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Centers of Excellence. The Way Health Care Gets Better™. Portrait of a Dysfunctional Market. Health Care Market Place Government pays for over 40% of the care delivered in the United States

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centers of excellence

Centers of Excellence

The Way Health Care Gets Better™

portrait of a dysfunctional market
Portrait of a Dysfunctional Market
  • Health Care Market Place
    • Government pays for over 40% of the care delivered in the United States
      • The Federal Government dictates what fees will be paid to providers for Medicaid and Medicare recipients
      • Economic principal of supply and demand to determine price is ignored (increased volume for lower price)
      • No incentives to use efficient, quality providers
      • Results in a cost shift to the private sector
  • Cost and quality information not available to consume to foster a competitive marketplace
  • Over Utilization
    • Financial incentives encourage more services
why centers of excellence
2.93% of the members used 50.7% of the claims dollars

12.63% of the members used 79.3% of the claims dollars

Why Centers of Excellence?
federal hhs four cornerstones
Federal HHS “Four Cornerstones”
  • Connecting the System Standards and support for e-health.
  • Measure & Publish Quality Partner with providers to get measures that work.
  • Measure & Publish Price “Episodes of Care” model.
  • Create Positive Incentives Reward those who offer, provider and choose value (Quality/Price).

“Every American should have access to a full range of information about the quality and cost of their health care options”

- HHS Secretary, Michael O. Leavitt

some enterprises found centers of excellence cut costs by 25 40
Some Enterprises Found Centers of ExcellenceCut Costs by 25-40%

Procedure: Several

Procedure: Cardiac, Spine, Orthopedic & Transplant

Procedure: Cardiac & Orthopedic

Procedure: Orthopedic

Procedure: Cardiac & Orthopedic

creation of centers of excellence for episode of care payment
Creation of Centers of Excellence for episode of care payment
  • Global Fees for Episodes of Care
    • Includes all services to complete episode
  • Episodes with Complications
    • Complicated cases revert to fee for service
  • Payment Systems
    • Global fee paid to facility for disbursement
    • Global fee based on episode benchmark
      • 20% Physician withhold
      • Complete Episode
        • Physician receives withhold plus 50% of savings if total costs are below benchmark
to enable the creation of centers of excellence a robust data base is required
To enable the creation of Centers of Excellence a robust Data Base is required
  • Cost Effective Quality Providers Selected from Database
    • Health Insurers Data Base
    • All Payer Data Base
    • Utah Health Information Network
  • Designated Centers of Excellence
    • Chronic conditions
    • Outpatient surgery
    • Inpatient surgery
  • Centers of Excellence Increases Volume to Designated Providers
    • Increased volume used to negotiate global fees
physician review
Physician Review

Specialty Episode Case-Mix Summary Top ETGs, by Total Costs (Complete Episodes of Care)

Episodes

results centers of excellence for prostate
Results: Centers of Excellence for Prostate
  • Total cost non-Center of Excellence: $38,533 (Patient paid $14,263)
  • Total cost Center of Excellence: $14,451 (Patient paid $1,298)
center of excellence member engagement
Center of Excellence Member Engagement

Online Consumer Guide

  • Procedure Education
  • List of DSP (Designated Service Plan) Providers
  • Favorable Co-Payments for DSP Providers
  • High, low and average cost for procedures