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A SHARED SAVINGS MODEL:
Marillac Clinic and St. Mary’s Hospital
March 2, 2010
Steve Hurd - [email protected]
David West - [email protected]
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Western Colorado and Eastern Utah
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Alignment
• Identical Mission and Values
• Same Sponsor - Sisters of Charity Leavenworth Health Systems
• Independent Boards of Directors
• Independent Audits
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Marillac Clinic
St. Mary’s ER
LOCATION, LOCATION, LOCATION
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Marillac Clinic: A Medical Home for the
Uninsured• Community-funded Safety Net Clinic (A CSNC not a FQHC or Free Clinic)
• Mesa County residents
• At or Below 250% of FPL
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Patient Fees21%
St. Mary's Hospital
18%
SCLHS Sponsorship
13%
Local Philanthropy
12%
Tobacco Tax16%
Foundations20%
Marillac Revenue Sources
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St. Mary’s Contribution• Total $1,350,000
• Cash $ 375,000
• In-Kind* $ 975,000
*Building, Utilities, IT Support, Environmental Services, Security
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Marillac Clinic 2009• Annual Budget $7,500,000 • Patient Panel 7,650• Visits 29,300• FTE 78• Open Access Appts 25%• CPT Billing 0
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The Medical Home Motto:
“The right care, at the right place, at the right time.”
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Five Lines of Service - All Under One Roof
• Medical
• Mental Health
• Dental
• Optical
• Low Cost Medication
Marillac’s Model
No Wrong Door
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Guiding Principle
Meeting several patient needs in one visit results in greater efficiency for both patients
and providers.
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Corollary Principles• Psychosocial issues patients bring to their
medical visit are as essential as their biological concerns.
• The Medical Home addresses the psychosocial determinants of health through close collaboration within the human service community.
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Inter-agency Referral Agreements for the Uninsured
MarillacClinic
Human Service Agencies
Lab and Radiology
HospitalBasedCare
Specialty Care
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Referral Resources
• 150 Specialists Sliding scale
• Lab & Radiology Sliding scale
• ER Care Sliding scale
• Inpatient Care Sliding scale
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Hospitalist Relies on:
• Predictable response from Marillac triage nurse
• Open access for post-hospital appts
• Marillac to address psychosocial issues that lengthen inpatient stay
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Steps to Medical Efficiency
• Not for profit hospitals, home health, hospice, health plans, and physician groups
• Working together on community problems• Cooperation for caring for the uninsured via
Marillac Clinic• Data – Medical records, communications, and
open knowledge concerning costs
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Characteristics of Medical Homes that Improve Quality and
Reduce Cost• Primary Care –continuing and comprehensive
– Hospital, office, nursing home, and emergency room– Hospital care – ER, OR, OB, and medical wards– Availability or after hours care via telephone or clinic
• Data Driven – Feedback on patient care and patient costs– Quality Health Network
• Observations– Favorable Ratio of Family Physicians: Patient Panels– Comprehensive care allowed by favorable liability climate
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Other Considerations to Successful Medical Homes in
Grand Junction• Relentless emphasis on quality• End of life care – Hospice• Accessibility of care – high cooperation
among hospital, Marillac, residency program, health department, and specialists
• Cost awareness• Physician leadership
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Physician Competitiveness
• Be the best – surgeon, primary care physician, subspecialist – by expense data
• Be the best quality• Be the best efficiency• Be the best with measurable parameters –
health screenings, vaccinations, length of stay, cost per procedure, and overall care of a panel of patients
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Aligning Incentives Produces Savings
MarillacClinic
Human Service Agencies
Lab and Radiology
HospitalBasedCare
Specialty CareOur
SharedPatients
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Leadership Alignment• CEOs of St. Mary’s and Marillac Clinic
meet monthly
• Marillac CEO presents to St. Mary’s Board of Trustees annually
• Member of Hospital Senior Leadership Team serves on the Marillac Board of Directors
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ClinicalWhat care is called for?
Is it high quality?
OperationalWhat will it take to accomplish care?
Is it well executed?
FinancialHow will care best use resources?
Is it a good value?
C.J. Peek (2008). Planning Care in the Clinical, Operational and Financial Worlds. Chapter in Collaborative Medicine Case Studies: Evidence in Practice. R. Kessler & D. Stafford (eds.) Springer
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Clinical Alignment• Marillac Medical Director meets
regularly with Medical Leadership of SMH Emergency Dept
• Marillac Medical Director meets regularly with St. Mary’s Hospitalists
• Marillac Medical Director follows up with specialists if referral develops a glitch
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Operational Alignment
• At the conclusion of their ER visit, eligible uninsured patients contact MC for a follow-up appointment
• Discharge planning at St. Mary’s Hospital arrange post-hospital follow-up with MC triage staff
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Financial Alignment
• An identical process is used to determine a patient’s place in the sliding scale
• Data scanned between the two organizations eliminates duplication – enhances the patient experience
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OUTCOMES
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9%
4%
22%
13%
0%
5%
10%
15%
20%
25%
Year 1 Year 2 Year 3 Year 4 Year 4.5
Hospitalization E.R. Visit
Utilization of ER and Inpatient Services by Marillac’s Integrated Care Patients
2000 - 2004
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2008 2009
Marillac N - 209 N - 220$19,078/stay $27,596/stay
Non-Marillac N - 940 N - 1029
$24,493/stay $30,596/stay
Marillac Average28% Lower
Marillac Average11% Lower
Financial OutcomesInpatient Charges forUninsured Patients
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2009 Clinical Utilization of ER
• Acute Pharyngitis• Strep Sore Throat• Ankle Sprain• Suture Removal
• Pain in Limb• Flu Symptoms• Otitis Media
Seven of the top 20 diagnoses occurring for uninsured non-Marillac patients not present in the Marillac Clinic cohort.
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OTHER SUCCESSES
Marillac patients presented at the ER for Dental Disorders NOS at one-third the rate of other uninsured patients
Marillac patients presented at the ER for Alcohol Abuse NOS at one-half the rate of other uninsured patients
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CHALLENGES
Some Marillac patients remain high utilizers of the ER:
• Chronic Pain• Alcohol Abuse
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