medical evaluation and management services, some surgical screening and services

This is the situation that we found ourselves in. 27This is the situation that we found ourselves in. 28What Costs Us the Most?HospitalPharmacyUnsuccessful discharge planningNot enough institutional bedsAging population, end of life approachesLack of anticipatory case managementPrimary care model not yet matureStatewide Specialty Referral CostsStatewide Emergency Room CostsStatewide Hospital Costs FY 2010-2011Need a slide that shows 2009 to 2010 to 2011. 32This is the situation that we found ourselves in. 33Current Challenges Costs of new technology and drugsEscalating expectations on all sidesDeveloping the primary care modelIT systemsRealignmentAging population

Valuable LessonsAlign Objectives Throughout Health Care Continuum- institution, hospital, specialist

Leadership Buy-inHealth Care Team Buy-inContract ManagementClaims managementCraft Legislation That HelpsAn excellent UM team is MANDATORY!