Critical Care Organizations: Business of Critical Care and Value/Performance Building Sharon Leung, MD, MS, MHA1; Sara R. Gregg, MHA2; Craig M. Coopersmith, MD, FCCM2,3; A. Joseph Layon, MD, FACP4,5; John Oropello, MD, FCCM6; Daniel R. Brown, MD, PhD, FCCM7; Stephen M. Pastores, MD, FCCM8,9; Vladimir Kvetan, MD, FCCM1; for the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine

Objective: New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened Jay B. Langner Critical Care System, Montefiore Medical Center, Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY. 2 Emory Critical Care Center, Emory University, Atlanta, GA. 3 Department of Surgery, Emory University School of Medicine, Atlanta, GA. 4 Critical Care Medicine Service Line, Department of Pulmonary/Critical Care Medicine, The Geisinger Health System, Danville, PA. 5 Department of Medicine, Temple University School of Medicine, Philadelphia, PA. 6 Division of Critical Care Medicine, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY. 7 Division of Critical Care Medicine, Mayo Clinic, Department of Anesthesiology, Mayo Clinic School of Medicine, Rochester, MN. 8 Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY. 9 Department of Medicine and Anesthesiology, Weill Cornell Medical College of Cornell University, New York, NY. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ ccmjournal). Dr. Coopersmith’s institution received funding from the National Institutes of Health and the Society of Critical Care Medicine (president-elect in 2014 and president in 2015, where an honorarium for his time was paid to Emory University for this role), and he disclosed grant support for research unrelated to this article. Dr. Oropello received funding from Association of Pulmonary and Critical Care Medicine Program Directors and New York Hospital Queens. Dr. Pastores’ institution received funding from Spectral Medical (grant support as principal investigator for Memorial Sloan Kettering Cancer Center for a septic shock trial) and Bayer Healthcare, and he disclosed other funding from Theravance and Bard Medical for Advisory Board participation, and from New York Hospital Queens and Winthrop University Hospital for medical grand rounds. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] 1

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000002696

Critical Care Medicine

a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for valuebased care. Design: Relevant medical literature was accessed through a literature search. Material published by federal health agencies and other specialty organizations was also reviewed. Collaboratively and iteratively, taskforce members corresponded by electronic mail and held monthly conference calls to finalize this report. Setting: The business and value/performance critical care organization building section comprised of leaders of critical care organizations with expertise in critical care administration, healthcare management, and clinical practice. Measurements and Main Results: Two phases of critical care organizations care integration are described: “horizontal,” within the system and regionalization of care as an initial phase, and “vertical,” with a post-ICU and postacute care continuum as a succeeding phase. The tools required for the clinical and financial transformation are provided, including the essential prerequisites of forming a critical care organization; the manner in which a critical care organization can help manage transformational domains is considered. Lastly, how to achieve organizational health system support for critical care organization implementation is discussed. Conclusions: A critical care organization that incorporates functional clinical horizontal and vertical integration for ICU patients and survivors, aligns strategy and operations with those of the parent health system, and encompasses knowledge on finance and risk will be better positioned to succeed in the value-based world. (Crit Care Med 2017; 45:00–00) Key Words: critical care; critical care organization; horizontal integration; value-based care; vertical integration

www.ccmjournal.org

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

1

Leung et al

THE CHANGING HEALTHCARE LANDSCAPE Although in 2015, healthcare expenditures accounted for 17.8% of the United States gross domestic product (GDP)— the most expensive in the world (1)—the United States has some of the worst outcomes noted in economically developed countries (2). In 2012, healthcare waste was estimated to account for 34% of total healthcare spending ($910 billion or 6% of the GDP) (3). Almost a decade ago, the Centers for Medicare and Medicaid Services began to reform the fee-for-service system towards a value-based system. The key components of value are outcomes and cost—a full set of patient health outcomes and the total costs of resources used to care for a patient’s condition over the entire care cycle (4). Today, many value-based programs have evolved into mandatory participation associated with performance-based penalties. Although the Affordable Care Act (ACA) is being challenged and appealed, a bipartisan steering committee from the National Academy of Medicine published four action priorities and four essential infrastructure needs to improve outcomes, efficiencies, and value in our healthcare system (5). The priorities are pay for value, empower people, activate communities, and connect care. The essential infrastructure needs are to measure what matters most, modernize skills, accelerate real-world evidence, and advance science (5). The ACA had expanded health coverage and helped to establish population-based health strategies. Over the past 5 years, more than 830 Accountable Care Organizations (ACOs) with different models have emerged, with healthcare focused on efficiencies, value, and coordination (6). In an industry with low margins, tying payment structure to quality, efficiency, and patient satisfaction, there is a need to build a continuum of care with aligned clinical staff. These new regulations leave hospitals seeking greater economies of scale, greater bargaining power, and leverage and better patient care coordination. Over the past 6 years, consolidations through mergers, acquisitions, and strategic alliances have surged (7). Although consolidation is not a magic formula for survival, the benefits of strategic partnership may outweigh the risk of independence in the new value-based world. Quality and performance metric transparency will impact health system organizational brand and market share, for example, Hospital Compare (8). Over the past decade, more than 25 Academic Medical Centers (AMCs) and/or health systems in North America have created critical care organizations (CCOs). The critical elements of a CCO are 1) They are either freestanding academic department or hospital-based; 2) A critical care physician leader has primary governance over the majority, if not all, of the ICUs; and 3) All the ICUs adopt a collaborative care model (9). Almost half of the CCOs were initiated by the hospital administration. CCOs manage all, or most, of the ICUs across their systems “horizontally” along with an interprofessional team, that is, intensivists, nurses, advanced practice providers (APPs; nurse practitioners, physician assistants), rehabilitation specialists, respiratory therapists, clinical pharmacists, case managers, palliative care and nutrition 2

www.ccmjournal.org

specialists (10). There remains, however, some heterogeneity in the degree of integration, transformation process, and maturity of the CCOs.

THE CURRENT STATE OF AFFAIRS IN CRITICAL CARE Critical care costs in the United States exceed $108 billion annually (11), with approximately 6 million patients admitted to ICUs annually (12). Under the fee-for-service payment system, the value and true cost of managing patients with critical illnesses to survivorship is not known. Managing critically ill patients throughout the care continuum is challenging; care fragmentation occurs within the ICU, post-ICU, and postacute care (13). Only 26% of patients are cared for by high-intensity ICU physician staffing models, as recommended by The Leapfrog Group (14). In many systems, providers from various specialties are involved in the care of critically ill patients, but patients are seen without responsibility of care coordination, and care is provided without accountability for long-term outcomes. In terms of ICU governance, in the traditional academic and private practice settings, most units are managed by different departments or divisions of primary specialties, with administrative and fiscal structures existing in isolation (i.e., they are “siloed”). For example, a system with five highly specialized ICUs may have five different academic departments each overseeing each ICU. Departmental leaderships create their own critical care budgets and negotiate with hospital administrators independently from each other. Inefficiencies abound: each ICU may operate with different provider staffing models depending on their budget and availability. Common aspects of care are often not standardized, responsibilities are duplicated, resource utilization is not maximized, and clinical leadership frequently develops strategic plans without a systems perspective (15). Post-ICU care is characterized by poor communication between providers (16, 17), intensified by the multitude of discharge destinations, and high readmission rates (18, 19). When facing critical illness, patients and families struggle with many issues, including, but not limited to, the physical and psychological symptoms, the treatment required, social, spiritual/ faith, end-of-life care, and grief; they value long-term outcomes, particularly functional status (20). Survivors acknowledge that impairment in neuropsychological and physical functions is disruptive and life-altering (21, 22). These impairments may persist for years and, for some, amount to a fate worse than death (23). In fact, 30% of ICU survivors develop significant physical, cognitive, and/or psychiatric impairments, a condition called Postintensive Care Syndrome (PICS). These patients can become subsequently vulnerable to various complications independent from the original illness (24–27). In addition, managing patients with chronic critical illnesses (CCIs) is especially challenging because of the high cost of care, frequent readmissions, and patient dissatisfaction (13, 28). CCI patients have 1-year mortality rates ranging from 48% to 69%, a prognosis worse than many metastatic cancers (28). XXX 2017 • Volume 45 • Number 12

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Feature Article

As the elderly population grows and medical technology advances,ICU beds,utilization,and costs will continue to rise (12). Therefore, optimal care of patients with critical illnesses, and the survivors, have enormous implications for expenditures and patient-centered quality outcomes and is a defining challenge of critical care in the 21st century (13, 29–31). To survive the ever-increasing regulations, and capitalize on consolidation opportunities, hospitals and health systems should shift their operating models to address unnecessary variations in care and to align different groups of clinicians around patientcentered care. In this article, we provide a framework for CCOs, propose a model, outline a nontechnical strategy that consists of a roadmap and a toolkit that critical care medicine leadership can adopt after consideration of its physician-hospital relationship, covered lives, the culture, complexity, and structure of their individual system to build a value-based care system. The model is intended to be applied to adult population in both AMCs and community hospitals.

ROADMAP AND TOOLBOX FOR IMPLEMENTING VALUE-BASED CARE The roadmap consists of two phases: horizontal integration as an initial phase (phase 1) and vertical integration as a succeeding phase (phase 2) (32). Figure 1 provides a synopsis of the roadmap and the toolbox. A list of recommended readings and tools are summarized in Supplemental Table 1 (Supplemental Digital Content 1, http://links.lww.com/CCM/C825).

ROADMAP PHASE 1 Horizontal Integration From a health system perspective, a CCO offers an excellent opportunity to bring all ICUs together under one umbrella, with defined responsibility and accountability to implement patient safety and quality initiatives through protocols, technology standardization across ICUs, consolidation of resources, waste reduction, critical care medicine research enhancement through enrollment of patients in clinical trials, and improved recruitment and retention of faculty and APPs (9). In a follow-up survey (Supplemental Digital Content 2, http://links.lww.com/CCM/C826) by Pastores et al (9), all CCOs showed improvement in quality of care, patient satisfaction, resource use, access to the ICU, support of hospital leadership, and physician supply and demand in comparing ICU performance before and after the creation of the CCO. Ten CCOs (77%) showed improvement in hospital cost of care. Eleven CCOs (55%) received more than $1M each for CCO integration from their health systems as a startup budgetary support, which was directed, at nine CCOs (47%), for overnight intensivist coverage, six CCOs (32%) for tele-ICU coverage, 15 CCOs (79%) for APP salaries, eight CCOs (42%) for data analytics, and six CCOs (32%) for care coordination, and 16 CCOs (84%) continued to receive annual budgetary maintenance support for the CCO integration. Critical Care Medicine

To date, CCOs have been formed in large tertiary/quaternary care health systems that provide advanced technologies, for example, implantable cardiac assist devices, extracorporeal membrane oxygenation and transplant surgery. For standalone neighboring hospitals, strategic alliances and a regional ICU network could be developed with a CCO. In such a model of care, the CCO could provide tertiary/quaternary care often not feasible at smaller institutions. Regionalization of critical care delivery and creation of ICU care networking with smaller regional hospitals may achieve better care, lower costs, and better health of the regional population. It will likely yield a better patient and family experience and lower costs for patients and payers. Furthermore, CCOs with tele-ICUs can provide outreach to distant hospitals without intensivists. Toolbox to Build a Value-Based CCO To build an effective and sustainable CCO, first and foremost, value should be created based on the customers (patients) and not the suppliers (hospitals, providers, and payers). Value-based healthcare starts with understanding the true cost of care and measuring and optimizing long-term patient outcomes (33). Second, health system leaders should assess the current state of their critical care services and how it differs from the desired state (goals). Hospital administration and critical care leaders should perform a strengths, weaknesses, opportunities, and threats analysis followed by a gap analysis of the current ICU governance to determine its services, culture, vulnerabilities, and opportunities. Third, moving to value-based care requires clinical and financial transformation. As stated by Don Berwick, “[Better] performance is not simply–it is not even mainly–a matter of effort; it is a matter of design.” There are six essential components involved in the transformation: integrated practice units, cost and outcomes measurement, bundled payments, integrated care delivery across facilities, expanded services across geography, and an information technology platform to enable those processes (33). The prerequisites to formation of a CCO and delivering a high-value–based system are transitioning exceptional clinicians to leaders, focusing on interprofessional team development, and change management (34–39); the goals, barriers, tasks, and tools are shown in Table 1. Highperforming teams are now widely recognized as essential tools for constructing patient-centered, coordinated, and effective healthcare systems delivering high-quality care. Healthcare leaders, in and out of critical care medicine, must measure their performance by patient outcomes; precisely apply incentives; improve processes; transform dysfunctional cultures; and develop meaningful metrics that can be measured, compared, and replicated (Supplemental Digital Content 3, http://links.lww. com/CCM/C827). In Table 2, we will discuss how a CCO can help manage some of the domains in the toolbox and its challenges. Examples of value-based care financial transformation and waste reduction incentive program are shown in Supplemental Digital Content 4 (http://links.lww.com/CCM/C828). www.ccmjournal.org

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

3

Leung et al

Figure 1. Roadmap and toolbox to build a value-based critical care organization (CCO).

4

www.ccmjournal.org

XXX 2017 • Volume 45 • Number 12

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Feature Article

TABLE 1.

Clinical Transformation: Prerequisites for Delivering a High Value-Based System

Domains

Benefits

Barriers

Recommendations (Tasks)

Clinician leadership

•  Transform exceptional clinicians into clinician leaders

•  Common, but flawed assumption— outstanding clinicians are capable of leading

•  Define and assign work (choosing people, planning, organizing, communicating, and delegating)

•  Create organizational •  Different mindsets and skillsets: “change capacity” and a critiExceptional clinicians, very often, cal mass are doers and deciders; they value autonomy, seek quick gratification, have a reactive mindset, and are patient advocates. Leaders are planners and designers; they value collaboration, delegate work, have a more proactive approach, and are organization advocates

•  Enable staffs to do their work (acquiring resources, problem solving, communicating, monitoring, and providing feedback) •  Build social connections to stakeholders, administration, and the frontline

Team development

•  Ensure that the patient and •  Unable to complete the five stages of team development: Forming, family are at the center— storming, norming, performing, and requires careful planning adjourning and execution •  Norming needs to develop before •  Target of team-based care real improvement occurs and matching resources to patient and family needs to •  Most teams never reach performing stage maximize value •  Build bridges to ongoing activities—critical to ensure efficiency •  Define a coordinated research agenda—to achieve continuously improving, highvalue care

•  Shape siloed physicians and stakeholders into teams •  Measure their performance not by how much they do but by how their patients fare •  Precisely apply financial and behavioral incentives •  Improve processes and transform dysfunctional cultures

Change management

•  Eliminate waste •  Improve workflow •  Optimize inventory •  Enhance customer relationships •  Change the work environment, ­manage time •  Manage variation •  Design systems to prevent errors •  Focus on the design of products and services

•  Current improvement methods are •  Understand both internal and external factors in the workplace and complex excessively dependent on vigilance human behaviors and hard work •  Use a systematic, comprehensive •  Educating staff, developing new framework for change management: policies, and promoting good will 1) Address the “human side” systemare weak actions and less effective; atically; 2) start at the top; 3) involve however, these actions represent every layer; 4) make the formal case; the large majority of healthcare 5) create ownership; 6) communicate improvement efforts the message; 7) assess the cultural •  Studies show that up to three landscape; 8) address culture explicquarters of improvement efforts fail itly; 9) prepare for the unexpected; due to a lack of focus on change and 10) speak to the individual management

Roadmap Phase 2: Vertical Integration—Managing Care Across the Continuum Value-based care is focused on the overall health of a patient or a patient population, not on an episode of care. Recently, the terms “acute care continuum” and “postacute care continuum” have appeared in healthcare; hospitals and post-acute care institutions are forming networks to ensure quality across this continuum. Critical illness survivorship is the focus of a new agenda in the value-based world. A new care model with integrated care delivery infrastructure and coordination is needed, one that incorporates personalized cognitive-behavioral-social-physical interventions, risk-based preventive management, chronic disease management, and goals of care. Vertical care integration Critical Care Medicine

for ICU survivors should include “alliances” with the CCO, hospital medicine, palliative care medicine, inpatient rehabilitation, psychiatry, nutrition, primary care providers, social workers, long-term acute care hospitals, skilled nursing facilities, and home care services as an interprofessional team. Since ICU survivors are living in a specific life stage with a collection of new impairments (e.g., PICS/CCI), a service line management model can be entertained. The New York Delivery System Reform Incentive Payment is creating ambulatory ICUs, a model endorsed by the Institute for Healthcare Improvement to improve care and health outcomes for high-risk and high-cost adult with complex and chronic care needs (58). Three critical care outpatient recovery centers have been established in the United States. www.ccmjournal.org

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

5

Leung et al

TABLE 2. How a Critical Care Organization Can Help Manage Some of the Domains in the Toolbox Current State and Challenges

Domains

Suggested Future State

•  Accurate activity-based cost accounting methods and transactional cost accounting analyses for critical care services is crucial (40, 41) •  Bundled payments offer strong financial incentives for integrated delivery networks to actively manage their critical care services through CCOs. An example is provided in shown in Supplemental Digital Content 4 (http://links. lww.com/CCM/C828) •  Plans that incentivize efficiency are more likely to improve performance than plans that focus on traditional productivity metrics, for example, relative value units and service metrics (42, 43) •  Applying financial and behavioral incentives with shared saving may increase awareness, promote teamwork and communication, and increase value for all stakeholders (44)

Advantages of Having a CCO

•  Administrators increasingly collaborate with critical care leaders on how operational objectives can synergistically decrease organizational costs, for example, developing standardized sepsis treatment protocols •  Understanding the clinical needs of the population being served and methods by which a CCO affects case volume and clinical outcomes is fundamental to relating efficiencies and the costs of care. Depending on the model used for intensivist staffing, substantial cost savings have been reported as well as increased costs over reported ranges of clinical outcomes (45) •  Studies of high-performing Accountable Care Organizations have identified that common ICU practices, such as interprofessional daily rounds, are associated with better outcomes (46) •  One of the valuable key functions of a CCO is its ability to align operational and financial incentives. Aligning incentives starts with a clear, complete, and transparent understanding of how those incentives align with patientcentered outcomes (47, 48). Recent studies suggest that incentives can be effective for reducing the costs of high-quality critical care (Supplemental Digital Content 4, http://links.lww.com/ CCM/C828) (44, 49). •  Effective CCOs that manage risk by using operationally correct approaches with financial incentives would seem to be more effective at improving performance and managing costs of high-quality services.

Financial transformation

•  CCO leaders need to understand how ICUs impact the total cost of care to hospitals and patients

Costs

•  Many healthcare systems •  The cost of the entire care cycle— •  Benefitting from economies of scale, CCO can recruit data analysts and, initial hospitalization, ICU admisstruggling to determine working with institutional finance departsion, long-term acute care hospithe true costs of care ments, study the cost data for the entire tals/rehabilitation, home care, and •  When facing advanced ICU patient cohort, identifying historireadmission—is linked illness, patients rank the cal trends and performing longitudinal cost of treatment as their analyses; this reduces the need for highest concern (50) individual departments to hire their own •  Without knowing the costs analysts and to generate databases, across different clinical saving system resources. settings and practices, •  The CCO can project and forecast financial risks cannot be outcomes for distinct patient groups managed by patients or accordingly and develop new strategies health systems and care pathways for ICU patients and survivors (Continued )

6

www.ccmjournal.org

XXX 2017 • Volume 45 • Number 12

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Feature Article

TABLE 2. (Continued ). How a Critical Care Organization Can Help Manage Some of the Domains in the Toolbox Current State and Challenges

Domains

Suggested Future State

Advantages of Having a CCO

•  The leadership and frontline staff •  Performance improvement will only be sustainable if the system is integrated should be all trained, engaged and the goals are strategically aligned and involved in performance with the organizational culture, team­improvement building and training needs, commu•  The IHI uses the Model for nication processes, and team-based Improvement as a framework to carrots and sticks guide improvement effort •  When all the ICUs across the system •  W. Edwards Deming’s 14 points are managed under a CCO, perforon quality management is a core mance improvement is more likely to concept on implementing total be sustained with a healthy dose of quality management competition among the units, which •  IHI strongly recommends applywould promote better teamwork than ing Lean principles to healthcare struggling for improvement in siloed delivery (51) units •  Lean thinking focuses on removing waste so that all work adds value and serves the customer’s needs •  To deliver Lean principles at the bedside, leadership and frontline staff must redesign processes to improve flow and reduce waste •  Buchman offers a concise eightstep management construct that serves as a framework for critical care leaders and is applicable to all types of ICUs (52)

Performance improvement

•  Root cause analysis by itself rarely improves processes; there should be an action plan, assigned to a responsible party, and a follow-up plan to assess effectiveness—an “effector arm” •  Only a portion of the leadership and frontline staff are trained in performance improvement

Outcomes

•  Some advanced CCOs have followed •  Current performance met- •  Future NQF measures will likely survivors in postacute care settings and assess interdisciplinary, integrated rics often evaluate critical monitored long-term outcomes care and emphasize patientcare as a discrete event in centered care and long-term, a patient’s care, and most functional outcomes (54) of the reporting metrics are short-term (e.g., length •  A value framework would offer a unifying orientation for all stakeof stay, mortality, hospitalholders: providers, patients, payers, acquired infections) and the hospital system (55) •  To date, Centers for Medicare and Medicaid Services •  Murthy proposed a value framework for patients in the ICU (53), whereas and the NQF have not Boucher proposed a framework endorsed patient-centered, for improving care for patients with long-term outcomes (e.g., chronic critical illness (56) functional status, quality of life) (Supplemental Digital Content 3, http://links.lww. com/CCM/C827) (53)

Meaningful metrics and real-time analytics

•  CCO can consolidate resources to •  Meaningful metrics in criti- •  Measuring outcomes may help to transform big data into actionable infordefine organizational goals, align cal care are still in their mation and intervention opportunities, team efforts with these goals, and infancy disseminate information efficiently in a motivate clinicians to compete with, •  Data need to be timely, horizontal manner across departmental and learn from, each other, often accurate, and actionable silos, and communicate with the frontso that advanced analytics highlighting value-enhancing and line, stakeholders, and leadership cost-reduction opportunities (57) can be effectively deliv•  An advanced level of measuring ered and communicated outcomes involves complex data to the frontline, stakeholdsets (“big data”) and analytics ers, and the leadership •  Health systems that invest •  Data analytics in business intelligence with solutions are not able advanced analytics as a core to work efficiently in strategy for delivering valuea horizontal manner based care require complex across departmental data governance and integration silos across the continuum of care

CCO = critical care organization, IHI = Institute for Healthcare Improvement, NQF = National Quality Forum.

Critical Care Medicine

www.ccmjournal.org

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

7

Leung et al

CCO and ACO Clinical integration focuses on care improvement for provider practices across specialty types and ACO focuses on care improvement across the continuum for an entire patient population (59). Horizontal integration focuses predominantly on quality, performance, and efficiency improvement within the ICU arena without embracing the full spectrum of care coordination. Vertical integration focuses on the full spectrum of care, from ICU to postacute care, which is, by definition, the model of an ACO. CCOs with horizontal and vertical integration serve as the provider platforms for building ACOs for ICU survivors, offering the framework needed to align a large group of providers from the interprofessional team around goals for standardization, coordination, efficiency in managing high-cost, high-risk ICU survivors. Since there has been an increase in value-based contracts from Medicare and other insurers, the unified governance structure of CCO is appealing to the ACO. Using the infrastructure and best practices from the ACO, a CCO can work synergistically with the ACO to more effectively manage care gaps, track cost and long-term outcomes, and provide resources for the survivors. Population health management is needed for ICU survivors.

HOW TO MAKE THE CASE TO HEALTH SYSTEMS Even with the best intentions, pursuing an integrated strategy for ICU patients and survivors is challenging; there are crucial benefits health system executives expect to see if they are to support the implementation of a CCO. In general, systems focus on clinical, operational, and financial outcomes. The role of the CCO as a model of horizontal integration is to become a high performing organization—effective standardization of processes, to provide effective oversight, attention to system design, build coalitions, provide appropriate incentives and accountability, and increase efficiencies from economies of scale to ensure long-term sustainability. Vertical integration has the potential to provide a unified transition of care across all settings for a given episode of illness. No matter what the model is, the goals are the same—to create meaningful longteam patient-centered outcome metrics, to examine long-term healthcare utilization and cost for ICU survivors, to formulate care pathways through constant learning from care processes, to reduce unwanted variations in ICU, post-ICU and postacute care and to improve patients’ experiences and outcomes—to provide value to patient, to physicians, to health system (e.g., reducing lengths of stay and readmission rates) and to payers. Increasing value of the care provided is the major driver in a CCO’s formation. Evidence-based medicine can be harnessed and utilized across all ICUs to reduce unwarranted variation in practice. CCO leaders can create hospital-wide critical care policies and procedures and ensure unit leadership is held accountable for their performance. Based on the follow-up survey, 10 CCO leaders (50%) agreed that CCO integration within the medical school and hospital system, which allows the CCO to appoint physicians to the faculty, was 8

www.ccmjournal.org

more effective (Supplemental Digital Content 2, http://links. lww.com/CCM/C826). Competitive advantage can be gained through these two phases (horizontal and vertical) of care integration. Common economic calculations presented in the business case include return on investment and cost-benefit analysis (CBA), with CBA being more comprehensive as it accounts for both tangible, and intangible, costs and benefits. In most cases, executives expect to see an economic justification based on phased benefits and costs over a 3–5–year window. In general, a positive CBA within a 2-year timeframe is favorable. Integration would lead to the development of innovative payment and care delivery models (32). Hospital costs are both fixed and variable. Fixed (operational) costs are required to provide care (60), for example, labor, medical technologies, equipment purchases, and maintenance are spread across each patient, whereas variable costs are associated with the care of individual patients and will fluctuate with patient volumes, for example, staffing, specific medications, transfusion, and imaging (61). How fixed and variable costs, clinical outcomes, and revenue are impacted by horizontal and vertical integration would depend on the current capability, maturity, and structure of health system under consideration. A successful CCO allows highly skilled leaders and its interprofessional team to concentrate their full attention on critical care operations. In the traditional model, each siloed ICU is managed by a different department with little communication among ICU directors. They create their own ICU budgets and negotiate with hospital leaders independently from each other; hospital subsidies for each ICU vary and variances in occupancy, acuity, provider staffing, quality, and access may exist. CCO leadership forms an effective dyad model with hospital leadership to achieve shared goals in managing this challenging population and its associated costs (34). Hospital executives will require that clinicians work together to manage risk and achieve quality outcomes over long periods, essential to preserving the premium brand and long-term fiscal sustainability of a hospital/health system. If care integration can be implemented horizontally and vertically, the competitive advantage of hospitals and health systems will be sustained.

CONCLUSIONS With a rising and unsustainable cost, patient- and familycentered, high-quality care ought to remain the order of the day for patients, providers, and payers. Many health systems operate on thin margins and battle cost while simultaneously striving to improve care. The Congressional Budget Office suggests that the magnitude of the financial impact hospitals will face depends on how much they can improve their productivity over time (62). Consolidation within and between hospitals and health systems does not mean functional clinical integration unless hospital administrators and clinicians agree to pull down the walls of their respective silos. In a “siloed” organization, managing patients with critical illness, PICS, and CCI have a high risk of failure. XXX 2017 • Volume 45 • Number 12

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Feature Article

We provide a framework for CCOs and a toolkit for health systems and critical care leaders to consider and adopt after consideration of its physician-hospital relationship, covered lives, and the culture, complexity, and structure of their individual system. All healthcare is local; there is no one-size-fitsall strategy. A CCO with functional clinical horizontal and vertical integration, alignment of strategy and operations with the health system, and knowledge of finance, risk-based contracting, and risk management is more likely to succeed in the value-based world than “siloed” ICUs without integration.

REFERENCES

1. National Health Expenditures 2015 Highlights. Available at: https:// www.cms.gov/Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed December 26, 2016 2. Davis K, Stremikis K, Squires D et al: Mirror, mirror on the wall. How the performance of the US health care system compares internationally. Available at: http://www.commonwealthfund.org/~/media/files/ publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014_ exec_summ.pdf. Accessed December 26, 2016 3. Berwick DM, Hackbarth AD: Eliminating waste in US health care. JAMA 2012; 307:1513–1516 4. Porter ME: A strategy for health care reform—toward a value-based system. N Engl J Med 2009; 361:109–112 5. Dzau VJ, McClellan MB, McGinnis JM, et al: Vital directions for health and health care: Priorities from a National Academy of Medicine Initiative. JAMA 2017; 317:1461–1470 6. Muhlestein D, McClellan M: Accountable Care Organizations in 2016: Private and public sector growth and dispersion. Health Affairs Blog, 2016. Available at: http://healthaffairs.org/blog/2016/04/21/ accountable-care-organizations-in-2016-private-and-public-sectorgrowth-and-dispersion/. Accessed May 20, 2017 7. US Health Services deals insights. Analysis and trends in US health services activity 2014 and 2015 outlook. PwC’s deals practice. Available at: https://www.pwc.com/us/en/healthcare/.../pwc-healthservices-deals-insights-2014.pdf. Accessed September 28, 2016 8. Milburn JB, Maurar M: Strategies for value-based physician compensation. 2013 Medical Group Management Association. Available at: http://www.mgma.com/Libraries/Assets/Store/Books/8652-excerpt. pdf. Accessed October 1, 2016 9. Pastores SM, Halpern NA, Oropello JM, et al: Critical care organizations in academic medical centers in North America: A descriptive report. Crit Care Med 2015; 43:2239–2244 10. Vincent JL: The future of critical care medicine: Integration and personalization. Crit Care Med 2016; 44:386–389 11. Halpern NA, Goldman DA, Tan KS, et al: Trends in critical care beds and use among population groups and Medicare and Medicaid beneficiaries in the United States: 2000-2010. Crit Care Med 2016; 44:1490–1499 12. Wunsch H, Angus DC, Harrison DA, et al: Variation in critical care services across North America and Western Europe. Crit Care Med 2008; 36:2787–2793, e1 13. Unroe M, Kahn JM, Carson SS, et al: One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: A cohort study. Ann Intern Med 2010; 153:167–175 14. Angus DC, Shorr AF, White A, et al; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS): Critical care delivery in the United States: Distribution of services and compliance with Leapfrog recommendations. Crit Care Med 2006; 34:1016–1024 15. Karpf M, Lofgren R: Commentary: Institutes versus traditional administrative academic health center structures. Acad Med 2012; 87:555–556 16. Czerwonka AI, Herridge MS, Chan L, et al: Changing support needs of survivors of complex critical illness and their family caregivers across

Critical Care Medicine

the care continuum: A qualitative pilot study of towards RECOVER. J Crit Care 2015; 30:242–249 17. Ellis KA, Connolly A, Hosseinnezhad A, et al: Standardizing communication from acute care providers to primary care providers on critically ill adults. Am J Crit Care 2015; 24:496–500 18. Prescott HC, Langa KM, Iwashyna TJ: Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions. JAMA 2015; 313:1055–1057 19. Jones TK, Fuchs BD, Small DS, et al: Post-acute care use and hospital readmission after sepsis. Ann Am Thorac Soc 2015; 12:904–913 20. Ferris FD, Bruera E, Cherny N, et al: Palliative cancer care a decade later: Accomplishments, the need, next steps—from the American Society of Clinical Oncology. J Clin Oncol 2009; 27:3052–3058 21. Gallop KH, Kerr CE, Nixon A, et al: A qualitative investigation of patients’ and caregivers’ experiences of severe sepsis. Crit Care Med 2015; 43:296–307 22. Cox CE, Docherty SL, Brandon DH, et al: Surviving critical illness: Acute respiratory distress syndrome as experienced by patients and their caregivers. Crit Care Med 2009; 37:2702–2708 23. Fried TR, Bradley EH, Towle VR, et al: Understanding the treatment preferences of seriously ill patients. N Engl J Med 2002; 346:1061–1066 24. Needham DM, Davidson J, Cohen H, et al: Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference. Crit Care Med. 2012; 40:502–509 25. Pandharipande PP, Girard TD, Jackson JC, et al; BRAIN-ICU Study Investigators: Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369:1306–1316 26. Jackson JC, Pandharipande PP, Girard TD, et al; Bringing to light the Risk Factors And Incidence of Neuropsychological dysfunction in ICU survivors (BRAIN-ICU) study investigators: Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: A longitudinal cohort study. Lancet Respir Med 2014; 2:369–379 27. Iwashyna TJ, Ely EW, Smith DM, et al: Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304:1787–1794 28. Nelson JE, Cox CE, Hope AA, et al: Chronic critical illness. Am J Respir Crit Care Med 2010; 182:446–454 29. Iwashyna TJ: Survivorship will be the defining challenge of critical care in the 21st century. Ann Intern Med 2010; 153:204–205 30. The Concentration of Health Care Spending. HIHCM Foundation Data Brief, 2012. Available at: http://www.nihcm.org/pdf/DataBrief3%20 Final.pdf. Accessed October 1, 2016 31. Hill AD, Fowler RA, Pinto R, et al: Long-term outcomes and healthcare utilization following critical illness—a population-based study. Crit Care 2016; 20:76 32. The value of provider integration. American Hospital Association March 2014. Available at: http://www.aha.org/content/14/14marprovintegration.pdf AHA 2014. Accessed November 18, 2016 33. Porter ME, Lee TH: The strategy that will fix health care. Harv Bus Rev 2013; 91:50–70 34. Angood P, Birk S: The value of physician leadership. Physician Exec 2014; 40:6–20 35. Health Research & Educational Trust: Building a Leadership Team for the Health Care Organization of the Future. Chicago, IL, Health Research & Educational Trust. Available at: http://www.hpoe.org/ futureleadershipcompetencies. Accessed September 28, 2016 36. Shaller D: Patient-centered care: What does it take? The Commonwealth Fund, 2007. Available at: http://www.commonwealthfund.org/usr_doc/Shaller_patient-centeredcarewhatdoesittake_1067.pdf?section=4039. Accessed October 1, 2016 37. McCarthy D, Mueller K, Wrenn J: Mayo Clinic: Multidisciplinary teamwork, physician-led governance, and patient-centered culture drive world-class health care. The Commonwealth Fund. Case Study Organized Health Care Delivery System. Available at: http:// www.commonwealthfund.org/~/media/Files/Publications/Case%20 Study/2009/Aug/1306_McCarthy_Mayo_case%20study.pdf. Accessed September 28, 2016 www.ccmjournal.org

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

9

Leung et al 38. HFMA’s Value Project: Phase 2. The value journey: Organizational road maps for value-drive health care. Healthcare Financial Management Association. Available at: https://www.hfma.org/ValueProject/ Phase2/. Accessed October 1, 2016 39. Page A (Ed): Keeping Patients Safe: Transforming the Work Environment of Nurses. Institute of Medicine (US) Committee on the Work Environment for Nurses and Patient Safety. Washington, DC, National Academies Press, 2004 40. Geyer BC, Peak DA, Velmahos GC, et al: Cost savings associated with transfer of trauma patients within an accountable care organization. Am J Emerg Med 2016; 34:455–458 41. Udpa S: Activity-based costing for hospitals. Health Care Manage Rev 1996; 21:83–96 42. Corneliuson SK, Hackman B: Strategies for redesigning physician compensation. Healthc Financ Manage 2014; 68:60–66 43. Levin LS, Gustave L: Aligning incentives in health care: Physician practice and health system partnership. Clin Orthop Relat Res 2013; 471:1824–1831 44. Murphy DJ, Lyu PF, Gregg SR, et al: Using incentives to improve resource utilization: A quasi-experimental evaluation of an ICU quality improvement program. Crit Care Med 2016; 44:162–170 45. Pronovost PJ, Needham DM, Waters H, et al: Intensive care unit physician staffing: Financial modeling of the Leapfrog standard. Crit Care Med 2006; 34:S18–S24 46. Mick SS, Shay PD: Accountable care organizations and transaction cost economics. Med Care Res Rev 2016; 73:649–659 47. Tzelepis F, Sanson-Fisher RW, Zucca AC, et al: Measuring the quality of patient-centered care: Why patient-reported measures are critical to reliable assessment. Patient Prefer Adherence 2015; 9:831–835 48. Reece EA, Nugent O, Wheeler RP, et al: Adapting industry-style business model to academia in a system of performance-based incentive compensation. Acad Med 2008; 83:76–84 49. Rosenthal MB, Fernandopulle R, Song HR, et al: Paying for quality: Providers’ incentives for quality improvement. Health Aff (Millwood) 2004; 23:127–141 50. Consumer perceptions and needs regarding advanced illness care: Are we listening? Report brief. Available at: http://www.thectac. org/wp-content/uploads/2014/10/C-TAC-Consumer-PerceptionsPaper-1-02-2014.pdf. Accessed September 28, 2016

10

www.ccmjournal.org

51. Going lean in health care. IHI Innovation Series white paper. Cambridge, MA, Institute for Healthcare Improvement, 2005. Available at: https://www. entnet.org/sites/default/files/GoingLeaninHealthCareWhitePaper-3. pdf. Accessed October 1, 2016 52. Buchman T: A perspective on ICU administration. In: Comprehensive Critical Care: Adult. Roberts PR, Todd SR (Eds). Mount Prospect, IL, Society of Critical Care Medicine, 2012, pp 861–873 53. Murphy DJ, Ogbu OC, Coopersmith CM: ICU director data: Using data to assess value, inform local change, and relate to the external world. Chest 2015; 147:1168–1178 54. Martinez EA, Donelan K, Henneman JP, et al: Identifying meaningful outcome measures for the intensive care unit. Am J Med Qual 2014; 29:144–152 55. Lee TH: Putting the value framework to work. N Engl J Med 2010; 363:2481–2483 56. Boucher NA, White S, Keith D: A framework for improving chronic critical illness care: Adapting the medical home’s central tenets. Med Care 2016; 54:5–8 57. Stowell C, Akerman C: Better value in health care requires focusing on outcome. Harv Bus Rev. Available at: https://hbr.org/2015/09/better-value-in-health-care-requires-focusing-on-outcomes. Accessed September 17, 2016 58. New York State Delivery System Reform Incentive Payment Program Project Toolkit. Available at: https://www.health.ny.gov/health_care/medicaid/redesign/docs/dsrip_project_toolkit.pdf. Accessed May 20, 2017 59. O’Hara S: The care transformation alphabet: What’s the difference between CI, ACO, and PCMH, 2014. Available at: https://www.advisory.com/research/care-transformation-center/care-transformationcenter-blog/2014/09/deciphering-the-reform-alphabet. Accessed May 22, 2017 60. Roberts RR, Frutos PW, Ciavarella GG, et al: Distribution of variable vs fixed costs of hospital care. JAMA 1999; 281:644–649 61. Rossi C, Simini B, Brazzi L, et al; Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva: Variable costs of ICU patients: A multicenter prospective study. Intensive Care Med 2006; 32:545–552 62. Hayford T, Nelson, J, Diorio A: Projecting Hospitals’ Profit Margins Under Several Illustrative Scenarios. Washington, DC, Working Paper Series Congressional Budget Office, 2016. Available at: http://www.cbo.gov/ sites/default/files/114th-congress-2015–2016/workingpaper/51919Hospital-Margins_WP.pdf. Accessed October 15, 2016

XXX 2017 • Volume 45 • Number 12

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Feature Article

Appendix 1 Academic Leaders in Critical Care Medicine (ALCCM) Task Force Co-Chairs: Vladimir Kvetan, MD, FCCM, Montefiore Medical Center, Bronx, NY; Stephen M. Pastores, MD, FCCM, Memorial Sloan Kettering Cancer Center, New York, NY. ALCCM Task Force Members: Derek C. Angus, MD, MCCM, University of Pittsburgh Medical Center, Pittsburgh, PA; Gregory Beilman, MD, FCCM, University of Minnesota, Minneapolis, MN; Daniel R. Brown, MD, PhD, FCCM, Mayo Clinic, Rochester, MN; Timothy S. Buchman, MD, MCCM, Emory Critical Care, Atlanta, GA; John Christman, MD, The Ohio State University, Columbus, OH; J. Perren Cobb, MD, FCCM, University of Southern California, Los Angeles, CA; Craig M. Coopersmith, MD, FCCM, Emory Critical Care, Atlanta, GA; Jose Diaz-Gomez, MD, FCCM, Mayo Clinic, Jacksonville, FL; Christopher Doig, MD, University of Calgary, Calgary, CA; J. Christopher Farmer, MD, FCCM, Mayo Clinic, Scottsdale, AZ; James Gasperino, MD, The Brooklyn Hospital Center, Brooklyn, NY; Sara R Gregg, MHA, Emory Critical Care, Atlanta, GA; Neil A. Halpern, MD, MCCM, Memorial Sloan Kettering

Critical Care Medicine

Cancer Center, New York, NY; Daniel L. Herr, MD, FCCM, University of Maryland, Baltimore, MD; R. Duncan Hite, MD, Cleveland Clinic, Cleveland, OH; A. Joseph Layon, MD, Geisinger Medical Center, Danville, PA; Andrew Leibowitz, MD, FCCM, Mount Sinai Medical Center, New York, NY; Sharon Leung, MD, Montefiore Medical Center, Bronx, NY; Craig M. Lilly, MD, FCCM, University of Massachusetts, Worcester, MA; Jon Marinaro, MD, FCCM, University of New Mexico, Albuquerque, NM; Henry Masur, MD, MCCM, National Institutes of Health Clinical Center, Bethesda, MD; Jason Moore, MD, University of Pittsburgh Medical Center, Pittsburgh, PA; Joseph L. Nates, MD, MD Anderson Cancer Center, Houston, TX; John M. Oropello, MD, FCCM, Mount Sinai Medical Center, New York, NY; Marc Popovich, MD, FCCM, University Hospitals, Cleveland, OH; Kristen Price, MD, MD Anderson Cancer Center, Houston, TX; Curtis Sessler, MD, FCCM, Virginia Commonwealth University, Richmond, VA; Daniel P. Stoltzfus, MD, Washington Hospital Center, Washington, DC; and Stephen Trzeciak, MD, FCCM, Cooper University Hospital, Camden, NJ.

www.ccmjournal.org

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

11

Performance Building.

New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the v...
479KB Sizes 2 Downloads 12 Views