ACOs: California Style

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1 ACOs: California Style ACO Congress John E. Jenrette, M.D. Chief Executive Officer Sharp Community Medical Group November 2, 2011

2 California Style

3 California Style

4 A CO California Style

5 California Style ACO

6 California Style ACO

7 Accountable Care Organizations (ACO) Working Definition A provider led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population

8 Goals Of Accountable Care Organizations Reduce, or at least, control the growth of health care costs Maintain or improve health of a population Improve in both clinical quality and patient experience and satisfaction

9 Opportunities for Improvement Improved prevention and early diagnosis Reductions in unnecessary testing, procedures, and referrals Reductions in preventable Emergency Department visits and hospitalizations Reductions in infections and adverse events in the hospital Reductions in preventable readmissions Use of lower cost treatments, settings, and providers

10

11 $ $ $ All Consultants On-board

12

13

14

15 2011

16

17 Affordable Care Act

18

19 Shared Savings Model ACO Regulations

20 Shared Savings Model ACO Regulations

21 Shared Savings Model ACO Regulations

22 Shared Savings Model ACO Regulations

23 Shared Savings Model ACO Regulations

24 Shared Savings Model ACO Regulations

25 Shared Savings Model ACO Regulations

26 Shared Savings Model ACO Regulations

27 And out of the rubble ACO

28 Pioneer ACO 3 year agreement, can be extended 2 more 15,000 Medicare FFS beneficiaries Must demonstrate ability to take risk hit the ground running 30 pilots June 28 Letter of Intent August 19 Application September Interviews at CMMI

29 2012 CMS Innovation Center 2011

30

31

32 SCMG Care Transformation Model Clinical Systems Accountable Care Organization Medical Group & Enterprise Level Activities Advanced Primary Care Under Patient-Centered Medical Home Patient & Family

33 SCMG Care Transformation Model Clinical Systems Accountable Care Organization Medical Group & Enterprise Level Activities Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation Advanced Primary Care Under Patient-Centered Medical Home Patient & Family

34 SCMG Care Transformation Model Clinical Systems Advanced Primary Care Under Patient-Centered Medical Home Prevention & Wellness Point of Care Analytics & Clinical Decision Support Gaps in Care Population Management & Chronic Care Registries Generic Prescribing Program Cost Effective Medical Management & Utilization of Services (SCP, Ancillary) Access, Same Day Appointments, e-visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction Patient & Family

35 SCMG Care Transformation Model Clinical Systems Medical Group & Enterprise Level Activities PCP/SCP Incentives Pay for Performance Hospitalists, Post Discharge Follow-Up Care Management (Acute, Chronic, Inpatient, SNF) Health Coaching (Shared Decision Making) ER Avoidance Programs Urgent Care End of Life (Palliative Care) Transitions of Care Behavioral & Mental Health Coordination of Services Advanced Primary Care Under Patient-Centered Medical Home Patient & Family

36 SCMG Care Transformation Model Clinical Systems Accountable Care Organization DME Integration & Oversight by Care Management Home Care Home Safety Visits Post Discharge Visits Home Health Ancillary Services Free-Standing ASC & Diagnostic Testing Centers Skilled Nursing Facilities SNFists On-site Case Management Efficiency Rating Systems Preferred Facilities Medical Group & Health Care System Enterprise Level Activities Advanced Primary Care Under Patient-Centered Medical Home Patient & Family Hospitals Service Line Integration Medical Staff Alignment Incentives for Efficiency Quality (SCIP, Leap Frog) Safety Outcomes & Evidence Based Medicine Call Coverage Hospice Home Palliative Care

37 SCMG Care Transformation Model Clinical Systems Home Care Home Safety Visits Post Discharge Visits Home Health Hospice Home Palliative Care Ancillary Services Free-Standing ASC & Diagnostic Testing Centers Care management (Acute, Chronic, Inpatient, SNF) Health Coaching (Shared Decision Making) Accountable Care Organization Skilled Nursing Facilities SNFists On-site Case Management Efficiency Rating Systems Preferred Facilities Medical Group & Enterprise Level Activities PCP/SCP Incentives Pay for Performance Hospitalists, Post Discharge Follow-Up Advanced Primary Care Under Patient-Centered Medical Home Prevention & Wellness Point of Care Analytics & Clinical Decision Support Gaps in Care Population Management & Chronic Care Registries Generic Prescribing Program Patient & Family Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation Hospitals Service Line Integration Medical Staff Alignment Incentives for Efficiency Quality (SCIP, Leap Frog) Safety ER Avoidance Programs Urgent Care End of Life (Palliative Care) Transitions of Care Coordination of Behavioral & Mental Health Services Cost Effective Medical Management & Utilization of Services (SCP, Ancillary) Access, Same Day Appointments, e-visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction Outcomes & Evidence Based Medicine Call Coverage DME Integration & Oversight by Care Management

38 SCMG Care Transformation Model Operational Systems and Structure Accountable Care Organization Medical Group & Enterprise Level Activities Advanced Primary Care Under Patient-Centered Medical Home Patient & Family

39 SCMG Care Transformation Model Operational Systems and Structure Value Based Benefit Design Benefit and Product to Steer Patients Enrollment in Model (Attribution) Communication Strategy Patient & Family

40 SCMG Care Transformation Model Operational Systems and Structure Advanced Primary Care Under Patient-Centered Medical Home Work Flow Redesign & Process Changes Education of Staff, PCPs, Team Measurement Sets, Dashboards Point of Care Analytics Job Descriptions for Additional Staffing Adequate Primary Care Base Financial Modeling Patient & Family

41 SCMG Care Transformation Model Operational Systems and Structure Medical Group & Enterprise Level Activities Network Development Contracts (PCP/SCP) Participation Criteria, Report Cards, Monitoring & Corrective Action Plans Health Care Team Education Financial Incentives Measurement Sets & Operational Tools Clinical Support Infrastructure for Care Management Teams & Programs IT Infrastructure (EHR, Care Management Platform Analytics Clinical Decision Support, E-Prescribing, Predictive Modeling Tools) Advanced Primary Care Under Patient-Centered Medical Home Patient & Family

42 SCMG Care Transformation Model Operational Systems and Structure Accountable Care Organization Medical Group Hospital Systemness & Network Development Contracting (Evaluate Ancillary Services; SNFs, Home Care) Facility Evaluation (ASCs) Sales & Marketing Strategic Planning Medical Group & Enterprise Level Activities Governance & Legal Structure Financial Incentives & Alignment (Shared Savings, Bundled Payments, Partial Cap, Full Cap) Measurement Sets & Targets Health Plan Role for Incentives, Payment Models and Data Exchange Advanced Primary Care Under Patient-Centered Medical Home Patient & Family

43 SCMG Care Transformation Model Operational Systems and Structure Accountable Care Organization HIT Incentives Leadership $ Sales & Marketing Strategic Planning Contracting (Evaluate Ancillary Services; SNFs, Home Care) Facility Evaluation (ASCs) Network Development Contracts (PCP/SCP) Participation Criteria, Report Cards, Monitoring & Corrective Action Plans Health Care Team Education Medical Group Hospital Systemness & Network Development Medical Group & Enterprise Level Activities Clinical Support Infrastructure for Care Management Teams & Programs IT Infrastructure (EHR, Care Management Platform Analytics Clinical Decision Support, E-Prescribing, Predictive Modeling Tools) Advanced Primary Care Under Patient-Centered Medical Home Work Flow Redesign & Process Changes Education of Staff, PCPs, Team Measurement Sets, Dashboards Patient & Family Governance & Legal Structure Financial Incentives & Alignment (Shared Savings, Bundled Payments, Partial Cap, Full Cap) Point of Care Analytics Job Descriptions for Additional Staffing Adequate Primary Care Base Financial Value Based Benefit Design Modeling Benefit and Product to Steer Patients Enrollment in Model (Attribution) Communication Strategy Measurement Sets & Targets Health Plan Role for Incentives, Payment Models and Data Exchange Financial Incentives Measurement Sets & Operational Tools

44 Compare and Contrast Commercial ACO Pioneer ACO Shared Savings ACO

45 Attribution/Alignment Commercial ACO Prospective Pioneer ACO Prospective Shared Savings ACO 18, ,000+ 5,000+ PCP and 9 medical specialties (Ob/Gyn, Gastroenterology) Episode Based PCP and 7 medical specialties (Nephrology, Oncology, Rheumatology, Endocrinology, Pulmonology, Neurology, Cardiology) Primary Care (Family Practice, General Practice, Geriatrics, Internal Medicine) 2-Step (Physicians, Nurse Practitioners, Physician Assistants and Clinical Nurse Specialists)

46 Commercial ACO Two years claims, encounters, Pharmacy data Data Exchange Pioneer ACO Three years claims Shared Savings ACO Three years claims Monthly updates Same as commercial Same as commercial Patients opt out Patients are part of ACO refuse their data Patients can refuse data and patients removed from alignment based on claims experience CHALLENGING! UNKNOWN UNKNOWN

47 Commercial ACO Parallel IHA - Preventive measures (breast cancer, colorectal cancer, childhood immunization, Chlamydia) - Diabetes (HbA1C, LDL, nephropathy) - Cardiology (cholesterol) - Imaging (low back pain) - Pediatrics (Pharyngitis) - Pulmonary (acute bronchitis) - Medication management (medication monitoring) Gateway Hospital +/- Quality Metrics Pioneer ACO 33 Quality Metrics (4 domains) - Patient/Caregiver Experience - Care Coordination/Patient Safety - Preventive Health - At Risk Population Reporting years versus performance years Fund CAHPS for 2 years Shared Savings ACO Same as Pioneer

48 Commercial ACO Efficiency Metrics Pioneer ACO Shared Savings ACO Total cost of care Emergency department utilization Appropriate outpatient surgery and diagnostic centers Appropriate laboratory Inpatient utilization Pharmacy utilization Total cost of care Ø Pharmacy Same as Pioneer

49 Commercial ACO Medical Management Pioneer ACO Shared Savings ACO Opportunities - Case and disease management - Pharmacy - Hospital admits, re-admits and length of stay - SNF management - Decrease emergency department use - Appropriate SCP utilization - End of life CHALLENGES!!! Opportunities - Same as commercial on steroids Same as Pioneer

50 Commercial ACO Shared savings Fee-for-service Patient management fee (PMPM) Future role of hospital capitation? Payment Models Pioneer ACO Shared savings Move to capitation Shared Savings ACO 2 Tracks - One-sided (No downside losses) - Two-sided (Shared savings and losses)

51 Network Development & Contracting Commercial ACO Medical group specific New PCP and SCP agreements (194 PCPs, 385 SCPs) Collaboration on ancillary providers Physician specific report cards and incentives New physicians added quarterly PCPs exclusive Pioneer ACO Integrated delivery system (Sharp Community Medical Group, Sharp Rees-Stealy, Sharp HealthCare) New PCP and SCP agreements (309 PCPs, 790 SCPs) All ancillaries contracted with Medicare (attempt steerage) Same as Commercial (first rewarded) New physicians added annually Same as Commercial 50% Meaningful Use by PCPs Shared Savings ACO Same as Pioneer EXCEPT No Meaningful Use Requirement

52 Commercial ACO Patient Engagement & Loyalty Pioneer ACO Shared Savings ACO Patient satisfaction rules Coordination of care Patient navigators Access Personal health records Same as commercial Same as commercial

53 Commercial ACO Product & Benefit Design (Growth Opportunity) Pioneer ACO Shared Savings ACO New product Financial incentives Marketing Benefit enhancement Marketing Future? Same as Pioneer

54 Commercial ACO Marketing & Communications Pioneer ACO Shared Savings ACO Providers Community Purchasers, employers, brokers Patients Providers Community Patients initial letters CMS approved Same as Pioneer

55 Commercial ACO Governance & Leadership Pioneer ACO Shared Savings ACO Medical group driven Capitalize on current successes CMS requirements - Patient advocate - Medicare beneficiary IDS Governance and Steering/Work Groups Same as Pioneer

56 Health Information Technology Access Secure messaging Care teams Remote monitoring PHR/EHR access Patient engagement tools Coordination of Care Reminders/outreach Team/care plan coordination / transitions of care Referral management Diagnostic results management Shared decision support Payment Reform Efficiency measurements Pay for performance and quality Gain sharing contribution tracking Risk and acuity measurement Predictive modeling Comparative effectiveness analytics

57 So there you have it Top 10 Considerations Attribution/Alignment Data Exchange Quality Metrics Payment Models Network Development & Contracting Patient Engagement & Loyalty Efficiency Metrics Product & Benefit Design Medical Management Health Information Technology

58 Opportunity and Challenge The Verdict on Accountable Care Organizations Somebody has to do something, and it s just incredibly pathetic that it has to be us...the late Jerry Garcia of the Grateful Dead

59 Fee-for-Service Medicine

60 Accountable Care Organization

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