A SHARED SAVINGS MODEL:

Marillac Clinic and St. Mary’s Hospital

March 2, 2010

Steve Hurd - Steve.Hurd@stmarygj.org

David West - Dwest000@bresnan.net

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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