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
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
WellMed
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.
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
Clinic Model Medical Service Organization 40 plus clinics in Texas and Florida 150 + Providers Full Risk Fully Delegated (claims, UM, DM, CC, CM) Family Practice and Internal Medicine Physicians Serving over 85,000 seniors 6
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 1000 -< 200 Bed Days per 1000 -< 800 Readmission with 30 days 8-12% HbA1c, LDL, near best in class Patient satisfaction high Provider satisfaction high
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.
System Design Drives Performance Bed Days Per 1000 Average 1260 High - 1622 Low - 952 WellMed - 722 (2011) 2008 Capitation Survey hcpro Admits per 1000 Average 263 High - 292 Low - 242 Median - 258 WellMed 194 (2011)
Results of WellMedCare Model 20 903 19.7 220 0 11.3
Results of WellMedCare Model 2500 Bed Days / 1000 2000 2200 1500 1000 20 11.3 903 19.7 220 0 500 903 722 0 WellMed 2009 WellMed 2011 Medicare FFS
Progress after implementing Systems Change (WellMed Care Model) Admits per 1000 350.0 300.0 250.0 200.0 150.0 100.0 50.0 0.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
Admits Per 1000 SAT 300.0 250.0 200.0 150.0 100.0 50.0 0.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
WellMed Care Model Plus Breakthrough Series 300 250 UCL=261.709 Admits Per 1000 SAT-NEF 36 months ending May 2011 200 CEN=217.785 150 LCL=173.86 100 Feb 2010 50 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
How did you do that?
WellMed Care Model Care Coordination Breakthrough Series Model of Improvement
Why We Are Here Unstainablecost inflation Wide Variation Low Reliability
What s the Problem
EFFICIENCY International Comparison of Spending on Health, 1980 2009 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 18 16 14 12 4,000 3,000 2,000 1,000 10 8 6 4 2 United States France Germany Canada United Kingdom Australia 0 1980 1982 1984 1986 1988 1990 1992 * PPP=Purchasing Power Parity. Data: OECD Health Data 2011 (database), version 6/2011. 1994 1996 1998 2000 2002 2004 2006 2008 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. 20
Relationship Between Quality of Care and Medicare Spending: As Expressed by Overall Quality Ranking, 2000 2001 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.
EFFICIENCY Medicare Admissions for Ambulatory Care Sensitive Conditions, Rates and Associated Costs, 2009 1,200 Rate of ambulatory care sensitive admissions per 10,000 beneficiaries 20 Costs of ambulatory care sensitive admissions as percent of all discharge costs 900 600 618 405 499 718 792 15 10 12.3 9.3 10.7 13.4 14.5 300 5 0 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, 2011. 24
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.
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.
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
ACO Most Critical Decision Regarding your $50 million budget
What will you do differently?
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 $0 1 2 3 4 5 6 7 8 9 101112131415161718192021222324252627282930313233343536373839404142
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
Where s It Go
Managing Cost Hospital-Hospital-Hospital SCP $$$$ Hospital PCP
Medical Cost Hospital = 40-50% in all markets Hospital
Risk - Modeling
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