Building a Technology Roadmap for Accountable Care. Grace Terrell, MD, MMM April 5, 2014

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1 Building a Technology Roadmap for Accountable Care Grace Terrell, MD, MMM April 5, 2014

2 Health care transformation is inevitable. The U.S. Health Care System is too expensive, wildly variable, with lower than desired quality and outcomes.

3 The transformation requires comprehensive change of to our business models. Volume Based Value Based Reimbursement Organizational model Value drivers Profit pools Investments FFS/DRGs No payment for readmits, never events, etc. Departmental Volume Efficiency (procedure level) Visits Surgery / Procedures Outpatient ancillary Capacity Revenue-producing assets Patient referrals Outcomes & Quality based Global payments Populations Conditions Focused factories Quality and low variability Efficiency (population level) Wellness and prevention Population management Chronic condition management Health IT Clinical integration Commercialization

4 Unfortunately HIT is designed for the system as it is, rather than for where we are going

5 Health information technology has undergone three developmental stages thus far Practice Management Systems Electronic Health Records and Clinical Decision Support Systems Population Health Management Systems

6 These HIT developmental stages are reactive vendor responses to the health care market ecosystem.

7 All businesses have the same strategic choices: Status Quo Sell Collaborate Innovate Transform

8 Cornerstone Health Care has chosen the strategic choice of transformation.

9 Cornerstone has developed a five-pronged strategy developing population health management capabilities. 1 Medical Home 2 Clinical Integration 3 Information Integration 4 Organizational Realignment = Population Health Management Hub 5 Reimbursement Model Transformation

10 Our Medical Home strategy is to develop higher quality capabilities across the continuum of care. Clinical Pharmacy Services Extended & Weekend Hours Medical Home Professional Outpatient Infusion Center Medical Home Patient Care Advocates

11 Opportunities for cost reduction require comprehensive clinical integration. Improved management of complex patients & use of lower cost settings and providers Primary Care Practices Hospitals and Specialists Clinical Integration Integrating specialty care into the Medical Home improves outcomes by managing the care continuum

12 Integrating disparate data platforms enable required reporting & data sharing to support population health management Information Integration EHR w/ CDS Provider Performance Reports Patient Registry Process Execution Process Improvement Risk Identification and Tracking Comparative Data Collaboration

13 Integrating high-impact specialty care models into the medical home improves outcomes via better management of the full care continuum. Cardiology Set up a dedicated clinic for multispecialty CHF clinic Organized around an integrated team coordinating care across the CHF continuum to ensure better outcomes and patient experience at a lower cost Aimed to proactively manage CHF and its associated comorbidities to prevent frequency of hospital admission and death due to acute exacerbations Oncology Created coordinated care models for the four most common solid tumors Used multidisciplinary care teams to enact a single treatment plan, reducing redundant services and variability in treatment Provided ancillary services to help patients navigate the cancer care environment and improve the care experience Advanced Primary Care Stratified patients into healthy/at-risk, high needs, and complex polychronic segments to better align needs with degree of care required Each patient group is treated in an increasingly more coordinated/selfsufficient care model based on the acuity of the patient s needs This stratification allows for allocation of resources in line with patient needs, limiting waste and redundancy to the system

14 Models of care must be designed around the patient s needs, not the tyranny of the 15 minute office visit. Healthy Population Health Segments Frail Healthy independent Health risk factors Early stage chronic Complex conditions Late state or poly-chronic Description No chronic conditions and free of key risk factors No major chronic conditions with one or more risks Chronic condition that is well controlled and has not substantially progressed Systemic or otherwise complex condition One or more chronic conditions that are uncontrolled or advanced Examples Normal BMI Non-smoker High blood pressure High cholesterol Obesity Smoke/drink excessively Diabetes Asthma Coronary Artery Disease Cancer Multiple Sclerosis Cystic Fibrosis Diabetes Asthma Coronary Artery Disease Congestive Heart Failure End Stage Renal Disease Population based models (Extensivist, PPCP, and PCMH) target specific health segments

15 Cornerstone followed a disciplined process to identify areas of opportunity and quantify savings 1 Identify Opportunity 2 Develop Care Model 3 Quantify Impact

16 Then we decided to accelerate things Dec 2010 CHC goes live on Humedica MinedShare July 2011 Service Line Monthly Meetings PFV: Jan 2012 Negotiating CHC & Oliver Contracts Wyman Redesign April 2012 Personalized Cancer Care w/embedded Primary Care February 2013 Care Outreach &Lifecare Clinics Transitions of Care Launch of CHESS April 2013 All lives under Shared Savings Contracts January CHC practices earn PCMH Recognition March 2011 PCA Program Conceived October 2011 Shareholder Vote to move to PFV Weekly Care Pathway Redesign meetings Optum & Teradata Tech partners March 2012 Personalized Cardiac Care Program July 2012 MSSP ACO Personalized Primary Care Program August 2013 Cornerstone Breast Clinic Opens November 2013 Strategic partnership with WFBMC & CHESS

17 We needed a comprehensive strategy for our health IT population health management solutions Population and Clinical Risk Management Financial and Network Management Core Clinical Technology Infrastructure Integrated Data Exchange and Aggregation Performance Management Patient Engagement

18 We invested heavily in infrastructure to built and buy basic population health capabilities. Cost Management Customer Satisfaction No model existed for defining and evaluating fully integrated HIT systems supporting effective and efficient patient-centered care Quality of Care

19 Cornerstone performed a gap analysis and found our HIT inadequate for population health management. Enablement Capability Capability Assessment Leveragable Assets Major Capability Gaps Financial and Network Management Targeted gain-sharing in place Financial system equipped to handle sophisticated reimbursements and integrated with clinical data Disbursement system to reconcile third-party payments Outcomes driven compensation aligned with FFV reimbursement Population and Clinical Risk Management Clinical Model Design and Management Core Clinical Technology Infrastructure Patient Engagement Performance Management Integrated Data Exchange and Aggregation Core clinical foundation in place (e.g. EMR, Humedica) Basic analytics for query-based reporting of EMR QBM initiative to operationalize standards of care at point of service (in progress) IntelliDose for oncology Integrated EMR with surround systems to extend capabilities Cloud initiative to merge separate clinical data sources Patient Portal (in progress) Patient health advocates program Extended hours Diabetes and wellness metrics tracked at the provider level Provider benchmarking against Cornerstone peer group ConnectR interface engine used internally Cloud initiative to merge separate clinical data sources Sophisticated analytical tools for patient stratification, clinical risk quantification and predictive modeling Patient attribution to automate medical home and episode eligibility determination Integrated EBM/ Clinical Pathways/ Protocols across sites and clinical systems at point of care EBM platform and rules engine, with standard bundles and episode definitions, to define clinical delivery & performance Automated point of care decision support Automated patient registry with active monitoring Clinical resource management, including referral tracking and intelligent scheduling Online tools for shared decision making Integrated service across administrative and clinical needs Patient centric care management platform Enhanced self-service with tailored support/ workflow tools Holistic performance benchmarks Institutionalized, programmed execution and tracking of quality & performance improvement Comparative effectiveness tracking Ability to safely and efficiently exchange clinical and associated administrative data with third parties Integrated clinical data store (financial and clinical data) with near-real-time alerts and information flows to physicians Scale Low Medium High

20 We began the process of building the IT infrastructure necessary for population health management.

21 Some of our tools are home-grown such as our QBM tab (Quality Benchmark).

22 We had to focus on new types of information integration such as severity adjustment coding.

23 Our quality heat map permits us to analyze our results at both the provider and system level.

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25 We began to develop practice insight information tools not focused solely on traditional FFS financial parameters.

26 Our practice Heat Maps are providing us with new insights into opportunities for improvement.

27 Humedica MindShare permits substantial analysis of clinical variability.

28 CCHIT has created a framework to address the HIT capability needs for ACOS and population health management Payers: Evaluating Provider Ability to Take on Risk Health IT Developers: Filling Identified Market Gaps Providers: Assessing and Planning

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33 An example: the Functions and HIT Capabilities in one Key Process

34 Some of Cornerstone s early results are promising Press Ganey Award for Patient Satisfaction $11 million in Quality and other P4P incentive payments since 2010 ACO contracts with Aetna, BCBS, Cigna, Coventry, Medicare, and UHC Clinical Co-management Agreements in cardiology and oncology (~ $1 Million saved) 2011 NCQA PCMH recognition NC Business Journal top employer

35 Our patient satisfaction scores have significantly improved.

36 We have been able to decrease hospital admissions.

37 Our heart failure patients are being admitted to the hospital less frequently % Pre HFC Post HFC Manually Extracted Data Percent Reduction Pre HFC Post HFC Claims-Based Data Percent Reduction - 29 %

38 And they are going to the emergency room less often Pre HFC Post HFC Manually Extracted Data Percent Reduction - 75 % Pre HFC Post HFC Claims-Based Data Percent Reduction - 38 %

39 Through our co-management agreement with High Point Regional we have reduced the number of admissions for chest pain.

40 Payer data indicates we are meeting high quality performance targets. Quality Measure Hemoglobin A1cTesting for Members with Diabetes Quality Target Quality Performance Annual Monitoring for Patients on Persistent Medication (ACE & ARB) Persistence of Beta-Blocker Treatment after a Heart Attack (PBH) 96% 98% 95% 97% 87% 100% Cardiovascular Care - Cholesterol Screening (CMC) 91% 100% Avoidable Emergency Room Visits Avoidable Inpatient Admissions Note: Performance below target is favorable.

41 Among Medicare ACOs Cornerstone has appears to be decreasing higher cost services.

42 Our hospital readmission rates are falling.

43 Our utilization rates continue to trend down.

44 But this is just the starting line

45 Get ready for the fourth and fifth developmental stages of health information technology...

46 Three transformational waves will reshape the health marketplace

47 The next two waves in HIT are closer than we realize. Practice Management Systems Electronic Health Records and Clinical Decision Support Systems Population Health Management Systems Consumerism Big Data and Personalized Health Care

48 The benefits from the value of HIT will accelerate during waves four and five.