Mission: We empower healthcare professionals to manage time, change, and complexity to deliver exceptional care

Welcome! Mission: We empower healthcare professionals to manage time, change, and complexity to deliver exceptional care What We Do: We provide tools, resources, and expertise to manage new reporting requirements and payment methods while improving quality and controlling costs of patient care. Primary Care Division Meeting September, 2016

2016 Primary Care Division Quarterly Meeting Series Quick Housekeeping Items Sign-In. For physicians to receive $100 for attending the entire event tonight, please record your attendance on the sign-in sheet. All non-cone physicians who have not completed and submitted a W9 this year must do so to receive payment. If you notice an empty box by your name, please fill in the missing information. Q&A. Index cards are provided, in your packet, to record questions throughout the presentation. If time allows, at the end of the meeting, THN Leadership will be available at each location to discuss questions. However, please allow us the opportunity to address all questions. Please print legibly, include your name and hand them to the THN moderator. All questions will be answered and we will provide via the THN Beacon in an FAQ format. PowerPoints. We will provide a link to the meeting presentation slides and FAQs via the THN Beacon later this month. Presentation copies are also included in your packet per feedback requests. Feedback Forms. We want to hear you thoughts about tonight s meeting, so please remember to complete the feedback form before you leave. IMPORTANT SURVEY: Please take a few moments and complete the Care Management survey in your packet and leave it with a THN representative before leaving.

Primary Palliative Care

Quill TE, Abernethy AP. N Engl J Med 2013;368:1173-1175.

Spotlight: Primary Palliative Care at the Internal Medicine Center

THN Available Resources Emmi Patient Education EmmiEngage program for Advance Directives to educate patients. Includes: benefits, common myths, topics to consider, and how to find the right forms ACP Toolkit Official medical decision-making documents, local advanced illness management services, other helpful resources for daily practice Serious Illness Conversation Guide Helps you lead the conversation when it s hard to know what to say

Pick up your ACP Toolkit tonight! Bland Clinic Brown Summit Family Practice Burlington Medical Center Cone Health Community Health & Wellness Center Cone Health Sickle Cell Center Crissman Family Practice Eagle @ Brassfield Eagle @ Lake Jeanette Eagle @ Oak Ridge Eagle @ Triad Eagle @ Village Edward Hawkins, MD Elizabeth Dewey, MD Five Points Primary Care Greensboro Adolescent & Adult Medicine Hodges Family Practice Mary John Baxley, MD Meridian Internal Medicine Nova Medical Associates: Khan Palladium Primary Care Piedmont Family & Sports Medicine Piedmont Triad Family Medicine Preston Clark, MD Primary Care Associates Primary Care @ MedCenter High Point Primary Care @ MedCenter Kernersville Reidsville Family Medicine Reidsville Primary Care Roy Fagan, MD Stephen Knowlton, MD Triad Internal Medicine Associates Triad Medicine and Pediatric Associates Urgent Medical & Family Care Primary Care West Burlington Medical Center Western Rockingham Family Medicine Zack Hall, MD

We empower healthcare professionals to manage time, change, and complexity to deliver exceptional care THN Primary Care Division Meeting September, 2016 Crystal Pike RN, MSN, Manager- Performance Improvement and Clinical Informatics

2015 MSSP Quality Report Domain Patient/Caregiver Experience Care Coordination /Patient Safety 2014 Performance Rate (%) 2014 Points 2015 Performance Rate (%) Earned Points Bonus Points Total Points 82.5 11.55/14 99.25 15.40 0.48 15.88 77.14 10.8/14 100 20.5 1.8 22 Trend (Earned Points) Preventative Health 88.75 14.2/16 100 14.20 2.24 16 At Risk Population 92.5 12.95/14 100 10.95 2.24 12

Summary 2015 Overall Quality scores= 99.81% (This includes bonus points given for significant quality improvement over the 2014 scores.) The earned quality score was 92.5% which is an increase over the 2014 score of 85.22% There were 10 measures with significant improvement. We had 3 significant declines. (Allowed for bonus points) Increased performance rate in 17 comparable measures and decreased in 7 measures. Compared to the 2015 mean performance rate of ACOs, we moved up in 24 measures and down in 9 measures. In 2014 we did not earn points for Heart Failure admissions, in 2015 we decreased our admissions for HF and earned 1.1 out of 2 points

Opportunities Admissions: CHF, COPD, and All cause chronic diseases Falls Risk assessments BMI with follow up Blood Pressure with follow up

Patient/Care Giver Experience CAHPS Survey Results Measure 2014 Performance (%) 2014 Achieved Points/Total possible points 2015 Performance (%) 2015 Achieved points/total possible points Performance Rate Trend Mean ACOs Percentage Compared to mean ACOs Getting Timely Care 80.37 1.85/2 85.2 1.85/2 80.61 How well providers communicate 92.7 2/2 91.83 2/2 92.65 Patients Rating of Provider 92.13 2/2 91.63 2/2 91.94 Access to Specialist 85.72 1.85/2 81.01 1.85/2 83.61 Health Promotion and Education 59.94 1.85/2 59.89 1.85/2 59.06 Shared Decision Making 71.28 0/2 76 1.85/2 75.17 Health Status/Function 69.74- Reporting only 2/2 73- Reporting only 2/2 75.17 Stewardship of Patients Resources NA NA 27 Reporting only 2/2 72.3

Care Coordination / Patient Safety Measure 2014 Performance (%) 2014 Achieved points/total possible points 2015 Performance (%) 2015 Achieved points/total possible points Performance Rate Trend Mean ACOs Percentage Compared to mean ACOs Risk Standardized, All Condition Readmissions 14.47- Reporting only 2/2 13.82 2/2 14.86 Admissions: COPD or Asthma 0.8 1.55/2 0.88 1.55/2 1.11 Admissions: HF 1.36 0/2 1.27 1.1/2 1.04 SNF 30 day all-cause Readmission NA NA All-cause Unplanned Admissions for Patients with Diabetes All-Cause Unplanned Admissions for patients with HF All-Cause Unplanned Admissions for Multiple Chronic Conditions NA NA NA NA 17.02- Reporting only 52.41- Reporting only 75.76- Reporting only 2/2 18.07 2/2 54.6 2/2 76.96 NA NA 65- Reporting only 2/2 62.92 Percent of PCPs who Successfully meet meaningful use requirements 81.86 3.4/4 92.24 4/4 76.22 Documentation of Current Medication in the Medical Record NA NA 78.91- Reporting only 2/2 84.07 Screening for future falls risk 65.69 1.85/2 63.67 1.85/2 56.46

Preventative Health Measure 2014 Percentage 2014 Achieved points/total possible points 2015 percentage 2015 Achieved points/total possible points Trend per percentage Mean ACOs Percentage Compared to mean ACOs Flu Immunization 62.48 1.55/2 78.99 1.7/2 62.03 Pneumonia Immunization 75.54 1.55/2 85.08 1.85/2 63.73 BMI and follow up 61.31 1.4/2 68.29 1.55/2 71.15 Tobacco Use and Cessation Intervention 89.92 1.85/2 91.53 2/2 90.16 Depression Screening and follow up 46.57 1.85/2 54.07 2/2 45.25 Colorectal Screening 74.55- Reporting only 2/2 80.24 1.85/2 60.06 Breast Cancer Screening 78.99- Reporting only 2/2 77.82 1.7/2 65.67 BP Screening and follow up 74.65-Reporting only 2/2 68.15 1.55/2 70.04

At Risk Population Measure 2014 Performance (%) Depression Remission at 12 months 2014 Achieved Points/Total possible points 2015 Performance (%) 2015 Achieved points/total possible points Trend (Performance Rate) Mean ACOs Percentag e NA NA 19.23- Reporting only 2/2 6.11 Compared to mean ACOs Diabetes Composite- All or Nothing NA NA 37.90- Reporting only 2/2 35.38 Hemoglobin A1C 15.53 1.85/2 18.15- Reporting only 20.38 Poor Control (>9.0) Eye Exam NA NA 43.15- Reporting only 41.05 HTN- Controlling High BP IVD- Use of ASA or Antithrombotic HF= Beta Blocker Therapy CAD and ACE/ARB 67.92 1.40/2 73.39 1.7/2 69.62 86.92 1.70/2 82.66 1.85/2 83.82 83.02- Reporting only 2/2 88.02 1.85/2 87.22 79.06-Reporting only 2/2 82.44 1.55/2 77.73

GREAT QUALITY RESULTS! Thanks for all you do!

We empower healthcare professionals to manage time, change, and complexity to deliver exceptional care Primary Care Division Meeting September, 2016

Financial Report Triad HealthCare Network Topics Transition of Care Update Iodine Update 23

Risk Triad HealthCare Network Risk and Shared Savings Contracts 2015 Medicare Shared Savings Program 2016 NextGen ACO Program 2015 Humana HMO 2016 Humana HMO 2016 HealthTeam Advantage Shared savings 2015 UHC 2016 UHC 24

Triad HealthCare Network Medicare Shared Savings Program THN began participation as an ACO in the Medicare Shared Savings Program (MSSP) in July 2012 with 40,000 Medicare Members Original agreement with CMS was for 3.5 years Began July 2012 and expires in December 2015 Three performance periods: 1) July 12-Dec 13; 2) Calendar year 2014; and 3) Calendar year 2015 25

Triad HealthCare Network Medicare Shared Savings Program Performance: $25M saved through PY2 (2014) PY1: July 2012 - December 2013 (18 months) Historical Benchmark $463,194,583 Actual Performance $441,688,961 Savings of 4.6%: $ 21,505,622 PY2: January 2014 December 2014 Historical Benchmark $307,105,802 Actual THN Performance $303,532,135 Savings of 1.16%: $ 3,573,667 Savings Distribution $10,537,755 Savings Distribution $0 26

Triad HealthCare Network Medicare Shared Savings Program Financial Performance: 2015 PY3: January 2015 December 2015 Historical Benchmark $316,422,097 Actual THN Performance $316,528,097 Over budget : $ -105,754 Comparison to other ACOs 392 ACOs: 203 generated savings (120 will get payments) 120 ACOs getting pmts: avg benchmark $11,364 PMPY 272 ACOs not getting pmts: avg benchmark $9,975 THN benchmark: $8,888 (22% lower than $11,364) Savings Distribution $0 28

Triad HealthCare Network Next Generation ACO Overview Transitioned to Next Gen ACO from Medicare Shared Savings Program ( MSSP ) in January 2016 Covers approximately 30,000 traditional Medicare beneficiaries 100% risk for medical expenses up to 15% savings or losses (risk corridor) Annual medical expenses approximately $300M Contract covers a calendar year (Jan-Dec) Receive quarterly reports and monthly claims 29

Triad HealthCare Network Next Generation ACO 2016 Projected Performance CMS Report CMS Report Optum Actuarial Jan-Mar 2016* Jan-Jun 2016** Jan-Dec 2016*** Members 30,015 29,831 29,487 Incurred Claims (provider payments) $ 49,857,006 $ 122,193,755 $ 191,088,389 IBNR 0.3839 0.1621 0.3837 IBNR Estimate $ $ 19,139,347 $ 19,649,032 $ 73,329,374 Total Estimated Claims $ 68,996,353 $ 141,842,787 $ 264,417,763 Estimated PMPM $ 770 $ 801 $ 767 Risk-adjusted trended baseline $ 805.67 $ 828 $ 792.99 Discount factor (range 0.5%-4.0%) 1.46% 1.46% 1.46% 2016 NextGen ACO Benchmark $ 793.91 $ 816.35 $ 781.43 Benchmark estimated expenditures $ 71,179,342 $ 144,591,697 $ 269,462,315 30 Net Loss/Savings (less 2% sequestration) $ 2,139,329 $ 2,693,931 $ 4,943,661 * CMS Report: Jan-Mar 2016 paid through Mar 31, 2016 ** CMS Report: Jan-Jun 2016 paid through Jun 30, 2016 *** Optum Actuarial Projections for Jan-Dec 2016 (based on Jan-Mar CMS report)

Risk Triad HealthCare Network Risk and Shared Savings Contracts 2015 Medicare Shared Savings Program ($0) 2016 NextGen ACO Program ($++) 2015 Humana HMO 2016 Humana HMO 2016 HealthTeam Advantage Shared savings 2015 UHC 2016 UHC 31

Risk Triad HealthCare Network Risk and Shared Savings Contracts 2015 Medicare Shared Savings Program ($0) 2016 NextGen ACO Program ($++) 2015 Humana HMO ($?) 2016 Humana HMO ($?) 2016 HealthTeam Advantage (too early to tell) Shared savings 2015 UHC 2016 UHC 32

Triad HealthCare Network UHC 2015 Projected Performance Had to hit four Quality Metrics This is a shared savings program (50/50) Final payment from CMS is a RAF adjustment payment that comes in late August every year 33

Triad HealthCare Network UHC 2015 Projected Performance Had to hit four Quality Metrics We hit all four (great work on everyone s part!) This is a shared savings program (50/50) Final payment from CMS is a RAF adjustment payment that comes in late August every year Final number not known, est in the $1-2M range 34

Triad HealthCare Network UHC 2016 Projected Performance Have to hit four Quality Metrics This is a shared savings program (50/50) Final payment from CMS is a RAF adjustment payment that comes in late August every year 35

Triad HealthCare Network UHC 2016 Projected Performance (thru 6/30/16) Jan-May 2016 PMPM Jan-June 2016 PMPM Members 10,654 10,610 Revenue (100% received by United) 49,475,330 $ 934 59,374,456 $ 933 Budget (82%) 40,569,770 $ 766 48,687,054 $ 765 Incurred Claims (provider payments) $ 25,583,801 $ 483 $ 31,870,736 $ 501 IBNR Estimate $ $ 11,616,187 $ 219 $ 11,702,409 $ 184 Total Estimated Claims $ 37,199,988 $ 702 $ 43,573,145 $ 684 Net Loss/Savings $ 3,369,782 $ 64 $ 5,113,909 $ 80 THN/Cone 50% $ 1,684,891 $ 2,556,954 36

Triad HealthCare Network Transitions of Care One of the times when our patients are most vulnerable is when they leave the hospital and transition to home Patients often lack support systems, adequate knowledge, and needed medications to prevent readmissions The communication necessary to make a good handoff between hospitalist and outpatient provider has not always been adequate We all have individual stories of where the system has failed patients What do we do about this? 38

Triad HealthCare Network Transitions of Care Review of medical literature Studies targeting one intervention have generally not worked There is no magic bullet Studies show that there are targetable populations The patients who have more chronic illness burden and who had a more serious acute illnesses derive the most benefit Studies show that the main three interventions which worked Care coordination by a nurse Home/Office visit soon after discharge Communication between hospital and PCP 39

Triad HealthCare Network Transitions of Care In February, 2016, we held a TOC Summit Vision: The patient has everything they need to safely transition to their home What is needed : Responsible provider Integrated, aligned, accessible, and agreed upon plan of care that includes roles and expectations of providers, ancillaries, patient, and caregivers, and takes into account the patient s goals of care Medications Knowledge Post-hospital visit and/or call Adequate mobility for home 40

Triad HealthCare Network Transitions of Care In February, 2016, we held a TOC Summit Vision: The patient has everything they need to safely transition to their home What is needed : Responsible provider Integrated, aligned, accessible, and agreed upon plan of care that includes roles and expectations of providers, ancillaries, patient, and caregivers, and takes into account the patient s goals of care Medications We have been Knowledge working on Post-hospital visit and/or call these two Adequate mobility for home needs 41

Triad HealthCare Network Transitions of Care Transition of Care Project Components Helping you make space for patients Helping you be aware of significant revenue opportunities for TOC, especially in Medicare and Medicare Advantage Helping you be aware of who is in the hospital and who has been discharged in the last 30 days Helping you get discharge summaries in a timely manner 42

Triad HealthCare Network Transitions of Care Transition of Care Project Components Helping you make space for patients Giving you data on number of NextGen discharge per provider per year Helping you be aware of significant revenue opportunities for TOC, especially in Medicare and Medicare Advantage Education materials on how to manage the requirements to bill for TOC Helping you be aware of who is in the hospital and who has been discharged in the last 30 days Transition of Care tool Helping you get discharge summaries in a timely manner Let us know if you routinely do not get discharge summaries on your patients 43

Triad HealthCare Network Transitions of Care Transition of Care Project Pilot sites Zack Hall, MD Triad Internal Medicine Associates Piedmont Family Medicine Greensboro Medical Associates Thanks!! We will be rolling this process out to all THN primary care sites and would appreciate your participation for the benefit of your patients 44

Triad HealthCare Network Iodine Update Initial plan was to start on 4/1/16 and be completed by 7/1/16 The Cone Health IT owner of this left and new staff had to be brought up to date Announced in the 8/18/16 Beacon Instructions on how to get the app activated on your smartphone or create web access to it (with email notifications) In case you missed it: http://www.triadhealthcarenetwork.com/resources/media-2/iodine-secure-textmessaging/ 45

Triad HealthCare Network Iodine Update When and how to use Iodine Anytime you need to have HIPAA compliant asynchronous communication with another provider Examples Saw Betty Smith, DOB 09/02/56, today. Seeing you next week. Her creatinine is up sharply to 3.6. Understand John Black, DOB 08/16/42, in with CHF. We talked about advanced planning at his last visit. Call me if you need update. Sharon Jones, DOB 4/25/48, stopped her Coumadin. You will need to reschedule her cardioversion. Evidence from literature and other health systems is that secure texting helps coordinate care and lower unnecessary costs 46

Triad HealthCare Network Iodine Update Please activate Iodine via smartphone or web access soon Phone numbers in the User Guide to help you if needed Important: If you don t use Iodine quarterly, your account will be deactivated You will receive a quarterly text message from Iodine/Cone Health please respond so that your account remains active If you find that this is being used inappropriately, please feel free to let me know! We want this to be an asset, not a burden! Cone IT staff on each site tonight to assist with enrollment 47