Accountable Care Collaborative: Transforming from Volume to Value

Transcription

1 Accountable Care Collaborative: Transforming from Volume to Value Risk Segmentation and Modeling American Medical Group Association Gary Piefer, MD, MS, FAAFP, FACPE Thursday June 14, 2010

2 WellMed Agenda What Problem are you trying to solve Provider Payor Both Competencies required One element of operational competency Risk segmentation and focused care coordination Discussion

3 WellMed

4 The WellMed Experience A fully functional patient centered medical home led and governed by primary care physicians operating as an accountable care organization delivering high quality, cost effective health care for seniors with excellent patient and provider satisfaction.

5 Company Overview Founded in 1990 in San Antonio Company Overview WellMed is a medical management company Specializes in managing medical services for SENIORSthrough full risk capitation contracts with CMS and Medicare Advantage ( MA ) plans Primary-Care, Physician-Centric Industry leading medical management metrics for higher than average risk members 5

6 Clinic Model Medical Service Organization 40 plus clinics in Texas and Florida Providers Full Risk Fully Delegated (claims, UM, DM, CC, CM) Family Practice and Internal Medicine Physicians Serving over 85,000 seniors 6

7 WellMed Experience Physicians see approximately 15 patients per day Physician compensation is 30%-50% greater than average primary care physician Clinical Quality Metrics exceed national/regional averages Admits per < 200 Bed Days per < 800 Readmission with 30 days 8-12% HbA1c, LDL, near best in class Patient satisfaction high Provider satisfaction high

8 WellMed A fully functional patient centered medical home led and governed by primary care physicians operating as an accountable care organization delivering high quality, cost effective health care for seniors with excellent patient and provider satisfaction.

9 System Design Drives Performance Bed Days Per 1000 Average 1260 High Low WellMed (2011) 2008 Capitation Survey hcpro Admits per 1000 Average 263 High Low Median WellMed 194 (2011)

10 Results of WellMedCare Model

11 Results of WellMedCare Model 2500 Bed Days / WellMed 2009 WellMed 2011 Medicare FFS

12 Progress after implementing Systems Change (WellMed Care Model) Admits per

13 Admits Per 1000 SAT

14 WellMed Care Model Plus Breakthrough Series UCL= Admits Per 1000 SAT-NEF 36 months ending May CEN= LCL= Feb

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16 How did you do that?

17 WellMed Care Model Care Coordination Breakthrough Series Model of Improvement

18 Why We Are Here Unstainablecost inflation Wide Variation Low Reliability

19 What s the Problem

20 EFFICIENCY International Comparison of Spending on Health, Average spending on health per capita ($US PPP*) Total expenditures on health as percent of GDP 8,000 7,000 6,000 5,000 United States Canada Germany France Australia United Kingdom ,000 3,000 2,000 1, United States France Germany Canada United Kingdom Australia * PPP=Purchasing Power Parity. Data: OECD Health Data 2011 (database), version 6/ Source: Commonwealth Fund National Scorecard on U.S. Health System Performance,

21 Relationship Between Quality of Care and Medicare Spending: As Expressed by Overall Quality Ranking, Data: Medicare administrative claims data and Medicare Quality Improvement Organization program data. Adapted and republished with permission of Health Affairs from Baicker and Chandra, Medicare Spending, The Physician Workforce, and Beneficiaries Quality of Care (Web Exclusive), 2004.

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24 EFFICIENCY Medicare Admissions for Ambulatory Care Sensitive Conditions, Rates and Associated Costs, ,200 Rate of ambulatory care sensitive admissions per 10,000 beneficiaries 20 Costs of ambulatory care sensitive admissions as percent of all discharge costs U.S. average 10% ile 25% ile 75% ile 90% ile Hospital Referral Region percentiles 0 U.S. average 10% ile 25% ile 75% ile 90% ile Hospital Referral Region percentiles See report Appendix B for complete list of ambulatory care sensitive conditions used in the analysis. Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance,

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26 ACO What is it An organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional feefor-service program who are assigned to it.

27 ACO What is it An organization of health care providers that agreesto be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional feefor-service program who are assigned to it.

28 ACO Critical Competencies SOURCE: Accountable Care Organizations: A new model for sustainable innovation. Produced by the Deloitte Center of Health Solutions Leadership Governance Operational management Clinical management Infrastructure and IT Risk assessment Work force

29 ACO Most Critical Decision Regarding your $50 million budget

30 What will you do differently?

31 What will you do differently to manage revenue and medical cost? $1,400 Revenue PMPM vsmedical Cost Inflation $1,200 $1,000 $800 $600 $400 $200 $

32 Back of the envelop! A decrease of 75 Admits per 1000 Members with 5,000 members equates roughly to $3.75 million savings to healthcare system and 3,75 fewer patients requiring hospitalization when cared for in the WellMed system

33 Where s It Go

34 Managing Cost Hospital-Hospital-Hospital SCP $$$$ Hospital PCP

35 Medical Cost Hospital = 40-50% in all markets Hospital

36 Risk - Modeling

37 Risk Segmentation Manage chronic disease Which members have multiple chronic conditions Which members have significant single conditions Manage transitions Hospital discharge All levels of care transfer Manage end of life 37