Duke Medicine ACO Preparedness A Clinically Integrated Network Approach Bill Schiff, MHA Duke Medicine Private Diagnostic Clinic, PLLC. (PDC) Duke Faculty Practice 1 A. Duke Medicine Organizing for HealthCare Reform and Accountable Care B. Alignment Models for AMCs and Faculty Practice Plans Overview at Duke C. Four Phases of ACO concept development and Preparedness at Duke 1. Phase One: Start with Something! Take on a Meaningful Patient Population 2. Phase Two: IPA Approach as Wrap Around Network 3. Phase Three: Clinically Focused Redesign Efforts 4. Phase Four: Gainsharing Structure for Alignment with Health System D. Final Thoughts and Considerations 2
Duke s Approach A Clinical Integrated Network 3 4
5 Duke Medicine: A Physician Focused Approach Four Phases for ACO Preparedness at Duke 1.Get Started: Identify and secure contract for meaningful patient population. Develop some momentum. 2.Network Development: Identify Strategy for Network Expansion beyond the traditional physician organization. 3.Care Redesign: Invest in new Care Redesign Efforts 4.Develop System Partnerships: Develop model for Gainsharing Model across the Duke Enterprise Goal: Work Towards a business model approach that can be transferrable to multiple payor sources. 6
PHASE ONE: Start with Something! Take on a Meaningful Patient Population Duke Started with its own Self Insured Employee Health Plan 7 Market Preparedness Duke Employee Plan 2011 Clinically Integrated Network 2011 Duke Employee Plan Redesign Transition Update In 2010 the PDC began discussions with Duke University to define a new approach that would provide a simplified design that would begin to allow both parties to prepare for health care reform while also providing a tighter physician network approach for enhanced clinical integration. Key Components of a New Simplified Design for 2011 A. Centralized Management Services Health Plan Third Party Administrator (TPA) at reduced Administration Fee Claims Processing (Network/Facilities) Medical Management Physician Credentialing Health Plan Member Services and Plan Materials B. Physician Network Design Duke Sponsored Integrated Network Approach Streamlined Duke Centric Physician Network Defined Financial Medical Budget for Physician Services Defined Network participation requirements Patient Direct Services C. Disease management and Wellness Services Duke Well Program Management Patient Stratification and Risk Identification Care Management Services (Diabetes and CHF/CAD) Coaching Services Patient and Physician Incentive Programs Data Analysis and Outcome Reporting 8
DukeWell Wellness Program at Duke 2011 Name/Brand Change Duke Prospective Health to DukeWell Health Risk Assessment (HRA) HRA administered by outside partner HRA data available to DukeWell Care Management of members with diabetes/cardiovascular disease 2010 program Disease self-management Behavior/motivational change Coaching (disease or risk modification) Participant Awards 2010 program Duke and non-duke affiliations Multiple delivery modes to participants 90 day program segments Medco pharmacy credits up to $450/yr Physician Incentive Model Align clinical outcomes with PDC Electronic data submission Physician/Clinical Practice Integration Communications Plan 9 Physician/Practice referrals Care Manager practice assignment Practice-based Program Coordinator Duke University Developed starting in January 2011 Open enrollment www.dukewell.org PHASE TWO: IPA Approach as Wrap Around Network 2012 Duke Medicine IPA Approach Augment Current Network Development Activities 10
Primary Care Employed Specialty Care and/or Primary Care PDC Hospital Affiliates IPA Wrap Around Network Primary Care Primary Care Expand primary care Feed patients to DUHS specialists Specialty Services Grow specialty and multi-specialty practices Support and feed ancillary, sub-specialty, inpatient, and Duke University Health System Hospital Network and Affiliations Generate targeted referral volumes Create margin from operations of local Dukeaffiliated specialty programs Facilitate expansion of academic activities within a community environment Clinical Strategic Alliance Contracted Network Organizational Affiliates Organizational Integration IPA Network 11 Independent d Physician i Association Provide a Low Cost flexible model for physicians Provide a means to fill in network adequacy gaps Provide network for new health care network models Tiered Networks Clinical performance gainshairing Employer direct networks Accountable Care contracting IPA MODEL Value Added Services 1. Exclusive Contracts: IPA s need to have access to a patient panel that is exclusive. This is probably one of the biggest drivers for physicians. 2. Reimbursement: Physician will require access to fee schedule that is better than market. 3. Tiered Payor Networks: Practices may want to join if payors will marginalize them and lock them out of employer networks. Differentials in fee schedules will drive these physicians to a IPA model 4. Clinical Outcome Requirements: Practices will want access to participate p in employer/payor y sanctioned clinical outcome programs especially if these are required for participation or affect reimbursement levels. 5. IT Investment: Practices will need help to keep up with EMR requirements. 6. Small Employer Business Management: Practices are also small employers so they may need access to group purchasing for health insurance etc. 7. Practice Management Expertise: Practices may want administrative services such as HR, Accounting, Retirement Planning, etc. 8. Purchasing Programs: Access to Dukes Purchasing Programs (medications, supplies, etc.) 9. Local Autonomy: Physician will want to run their local office and will not want to be employed or run by Duke. 10. Vendor Discounts: Practices will want access to companies that Duke can offer at discounted rates (Billing services, EMR, accountants, etc.) 11. Real Estate Services: Practices will want the ability to access Duke Real Estate services and also potentially have joint ownership. Practice may also need Duke financing services. 12
PHASE THREE: Clinically Focused Redesign Efforts 2012 Duke Investment in Infrastructure to Delivery ACO concepts 13 PDC Clinical Redesign Pilots 2012-2013 Physician Directed Clinical Redesign Pilots Programs A. Medical Home Concept for High Volume Primary Care Practices (Two Pilot Primary Care sites) PDC at Duke Family Medicine (Pickens Clinic) DPC at Picket Road (Duke Diet and Fitness Center) Overview and Concept B. Clinical Guideline Deployment Colonoscopy Sleep Studies Muscular Skeletal Imaging C. Pharmacy Management Program Psychotropic Medications Diabetic Management Specialty Medications D. Further Development of DukeWell Integrated Physician Services Care Manager scheduling in IDX; clinical documentation directly into Duke Browser Real-time follow-up to physician appointments Focus on coordination of care and support of new program offerings. 14
Pilot Practices 4 Quadrants of Outcome Measurement 1. Employer Based Metrics Absenteeism Patient Satisfaction Workers Compensation Rates Access and Availability for Patients t Patient Direct Services (Portal) 2. Financial Management: Pharmacy Costs Inpatient Facility Costs Ancillary Costs Specialists Referrals Costs Primary Care FFS Equivalent cost Behavior Health Costs Program Impact 3. Clinical Outcomes for Patients: Preventative Disease Markers Diabetes, Asthma, CHF, Obesity Adherence with Clinical Guidelines Pharmaceutical Guideline Adherence 4. Resource Utilization: Hospital LOS ER Utilization Hospital Readmission Rates Ancillary Imaging Utilization Behavior Health Utilization 15 PHASE FOUR: Gainsharing Structure for Alignment with Duke University and Duke Health System 2012 16
Duke Employee Health Plan Shared Savings Model Quality Improvement Program (QIP) Measures WP Proposed PDC Response PDC Redesign Meaningful Use Shared Savings Model QIP Measures DukeWell Notes Evidence Based Guideline Compliance (Physician Measurement Specification) 30% Gain Share QIP Colorectal Cancer Screening (COL) P A Yes Yes Yes High Alignment Breast Cancer Screening (BCS) P A Yes Yes Yes High Alignment Diabetes Care - Cholesterol screening P A Yes Yes Yes High Alignment Cardiovascular Care - Cholesterol screening P A Yes Yes Yes High Alignment Hemoglobin A1C testing for members with diabetes (type 1 and 2) (HEDIS sub measure) P A Yes Yes Yes High Alignment Rx Compliance/Performance 15% Gain Share QIP Generic Compliance Rate P A Yes Yes Medco Alignment Formulary Compliance Rate P A Yes Yes Medco Alignment Avoidable ER Admissions P A Yes NA 25% Gain Share QIP Preventable Inpatient Admissions NA 30% Gain Share QIP COPD P A Yes NA High Alignment DUHS CHF P A Yes NA High Alignment DUHS Diabetes No P Yes NA High Alignment DUHS Follow-Up Visits Within Two Weeks of Inpatient Discharge P A Yes NA High Clinical Redesign Readmission Rate (PDC Proposed) No A Yes NA High Alignment DUHS NOTES: 1. Duke University proposed for Duke Employee Health Plan Shared Savings Model September 2011 17 Issues and Considerations: Academic Faculty Practice Running a Current Business while also designing a new structure: Institutional need to build external physician services (primary and specialty care) at a greater pace while continuing current services provided by Department/Divisions within the faculty practice plan on a FFS basis. Patients are the New Currency: Perceived and real competition for primary care referrals with newly added specialists. Investment: Overhead costs for network and marketing services will inevitably be questioned by departments/faculty. Managing different Physician Agreements while growing the network: Different individual financial deals for Private Practice Physicians vs. Duke Specialists sets up competition for the best deal. Proposal is for Duke Specialist to be paid based on initial guarantees and then productivity. Management of Academic Contributions and Mission: Select faculty physicians may want a similar deal as those being employed, thereby reducing their academic taxes and support to departments. Perceived Market Overlap: Territorial market issues within the network between similar specialist will certainly develop from a two-tiered system. Management Services Restructure: MSO services already exist in practice that otherwise would need to be duplicated, resulting in a more costly system. However, focused MSO efforts of combined units may be seen as preferential and continuously debated internally. Competition for Financial Resources: Institutional dollars need to be spent to build out network, but compete with internal needs for financial resources. All of the above issues are at the center of attention while internal challenges are faced by clinical departments and faculty with regards to maintaining their academic funds flow and compensating their faculty for clinical productivity. 18
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