Lessons Learned From ACO/Clinical Integration Implementation: 3 Successful Case Studies. October 31, 2012

Transcription

1 Lessons Learned From ACO/Clinical Integration Implementation: 3 Successful Case Studies October 31, 2012

2 Agenda Introductions Overview Three Case Studies Central Maine Medical Center The Reading Hospital and Medical Center Henry Ford Health System Q & A 1

3 Why Change is Necessary Problem Fee for service is fading as dominant payment mechanism CMS and commercial payers instituting performance benchmarks Costs are squeezing employers and limiting enrollment Health status of many communities requires a different paradigm Opportunity Redesign care around patients Produce better care for less Increase market share with better product Improve professional satisfaction through collaboration 2

4 The Cost of Not Changing Erosion of patient base Reduced physician income Decline in community health status (diabesity) 3

5 Value Defined Value = Health outcomes Total money spent Cost is intrinsic to quality rather than separate from it 4

6 Principles of Value Based Healthcare Delivery Quality improvement is the most powerful driver of cost containment and value improvement, where quality is health outcomes Prevention of illness Early detection Right diagnosis Right treatment to the right patient Rapid cycle time of diagnosis and treatment Treatment earlier in the causal chain of disease Less invasive treatment methods Fewer complications Fewer mistakes and repeats in treatment Faster recovery More complete recovery Greater functionality and less need for long term care Fewer recurrences, relapses, flare ups, or acute episodes Reduced need for ER visits Slower disease progression Less care induce illness Better health is the goal, not more treatment Better health is inherently less expensive than poor health Source: Michael Porter, American Academy of Orthopedic Surgeons Conference, March 31,

7 Getting from First Curve to Second Curve Volume based first curve Fee for service reimbursement segment High quality not rewarded No shared financial risk Acute inpatient hospital focus IT investment incentives not seen by hospital Stand alone care systems can thrive Regulatory actions impede hospital physician collaborations The gap Development of core competencies Payment rewards population value: quality and efficiency Quality impacts reimbursement Partnerships with shared risk Increased patient severity IT utilization essential for population health management Scale increases in importance Realigned incentives, encouraged coordination Metrics to evaluate progress Self assessment questions Source: Hospitals and Care Systems of the Future, American Hospital Association, September

8 Transition to Enhanced Quality of Care Communication, Education, Performance Incentives Current Individuality Clinical autonomy One on one patient care Captain of my ship Procedure driven Fee for service Ideal Interdependence Evidence based medicine Patient centered medical home Member of the team Evidence based medicine Performance linked payment 7

9 Seven Key Take Aways Trust Transparency Leadership Communications Data Flexibility Patience 8

10 Current Healthcare Delivery/Payment Models Lower Initial Hypotheses on Prioritization of Provider Engagement and Payment Models Rationale Preliminary Hypotheses 1 Medical Homes: Strong support and emerging evidence around impact; potential to leverage existing pilots and scale up rapidly Degree of Difficulty Higher Lower 6 P4P Centers of Excellence 10 ebay for Healthcare Admin Integration Most Promising Models Pay for Outcomes Products 8 Degree of Impact 3 Medical Homes 1 4 Bundled Case Rates CI/ACO 9 11 Global Payment Uniform Hospital Pricing Higher Degree of Impact: Potential effect on bending the cost curve in 3 5 Degree years of Difficulty: Ability to implement based on provider environment, historical relationships, and Horizon s existing capabilities 2 Centers of Excellence: Superior outcome and cost profile for selected high cost diseases and procedures; opportunity to explore providers outside NJ market (e.g., NYC, Philadelphia) 3 Disease/Procedure Based Products : Increasing adoption and evidence of potential impact on cost curve; may be selectively implemented with handful of providers 4 Accountable Care Organizations: Increased popularity and visibility in reform proposals; potential for Horizon to facilitate coordination given fragmentation Admin Integration: Potential to reduce back office complexity; 5 will require technology and infrastructure to facilitate integration Mature P4P: Various P4P programs implemented with limited 6 impact; opportunity to optimize existing programs to generate more incremental savings and avoid excess administration 7 Pay for Outcomes: Greater potential for cost savings than P4P however, difficulty in developing outcomes based measurement Bundled Case Rates: Some pilots being implemented with 8 varying levels of impact; requires EBM, case rates and episodes of care, and underlying infrastructure/systems 9 Global Payments: Potential to deliver significant savings; raises concerns on capitation; relatively challenging given fragmented nature of NJ provider environment 10 ebay for Healthcare: Market sets the price for highly elective procedures; however, limited enabling infrastructure at present; may lead to reduced health plan role in the future 11 Uniform Hospital Pricing: May significantly cut delivery costs; however, potential policy issues from previous implementation; may also minimize Horizon provider discount advantage 9

11 Business Case for Clinical Integration/ACOs The success of Clinical Integration/Accountable Care Organizations will hinge on how well the case is made that outcomes are improved and value is being delivered. To date, the provider community has not been able to adequately define, let alone deliver on, what quality means and how it can be measured. This appears to be a major stumbling block in the shift from fee for service to fee for value. For those organizations that can effectively make the case for improved quality (along with cost management), they may be able to capture a significant share of the employer market. 10

12 Growth of Government and Commercial ACOs/Clinical Integration 11

13 Accountable Care Organizations (ACOs) ACOs an entity in which providers take responsibility for a defined population, coordinate care across settings, and are held to benchmark levels of quality and cost ACOs seek to balance cost control with efforts to improve outcomes and enhance people s satisfaction 12

14 Clinical Integration A Clinically Integrated Organization is an entity that emerges out of a regulatory framework to allow physicians and hospitals to come together and negotiate fees and bonuses with payers and employers as long as they can demonstrate quality improvements. What does Clinical Integration accomplish? It aggregates and integrates physician and hospital services to generate better care at less cost and more favorable contracting with payers. What must a Clinically Integrated organization do? The FTC/DoJ has stated it would not pursue antitrust action ( safe harbor ) if they meet a three part test: 1. Likely to achieve real integration of providers; 2. Program initiatives are designed to achieve likely improvements in healthcare cost, quality and efficiency (e.g., evidence based protocols) and; 3. Collective contracting with health plans is reasonably necessary to achieve efficiencies and clinical objectives of the program. 13

15 FTC Clinically Integrated Requirement (1996) Following conditions must be met 1. Network of physicians willing to demonstrate a high degree of interdependence and cooperation, through 2. Program of initiatives designed to control costs and ensure quality, which 3. Supported by an infrastructure that allows the physicians to evaluate and modify practice patterns. 14

16 A comparison of ACO characteristics and those used by the FTC to determine whether the goal of clinical integration has been met shows a high degree of concordance. Burke & Rosenbaum, Accountable Care Organizations: Implications for Antitrust Policy, BNA Health Law Reports, March 11, Source: Hogan Marren, Ltd. 15

17 Clinical Integration (CI) vs Accountable Care Organizations (ACOs) Characteristics CI ACO Source of Patients Commercial Insurance & Employers Medicare Basic Reimbursement Fee for Service Fee for Service with opportunity for shared savings (Track 1) or shared savings/losses (Track 2) Number of Metrics 5 10 per specialty 33 measures (patient experience, care coordinator, preventive health at risk population) Compliance Requirements Antitrust law Medicare Requirements & Antitrust Physician participation Participation Agreement Participation Agreement Legal Entity Beneficiary alignment Not required for CI, but CI org can be the service corporation Not applicable on non risk management Separate legal entity with independent board (75% ACO participants) Alignment of beneficiaries based on primary care codes Physician Exclusivity Not required under CI Exclusivity of PCPs and specialists providing primary care services Source: Hogan Marren, Ltd. 16

18 Key Foundation Capabilities for Clinical Integration/ACOs Select Capabilities Clinical Integration Clinical Effectiveness Informatics Infrastructure Medical Management Product Development Provider Selection/ Contracting/ Funds Flow Strategic Communications Description Active and ongoing program to evaluate and modify practice patterns by the network's physician participants and create a high degree of interdependence and cooperation among the physicians Develop analytical methods and tools to reduce physician variation across key cost & quality metrics Design and optimize care quality programs Develop infrastructure which collects and mines clinical and claims related information into a useful database to support evidence based medicine Capture quality metrics to enable provider benchmarking and reporting Infrastructure to support real time eligibility and claims, adjudication based on episodic care, and billing/ payments integration Collaborative case management and utilization review based on clinical care guidelines (optimize case management), with attention paid to appropriate transitions of care Create episodic product groupers and tie reimbursements to episodes of care (e.g., knee, hip) Identify provider risk/ cost share mechanisms to maximize P4P value Select providers based upon basic quality standards and commitment to the CI/ACO's philosophy and delivery model Engage in joint contracting with providers based on gain share/ bundled payments modeling Conduct perception research with physicians and patients to understand key motivations and resistance points Drive physician behavior and uptake of new processes through education External branding, and differentiation of CI/ ACOs and new product/services highlight benefits and drive participation rates 17

19 The Road Ahead Cultivate physician leadership Align payment with expectations for performance Develop transitions of care and care management capabilities, focused on the highest risk patients Make time to allow for buy in from physicians Develop the data model, IT infrastructure and tools for data modeling and analytics Invest in population health solutions Take an organizational change view and continually assess readiness for next steps. Communicate with all involved stakeholders. 18

20 Patient Care Is a Team Sport Now Today Tomorrow 19

21 Going Forward We can't solve problems by using the same kind of thinking we used when we created them. Albert Einstein 20

22 Contact Information Phil Polakoff MD Chief Medical Executive FTI Health Solutions

23 3 rd National ACO Congress October 31, 2012 Edmund (Ned) Claxton, Jr., MD Medical Director, CMH ACO 22

24 Organization & Context Central Maine Healthcare CMMC 225 beds, census ~ 125 (85 175) 2 Critical Access hospitals (25 beds each) 1 Managed hospital (50 beds) 3rd largest hospital in Maine (600, 400, 200) Catchment area ~ 400,000 people, 100 miles Maine Same size as Indiana with 20% of the people ACO is separate corporation under CMH Limited resources 23

25 Integration System Common leadership and 1 board 1990 Major IT investments 1998, 2006, 2011 Hospitals Centralized administrative functions Integrated and shared staffing Medical staffs LAPA, 1986 PHO Separate staffs, common leadership Moving to common bylaws for medical staffs 24

26 Central Maine Medical Group Employed providers: 250 physicians 110 APS CRNA, CNM, NP, PA >80% of the hospital staffs Started ~ 1991, added small practices since New position of President 2009 New Bylaws 2010: Pres of CMMC Medical staff Division/Chief structure 3 hospitals + Hospital based, PCP, Surgery, Specialty 100,000 PCP + 40,000 Specialist patients 25

27 ACO Foundational Work Business development Employee health plan ACO like Risk assessment, employee benefits structure, health coach ACO regularly in discussions March 2011 Existing payers increasingly migrating to ACO efforts CMS/ACA Readiness assessment Premier June

28 ACO Foundational Work (cont d) Clinical PCMH commitment Maine PCMH multi payer pilot Provider quality incentives: +3%, +/ 6%, +/ 9% Population management Saving Lives Initiative (Mining 12 years of Centricity history) AAA Critical 3 Urgent 12 Breast Cancer Cat 5 8 Cancer 8 Colon Cancer Pre cancer 645 Cancer 15 Medical staff bylaws revisions

29 ACO Status Employees ~ 3000 covered lives Expenses decreased 4% YTD Private insurers ~ 8,000 CMS MSSP ~ 16,000 (July 1 start) Success: Readmission rates, advanced imaging, LOS Challenges: ED visits, Amb Care Sensitive conditions Resources Registries Centricity (Meridios) Case (Care) Managers Health coaches, LCSW s 28

30 Lessons Being Learned Patients Earlier and greater involvement (Board, Steering, Ops) Communication Social media? Mental Health integration Providers and Administration Communication Champions Cultural sensitivity and change management Transparent and shared decision making PCP burden Aligned incentives 29

31 ACO Concepts 30

32 3 rd National ACO Congress October 31, 2012 Clint Matthews President & Chief Executive Officer 31

33 Organization & Context The Reading Hospital & Medical Center Licensed Beds 775, Staffed Beds ~ 660, 29,000 annual admissions Over 800 physicians on medical staff, about 300 of whom are employed Post acute facility Berkshire Health Partners (BHP) Non profit PPO servicing Berks and surrounding counties 50/50 ownership with physicians Contains Medicus Resource Management, a care management subsidiary Reading Hospital Medical Group & Reading Professional Services Over 300 employed physicians in two corporate structures providing both primary care and specialty services. 32

34 Why Pursue Clinical Integration? Align our medical staff (both employed and independent) around common goals of quality and efficiency Improve community health Respond to employer and payer demands for better healthcare value Prepare for changing reimbursement structures Complement other health system strategies, most notably Reading HealthConnect (Epic) 33

35 The Reading Path to Clinical Integration TRH CLIO is here Readiness Assessment Phase 1: Conceptual Design Phase 2: Hypothesis Testing & Implementation Planning Phase 3: Detailed Design and Year One Build & Deploy Ongoing Phases: Future Capability Deployment Inventory existing quality improvement programs Understand leadership perspectives Assess levels of understanding Understand business drivers Assess physician alignment level(s) Build list of participants for design Answer key questions Inventory assets Create functional models Create Business Case and Budget Develop early consensus Engage hospital and physician leadership Plan for implementation Finalize communication materials Obtain necessary approvals 63 Physicians Engaged in Design Detailed design Build key elements Launch organization Hire redeploy executives Deploy assets Deliver proof of concept Obtain FTC/DOJ anti trust guidance, if necessary Initiate Learning Laboratory TBD 4 weeks 12 weeks 8 10 weeks months Ongoing 34

36 Clinical Integration Design Effort DESIGN SUMMIT Outputs: Finalize Straw Models, Determine Interdependencies and Obtain Senior Leadership Validation 35

37 Clinical Integration Design Engagement 15 Design Sessions (30 Total Design Hours) 62 Physician Participants 36 Employed and 26 Independent Physicians 75% attendance at meetings 25 Specialties represented 36

38 Clinical Integration Governance Reading Physician Organization (RPO) Clinical Integration Operations Company Physicians can elect to participate in the CI Program RPO nominates Physician members Coordinated, Physician Led Governance Structures BHP enters into CI contracts with payers P4P bonuses, shared savings payments, etc. Physicians continue to receive FFS payments under BHP s CI payer contracts 37

39 Over the next 4 years, the staffing component of BHP will transition to focus on Clinical Integration initiatives FTE(s) 2012 CLIO FTEs support existing care management initiatives including East Penn and the new Heart Failure protocols. Salary expenses for these 7 FTEs was annualized in 2012 to reflect.5 year expense. Note: variance in timing of FTEs attributed to the Fiscal Year (FY) versus Calendar Year (CY). 38

40 Clinical Integration will Change our Contracting Approach Today Nonnegotiated FFS rates Separate contracting activities Messenger Model at BHP Reading Physician Organization Berkshire Health Partners The Reading Hospital and Medical Center Hospital Contracting Negotiated FFS Rates Provider Contracting Non negotiated FFS Rates Payers Employers Tomorrow Collective Negotiation Performance Incentives Reading Physician Organization The Reading Hospital and Medical Center Contracted Services CI Operating Company (hospital owned, physician led) Payers Berkshire Health Partners Collective Negotiation Negotiated FFS Rates, P4P, Shared Savings 39 Employers

41 Our Foundation to Build Upon Heart Failure Pilot Results (25 Patients Enrolled) Admissions Decreased by 74% 73% Patient Reported Improvement in Quality of Life, per survey Readmissions Decreased by 37.5% Branded the Heart Partners Program 128 patients currently enrolled Team has now started on Chronic Obstructive Pulmonary Disease (COPD) Goals are to grow and maintain these programs while rewarding providers who meet quality and efficiency thresholds 40

42 How Care Changes The New Reading Model Acute Care Center Procedure Center Diagnostic Center Communication Coordination Transitions of Care Measurement Post Acute Care Center Physician Office Home Health Center 41

43 Key Success Factors Physician, governance, leadership and participation Consistent and ongoing leadership commitment through the full implementation of a Clinically Integrated Organization (CLIO) Collaboration and coordination across The Reading Hospital & Medical Center and its physicians Adherence to a disciplined plan for development and excellent execution Strategic awareness of the changing healthcare reform environment and an entrepreneurial mindset to react quickly in response 42

44 Key Learnings Obtaining widespread consensus among both physicians and executives is critical to proceeding, but Board members must also be engaged along the journey. Technology is critical, difficult and expensive. Converting from FFS reimbursement to value based contracting is inevitable but a much more difficult transition for many health systems in the heartland than in environments that have a significant penetration of managed care. Employers are changing the game even more quickly than payers in some environments. CI must enable us to respond to employer demands for reduced costs and higher value. 43

45 3 rd National ACO Congress October 31, 2012 Dr. Charles Kelly President & Chief Executive Officer 44

46 Where does the HFPN fit in? The Henry Ford Physician Network (HFPN) is a subsidiary of HFHS HENRY FORD HENRY FORD HEALTH SYSTEM HEALTH SYSTEM HENRY FORD HENRY FORD CONTINUING CONTINUING CARE CARE CORP. CORP. HENRY HENRY FORD FORD MEDICAL MEDICAL GROUP GROUP HENRY HENRY FORD FORD HOSPITAL HOSPITAL BEHAVIORAL BEHAVIORAL HEALTH HEALTH (Includes Kingswood (IncludesHospital & Maplegrove Kingswood Hospital Center) & Maplegrove Center) HFHS HFHS FOUNDATION FOUNDATION HENRY FORD HENRY FORD WYANDOTTE WYANDOTTE HOSPITAL HOSPITAL HENRY FORD HENRY FORD PHYSICIAN PHYSICIAN NETWORK NETWORK P COR P COR L.L.C. L.L.C. (OptimEyes) (OptimEyes) FAIRLANE FAIRLANE HEALTH HEALTH SERVICES SERVICES CORP. CORP. HEALTH HEALTH ALLIANCE ALLIANCE PLAN PLAN COMMUNITY COMMUNITY CARE CARE HENRY FORD HENRY FORD WEST WEST BLOOMFIELD BLOOMFIELD HOSPITAL HOSPITAL ONIKA ONIKA INSURANCE INSURANCE COMPANY COMPANY LIMITED LIMITED HENRY FORD MACOMB HENRY FORD HOSPITAL MACOMB HOSPITAL CORPORATION CORPORATION DOWNRIVER CENTER DOWNRIVER FOR CENTER ONCOLOGY FOR ONCOLOGY FAIRLANE FAIRLANE PHARMACY PHARMACY SERVICES SERVICES CORP. CORP. ALLIANCE ALLIANCE HEALTH HEALTH AND LIFE AND LIFE INSURANCE INSURANCE COMPANY COMPANY PREFERRED PREFERRED HEALTH HEALTH PLAN, INC. PLAN, INC. SHA REALTY SHA REALTY HORIZON HORIZON PROPERTIES PROPERTIES INC. INC. Ownership Operating Division 45

47 Current Recruitment Status Summary by Affiliation Affiliation Category Signed PCPs %PCP HFMG % Employed % Private Practice % Contracted % Total (goal 2011) % Summary by Region Region Signed PCPs Private Practice HFMG* Employed Contracted Total Total % Macomb % Oakland % Downriver % Detroit % Total (goal 2011) % 46

48 HFPN Board Composition and Committee Structure 50% Private Practice 50% Henry Ford Medical Group President/CEO HFPN CEO, HFHS or designee CEO, HFMG or designee CFO, HFHS Private Practice Physician Trustee, HFHS Board 47

49 Why did we do this? System transition from AMC and HFMG reliance on feeder source referrals to an IDS with more Community Beds and more independent than employed physicians Physician alignment strategy become the preferred health system partnership Began late 2008 (18 months pre PPACA) Prepare for reform regardless of how it might look 48

50 Critical Goals and Objectives Be first to market and recruit private docs into our network with aligned vision and financial incentives Reduce internal concerns of HFMG Deploy IT connectivity on shared EMR Educate, deploy and support true clinical integration Negotiate contracts rewarding docs for doing the right thing 49

51 Clinical Integration HFPN Program Development Timeline Strategy Retreat Prompted by Employer Interest Commitment to Vision Clinically Integrated network Private Practice & HFMG Physicians Commit to Lead Program Development Year 1 Clinical & Efficiency Metrics Defined & First Physician Par Agreement Signed Initial Data flowing via Crimson from source systems 1 st Clinical Program Live Crimson Full Access Rollout to connected physicians Apr 2009 Oct 2009 Apr 2010 Dec 2010 March 2011 Jan 2012 PPACA Passed Jan 2009 Jul Jan Jul Jan Sept April 2012 Site Visit to Advocate Health System Strategy Retreat to Confirm New Business Entity New Business Entity Incorporated & Physician led Board of Trustees Launched Program review with the Federal Trade Commission (FTC) 1 st HFPN Portal User 1st Contract Effective 50

52 Results to Date Clinical Supportive Initiatives Diabetic education, anticoagulation clinic, Medication Therapy Management (harm and readmission reductions), biomechanical approach to chronic pain and stress classes, and developing mobile case management Educational and IT deployments Epic transition with well priced ambulatory offering data driven CME focused on ED utilization and COPD/advanced CHF Telemedicine pilot with medication dispensing unit Communication pilot with mobile Application for Smart phones 51

53 Results to Date Contracting success HFHS Employee learning lab Upside P4P CMMI Bundled Payment Application Gainsharing Commercial Bundled Offerings Shared savings Narrow network discussions Commercial self funded employer Individual offering with HAP Ambulatory intensivist pilot Population management/case management CMMI SNF/ dual eligible LTC grant Model organizing a new clinical and shared risk relationship 52

54 Key Learnings The leading message on the benefits of CI is quality and efficiency outcomes for the patient what you ultimately need are contracts The ultimate goal should be opportunity to focus on meaningful measures for all payers don t start with 104 of your own There is as much internal resistance and misunderstanding as you encounter externally CI leadership requires much passion and integrity 53

55 Questions 54