(Post Two in a series)
By Joanne Conroy, MD
Over the past few weeks, we have been executing contracts and scheduling workgroups to determine:
- Five disease groups that will define the specific episodes and work of care delivery redesign
- A financial team that will struggle with gainsharing (how are profits split?), calculating the bundle and risk adjustment that should be applied if our patients are sicker or more complicated
- A legal and governance team that will try to facilitate the integration of providers that are not employed by the AMC but are engaged in the care of the patient who has an anchor admission.
We have been studying the Prometheus logic that Brandeis will use to run the Medicare data for each hospital. Prometheus is a company that developed an inclusion logic to assign services and claims (for the episode duration), categorized as typical or “potentially avoidable complications,” to the anchor episode. Using this code, Brandeis will be able to run the Medicare data quickly and identify the resources required to provide care for the defined episode.
AMCs should be able then to compare the episode costs across and within groups, which will reveal opportunities for savings by addressing “potentially avoidable complications” or excessive services that do not advance care.
Some seasoned CEOs are working with us, as well as UHC, to keep the groups grounded in creating a successful application and profitable demonstration.
One ongoing concern is what happens if an AMC gets an expensive patient with multiple co-morbidities, whose costs destroy any potential profit. I wish there was a backstop reinsurance I could purchase for this project. Then I could wear a T shirt that says, “Really….No One Loses Their Shirt!”
–Joanne Conroy, MD, is Chief Health Care Officer at the Association of American Medical Colleges. She can be reached at firstname.lastname@example.org. Follow her on Twitter @joanneconroymd.