Ti Time Cr Critical al Diagn agnosi sis P s Plan anning State of Missouri May 17, 2019
Age genda • Introductory Remarks • Dr. Randall Williams, Director, Missouri Department of Health and Senior Services • Review TCD History and Current State • Dean Linneman, Director, Division of Regulation and Licensure, DHSS • Methodologies and Innovative Strategies “Time is of the Essence” • Dr. David Marcozzi, MD, MHS-CL, FACEP • Review Missouri’s Forward Plan of Action • Douglas Havron, RN, BSN, MS • Question & Answer Session • Closing Remarks • Dean Linneman, Director, Division of Regulation and Licensure, DHSS
Introd oductor ory R Remarks Dr. Randall W l Williams, D Direc ector or Missouri D i Dep epartment of of Hea ealt lth a and S Sen enio ior S Ser ervic ices
Re Review TC TCD Hist story & & Current State De Dean L Linne neman an, Di Director Di Division o of Regulation a and L Licensure, DHS DHSS
Methodologies and Innovative Strategies “Ti Time i is of s of the Es Esse sence” Dr Dr. Da David M Marcozzi, M MD, MHS HS-CL, FA FACEP
Disclaimer • The presenter has no financial relationships to disclose regarding time critical illnesses, the State of Missouri, or the Maryland Hospital Association • The views presented do not represent the Department of Defense of the the University of Maryland • A honorarium was received for this presentation from Harvon & Associates, LLP
Agenda • Who the heck is this guy • What this is/is not • How did you get here • IMO • Emergency care • A suggestion
What this is • A perspective from a provider, policy maker and administrator • Honest thoughts to Missouri’s healthcare leaders • Potential paths forward based on lessons learned
What this is not • Cheerleading • Filtered • Easy solutions
TIME CRITICAL DIAGNOSIS SYSTEM OVERVIEW AND FACT SHEET • Missourians expect timely and appropriate emergency medical treatment when suffering from an injury, stroke or heart attack. Missouri has launched an exciting new initiative – the Time Critical Diagnosis System – to improve health outcomes for patients who suffer trauma, stroke or heart attacks known as ST-Elevation Myocardial Infarction, or STEMI.
The walls of a hospital are artificial boundaries Prehospital Healthcare is Healthcare
The ‘They Don’t Care’ Game • About meetings • About conference calls • About emails • About the organizational structure • About silos • About the state vs the locals vs the feds • About why it was so hard • About why it didn’t get done
This work is needed-right now • Captain Obvious • The optimal care for patients with time critical patients isn’t needed tomorrow, it was needed yesterday and needs to be maintained • With any crisis, there is opportunity • Missouri is at a critical juncture • Leadership is essential • Cooperation is needed • Openness catalyzes change • Innovation is fundamental
"A Pessimist Sees The Difficulty In Every Opportunity; An Optimist Sees The Opportunity In Every Difficulty." – Winston Churchill
Paymen ent T Taxonomy Framework Payment Taxonomy Framework Category 4: Category 1: Category 2: Category 3: Population-Based Payment Fee for Service— Fee for Service—Link to Alternative Payment Models Built on Fee- No Link to Quality Quality for-Service Architecture Payment is not directly Payments are At least a portion of Some payment is linked to the effective triggered by service delivery based on volume payments vary based on management of a population or an so volume is not linked to of services and not the quality or efficiency episode of care. Payments still triggered by Description payment. Clinicians and linked to quality or of health care delivery delivery of services, but opportunities for organizations are paid and efficiency shared savings or 2-sided risk responsible for the care of a beneficiary for a long period (e.g. >1 yr) • • • • Eligible Pioneer Limited in Hospital value- Accountable care organizations • accountable care Medicare fee- based purchasing Medical homes • • organizations in years 3- for-service Physician Value- Bundled payments Medicare FFS 5 • • Majority of Based Modifier Comprehensive primary care • Medicare Readmissions/Hosp initiative • payments ital Acquired Comprehensive ESRD • now are Condition Medicare-Medicaid Financial linked to Reduction Program Alignment Initiative Fee-For-Service quality Model 25
Target p per ercentage o of M f Med edicare F FFS p payments l linked t to q quality ty a and alter ternative p e payment m model els i in 2016 a and 2 2018 All Medicare FFS (Categories 1-4) FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4) 2018 2016 30% 50% 85% 90% 26
Four MIPS Categories Make up Total Performance Score Category Description Relative Difficulty Relative Weight of Each MIPS Category Over Time Quality Clinicians must select 6 measures of the over 200+ available to report to CMS; score in this category not just awarded for reporting, but for Score based on high performance 30% peer 45% 50% performance Points awarded for cost Resource Use benchmarks 30% savings; clinician scores based 15% 10% on Medicare claims, no reporting required 15% 15% 15% 25% 25% 25% Clinical New category that rewards clinicians for clinical practice 2019 2020 2021+ Practice improvement activities; over 90 Improvement Quality activities to choose from Cost/Resource Use Score based on Clinical Practice Improvement Eligible Tracks clinicians EHR 2 use Clinicians’ 3 own Advancing Advancing Care Information offering partial credit, can performance Care report as individual or group Information Merit-Based Incentive Payment System. Electronic Health Records. Eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians. Source: CMS, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” May 9, 2016, available at: https://s3.amazonaws.com/public- inspection.federalregister.gov/2016-10032.pdf; Advisory Board research and analysis. ;
Systems of Healthcare Delivery Mental Trauma Stroke Pediatric Cardiac Health Emergency Care System 28
Washington, D.C., 1966.
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Inefficiency= Sub-Optimal Care • Prolonged ED boarding = mortality by 5% • When >6h delay, 5% increased mortality (Chalfin DB, et al. Crit Care Med 2007;35:1477-83.) • Delayed transfer of floor patients = mortality by 9% • When >6h delay, hosp 9% mortality incr & 3% hourly incr (Churpek MM, et al. J Hosp Med 2016; Jun 28.) • Delayed transfer of PACU boarders = mortality (OR 5.32) • When ≥ 6h delay, ICU mortality increase, with OR 5.32 (Bing-Hua YU. Am J Surg 2014; 208:268-74.) • Patients recovered in OR put “ CODE 1” patients at risk O’Leary DP, et al. Int J Surg 2014; 12:1333-6. • • Delayed transfer of outside hospital patients with time-sensitive tertiary care and trauma needs at risk • Faine BA, et al. Crit Care Med 2015; 43:2589-96. 32
Ann Emerg Med. 2014 May;63(5):572-9. doi: 10.1016/j.annemergmed.2013.11.018. Epub 2013 Dec 22.
“We are better, but we aren’t ready.” David Marcozzi, MD, MHS-CL, Testimony to the Blue Ribbon Panel Meeting on the State, Local, Tribal, and Territorial Ability to Respond to Large Scale Biological Events: Challenges and Solutions, Wednesday, January 17, 2018
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Time is muscle-Door to Balloon time • ED physician activates • Single-call activation system • Response team is available within 20–30 minutes • Prompt data feedback • Senior management commitment • Team based approach • Paramedics perform pre- hospital tests
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