Cultural Transformation and the Road to an ACO Lee Sacks, M.D. CEO Mark Shields, M.D., MBA Senior Medical Director AMGA Pre-conference Workshop 1 April 14, 2011 Washington, D.C. Disclosure Nothing in Today s Presentation Should Be Construed as Advising or Encouraging Any Person to Deal, Refuse to Deal or Threaten to Refuse to Deal with Any Payer, or Otherwise Interfere with Commerce Opinions Expressed by Speakers are Their Own Advocate Physician Partners is a Partner in CI- Now 2 Agenda Health Reform and ACOs Structures Incentives Technology Clinical Integration Opportunities 3 1
Advocate Physician Partners Advocate Physician Partners delivers services throughout Chicagoland. Physician Membership 1,100 Primary Care Physicians 2,700 Specialist Physicians Total membership includes 900 Advocateemployed Physicians 10 Acute Care Hospitals and 2 Children s Hospitals Central verification office certified by NCQA 230,000 Capitated Lives/700,000 PPO Lives 4 Health Reform and ACOs Structures Incentives Technology Clinical Integration Opportunities 5 Viewer Discretion Advised 6 2
Value Based Purchasing Requires Integration Bundled Payments Payment Denials Accountable Care Organizations Cost Pressures 7 It s A New Day MCO s Acknowledge Inability to Manage Rising Costs Medicare Finances are Not Sustainable Payers Can No Longer Sustain Double-Digit Increases Population is Aging Uninsured Will Enter Care Delivery System 8 Change is Necessary Significant Waste In System Value of Partnering To Eliminate Waste To Have Price Competitive Product Current Payment Model Does Not Support Shared Vision Sense of Urgency 9 3
Accountable Care Organization HHS to create by January 2012 Provider Groups accept responsibility for cost and outcomes for a specific population Must provide data to be used to assess performance Attribution 10 Accountable Care Organizations* Accountable Care Models Integrated Delivery Systems Multispecialty Group Practices Physician-Hospital Organizations Independent Practice Associations Virtual Physician Organizations *Shortell, Stephen M., Lawrence P. Casalino, Elliott S. Fisher How the Center for Medicare Innovation Should Test Accountable Care Organizations Health Affairs 29. No 7 pp. 1293-1298 11 Accountable Care Organizations* Strategy to Bend the Cost Curve and Improve Coordination and Quality of Care Implementing a Learning System Strategic Focused Goals and Objectives Skills and Tools Measurement and Accountability Leadership *Shortell, Stephen M., Lawrence P. Casalino, Elliott S. Fisher How the Center for Medicare Innovation Should Test Accountable Care Organizations Health Affairs 29. No 7 pp. 1293-1298 12 4
Challenges for ACOs Large Multi-specialty Groups are the Exception 9 of 10 Americans Get Their Medical Care in a Solo or Small Practice* Infrastructure is Required to Drive Quality Outcomes Demonstrated by Multi-specialty Groups Culture is not Created Over Night * NEJM 360;7 Feb. 12, 2009 13 Health Reform and ACOs Structures Incentives Technology Clinical Integration Opportunities 14 Advocate Physician Partners The Vision of APP is to be the leading care management and managed care contracting organization. Advocate Medical Group BroMenn Christ Condell Dreyer Medical Clinic Good Samaritan Good Shepherd Illinois Masonic Lutheran General South Suburban Trinity Future Future Medical Group 15 5
APP Board and Committee Structure APP Board of Directors Contract Finance Committee Utilization Management Committee Quality & CI Improvement Committee Credentialing Committee 1,100 PCPs + 2,700 Specialists = 3,800 Total Physician Members Average Group Practice Size 2.5 16 Local Site Engagement in Governance APP Board and Committees BroMenn Christ Condell Good Samaritan Good Shepherd Illinois Masonic Lutheran General South Suburban Trinity 17 Health Reform and ACOs Structures Incentives Technology Clinical Integration Opportunities 18 6
Advocate Physician Partners Incentive Fund Design 1-9 Group / Incentives (30%) Individual Incentives (70%) Group/ Distribution Group / Criteria Tier 1 (50%) Tier 2 (33%) Tier 3 (17%) *Residual Funds Individual Tiering Based On Physician s Individual Score Individual Criteria Individual Distribution *Residual Funds * Residual Funds are rolled over into general CI fund (not tied to individual physician or originating ) to be distributed in the following year 19 Calculation and Distribution of CI Incentives to Physicians CI Incentive Distribution for Each Physician Based on the Following: Physician s Allowable Physician Billings Individual CI Score CI Score of the Physician s Primary 20 Radiology Report Turnaround Time Hospital Efforts 49% Decrease From 49 to 25 Hours Hospital w/app Efforts Additional 65% Decrease From 23 to 8 Hours 21 7
Incentives for Outcomes CI Incentive Funds Distribution Performance Year Funds Distributed 2005 $12.4 Million 2006 $16.7 Million 2007 $25.0 Million 2008 $28.2 Million 2009 $38.0 Million 2010 Est. $50.0 Million 230,000 Capitated Lives / 700,000 PPO Lives Unearned Funds Roll Over into Next Year Great Clinical Outcomes and Good Business 22 Aligning Physician and Hospital Incentives 2009 CPOE Core Measures 2010 CPOE Core Measures Core Measures Readmissions Length of Stay 2011 ED Efficiency Meaningful Use Core Measures Readmissions Length of Stay 23 Health Reform and ACOs Structures Incentives Technology Clinical Integration Opportunities 24 8
Advancing Technologies Year 2004 High Speed internet Access in Physician Offices Centralized Longitudinal Registries Access to hospital, lab and diagnostic test information through a centralized Clinical Data Repository (Care Net and Care Connection) 2005 Electronic Data Interchange (EDI) 2006 Computerized Physician Order Entry (CPOE) Electronic Medical Record Roll out in Employed Groups 2007 Electronic Intensive Care Unit (eicu) use 2008 e-prescribing 2009 Web-based Point of Care Integrated Registries (CIRRIS) 2010 e-learning Physician Continuing education Electronic medical records Roll out in Independent Practices 25 High Speed Internet Implications Over 3,800 physicians access: CIRRIS (Registries, Pharmacy, Report Cards) Electronic Referral Module APP Website, Newsletters Carrier Connections Clinical Protocols and Patient Education Material Clinical Reference Tools CareNet/CareConnection eprescribing 26 Electronic Medical Record Point of Care Prompts Standardized Patient Education Materials Linked with CIRRIS Roll-out to Employed Physician Practices Almost Complete Major Roll-out to Independent Practices Began 2010 27 9
Clinical Integration Registry and Reporting Information System (CIRRIS) Web-Based Commercial Registry Integrates All Registries, Pharmacy, Labs, Claims and Performance Reporting Integrates Physicians Integrated with EMR 28 CIRRIS Infrastructure Data Inputs Hospitals Primary Care Physicians Medicare Intermediary Specialists & Ancillary Providers Health Plans APP DATA WAREHOUSE Web Based Administrative Data Inputs Hospital & Physician Office Labs EMRs National & Regional Labs Pharmacy Benefit Managers 29 Data Populates Disease & Preventive Care Registries Acute and Chronic Cardiovascular Diseases Breast, Cervical, & Colorectal Preventive Care Smoking, BMI, BP Clinical Observations Generic Prescribing Efficiency APP DATA WAREHOUSE Childhood Flu Immunizations Diabetes and Other Chronic Diseases Seamlessly View Patients Across Registries Employer & Population Management 30 10
Health Reform and ACOs Structures Incentives Technology Clinical Integration Opportunities 31 Clinical Integration: Definition A structured collaboration among APP physicians and Advocate Hospitals on an active and ongoing program designed to improve the quality and efficiency of health care. Joint contracting with fee-for-service managed care organizations is a necessary component of this program in order to accelerate these improvements in health care delivery. 32 What Clinical Integration Looks Like Jane Smith, Patient with Diabetes OB-GYN Mammography Endocrinologist Primary Care Physician Pharmacy Lab Test Results APP Data Warehouse and Disease Registries Primary Care Physician OB-GYN Endocrinologist 33 11
2011 Clinical Integration Program Overview Physician Commitment to a Common and Broad Set of Clinical Initiatives 57 Initiatives Broad Area of Focus 146 Individual Performance Measures Primary Care and Specialty 5 Performance Domains Clinical Outcomes Efficiency Medical and Technological Infrastructure Patient Safety Patient Satisfaction 34 Clinical Integration 3.0: Increasing Physician/System Integration Primary Care/ Ambulatory Measures Increasing Specialist Measures Increasing Physician/ System Integration Early Years: 2004-2006 Middle Years: 2007-2009 Maturing Years: 2010-2013 35 Expansion of Program Over Time CI Program Categories Reporting YR 2006 Reporting YR 2007 Reporting YR 2008 Reporting YR 2009 Reporting YR 2010 Reporting YR 2011 Med & Tech Infrastructure 5 7 7 8 9 9 Clinical Effectiveness 35 46 63 73 72 90 Efficiency 9 10 11 13 21 30 Patient Safety 2 2 12 10 11 11 Patient Experience 1 3 3 3 3 6 Total Measure Count 52 68 96 107 116 146 36 12
No. of Physician Requirements 4/18/2011 Membership Criteria 25 20 15 10 5 0 Physician Membership Requirements 04 05 06 07 08 09 10 11 CI Years 37 New CI Measure Development Annual Process Jan - March Collect Measure Suggestions from MDs, Boards, Specialty Committees and MCOs August APP QI Committee and Board Approve Entire Program Sept Staff Compiles Program Specs and Measure Documentation April Engage New Measures Sub Committee & APP QI Committee July Construct ecw and CIRRIS Registry Updates Oct - Nov ecw & CIRRIS Updates Complete May Work Group Assesses New Measure Adequacy June QI Committee Finalizes New Measure Recommendations in June Dec IHC & APP Staff Implement Admin Processes & Educational Plans 38 Advancing Evidence-Based Medicine and Care Year 2004 Physician Reminders for Care 2006 Patient Outreach Chart Based Patient Management 2007 Physician Office Staff Training Pharmacy Academic Detailing Program Generic Voucher Program 2008 Diabetes Collaboratives Patient Coaching Program Hospitalists 2009 Diabetes Wellness Clinics Asthma and HF/CAD Collaboratives Added 2011 Access and COPD Collaboratives Added 39 13
Patient Outreach Response to Physicians Concerns About Patient Non-Adherence Encouraging and Educating Patients to Obtain Appropriate Services Enhancing Patient Education Mail Phone Linking/Branding with APP Physicians 40 Office Staff Education CI Orientation Use of Registries and Flow Sheets Office Flow Redesign MCO Updates 41 Diabetes Wellness Clinics Two Clinics Established Supports Maintenance of Select Diabetics Additional Monitoring, Education and Protocol Driven Patient Management Supported by APP Staffed by Nurse Practitioner Dietician Collaborating APP Physician 42 14
Diabetes Wellness Clinics: Patient Impact A1c Levels 3% Improvement Top 100 Patients Success Stories Were (Based on Averages): 55 Years of Age 3% Improvement in A1c over 4 ½ Months Between Initial and Follow-up Visits 27.6% Improvement in A1c s 43 Diabetes Wellness Clinics: Impact 2009-2010* % HbA1c performed (>= 81%) % HbA1c performed < 7 (>= 32%) % HbA1c performed > 9 or untested (<= 40%) % LDL performed (>= 79%) % of LDLs < 100 mg/dl (>= 46%) % of LDLs > 130 mg/dl or untested (<= 36%) *Pending reconsiderations Trinity Trinity SSub 2009 SSub 2010 2009 2010 Trinity SSub (1095 (1832 (576 (658 Improvement Improvement Patients) Patients) Patients) Patients) 83% 90% 7% 80% 94% 14% 35% 43% 8% 38% 51% 13% 43% 34% -9% 39% 23% -16% 80% 89% 9% 74% 91% 17% 47% 55% 8% 43% 59% 16% 37% 31% -6% 41% 26% -15% 44 Diabetic Care Outcomes 2009 Outcomes Exceeded Targets Performed Above National Expected Rate for 9 of 9 Diabetic Care-Related Measures Diabetic Care Initiative Resulted in An Additional: 12,350 Years of Life 19,760 Years of Sight 14,820 Years Free from Kidney Disease 45 15
NCQA Data on Diabetes Measures: How 2010 APP Performance Stacks Up Measure HMO PPO Actual HbA1C TestingManaging 89.2% 83.3% 89.0% Poor Control (>9) Results! 28.2% 44.6% 24.0% Good Control (<7) 42.1% 30.3% 52.0% Annual Eye Exam 56.5% 42.6% 60.0% LDL-C Screening 85.0% 78.6% 87.0% LDL-C Control (<100) 47.0% 36.8% 60.0% Monitoring Nephropathy 82.9% 69.9% 85.0% Blood Pressure Control (<130/80) 33.9% 23.6% 54.0% Blood Pressure Control (<140/90) 65.1% 46.3% 80.0% 46 2010 Value Report The 2010 Value Report www.advocatehealth.com/app or call 1-800-3-ADVOCATE (1-800-323-8622) The 2011 Value Report Available Late April 2011 47 Health Reform and ACOs Structures Incentives Technology Clinical Integration Opportunities 48 16
Opportunities Align Incentives P4P is Catalyst for Clinical Integration Create Infrastructure Identify Partners 49 Opportunities to Bend the Cost Curve Potentially Avoidable Admissions Readmissions Inappropriate ED Visits Care Coordination 50 Strategies Improve Primary Care Access Enterprise Care Management Embedded Care Managers Emergency Department Care Managers Redesign Inpatient Care Model Perfect Transitions Data / Analytics 51 17
Questions / Discussion 52 18