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Healthcare Environment in Transition: Opportunities for Rural Health Systems

"BeaverkillBridge" by Peter Bond from Philadelphia, USA - Licensed under CC BY-SA 2.0 via Wikimedia Commons

2015 Missouri Hospital Association Rural Healthcare Conference

Rural Healthcare: Its Effect on Rural CommunitiesHilton Garden Inn Conference Center

Columbia, MOSeptember 15, 2015

Eric K. Shell, CPA, MBA

2

• In the past 36 months, the healthcare field has experienced considerable changes with an increased number of rural-urban affiliations, physicians transitioning to hospital employment models, flattening volumes, CEO turnover, etc.

• Federal healthcare reform passed in March 2010 with sweeping changes to healthcare systems, payment models, and insurance benefits/programs

• Many of the more substantive changes will be implemented over the next two years

• State Medicaid programs are moving toward managed care models or reduced fee for service payments to balance State budgets

• Commercial insurers are steering patients to lower cost options

• Thus, providers face new financial uncertainty and challenges and will be required to adapt to the changing market

The Healthcare Environment Has Changed!

INTRODUCTION

3

• High Deductible Health Plans• Non Healthcare CEO quote:

• “We just renewed our High Deductible Plan going into our third year, and guess what.....5% reduction in premium!!! Needless to say everyone is thrilled. Not sure what the average HSA balance is, but I think it is high. Doing what it is supposed to do, turning health care patients into consumers.”

• Underinsurance• State Budget Deficits• Recovery Audit Contractors (RAC)• Reduced Re-admissions• Accelerating shift to outpatient care•SGR Fix•Comprehensive Pay Model•340B attacks•New payment models

Market Overview

MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

4

Growth of High Deductible Plans


5

Underinsurance Rates Among Adults Who Were Insured All Year by Source of Coverage at the Time of Survey

Source: http://www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance


6

High Deductible Insurance Impact


7

Reduced Readmission Rates


CMS: 2,610 PPS hospitals to receive penalties in 2015Source: Centers for Medicare and Medicaid Services, Offices of Enterprise Management

8

Trend of Lower Inpatient Use

Inpatient Days per 1,000 Persons, 1991 – 2011

91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11400

600

800

1,000

883.9

600.374890882947

Inpa

tient

Day

s pe

r Tho

usan

d

Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2011, for community hospitals. US Census Bureau: National and State Population Estimates, July 1, 2011. Link: http://www.census.gov/popest/data/state/totals/2011/index.html.

Compound Adjusted Annual Rate Decline of 2%


9

• Declining Patient Volumes

Market Overview – Results


Source: Kaiser State Health Facts, kff.org

2005 2006 2007 2008 2009 2010 2011 2012 2013120

125

130

135

140

145

150

144142 142 141

138 137 136133

129

Missouri Hospital Admissions per 1000 Population

10

SGR Fix – Rate Changes Summary

Time frame Rate Increase

2016 – 2019 0.5%

2020 – 2025 0%. Adjustments made based on physician’s choice to participate in 2 track program of MIPS or APM program• APM 5% bonus (2020 – 2024; fee increase of

0.75%/yr.)• MIPS -4 to +9%

2026+ • 0.75% for physicians participating in MIPS (Merit-Based Incentive Payment System) or an APM (Alternative Payment Model) program

• 0.25% for all other physicians

Sources: Health Affairs, Modern Healthcare, Congressional Budget Office


11

SGR Fix – Implications (Source: H&HN Daily 4/6/2015)

• Accelerating the replacement of Medicare¹s fee-for-service payments to physicians with risk-based alternatives• Implication: Hospital participation in patient-centered medical homes, bundled

payment and accountable care organizations as partners with their physicians is a business imperative. If a hospital is not active in these pursuits, nonemployed physicians might find business partners with capital, expertise and infrastructure elsewhere.

• Increasing Medicare payments to physicians by 0.5 percent per year through 2019 is hardly enough to offset medical inflation, regulatory compliance requirements in the Affordable Care Act, IT costs for meaningful use and ICD-10 implementation.• These additional operating costs will require hospitals to develop more

sophisticated ways to manage the medical practices they own and support independent practices with whom affiliation is necessary. That might mean deferring capital from other projects to invest in better systems and personnel to assist these practices.


12

Joint Replacement Comprehensive Pay Model


13

340B Program Under Attack – GAO Report


14

340B Mega Bill – August 28, 2015


15

Service Area

• Coverage Expansion• By 1/1/14, expand Medicaid to all non-Medicare eligible individuals under age 65 with

incomes up to 133% FPL based on modified AGI • Currently, Medicaid covers only 45% of poor (≤ 100% FPL)• 16 million new Medicaid beneficiaries; mostly “traditional” patients• FMAP for newly eligible: 100% in 2014-16; 95% in 2017; 94% in 2018; 93% in 2019; 90%

in 2020+ • Establishment of State-based Health Insurance Exchanges• Subsidies for Health Insurance Coverage• Individual and Employer Mandate

• Provider Implications• Insurance coverage will be extended to 32 million additional Americans by 2019

• Expansion of Medicaid is major vehicle for extending coverage• May release pent-up demand and strain system capacity• Traditionally underserved areas and populations will have increased provider competition • Have insurance, will travel!

Market Overview – Healthcare Reform


16

Service Area

• Results (Source: Gallup August 10, 2015 Survey)



MO – 15.2% to 11.4%

17

Service Area

• Medicare and Medicaid Payment Policies• Medicare Update Factor Reductions

• Annual updates will be reduced to reflect projected gains in productivity • Medicare and Medicaid Disproportionate Share Hospital (DSH) Payment Reductions • Medicare Hospital Wage Index• Independent Payment Advisory Board (IPAB)

• Charged with figuring out how to reduce Medicare spending to targets with goal of $13B savings between 2014 and 2020

• Summary Impact



18

Service Area

• Medicare and Medicaid Payment Policies (continued)

• Provider Implications• Payment changes will increase pressure on hospital margins and increase competition

for patient volume• “Do more with less and then less with less”• Medicaid pays less than other insurers and will be forced to cut payments further



19

Service Area

• Medicare and Medicaid Delivery System Reforms• Expansion of Medicare and Medicaid Quality Reporting Programs • Medicare and Medicaid Healthcare-Acquired Conditions (HAC) Payment Policy

• By Oct. 2014, the 25% of hospitals with the highest HAC rates will get a 1% overall payment penalty

• Medicare Readmission Payment Policy• Hospitals with above expected risk-adjusted readmission rates will get reduced

Medicare payments • Value based purchasing

• Medicare will reduce DRG payments to create a pool of funds to pay for the VBPP• 1% reduction in FFY 2013, Grows to 2% by FFY 2017

• Bundled Payment Initiative• Accountable Care Organizations

• Each ACO assigned at least 5,000 Medicare beneficiaries• Providers continue to receive usual fee-for-service payments• Compare expected and actual spend for specified time period• If meet specified quality performance standards AND reduce costs, ACO receives

portion of savings



20

Service Area

• Medicare and Medicaid Delivery System Reforms (continued)• Medicare Accountable Care Organizations (continued)

• 154 ACOs effective August, 2012• 287 ACOs effective January, 2013• 391 ACOs effective January, 2014• 426 ACOs effective January 2015

• More than 70% of the U.S. population now live in localities served by ACOs and almost 44 percent live in areas served by two or more

• 7.8 million Medicare beneficiaries, or about 22% of total Medicare fee-for-service beneficiaries, now in Medicare ACOs

• These organizations also provide care to 35 million non-Medicare patients, about 6 % more than last year


http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspxhttp://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News.html


Source: Oliver Wyman, ACO Update: A Slower Pace of Growth in 2014, via healthcare-executive-insight.advanceweb.com

http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx

http://www.oliverwyman.com/insights/publications/2015/apr/aco-update--a-slower-pace-of-growth.html#.VUe6CflVhBc

21

Where Are Medicare ACOs Forming?


Source: CMS 1/20/15- Mapped from address of parent ACO

ACOs per State1-5

6-10

11-20

21-30

31-40

41+

Type Existing New 2015 Grand Total

Medicare Shared Savings Program

Advance Payment ACO Model

Pioneer ACO

Grand Total 480

19

35

426

89

89

391

19

35

337

22

ACOs in Missouri


Sources: OliverWyman.com; Franklin St ACO Database; www.missouridelta.com

According to a 2015 Oliver Wyman analysis, more than 50% of Missouri residents have access to an ACO or could receive their healthcare from an ACO.

http://gojunto.com/aco-database/location/tennessee/

http://gojunto.com/aco-database/location/tennessee/

23MARKET OVERVIEW TRANSITION FRAMEWORK STRATEGIES

ACO Growth 2010-2013


ACO Growth 2010-2013


ACO Growth – 2015 and beyond

26

ACOs – New Regulations


• ACO Investment Model (AIM) – October 15, 2014• Goal: help rural providers offset the cost of operating a MSSP ACO• Benefits:

• New MSSP candidates receive upfront fixed payment ($250K) and variable payment based on attributed beneficiary ($36/beneficiary), and monthly variable payment based on attributed beneficiary ($8)

• Upfront payments will be recovered out of shared savings• Pre-payments act as forgivable loan if applicant remains in MSSP for 3 years

and meets eligibility and performance requirements• Eligibility

• Accepted into MSSP• Less than 10K lives• No hospital unless CAH or rural hospital > 100 beds• Competitive grant with positive points for providers willing to take downside

risk

27

ACOs – New Regulations


• Next Generation ACO Model – March 10, 2015• Goal: Test ACO capacity to take on near-complete financial risk in combination with

a stable, predictable benchmark and payment mechanism• Design/Benefits

• Prospectively-set benchmark that incorporates historical and regional costs• Future trend to incorporate regional trend, patient acuity, and

quality/efficiency discount• Payment options including normal FFS payment, normal FFS plus monthly

infrastructure payment, population based payment; and capitation• Choice of one of two risk sharing arrangements that determine portion of

savings or losses that accrue to the ACO• Minimum of 10K attributed beneficiaries or 7.5K if deemed rural

28

ACOs – New Regulations – June 4, 2015

• More time under shared savings• Added Track 3: 75% savings on risk sharing plans• New methods to identify which patients are included• Refines policies for resetting ACO benchmarks

• Announces CMS’ intent to propose further improvements to benchmarking

MARKET OVERVIEW

29

Medicare ACO 2014 Results

MARKET OVERVIEW

• In August 2015, CMS issued 2014 quality and financial performance results showing that Medicare Accountable Care Organizations (ACOs) continue to improve the quality of care for Medicare beneficiaries, while generating financial savings, suggesting that ACOs are delivering higher quality care to more and more Medicare beneficiaries each year.

• According to the results During the third performance year, Pioneer ACOs generated total model savings of $120

million, an increase of 24% from Performance Year 2 ($96 million). Total model savings per ACO increased from $2.7 million per ACO in Performance Year 1 to

$4.2 million per ACO in Performance Year 2 to $6.0 million per ACO in Performance Year 3. The mean quality score among Pioneer ACOs increased to 87.2 percent in Performance

Year 3 from 85.2 percent in Performance Year 2, which was itself an improvement from 71.8 percent in Performance Year 1.

The organizations showed improvements in 28 of 33 quality measures and experienced average improvements of 3.6% across all quality measures compared to Performance Year 2.

Ninety-two Shared Savings Program ACOs held spending $806 million below their targets and earned performance payments of more than $341 million as their share of program savings.

Shared Savings Program ACOs that reported in both 2013 and 2014 improved on 27 of 33 quality measures.

Source: CMS.gov 2015 Fact Sheets

TRANSITION FRAMEWORK STRATEGIES

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-08-25.html

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-08-25.html

30

Fee-For-Service Financial ModelAssumptions

• Utilization• Inpatient and Outpatient

• Impact of ACA• Impact of Blue Cross steerage initiatives

• Revenue• Third party price increases• Cost based Medicare revenue• DSH payments (Zeroed out in 2014)• Bad debt % of patient service revenue (75% reduction in 2014)

• Impact of ACA• Meaningful use incentive payments• Other operating revenue• Non-operating gains and

• Expenses• Salaries, wages and benefits• Productivity• Supplies and other


31

Age Normalized Use Rate Comparisons – Discharges/1,000


Maryville MOAurora MOPerryville MOBranson MOOsage Beach MOHouston MOSmithville MOBolivar MOWarrensburg MOLouisiana MOKirksville MOTrenton MOLiberty MOMexico MOChillicothe MOWest Plains MOBrookfield MOCameron MONevada MOSte. Genevieve ..Clinton MOSedalia MOHannibal MOLake Saint Louis ..Excelsior Spring..MO TotalButler MOUS TotalSalem MOLexington MOFredericktown MOMarshall MODexter MOHarrisonville MOBlue Springs MOLees Summit MOLamar MOPilot Knob MOSikeston MOCarthage MONeosho MORichmond MOFarmington MOTroy MOPotosi MOCrystal City MOKennett MOHayti MO

0

20

40

60

80

100

120

140

160

180

Normalized Discharges/1,000

121.1119.2118

96

70

42

93

61

Current use rates based on Truven Healthcare Analytics population and discharge estimates by Dartmouth Hospital Service Area (HSA).2021 use rates based on Milliman Governance Institute Presentation (2/2012).

Limited to Missouri HSA’s that have a 2014 population between 10,000 and 100,000

2021 Minimally Managed Market (High 118/Low 96)

2021 U.S. Average (High 93/Low 61)

2021 Highly Managed Market (High 70/Low 42)

32

Fee-For-Service Financial Model – Results

When operating income becomes negative in 2016, cash reserves start to decline

$(18)

$(16)

$(14)

$(12)

$(10)

$(8)

$(6)

$(4)

$(2)

$-

$2

$4

2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Mill

ions

Operating income (Consolidated)

• Operational improvement and shared service economies of scale are insufficient to combat

declining utilization

• Can’t cut your way to sustainability


33

Service Area

• Medicare and Medicaid Delivery System Reforms (continued)

• Provider Implications• Hospitals are taking the lead in forming Accountable Care Organizations with

physician groups that will share in Medicare savings• Value based purchasing program will shift payments from low performing

hospitals to high performing hospitals• Acute care hospitals with higher than expected risk-adjusted readmission

rates and HAC will receive reduced Medicare payments for every discharge• Physician payments will be modified based on performance against quality

and cost indicators• There are significant opportunities for demonstration project funding



34

Sources: Kaiser Commission on Medicaid and the Uninsured (Medicaid Expansion)The North Carolina Rural Health Research Program (Closures)

Closed Rural Hospitals Since the Beginning of 2010


Closure Year CAH PPS MDH SCH

Re-based SCH DSH

Grand Total

2010 2 1 32011 2 2 1 52012 2 5 2 92013 6 5 3 1 152014 7 2 5 1 1 162015 3 4 1 1 9Grand Total 20 20 11 3 2 1 57

Medicare Payment Type

35

How Do Real and Projected Spending Compare?

Chart source: The New York TimesData source: CBO


36

• Factors that will have a significant impact on rural hospitals over the next 5-10 years • Difficulty with recruitment of providers and aging of current medical staff

• Struggle to pay market rates• Increasing competition from other hospitals and physician providers for limited

revenue opportunities• Small hospital governance members without sophisticated understanding of

small hospital strategies, finances, and operations• Consumer perception that “bigger is better”• Severe limitations on access to capital for necessary investments in infrastructure

and provider recruitment• Facilities historically built around IP model of care

• Increased burden of remaining current on onslaught of regulatory changes• Regulatory Friction / Overload

• Payment systems transitioning from volume based to value based• Increased emphasis of quality as payment and market differentiator• Reduced payments that are “Real this time”

• 3rd party steerage (surgery, lab, and Imaging), RAC audits

Challenges Affecting Rural Hospitals


37

• Subset of most recent challenges

• Payment systems transitioning from volume based to value based• Increased emphasis as quality as payment and market differentiator• Reduced payments that are “Real this time”

•New environmental challenges are the TRIPLE AIM!!!•Market Competition on economic driver of healthcare: PATIENT VALUE

We Have Moved into a New Environment!


38

• Definitions• Patient Value

• Accountable Care:• A mechanism for providers to monetize the value derived from increasing

quality and reducing costs• Accountable care includes many models including bundled payments,

value-based payment program, provider self-insured health plans, Medicare defined ACO, capitated provider sponsored healthcare, etc.

• Different “this time”• Providers monetize value• New information systems to manage costs and quality• Agreed upon evidence-based protocols • Going back is not an option

Quality

Cost

Patient

Value

Future Hospital Financial Value Equation


39

• ACO Relationship to Small and Rural Hospitals

• Revenue stream of future tied to Primary Care Physicians (PCP) and their patients

• Small and rural hospitals bring value / negotiating power to affiliation relationships as generally PCP based• Smaller community hospitals and rural hospitals have value through

alignment with revenue drivers (PCPs) rather than cost drivers but must position themselves for new market:• Alignment with PCPs in local service area• Develop a position of strength by becoming highly efficient• Demonstrate high quality through monitoring and actively pursuing

quality goals



40

• Economics

• As payment systems transition away from volume based payment, the current economic model of increasing volume to reduce unit costs and generate profit is no longer relevant • New economic models based on patient value must be developed by

hospitals but not before the payment systems have converted• Economic Model: FFS Rev and Exp VS. Budget Based Payment Rev and Exp

Loss Zone

Service Volumes

Dollars

Cost

Revenue

Profit Zone



41

Source: Forbes July 7, 2015

Primary Care Compensation


42

• Value in Rural Hospitals

• Lower Per Beneficiary Costs

• Revenue centers of the future

• PCP based delivery system

• CAH cost-based reimbursement

• Incremental volume drives down unit costs

• Once commitment to community Emergency Room, system incentives to drive low acuity volume to CAH

• MedPAC Confusion – Limited Incentives to manage costs???



43

The Challenge: Crossing the Shaky Bridge

2012 201520142013 2016

Fee for Service

Payment System

Population Based

Payment System


44

• Shaky Bridge• Concern of task force members is that transitioning of the delivery system

functions must coincide with transitioning payment system of rural hospitals, without adequate reserves, will be a financial risk• “Stepping onto the shaky bridge” analogy

• Necessary for hospitals to survive the gap between pay-for-volume and pay-for-performance• Delivery system has to remain aligned with current payment system while

seeking to implement programs / processes that will allow flexibility to new payment system• Delivery system must be ready to jump when new payment systems roll

out

The Challenge


45

Finance Function Form

Macro-economic Payment System• Government Payers

• Changing from F-F-S to PBPS

• Private Payers• Follow Government

payers• Steerage to lower cost

providers

Provider Imperatives• F-F-S

• Management of price, utilization, and costs

• PBPS• Management of care

for defined population • Providers assume

insurance risk

Provider organization• Evolution from

• Independent organizations competing with each other for market share based on volume to

• Aligned organizations competing with other aligned organizations for covered lives based on quality and value

The Premise

Network and care management organization• New competencies

required• Network development• Care management• Risk contracting• Risk management


46

Implementation Framework – What Is It?


47

Delivery System Strategy

• Delivery system must respond to at a similar pace to changing payment models in order

to maintain financial viability

• Getting too far ahead or lagging behind will be hazardous to their health


48

• Hospitals not operating at efficient levels are currently, or will be, struggling financially

• “Efficient” is defined as• Appropriate patient volumes

meeting needs of their service area

• Revenue cycle practices operating with best practice processes

• Expenses managed aggressively• Physician practices managed

effectively• Effective organizational design

Initiative I – Operating Efficiencies, Patient Safetyand Quality


Graphic: National Patient Safety Foundation

49

•Focus on Quality and Patient Safety• As a strategic imperative• As a competitive advantage


Initiative I – Operating Efficiencies, Patient Safety and Quality

50

• Understand that revenue streams of the future will be tied to primary care physicians, which often comprise a majority of the rural and small hospital healthcare delivery network

• Thus small and rural hospitals, through alignment with PCPs, will have extraordinary value relative to costs

•Physician Relationships• Hospital align with employed and independent providers to

enable interdependence with medical staff and support clinical integration efforts• Contract (e.g., employ, management agreements)• Functional (share medical records, joint development of

evidence based protocols)• Governance (Board, executive leadership, planning

committees, etc.)• Potential Model for Rural:

• New PHO

Initiative II – Primary Care Alignment


51

• Develop system integration strategy

• Evaluate wide range of affiliation options ranging from network relationships, to interdependence models, to full asset ownership models• Interdependence models through alignment on contractual,

functional, and governance levels, may be option for rural hospitals that want to remain “independent”

• Explore / Seek to establish interdependent relationships among small and rural hospitals understanding their unique value relative to future revenue streams

• Identify the number of providers needed in the service area based on population and the impact of an integrated regional healthcare system

• Conduct focused analysis of procedures leaving the market

• Understand real value to hospitals• Under F-F-S• Under PBPS (Cost of out of network claims)

Initiative III – Rationalize Service Network


52

Payment System Strategy

• Providers have opportunities to “shorten” and “stabilize” the shaky bridge by:

• Working with payers to create transitional payment models

• Initiating development with payers of full-capitation payment models

MARKET OVERVIEW TRANSITION STRATEGIESFRAMEWORK

53

Payment System Strategy – Initiative I


• Develop self-funded employer health plan• Hospital is already 100% at risk for medical claims thus no risk for improving

health of employee “population”• Change benefits to encourage greater “consumerism”

• Differential premium for elective “risky” behavior• “Enroll” employee population in health programs – health coaches, chronic

disease programs, etc.

• FFS Quality and Utilization Incentives• Maximize FFS incentives for improving quality or reducing inappropriate

utilization (e.g., inappropriate ER visits, re-admissions, etc.)

54

Payment System Strategy – Initiatives II and III


Initiative II: Implementation planning for transitional payment models• Transitional payment models include:

• FFS against capitation benchmark w/ shared savings

• Shared savings model Medicare ACOs

• Shared savings models with other governmental and commercial insurers

• Partial capitation and sub-capitation options with shared savings

• Prioritize insurance market opportunities

• Take the initiative with insurers to gauge interest and opportunities for collaborating on transitional payment models

• Explore direct contracting opportunities with self-funded employers

Initiative III: Develop strategy for full risk capitated plans

55

Population Health Strategies


• A narrow rural/urban provider network focused on patient value

• Aggregates multiple rural/CAH populations for critical mass

• Restricted to payers willing to commit to population health and payment

• On CCO’s terms

• NOT for existing fee-for-service or cost contracts

• Legal entity with corporate powers

• Governance structure for setting strategy, policy, accountability

• Actively secures and manages risk/reward-based payer contracts

• Supports PCP-focused quality & care coordination across the network

• Retains local hospital independence, but with contractual accountability

• Houses care management infrastructure


Phase I: Develop Population Health building blocks• Goal: Infrastructure to manage self insured lives and maximize FFS

Utilization and quality incentives• Initiatives:

• PCMH or like structure• Care management

• Discharge planning across the continuum • Transportation, PCP, meds, home support, etc.

• Transitions of care (checking in on treatment plan)• Medication reconciliation • Post discharge follow-up calls (instructions, teach back,

medication check-in)• Identifying community resources• Maintain patient contact for 30 days

• Develop claims analysis capabilities/infrastructure• Develop evidenced based protocols

Population Health Strategies – Phase I

57

Implementation Framework – In Review


58

• For decades, rural hospitals have dealt with many challenges including low volumes, declining populations, difficulties with provider recruitment, limited capital constraining necessary investments, etc. • The current environment driven by healthcare reform and market realities now offers

a new set of challenges. Many rural healthcare providers have not yet considered either the magnitude of the changes or the required strategies to appropriately address the changes

• Core set of new challenges represents the Triple Aim being played on in the market• Locally delivered healthcare (including rural and small community hospitals) has high

value in the emerging delivery system• “Shaky Bridge” crossing will required planned, proactive approach

• Finance will lead function and form• Maintain alignment between delivery system models and payment systems building

flexibility into the delivery system model for the changing payment system

Conclusions/Recommendations

CONCLUSIONS / RECOMMENDATIONS

59

• Important strategies for providers to consider include:• Increase leadership awareness of new environment realities• Improve operational efficiency of provider organizations• Adapt effective quality measurement and improvement systems as a strategic

priority• Align/partner with medical staff members contractually, functionally, and through

governance where appropriate• Seek interdependent relationships with developing regional systems

Conclusions/Recommendations (continued)

CONCLUSIONS / RECOMMENDATIONS

Eric K. Shell, CPA, [email protected]

50 Sewall Street, Suite 102Portland, Maine 04102

(207) 221-8252

www.stroudwater.com

image: "concord covered bridge 2" by maksim sundukov - own work. licensed under cc by-sa...

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