capg health winter 2015

HEALTHDiane Laird: Innovative Partnerships at MemorialCare, p.8

Raising Quality of Life,Lowering Costs forComplex Patients, p.22

CAPG Members Honoredfor Exemplary CareDelivery, p.6, 24

Volume 9 • No. 1 Winter 2015

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At Hill Physicians, we continue to improve upon coordinated care, with remarkable results. We provide the tools and support that practices need to be financially successful and improve the coordinated care experience for their patients. Our advantages include:

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Gilbert Martinez, M.D.Hill Physicians provider since 2010.

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VITAS Is The ACO Partner You Need For Success

Having a hospice and palliative care partner in place is critical to the success of any ACO. Since 1978, VITAS Healthcare has held itself to the standards of today’s ACO. Skilled, appropriate and timely hospice and palliative care reduce unnecessary admissions by relying on VITAS’s evidence-based care protocols,

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VITAS Is The ACO Partner You Need For Success

Having a hospice and palliative care partner in place is critical to the success of any ACO. Since 1978, VITAS Healthcare has held itself to the standards of today’s ACO. Skilled, appropriate and timely hospice and palliative care reduce unnecessary admissions by relying on VITAS’s evidence-based care protocols,

transition processes and ancillary resources.

VITAS.com

To discuss a specialized program or speak with a VITAS representative, please call 800.873.5198

TAB

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TS ON THE COVER 8Diane Laird: Improving Healthcare Delivery Through Creative Partnerships

DEPARTMENTS

5Notes from the President

6Names in the News

10Upcoming Events

12 Federal Legislative Update:

Challenges and Opportunities

in 2015

18CAPG Member List

20State Legislative Update: Moving

Medi-Cal Toward Coordinated Care

FEATURES

14Grassroots Advocacy: How to

Win Friends and Influence

Policy Makers

22Raising Quality of Life and

Lowering Healthcare Costs for a

Shifting Patient Population

24St Jude Medical Group Named a

“Most Valuable Care” Provider

26Annual Wellness Visits: A Key

Benefit for Medicare Patients

28Top Business Risks for Medical

Practices

4 l CAPG HEALTH Winter 2015

HEALTHPublisherValerie Okunami

Editor-in-ChiefDon Crane

Editorial Advisory Board Lura Hawkins, MBA Amy Nguyen Howell, MD, MBA Mary Kay Payne

Managing EditorDaryn Kobata

Editorial AssistantNelson Maldonado

Contributing WritersBill BarcellonaDon CraneValerie Green-Amos, MDJanet Mullins GrissomMara McDermottMike RosenthalVivien Tran, MPH

CAPG Health Magazine is published byValerie Okunami MediaPO Box 674, Sloughhouse, CA 95683Phone 916.761.1853

capghealth.com

Please send press releases and editorial inquiries to [email protected] and/orc/o CAPG Health, 915 Wilshire Blvd., Suite 1620, Los Angeles, CA 90017

For advertising, please send email to [email protected]

Subscription rates: $32 per year; $58 two years; $3.00 single copy.

Advertising rates on request. Bulk third class mail paid in Jefferson City, MOEvery precaution is taken to ensure the accuracy of the articles published inCAPG Health Magazine.

Opinions expressed or facts supplied by its authors are not the responsibility ofCAPG Health Magazine.

© 2015, CAPG Health Magazine.All rights reserved.

Reproduction in whole or in part without written permission is strictly prohibited.

Winter 2015 CAPG HEALTH l 5

CAPG Members and Friends:

I want to take this opportunity to reflect on the success of our new Colloquium

on Physician Groups in Medicare Advantage held last fall in Washington, DC.

Participation, onsite and online, exceeded our expectations and demonstrated the

intense interest there is in continuing this valuable connection to our nation’s capital.

When we hear directly from policy makers and they observe the professionalism and

innovation of our members, it can only be to the benefit of all.

Along the same lines, in October CAPG board members had the chance to sit down

with Senate Finance Committee Chairman Ron Wyden (D-OR). At the meeting, we discussed the importance of a strong

future for coordinated care across the Medicare program. Senator Wyden is a strong supporter of Medicare Advantage

and other capitated payment models, and CAPG looks forward to working with him well into the future.

Please plan to join us at one or both of our annual conferences in 2015. The traditional CAPG Annual Healthcare

Conference (June 11–14) offers a broad program of nationally acclaimed speakers, educational sessions, and a range

of celebratory social events. The Annual Colloquium (October 5–7) presents an intensive educational opportunity plus

firsthand exposure to the Washington, DC culture. The East Coast location also provides an opportunity for all of us

to reach out and welcome our growing national membership. These two events are among the most prized benefits of

CAPG membership.

For more information on any of these programs, please contact CAPG. My best wishes to all of you for a happy and

successful New Year. o

From the PresidentA MESSAGE FROM DONALD CRANE, PRESIDENT AND CEO, CAPG

Donald Crane, CAPG President and CEO

CAPG President Don Crane and Senator Ron Wyden (D-OR)

CAPG GROUPS HONORED WITH SCAN-UCLA “BETTER WAY TO CARE” AWARDS

Five CAPG members recently received “Better Way to Care” honors from SCAN Health Plan and the UCLA Multicampus Program in Geriatric Medicine and Gerontology. The awards were made at the SCAN-UCLA Best Practices Summit, where California physician groups shared best practices in two main areas: multiple chronic disease management and end-of-life care.

Presenters sharing their organization’s best practices were:

� Marcus Zachary, MD, Brown & Toland Medical Group

� Jay Thomas, MD, PhD, HealthCare Partners

� Terry Hill, MD, FACP, Hill Physicians Medical Group

� Lowell Kleinman, MD, and Louise Della Bella, RN, MN, MemorialCare Medical Group

� Nancy Boerner, MD, MBA, Monarch HealthCare

Other Summit participants were Applecare, EPIC Management, LP, Facey Medical Foundation, Meritage Medical Network, PrimeCare, and St. Joseph Health.

Brown & Toland was recognized for its population health management program aimed at reaching Medicare patients at high risk for hospitalization. To identify these individuals, the group uses sophisticated medical analytic tools and direct input from its provider network. Once they’re identified, patients are connected with individual care managers who closely monitor their health and coordinate their care. In the first year of full implementation, inpatient utilization rates dropped by 25 percent, resulting in better health, higher patient satisfaction, and cost savings of almost $11 million.

HealthCare Partners presented its advance-care planning program for patients who may be in the last year of life. The program seeks to reduce suffering, promote quality of life, and enhance communication among all parties. Once enrolled, patients and their surrogates meet with a trained facilitator, typically a social worker, who guides meaningful discussions between them. The resulting end-of-life decisions are


Names in the Newslegally documented and placed in the electronic medical record.

Hill Physicians Medical Group was honored for its Virtual Care Team Initiative to reach high-risk patients. This team, including nurse case managers, social workers, pharmacists, and health coaches, serves as an extension of smaller practices in providing coordinated care. The program builds on the group’s patient-centered medical home pilot project, which has positively impacted readmission rates, emergency room usage, chronic condition screening rates, and patient satisfaction.

MemorialCare Medical Group shared its best practice in assuring that appropriate hospitalized patients receive a palliative care consult. The group introduced a nurse training program in the “Ask, Tell, Ask” communication model that includes engaging the attending physician in submitting a palliative care referral request. Outcomes include a significant increase in the number of palliative care referrals as well as anecdotal evidence of improved nurse job satisfaction.

Monarch HealthCare discussed its Outpatient Palliative Care Program, a multidisciplinary team that makes home visits to patients who have declined hospice and are deemed to be in their last year of life. Unlike hospice, palliative care allows patients to continue curative therapy while providing extra support to patients, families, and physicians. The program has resulted in a 57 percent decrease in hospitalizations while enabling patients to receive care in the comfort of their homes, and has been highly praised by patients and their families.

Summit attendees also worked with the presenters and UCLA and SCAN gerontology experts to develop action plans for implementing best practices in their own organizations. The groups will receive six months of clinical and operational mentoring as they implement new programs to better serve patients.

“In order to enrich the patient experience, improve health outcomes, and reduce the cost of care, healthcare organizations must work together as never

continued on page 30


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It was clear to GNP leaders that MemorialCare shared this vision and had a track record of collaborating with physicians to achieve the quality, patient satisfaction, and cost reduction needed to create a competitive advantage.

For MemorialCare, adding an IPA relationship within its medical foundation complemented MemorialCare Medical Group and expanded the depth of population health expertise within the system. For GNP, partnering with a health system with a broad geography stretching from the South Bay to San Clemente was a smart move. Today, in addition to its Hoag network, Greater Newport Physicians has three growing tailored networks exclusive to Long Beach Memorial and Miller Children’s Hospital, Orange Coast Memorial, and Saddleback Memorial.

PARTNERSHIPS DEMAND EVEN GREATER OPERATIONAL RIGOR

“When GNP affiliated with MemorialCare, we didn’t envision just how fast we’d need to fully integrate at every level, including IT, financial reporting, and HR systems,” Laird noted. “Maximizing synergy is deeply embedded in MemorialCare’s culture.” The case for full integration was compelling, and “we knew it was critical for long-term success, so we rolled up our sleeves, applied Lean principles, and moved ahead with integration much faster than planned.

“We needed to relocate the teams to gain efficiencies,” she added, “so we found a central location large enough to accommodate growth.” MemorialCare bought and renovated a 15-acre, 300,000 square foot property in Fountain Valley, where over 1,500 employees now reside.

MEMORIALCARE AND UC IRVINE HEALTH ANNOUNCE AFFILIATION

Laird was also pivotal in forming a strategic partnership between MemorialCare and UC Irvine Health that expands access to primary care in north Orange County.

The business of healthcare is transforming. The launch of public and private exchanges, new reimbursement models, greater consumerism, and the demand for more transparency are spurring providers to forge innovative partnerships in the pursuit of better healthcare delivery.

Diane Laird, CEO of Greater Newport Physicians and Chief

Strategy Officer for MemorialCare Health System, has an inside view of how new partnerships are reshaping the marketplace in Orange County and the greater Long Beach area in Southern California. Over the past two years, she has played a key role in the affiliation of Greater Newport Physicians with MemorialCare; an affiliation between UC Irvine Health and MemorialCare; and the recent creation of Vivity, a partnership of seven health systems and Anthem Blue Cross.

PARTNERING TO PROVIDE GROWTH

Greater Newport Physicians (GNP), an independent practice association, and Nautilus Healthcare Management Group joined MemorialCare Health System in early 2012. The IPA, including more than 800 private practice physicians, had a proud 27-year history and a longstanding affiliation with Hoag Hospital. GNP was thriving with strong profits, quality outcomes, and industry accolades, but also was seeing commercial enrollment declining.

By 2010, it was clear to GNP’s leadership that, in a rapidly consolidating market where quality and cost were increasingly important, they needed new options for long-term growth and stability. “We began looking for partners with a vision for growth and a commitment to population health,” said Laird, who has been GNP’s CEO since its inception.

ON THE COVER


Improving Healthcare Delivery Through Creative Partnerships

“

Diane Laird, CEO, GreaterNewport Physicians; ChiefStrategy Officer, MemorialCare Health System

CAPG HEALTH September/October 2014 l 7

In November 2014, as a first step in the partnership, UC Irvine Health opened two primary care sites in Tustin and Orange with 13 physicians. The new health centers are leveraging MemorialCare Medical Foundation’s infrastructure and extensive expertise in physician practice management and operations.

UNPRECEDENTED PARTNERSHIP AMONG SEVEN HEALTH SYSTEMS AND ANTHEM BLUE CROSS

In September 2014, Anthem Blue Cross announced a first-in-the-nation partnership with seven health systems. Laird joined MemorialCare CEO Barry Arbuckle and leaders from other prominent systems to create a new, competitively priced product designed to offer exceptional patient experience and a choice of renowned providers. “It was clear we needed to forge a new kind of partnership among health systems and a payor,” she said.

The Vivity partners are accepting risk-based contracts with a focus on the consumer experience and population health. “The great response we’ve received to date from brokers


and employers validates that there really was a gap in the commercial market,” she said.

According to Laird, groundbreaking partnerships like Vivity, unique affiliations like the one between MemorialCare and UC Irvine Health, and MemorialCare’s acquisition of Nautilus and affiliation with GNP all require a level of flexibility, agility, and innovation not seen before in the healthcare industry. “But we can’t stop there. There are new kinds of partnerships and investments that will be necessary if we’re going to transform the delivery system and thrive in this environment.”

MemorialCare Health System is a nonprofit integrated delivery system that includes six top hospitals—Long Beach Memorial, Miller Children’s & Women’s Hospital Long Beach, Community Hospital Long Beach, Orange Coast Memorial, and Saddleback Memorial Laguna Hills and San Clemente; MemorialCare Medical Foundation, featuring MemorialCare Medical Group and Greater Newport Physicians; Seaside Health Plan; and numerous outpatient health centers, imaging centers, and surgery centers throughout Orange County and Los Angeles County. o

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SHEALTHCARE EXECUTIVES OF SOUTHERN CA IDEA LAB

Four Wednesdays, starting January 14hce-socal.org/events/idea-lab; [email protected]

CONTRACTS COMMITTEE

Thursday, January 22Los Angeles, CAPG Office*

NATIONAL CAPG COMMITTEE

Thursday and Friday, January 22–23San Juan, Puerto Rico*

SAN DIEGO REGIONAL MEETINGS

Tuesday, January 27Sharp Spectrum Auditorium*

PUBILC RELATIONS/MARKETING COMMITTEE

Tuesday, February 3Los Angeles, CAPG Office*

GENERAL MEMBERSHIP (SO CAL)


GENERAL MEMBERSHIP (NOR CAL)

Thursday, February 12Oakland, Hilton Oakland Airport Hotel*

PUBLIC POLICY COMMITTEE

Thursday, February 12Conference Call*

PHARMACEUTICAL CARE COMMITTEE


PRIMARY CARE PRACTICE TRANSFORMATION COLLABORATIVE

Wednesday, February 25Los Angeles, CAPG Office*

*For more information contact CAPG at (213) 642-CAPG.

If you have an event to submit for this column, please do so at [email protected]. Please include the name of the event, date, location and where to get additional information.


IHA 10TH NATIONAL PAY FOR PERFORMANCE SUMMIT

Monday to Wednesday, March 2–4San Francisco, Hyatt Regencywww.pfpsummit.comCAPG members receive discounted registration. Contact Jen Kellar, [email protected] or 510.208.1742.

LOWN INSTITUTE 3RD ANNUAL CONFERENCE

Sunday to Wednesday, March 8–11San Diego, Omni Hotelwww.lowninstitute.org

CLINICAL QUALITY LEADERSHIP COMMITTEE

Tuesday, March 10Los Angeles, CAPG Office*

STATE GOVERNMENT PROGRAMS COMMITTEE

Tuesday, March 10Sacramento, TBD*

PHILADELPHIA REGIONAL MEETING

Thursday, March 12TBD*

PUBLIC POLICY COMMITTEE

Thursday, March 12Conference Call*

NATIONAL CAPG COMMITTEE

Monday and Tuesday, March 16–17 Washington, DC*

November/December 2014 CAPG HEALTH l 25

Accountable CareACCELERATING THE EVOLUTION

June 11 - 14, 2015Grand Hyatt, San Diego, CA

12th Annual CAPG Healthcare Conference

REGISTER NOW!capg.org/conference2015

The new year brings with it a great deal of opportunity for CAPG’s federal advocacy. Below is a brief recap of CAPG’s activities in federal advocacy in 2014 and a preview of what is to come in 2015.

PROTECTING AND STRENGTHENING MEDICARE ADVANTAGE

The Affordable Care Act set in motion a series of cuts to the Medicare Advantage program. The intention of the cuts was to bring payment for Medicare Advantage down to 100% of fee-for-service. The reductions to the MA program have since been compounded by additional cuts through subsequent legislation and the regulatory process.

CAPG has established itself in Washington, DC, as a leading physician voice on Medicare Advantage. Over the past 18 months, CAPG had three board members testify before Congress on the issue. In addition, CAPG led a letter signed by over 140 physician groups and independent practice associations opposing further cuts to the program. CAPG has also co-hosted a series of meetings in Congressional districts with members of Congress and beneficiaries to highlight the value of Medicare Advantage.

However, our work is certainly not done. Threats to Medicare Advantage persist this year. The proposed CY 2016 Medicare Advantage rates will be announced in February 2015. We anticipate that the Administration will again propose modifications that reduce the program funding. CAPG and all of its members will

need to weigh in again with Congress and the Administration to mitigate additional

program cuts.

In 2015, CAPG will once again call on its members to support our

federal MA advocacy. This will include

BY MARA MCDERMOTT, DIRECTOR OF FEDERAL AFFAIRS, CAPG

CAPG Federal Affairs: Challenges and Opportunities in 2015


Federal Legislative Update

“CAPG will continue to work with members of Congress to ensure that the incentives for risk-based models are appropriate and encourage physicians to experiment with risk-based payment models well into the future.”

signing on to letters to Congress and the Administration, and weighing in directly with your members of Congress and their staffs. We encourage you to visit our grassroots webpage, www.SupportMedicareAdvantage.org, to add your voice to a growing chorus of healthcare providers that want to protect this program.

Beyond the immediate threat to program funding, CAPG continues to emphasize the valuable role that Medicare Advantage plays in moving the delivery system from volume to value. Specifically, the risk-based physician model that CMS strives to create in Medicare Part B is already thriving in Medicare Advantage. CAPG’s team in Washington, DC, is working to encourage policymakers to invest in this model for a higher-value system for beneficiaries in the future.

SUSTAINABLE GROWTH RATE (SGR) LEGISLATION

In 2014, the committees with jurisdiction over Medicare issues came to a bipartisan, bicameral agreement on policy to permanently repeal and replace the flawed Medicare Part B payment formula. Of interest to CAPG members, the agreement included incentives for physicians and physician groups to enter two-sided risk bearing arrangements in Medicare Part B.

Although the cost of repealing the formula was at a historical low due to the slowdown in healthcare spending, lawmakers were unable to come to an agreement on how to pay for the repeal legislation. As a result, Congress kicked the can again, with the current patch set to expire March 31, 2015.

Early in 2015, the SGR legislation will undoubtedly come up again. With a number of new members of Congress, new committee chairs, and an incredibly compressed timeframe, it remains unclear whether the 114th Congress will be able to repeal and replace the SGR formula. It is certainly an uphill battle.

CAPG will continue to work with members of Congress to ensure that the incentives for risk-based models are appropriate and encourage physicians to experiment with risk-based payment models well into the future.

ACCOUNTABLE CARE ORGANIZATIONS

Perhaps the most highly anticipated delivery system reform in the ACA was the accountable care organization (ACO) program. 2014 was a bit of a bumpy year for Medicare ACOs. News of Pioneer ACOs dropping out of the program dominated news coverage. At the end of 2014, the Administration released a proposed rule to make improvements to the Medicare Shared Savings

ACO program, but many stakeholders questioned whether proposed changes went far enough to ensure the long-term sustainability of the program.

Given the high level of interest and participation in Medicare ACOs—over 300 participants to date—the policy activity around this program is likely to increase in 2015. Last summer, CAPG worked closely with Representatives Peter Welch (D-VT) and Diane Black (R-TN) to introduce legislation requiring CMS to create a globally capitated ACO. We will continue collaborating with lawmakers to advance this goal. Our members also are working with the Administration to develop a full-risk ACO through the Innovation Center. Finally, we continue to work through regulatory channels to make improvements to the Medicare Shared Savings Program.

CONCLUSION

CAPG’s DC advocacy team looks forward to welcoming the 114th Congress and continuing to work on these and other issues for our members in 2015. We encourage each of you to look for ways to engage in CAPG’s federal advocacy—through grassroots engagement, or otherwise. We welcome the challenges and opportunities ahead. o


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Grassroots Advocacy: How to Win Friends (in Congress) and Influence Policy MakersBY JANET MULLINS GRISSOM, PARTNER, PECK MADIGAN JONES

Call it what you will—a “wave” election, a referendum on the Obama administration, a rejection of the status quo, or a reflection of voter apathy. In any case, the November elections shook up the Capitol, upended the balance of power, sent many friends of the healthcare industry packing, and ushered in a wave of new House and Senate members who will need to be educated on the issues of importance to CAPG.

Advocacy is a core mission of CAPG, assuring that physician organizations have a voice in the policy making process in Washington. And grassroots advocacy—the voice of you, the constituent—is perhaps the most effective lobbying tool for any organization seeking to influence the legislative agenda.

Consider the findings of a study recently released by the Congressional Management Foundation that examined strategies for lobbying the Congress. The study, compiling survey data from 450 House and Senate staffers, concluded that visits from constituents make a stronger impression on lawmakers than any other means of advocacy. As a former Chief of Staff to two United States senators, I can vouch for those findings.

Members of Congress pack a variety of meetings, hearings, briefings, speaking engagements, media appearances, and, yes, fundraisers into their daily schedules. But all members of Congress, at least those who hope to get reelected, take time in their day to meet with constituents. Whether in DC or in their districts, your elected representatives prioritize constituent meetings and rely upon the information you provide when evaluating what legislation to support.

On January 6, 12 new United States senators and 52 new House members took their seats for the 114th Congress. Some will sit on committees that shape healthcare policy. All will be casting votes on your priority issues, be they Medicare Advantage, the SGR (the so-called “doc fix”), or the ongoing implementation of the Affordable Care Act. At the same time, Republicans assumed control of the U.S. Senate for the first time in eight years, ushering in a new crop of committee and subcommittee chairs and a new Republican leadership that will dictate the legislative agenda.

These changes present great opportunity for CAPG to introduce itself, to educate new members and their staffs on your policy priorities, to work with your supporters among the new Senate majority to strengthen Medicare Advantage, and to leverage that congressional support to challenge regulatory policies that threaten your practices or payments.

My former boss, Secretary of State James A. Baker III, was fond of reciting his “5 P’s” mantra to his staff: Prior Preparation Prevents Poor Performance. It’s important to apply those principles to your advocacy plans for the new Congress. Your CAPG federal lobbying team is prioritizing a schedule of new member visits that will commence on day one of the new Congress. Informational and advocacy materials

“Advocacy is a core mission of CAPG…. And grassroots advocacy—the voice of you, the constituent—is perhaps the most effective lobbying tool for any organization seeking to influence the legislative agenda.”

are being prepared for your outreach and education efforts. Political mapping will match physician groups with new members of Congress so that your messages will be carried by those who matter most: constituents. You will be invited and encouraged to reach out to

October 5-7Washington Marriott Wardman Park, Washington, DC

www.capg.org/colloquium2015

2015 CAPG COLLOQUIUM Save the Date!

members of Congress to advocate for policy priorities. Member meetings, phone calls, offers to meet with staff, site visits, speaking opportunities, letters, emails, and, yes, even tweets and Facebook posts are all tools in your advocacy toolbox that will be utilized for CAPG advocacy efforts in the new Congress.

Your organizations need no reminder of the impact of federal policy on your bottom line. Your engagement in a robust grassroots effort with the new Congress will be critical to your efforts to energize your friends and cultivate new CAPG champions in the 114th Congress.

Janet Mullins Grissom is a partner at Peck Madigan Jones, a government relations firm representing CAPG. Ms. Mullins Grissom has held numerous senior positions in the Executive Branch, Congress, and the White House, including Assistant to President George W. Bush for Political Affairs and chief legislative strategist for Secretary of State James A. Baker III. She was the first woman to serve as Chief of Staff for two different U.S. Senators, Bob Packwood (R-OR) and Mitch McConnell (R-KY). o


Pressures on individual physicians and medical practices increase daily as the nation’s healthcare system transitions from traditional fee-for-service and volume-based care to a performance and value-based system of care.

A review1 of a recent RAND/AMA report on professional satisfaction noted, “Cumbersome workflows and confusing interfaces are a significant source of stress for providers who want to focus on their patients, contributing to high levels of disgruntlement that may serve as an early warning of deeper problems in the healthcare system.”

It comes as little surprise, then, that doctors’ satisfaction is at record lows. In fact, according to the Commonwealth Fund,2 U.S. primary care doctors are far less satisfied than their peers in other countries, in spite of earning up to twice as much.

A recent study3 published in Health Affairs identified critical factors that contribute to physician satisfaction, including: “Reasonable control over the environment, pace, and content of work.”

Managing Productivity, Revenues, and Satisfaction

KairoiCareLogic has observed that clinics can control the environment, pace, and content of work. We have found that productivity can be dramatically increased by 20 to 30% without adding providers, rooms, or hours.

• In recent demonstrations, KairoiCareLogic identified opportunities for clinics to increase visits from 11 to 23% - just to reach their optimal level of productivity.

• While a variety of factors contribute to inefficiency and lost productivity, at one provider group studied by KairoiCareLogic, the no-show and late-cancellation rate was as high as 20%.

Poorly managed office productivity increases administrative costs and takes physician time away from not only patients, but also from family and personal interests.

By optimizing time allocation in the clinic via KairoiCareLogic, physicians find the additional time they need during office hours to complete tasks and notes.

• In recent demonstrations, KairoiCareLogic found that physicians spent anywhere from 45 to 240 minutes performing administrative tasks outside the exam room and from 60 to 300 minutes finishing the day’s work at home.

• There was significant variation on the time needed to complete notes and other tasks associated with patients seen during the day: some providers reported spending as little as 7 or 8 minutes per patient, while others reported spending from 18 to 34 minutes.

Extreme variation in productivity among providers can be reduced only by generating accurate, useful, real-time data on performance.

Optimized Scheduling Increases Productivity, Revenues, and Satisfaction An underlying cause of poor productivity in many physician practices is an unsophisticated appointment scheduling system that fails to account for administrative demands, physician preferences, visit type or complexity, workflow, and other critical factors that directly impact productivity, revenues, and – of course – provider and patient satisfaction.

Often added to EHRs as an afterthought – or modeled on rudimentary consumer calendaring software programs – scheduling programs in many offices:

• Lack accurate historical data• Are unable to optimize multiple variables• Fail to put physicians in control of their schedule• Don’t generate easy-to-use, flexible templates • Can’t generate meaningful dashboard reports

Most scheduling systems lack the accurate, real-time data on utilization and productivity needed to make substantial improvements in efficiency and effectiveness.

The KairoiCareLogic Process was developed by skilled logistics and clinic scheduling experts. In contrast to bolt-on generic software tools, it uses historical data coupled with onsite analysis to generate easy-to-use templates that enable medical practices to optimize scheduling with existing staff and facilities.

KairoiCareLogic is a software tool combined with hands-on analytical evaluation and implementation support that enables medical practices to drive scheduling based on their own actual data.

It puts individual physicians in control of their schedules.

KairoiCareLogic is the patient flow management system that can make an enormous difference in patient and provider satisfaction, your bottom line, and the quality of care you deliver.

For more information visit: www.kairoicarelogic.com/YES or call 415-684-1670

When hours are totaled, many providers believe that their income covers

administrative time alone and that patient care is essentially a free service.Can physicians be productive, profitable, and satisfied – all at the same time? KairoiCareLogic says, “Yes.”

KairoiCareLogic PROCESS

HISTORICAL DATA

SITE VISIT

Data Cleansing

Clean Data

Optimizer

ImplementationConsulting

Coaching Clinic Management

Customized Templates

Weekly Dashboard Report

1 Jennifer Bresnick, “EHRs are a source of stress for physicians,” EHR Intelligence, September 12, 20142 Cathy Schoen, et al; A Survey of Primary Care Doctors in Ten Countries Shows Progress in Use of Health Information Technology, Less in Other Areas; Commonwealth Fund, November 15, 2012.3 Mark Freidberg, Jay Crosson, Michael Tutty, Physicians’ Concerns About Electronic Health Records: Implications And Steps Towards Solutions, Health Affairs Blog, March 11, 2014


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ORGANIZATIONAL MEMBERS

Accountable Health Care IPAGeorge M. Jayatilaka, MD, CEODruvi Jayatilaka, Vice President

Advanced Medical Management, Inc.Kathy Hegstrom, President

• Access Medical Group/Access Santa Monica • Community Care IPA • Future Care IPA • MediChoice IPA • Pacific Healthcare IPA • Premier Care IPA • Seoul Medical Group •

Affinity Medical GroupRichard Sankary, MD, PresidentScott Ptacnik, COO

AllCare IPA*Randy Winter, MD, PresidentMatt Coury, CEO

All Care Medical GroupSamuel Rotenberg, MD, Medical DirectorCraig Kaner, Administrator

Allied Physicians of CaliforniaThomas Lam, MD, CEOKenneth Sim, MD, CFO Alta Bates Medical GroupRichard L. Oken, MD, President and Chairman of the BoardEvan Moore, Vice President, East Bay Region AltaMed Health Services Corporation*Martin Serota, MD, Chief Medical OfficerCastulo de la Rocha, JD, President/CEO

AppleCare Medical Group, Inc.*Surendra Jain, MD, Chief Medical OfficerVinod Jivrajka, MD, President/CEO

Bakersfield Family Medical CenterJu Hwan Lee, MD, Medical Director

Bayhealth Physician Alliance, LLCJoseph M. Parise, DO, Medical DirectorEvan W. Polansky, JD, Executive Director

Beaver Medical Group*Charles Payton, MD, VP Medical Administration/CMOJohn Goodman, President/CEO Brown & Toland Physicians*Andrew M. Snyder, MD, Chief Medical OfficerRichard Fish, CEO

California Pacific Physicians Medical Group, Inc.Dien V. Pham, MD, Chief Executive OfficerCarol Houchins, Administrator

CareMore Medical GroupTom Tancredi, Dir. of Practice Operations

Catholic Health Initiatives*Clifford Deveny, MD, SVP, Physician Services and Clinical Integrations James Slaggert, VP Physician Practice Management

Central Ohio Primary Care Physicians, Inc.J. William Wulf, MD, CEOMichael Ashanin, COO

Cedars-Sinai Medical Group*Stephen C. Deutsch, MD, Chief Medical DirectorThomas D. Gordon, CEO

Children’s Physicians Medical GroupLeonard Kornreich, MD, President and CEO

Chinese Community Health Care AssociationJohn M. Williams, PharmD., CEOPolly Chen, Director of Operations

Choice Medical Group IPAManmohan Nayyar, MD, PresidentMarie Langley, IPA Administrator

Cigna Medical GroupKevin Ellis, DO, Chief Medical OfficerEdward Kim, President and General Manager

Conifer Health SolutionsMegan North, CEO

• AKM Medical Group • Amvi Medical Group • Exceptional Care Medical Group • Family Choice Medical Group • Family Health Alliance • Huntington Park Mission Medical Group • Medicina Familiar Medical Group • New Horizon Medical Group • Noble Community Medical Associates • OmniCare Medical Group • Premier Physician Network • United Care Medical Group •

DCHS Medical FoundationDean M. Didech, MD Chief Medical OfficerErnest Wallerstein, CEO

Desert Oasis HealthcareMarc Hoffing, MD, Medical DirectorDan Frank, Chief Operating Officer

Dignity HealthBruce Swartz, SVP, Physician Integration

Edinger Medical GroupMatthew C. Boone, MD, Executive Medical DirectorDenise McCourt, Chief Operating Officer

Empire Physicians Medical Group*Steven Dorfman, MD, PresidentYvonne Sonnenberg, Executive Director

Everett Clinic, P.S., The*Adrianne Wagner, Quality Improvement Consultant ManagerShashank Kalokhe, Associate Administrator of Value-Based Contracting and Coordinated Care

Facey Medical Foundation*Erik Davydov, MD, Medical DirectorBill Gil, President/CEO

Golden Empire Managed Care, Inc.*C. Vincent Phillips, MD, PresidentRobert Severs, CEO

Good Samaritan Medical Practice AssociationNupar Kumar, MD, Medical Director

Greater Newport Physicians Medical Group, Inc.*Diane Laird, CEO

HealthCare Partners*Robert Margolis, MD, Co-Chairman of the Board, DaVita Heritage Provider Network*Richard Merkin, MD, PresidentRichard Lipeles, Chief Operations Officer

• Affiliated Doctors of Orange County • Bakersfield Family Medical Group • California Coastal Physician Network • California Desert IPA • Desert Oasis Healthcare • Greater Covina Medical Group • Heritage Physician Network • Heritage Victor Valley Medical Group • High Desert Medical Group • Regal Medical Group • Sierra Medical Group •

High Desert Medical GroupCharles Lim, MD, FACP, Medical DirectorAnthony Dulgeroff, MD, Assistant Medical Director

Hill Physicians Medical Group, Inc.*Tom Long, MD, Chief Medical OfficerDarryl Cardoza, CEO

Independence Medical GroupArmi Lynn Walker, MD, Medical DirectorGary M. Bohamed, Executive Director

John Muir Physician Network Ravi Hundal, MD, Medical DirectorLee Huskins, Interim CEO/SVP/COO Lakeside Community HealthcareKerry Weiner, MD, Chief Medical OfficerJonathan Gluck, Counsel

Lakeside Medical Group, Inc. Lakewood IPAJean Shahdadpuri, MD, MBA, Chief Medical OfficerVarsha Desai, Chief Operating Officer

• Alamitos IPA • St. Mary IPA • Brookshire IPA •

Loma Linda University Health CareJ. Todd Martell, MD, Medical Director Maverick Medical GroupWarren Hosseinion, MD, ChairmanMark C. Marten, CEO MED3000Gary Proffett, MD, Medical DirectorLynn Stratton Haas, CEO

• SeaView IPA • Valley Care IPA •

MedPoint ManagementRick Powell, MD, Chief Medical OfficerKimberly Carey, President

• Apollo Healthcare • Bella Vista Medical Group IPA • Centinela Valley IPA • El Proyecto Del Barrio, Inc. • Global Care Medical Group • HealthCare LA IPA • Jewish Home for the Aging IPA • Redwood Community Health Network • United Physicians International • Watts Healthcare Corporation •

MemorialCare Medical Group*Mark Schafer, MD, CEOJennifer Jackman, Chief Operating Officer

Meritage Medical NetworkJ. David Andrew, MD, Medical DirectorJoel Criste, CEO

Mid-Atlantic Permanente Medical Group, PCBernadette Loftus, MD, Associate Executive Director for MASJessica Locke, Special Assistant

Molina Medical Centers* Keith Wilson, MD, Vice President of Clinical Services Gloria Calderon, Vice President of Clinic Operations

Monarch HealthCare*Bart Asner, MD, CEORay Chicoine, President and COO

MSO of Puerto RicoRichard Shinto, MD, CEORaul Montalvo, MD, President

Muir Medical Group, IPA Steve Kaplan, MD, PresidentUte Burness, RN, CEO NAMM California*Leigh Hutchins, President, COOElizabeth Haughton, Vice President, Legal Affairs

• Coachella Valley Physicians of PrimeCare, Inc., • Mercy Physicians Medical Group • Primary * Indicates 2015 - 2016 Board Members

Care Associated Medical Group, Inc. • PrimeCare Medical Group of Chino • PrimeCare of Citrus Valley • PrimeCare of Corona • PrimeCare of Hemet Valley Inc • PrimeCare of Inland Valley • PrimeCare of Moreno Valley • PrimeCare of Redlands • PrimeCare of Riverside • PrimeCare of San Bernardino • PrimeCare of Sun City • PrimeCare of Temecula • Redlands Family Practice Medical Group, Inc. •

New West Physicians, PCThomas M. Jeffers, MD, President and ChairRuth Benton, CEO

Omnicare Medical GroupAshok Raheja, MD, Medical Director Toni Chavis, MD, President

The Permanente Medical Group, Inc. Oakland (North)*Sharon Levine, MD, Associate Executive DirectorSuketu Sanghvi, MD, Associate Executive Director

Physicians DataTrustAnthony Ausband, President Lisa Serratore, Chief Operations Officer

• Greater Tri-Cities IPA • Noble AMA IPA • St. Vincent IPA •

Physicians Medical Group of Santa Cruz County*Nancy Greenstreet, MD, Medical DirectorMarvin Labrie, CEO

Physicians Medical Group of Santa MariaJohn Okerblom, MD, PresidentBarbara Cheever, Executive Director

Physicians of Southwest Washington, LLCGary R. Goin, MD, PresidentMariella Cummings, CEO

PIH Health PhysiciansDeeling Teng, MD, Sr. Medical Director, Group OperationsRamona Pratt, RN, Chief Operating Officer, Group Operations

Pioneer Medical Group, Inc.*Jerry Floro, MD, President John Kirk, CEO

Preferred IPA of CaliforniaMark Amico, MD, Medical DirectorZahra Movaghar, Administrator Prospect Medical Group*Prasad Jeereddi, MD, ChairmanMitchell Lew, MD, CEO

• AMVI/Prospect Health Network • Gateway Medical Group • Genesis Healthcare • Nuestra Familia Medical Group • Prospect Corona • Prospect HealthSource • Prospect Huntington Beach • Prospect Northwest Orange County • Prospect Orange County • Prospect Professional Care • Prospect Van Nuys •

Providence Medical Management ServicesBart Wald, MD, Physician Chief ExecutivePhil Jackson, Chief Integration and Transformation Officer

• Korean American Medical Group • Providence Care Network •

Providence Health & ServicesBart Wald, MD, Physician Chief ExecutiveBill Gil, Chief Executive Medical Foundations

River City Medical Group, Inc.Jose Abad, MD, President/Medical DirectorLoren Douglas, CEO

Riverside Medical ClinicSteven Larson, MD, ChairmanJudy Carpenter, President/COO

Riverside Physician Network Paul Snowden, COOHoward Saner, CEO

St. Joseph Heritage Healthcare*Khaliq Siddiq, MD, Chief Medical OfficerC.R. Burke, CEO

• Hoag Medical Group • Mission Heritage Medical Group • St. Mary High Desert Medical Group •

San Bernardino Medical GroupThomas Hellwig, MD, PresidentJames Malin, CEO

San Diego Physicians Medical GroupJames Cordell, MD, PresidentJoyce Cook, CEO

San Luis Obispo Select IPABarbara Cheever, Executive Director

Sansum Clinic*Kurt Ransohoff, MD, Medical Director/CEOVince Jensen, COO Santa Clara County IPA (SCCIPA)*J. Kersten Kraft, MD, President of the BoardLori Vatcher, CEO

Santé Health System, Inc Daniel Bluestone, MD, Medical DirectorScott B. Wells, CEO

Scripps Coastal Medical CenterLouis Hogrefe, MD, APC, Chief Medical OfficerTracy Chu, Assistant Vice President of Operations

Sharp Community Medical Group*John Jenrette, MD, CEOChristopher McGlone, Chief Operating Officer

• Graybill Medical Group • Arch Health Partners • Sharp Rees-Stealy Medical Group*Donald C. Balfour, III, MD, Chief Medical OfficerStacey Hrountas, SVP and CEO

Southeast Permanente Medical Group, Inc., TheMichael Doherty, MD, Executive Medical Director and Chief of Staff

Southern California Permanente Medical Group*Vito Imbasciani, MD, Director of Government RelationsJames Malone, Medical Group Administrator

Sutter Health Foundations & Affiliated Groups*Jeffrey Burnich, MD, SVP and Executive Officer, Sutter Medical Network Brian Roach, President, Mills Peninsula Division of PAMF

• Brown & Toland Physicians • Central Valley Medical Group • East Bay Physicians Medical Group • Gould Medical Group • Marin Headlands Medical Group • Mills-Peninsula Medical Group • Palo Alto Foundation Medical Group • Palo Alto Medical Foundation • Peninsula Medical Clinic • Physician Foundation Medical Associates • Sutter East Bay Medical Foundation • Sutter Gould Medical Foundation • Sutter Independent Physicians • Sutter Medical Foundation • Sutter Medical Group • Sutter Medical Group of the Redwoods • Sutter North Medical Group • Sutter Pacific Medical Foundation •

SynerMed*George Ma, MD, Medical DirectorJames Mason, President and CEO

• Alpha Care Medical Group • Angeles IPA • Crown City Medical Group • EHS Inland Valleys IPA • EHS Medical Group – Central Valley • EHS Medical Group – Los Angeles • EHS Medical Group – Sacramento • Employee

Health Systems • MultiCultural IPA • Pacific Alliance Medical Center • Southern California Children’s Network • Talbert Medical GroupPratibha A. Patel, MD, Market PresidentDonald Rebhun, MD, Corporate Medical Director

Torrance Hospital IPANorman Panitch, MD, PresidentStephen J. Linesch, CEO Triad HealthCare Network, LLCThomas C. Wall, MD, Executive Medical DirectorSteve Neorr, VP, Executive Director

U.C.L.A. Medical Group*Sam Skootsky, MD, Medical DirectorDavid Hartenbower, MD, COO

USC Care Medical Group, Inc.Donald Larsen, MD, Chief Medical OfficerKeith Gran, CEO

WellMed Medical Group, P.A.George M. Rapier III, MD, Director and VPCarlos O. Hernandez, MD, President

CORPORATE PARTNERS

Anthem Blue Cross of CaliforniaAthenahealthBayer HealthCare PharmaceuticalsBoehringer Ingelheim Pharmaceuticals, Inc.Humana, Inc.Merck & Co.Novartis PharmaceuticalsNovo NordiskPatient-Centered Primary Care CollaborativeSCAN Health Plan

ASSOCIATE PARTNERS

abbvieActavis Pharma, Inc.ArkrayAstellas Pharma US, Inc.AstraZeneca PharmaceuticalsCVS Caremark, Corp.Daiichi SankyoEisai, Inc.GenPath DiagnosticsGenomic HealthGilead SciencesIncyte CorporationJohnson & Johnson Family of CompaniesKaufman, Hall & AssociatesKindred Healthcare, Inc.Lilly USA, LLCPfizer, Inc.Ralphs Grocery CompanySanofiSunovion Pharmaceuticals Inc.The Doctors CompanyVitas Healthcare Corporation of California

AFFILIATE PARTNERS

Alignment Healthcare AlturaAscender Software, LLCChildrens Hospital Los Angeles Medical GroupMills Peninsula Medical GroupMZI HealthCare, LLCNifty After Fifty Monarch LLC Partners in Care FoundationPharmacyclics, Inc.Redlands Community HospitalSaint Agnes Medical GroupSullivanLuallin GroupVentegra, LLC



Moving Medi-Cal Further Toward an Accountable/Coordinated Care SystemBY BILL BARCELLONA, SENIOR VP, GOVERNMENT AFFAIRS, CAPG

California’s Medicaid program is known as “Medi-Cal” and is administered by the California Department of Healthcare Services (DHCS). Next year, DHCS will submit a new application for a five-year Section 1115 Medicaid Waiver. A “waiver” is authorized by the Centers for Medicare and Medicaid Services (CMS) as a demonstration program.

California’s existing “Bridge to Reform Waiver” was approved in 2010 and is now in its fourth year. It has provided a successful demonstration of several delivery system reform concepts.

The existing Waiver included the enrollment of 650,000 individuals into an early expansion of Medicaid eligibility for adults under 138 percent of the federal poverty level. Under federal law, the renewal of a waiver must be submitted to CMS six months prior to the expiration of the existing waiver, which will be in May 2015. The Legislature has already introduced SB 20, a spot bill by Senator Ed Hernandez, to facilitate the final form of the Waiver submittal.

The 2015 Waiver will focus on the continued implementation of the health reforms incorporated under the Affordable Care Act, including delivery system reform and preserving the safety net. The renewal of the Waiver would have to incorporate “state match” funding sources to complement federal funding sources for new programs. This will likely include mechanisms that draw down funding through partnerships with counties and public hospitals.

Current initiatives under the existing Waiver, such as the transition of seniors and persons with disabilities into managed care and the Coordinated Care Initiative, would continue through the renewal. The next Waiver will likely move further by including additional delivery and payment system transformation initiatives. It will also concentrate on expanding access, improving quality and outcomes, and controlling the cost of care. In fact, the next Waiver may serve as a vehicle to implement the goals of the California State Innovation Model (CalSIM) grant application.

State Legislative Update

California issued a concept paper in July 2014 that expressed eight initial concepts to be explored in the Waiver renewal process:

� Federal/State Savings Initiative—creating a new payment system under a capped budget on a per-beneficiary basis.

� Payment/Delivery Reform Incentive Payment Programs—a twofold approach to create accountable care group delivery models that coordinate care across an entire spectrum of providers, and an incentive payment program aimed at integrating county behavioral healthcare systems with managed care plans.

� Safety net payment reforms that support coverage for the remaining uninsured—creating a global payments model for public hospitals and clinics.

� FQHC Payment/Delivery Reform—transforming FQHC payment to a risk-based model.

� Successor Delivery System Reform Incentive Payment program—continued development of more comprehensive care delivery models among the 21 public hospitals.

� California Children’s Services (CCS) Program Improvements—developing a more comprehensive care model for children’s specialty care.

� Medicaid-funded Shelter for Vulnerable Populations—exploring how to create a Medicaid-funded housing program for vulnerable populations.

� Workforce Development—a federally funded malpractice insurance premium subsidy that would be paid to health plans and passed through to participating physicians.

California has commenced a stakeholder process to gain input into the components of the renewal application. Workgroups have been created to cover five key areas, to run from November to mid-February, with three to five sessions focused on each concept, varying in frequency depending on the subject area. Workgroup membership comprises 15 to 20 extremely knowledgeable stakeholders in each of the five delivery system and payment reform concepts below:

� Provider/MCO incentive programs

� Safety Net Reform—DSH/SNCP bundled payments

� Delivery System Reform Incentive Program 2.0 (DSRIP)

� Medicaid-funded Shelter/Housing

� Workforce Development

Each of the five main stakeholder workgroups will also include behavioral health integration as a subfocus. CCS Program redesign and FQHC payment reform efforts are under active discussion in separate pre-existing stakeholder forums. The federal-state shared savings concept approach will be a DHCS-led stakeholder meeting open to the general public.

One of the most critical potential outcomes of this waiver renewal process will be development of the second iteration of the Delivery System Reform Incentive Payment (DSRIP) program. Since California pioneered the first DSRIP demonstration four years ago in the 2010 Waiver, six other states have followed with ever more sophisticated demonstrations under their own waivers: Arizona, Kansas, Massachusetts, New Jersey, New York, and Texas. With each successive waiver, the thinking at CMS has evolved. There are eight areas of focus that should apply to California’s renewal Waiver application, based on experience in the six other states.

Driving toward a statewide quality agenda. In New York, which is the most recent DSRIP waiver demonstration, all DSRIP projects are designed to work toward lowering all preventable hospitalizations by 25 percent. Payments under the New York DSRIP projects will move on a sliding scale during each of the five years based on the level of performance toward the overall target goal. Payments will vary from 5 to 55 percent, depending upon how well the performance targets are achieved.

Narrower menu of projects. Texas proposed project menus that were hundreds of pages long. CMS subsequently narrowed the New Jersey and New York project menus. In New York, providers can choose among a set menu of metrics and milestones related to no more than 25 specific projects.

Inclusion of a broad range of providers beyond hospitals. Both the Texas and New York DSRIP programs include a broader range of providers, including private DSH hospitals, nursing homes, home care agencies, ambulance service, behavioral health providers, and clinics. California’s 2010 waiver restricted the DSRIP to public hospitals.


Stabilization funding for vulnerable public hospitals. The New York waiver includes provisions for some level of stabilization funding for public hospitals that are financially vulnerable during the transition toward full ACA coverage expansion.

Setting stretch goals. Because California hit some of its milestones early under the Bridge to Reform Waiver after 2010, CMS has required all subsequent DSRIP programs to include tighter stretch goals that may not be readily achievable, and that can be reassessed midterm if objectives are reached. In New York, CMS created an incentive pool of unassigned funds payable to providers that exceeded their performance metrics.

Creating a formal, uniform approach to valuing projects. CMS has moved away from the 2010 California experience of privately negotiated funding toward a more transparent approach in all subsequent state waivers. Subsequent DSRIP programs are

valued according to population size, geographic differences, and strength of the evidence base.

Paying for planning. CMS has started to allow all or part of the first year of the demonstration to be devoted to planning and project development and has accordingly set aside incentive funding based on meeting planning milestones.

Shared learning and best practices. CMS has required providers to share best practices with others in learning collaboratives within each new state waiver. As the approved menu of projects is narrowed by CMS, more providers are undertaking similar projects, and can avail themselves of best practices collaboration.

Peter Harbage, a consultant to DSRIP programs in California and four other states, has opined that “A key consideration is whether our current delivery systems have the right infrastructure and programs to meet the Triple Aim goals of the Affordable Care Act.” He has stated that the “fundamental design of post-ACA delivery systems should begin with providers across the spectrum coming together to meet local needs.”

CAPG members in California and other states will be very keen to follow developments with the new Waiver Renewal in 2015. Further information on developments can be obtained from me and from the Department of Healthcare Services on its public webpage devoted to the 2015 Waiver Renewal: http://www.dhcs.ca.gov/provgovpart/Pages/1115-Waiver-Renewal.aspx. o

“Since California pioneered the first DSRIP demonstration in the 2010 Waiver, six other states have followed with ever more sophisticated demonstrations under their own waivers ... With each successive waiver, the thinking at CMS has evolved.”

5 l CAPG HEALTH July/August 2014

Raising Quality of Life and Lowering Healthcare Costs for a Shifting Patient PopulationBY VALERIE GREEN-AMOS, MD, PRESIDENT, J . MARIO MOLINA MEDICAL PROFESSIONAL CORPORATION

For over 30 years, Molina Medical clinics have been treating low-income patients. Traditionally, we’ve served a largely young and healthy Medicaid population, but recently we’ve seen a tremendous increase in chronically ill adult patients with

significantly different health challenges.

A large percentage of them face barriers that are physical and behavioral as well as societal, including mental health disorders, substance abuse, physical impediments from their disease burden, and a lack of financial resources. Compared to other patient types, these chronically ill patients tend to overuse expensive resources such as the ER and DME, with longer and more frequent hospital stays. Additionally, some haven’t had access to primary care; thus, numerous conditions may have gone untreated.

To address the needs of this demographic, we’ve developed a comprehensive, multifaceted solution: the Molina Complexist initiative.

MULTIPLE FACETS OF CARE FOR A RANGE OF ISSUES

Molina Complexist is a team approach to complete medical care for each patient. Every member of the Complexist team focuses on a different facet of treatment:

The physician/clinician leads the team, recommending treatment and identifying potential

problems in a patient’s progress. The physician also manages the most complex cases, especially those who have had hospital stays or been difficult for the PCP to control. With

extended access to the patient, the physician

can focus on an array of challenges

and provide comprehensive examinations and assessments.

The licensed clinical social

worker (LCSW) offers insight into mental health concerns and methods for addressing



environmental and behavioral issues. The LCSW also connects the patient to helpful resources, maintains a supportive relationship to foster the patient’s ability to utilize community services, and provides counseling as needed.

The doctor of pharmacy recommends the best medicines, offers advice about possibly risky drug-drug interactions, and ensures that

treatment meets guidelines for pharmaceutical compliance.

The ambulatory LVN/ case manager searches for Complexist patients based on medical need. Working closely with the team physician, the LVN ensures services can be provided and schedules patients for urgent or routine needs. The LVN also keeps a registry of patients and attends to each one while following up with the clinician regarding any problems.

The medical assistant supports the LVN and the rest of the team by performing clinical and administrative duties, including helping locate and contact possible patients for this initiative.

FOCUSED ON PROCESS, NOT PROBLEMS

While traditional care relies on patients bringing problems to the provider, Complexist treatment is process oriented. We actively seek those who are in the greatest need of care, and then address each of their issues.

It begins with the LVN, who searches local records for those Medicaid members who are most ill, based on recent hospitalization and highest Risk Adjustment Factor Scores. The LVN compiles an “opportunity

list” of candidates, from which the team selects participants.

A patient’s first visit is an extensive one. In weekly meetings, the team reviews first visit reports and maps out a plan of care for new patients, makes adjustments for current ones, and follows up wherever needed.

Patients are seen only by Complexist providers—typically more frequently than those who receive standard care. Patients remain in the program until they no longer need close follow-up and then are discharged to their PCPs.

ONE SUCCESSFUL LAUNCH AFTER ANOTHER

Led by a Molina physician with extensive experience treating chronically ill adults, the first Molina Complexist center opened in Sacramento, California, in October 2013. Since we began this effort, our ability to decrease ER utilization, minimize unnecessary hospital bed days, and bond patients to our medical clinics has been greatly enhanced. Patients consistently report being very satisfied with Complexist care and are enthusiastic about participating.

In fact, the success of the first center prompted the launch of another Sacramento location within three months. And we’ve added two additional centers—one in Riverside and another in Long Beach—for a total of four Complexist centers in less than 18 months.

HEALTHIER PATIENTS COST LESS

Over a five-month period, medical expenditures for these complex cases dropped a dramatic 31 percent per patient on average, largely due to a 51 percent plunge in hospital inpatient costs. Utilization also fell—hospital admissions were down by 29 percent and patients who were admitted had visits that were 14 percent shorter.

These figures show that, by treating the complete patient, we can effectively preserve resources and cut costs while helping our patients feel better. It’s increasingly important to meet these objectives as the population ages. With the Molina Complexist initiative, we’ve proven that we can. o

“Over a five-month period, medical expenditures for these complex cases dropped a dramatic 31 percent per patient on average, largely due to a 51 percent plunge in hospital inpatient costs.”

5 l CAPG HEALTH July/August 2014

St. Jude Heritage Medical Group Named a “Most Valuable Care” ProviderSt. Jude Heritage Medical Group’s Yorba Linda office has been named one of 11 primary care practices delivering significantly higher quality care—at a substantially lower cost—than nearly all of their peers across the U.S.

Researchers at Stanford University’s Clinical Excellence Research Center looked for primary care practices that performed in the top 25 percent on nationally recognized quality measures and in the lowest 25 percent on healthcare costs per patient.

Out of 15,000 primary care practices considered, just 5 percent met the criteria. Of these, researchers conducted in-depth visits to a sample of the highest performing sites, including St. Jude Heritage Medical Group, based in Yorba Linda, California.

The researchers observed that these “MVPs”—providers of America’s Most Valuable Care—stand out from average performers in three distinct ways: They have deeper relationships with patients; more coordinated interactions within the local healthcare system; and practices that are organized to foster teamwork.

“Our findings challenge the belief that excellent primary care can only be provided by large healthcare organizations that are household names,” said Arnold Milstein, MD, director of the Clinical Excellence Research Center.

“We found unsung physicians who are achieving something extraordinary—much better quality at a lower cost,” he said. “What’s most encouraging is that their distinguishing features are tangible, and transferable to other primary care practices nationwide.”

Part of St. Joseph Heritage Healthcare, St. Jude Heritage Medical Group is a multispecialty practice with more than 180 physicians in eight locations in North Orange County and Diamond Bar, California. The Yorba Linda office selected by the program is staffed by 12 family physicians, six pediatricians, and five internists, along with a nurse practitioner, a physician assistant, and a licensed vocational nurse. The practice also includes a range of onsite specialists. According to the study, features that contribute to the group’s high performance include:

• The practice offers same-day access and, with integrated


C.R. Burke, President and CEO, St. Joseph Heritage Healthcare

Khaiq Siddiq, MD, Medical Director, St. Jude Heritage Medical Group

urgent care, is open seven days a week. Continuity is emphasized.

• Specialists provide education sessions to primary care physicians to help them take on low-complexity specialty care.

• After hospitalization, patients are seen in a special transition clinic, which reduced readmissions by 67 percent.

• The office space was designed with patient flow in mind. There are no waiting rooms and care teams work together in a shared space, facilitating communication between patient interactions. This design improved physician productivity by 21 percent.

Khaliq Siddiq, MD, medical director at St. Jude Heritage Medical Group, explained what these qualities look like in practice. “Physicians and operations managers work together, which increases efficiency in patient care and clinical outcomes,” he said. “For example, all of the primary care medical assistants were educated on clinical measures that are being looked at today—whether they be pay for performance or otherwise—to give context to certain procedures.

“Not only would they know how to examine a diabetic patient’s feet, but they would understand why this is important,” Dr. Siddiq said. “This bottom-up approach has empowered staff to come up with their own ways to improve clinical outcomes. When the medical assistants felt more connected to what each clinical measure meant, it gave them greater interest in improving those measures.”

C.R. Burke, President and CEO of St. Joseph Heritage Healthcare, expressed his gratitude to the Stanford team and Peterson Center on Healthcare for developing such a comprehensive analysis of data and conducting the onsite evaluation and interviews. Burke stated, “This recognition further validates that the investments made in the early 2000s to deploy electronic medical records and fully participate in quality reporting programs, such as the IHA Pay for Performance program and Medicare PQRS models, allow physicians and care teams to perform at the level discovered by this research and assessment.”

He added, “The recognition from this unique and exciting program was particularly inspiring as the research and initial notification were done without the knowledge of any our team members or submitting data via an


application process. The work being done by our staff and physicians spoke for itself in the data and subsequent site visits and interviews.”

“The U.S. healthcare system is the most expensive in the world, but patient outcomes are often worse than many other nations,” said Jeffrey D. Selberg, executive director of the Peterson Center on Healthcare, which funded the study. Yet, he noted, “There are healthcare providers in communities large and small who are consistently delivering high-quality care at a lower-than-average total cost.

“If we replicated what these providers are doing on a national scale, America would have one of the world’s highest-performing healthcare systems.”

To learn more about the Most Valuable Care study, visit http://petersonhealthcare.org/most-valuable-care. o

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Annual Wellness Visits: A Key Benefit for Medicare Patients

Healthcare costs are now over $3 trillion annually and the rising costs have been attributed to unnecessary and duplicative services. Within the past decade, healthcare in the United States has been evolving from providers focusing on episodic care treatments to care that emphasizes prevention and wellness—a change that leads to better health outcomes and lower costs.

Medicare has played a role in the transformation by encouraging providers to focus on preventive medicine with the introduction of the Annual Wellness Visit (AWV) in the 2010 Affordable Care Act (ACA). The visit was designed to deliver evidence-based preventive services by conducting a Health Risk Assessment (HRA) addressing the patient’s current health and risk factors.

Many physicians will agree that prevention of disease is the best care method for patients, but nationally only 12% of Medicare beneficiaries have received an AWV. This visit is the most underutilized Medicare benefit. Contributing to the low utilization rates of AWVs is that patients are not aware of this benefit and primary care physicians often do not have the time to promote and provide the service. Physicians have said that requirements imposed by CMS are arduous and do not address disease maintenance and treatment. Another important factor is confusion over what the visit entails. Patients often come expecting an annual physical exam and the AWV, with its specialized focus, excludes the components of the yearly physical.

For IPAs and medical groups, efforts should be undertaken to encourage all clinical practices to provide AWVs to their patients. Increasingly, this requirement is being built into the plan agreements that the groups are contracted with.

Within the IPAs managed by Coast Healthcare, less than 5% of our members have had their AWV within the year, although more than 90% of the members have had multiple visits with their primary care physician. This has led to an organizational strategy to partner with a home visit provider to conduct the AWV in the home setting, allowing enough time to conduct the required visit elements. Coast Healthcare Management’s IPAs have partnered with HouseCall Medical Associates (HCMA), managed by Medical Home Center (MHC), to conduct outreach to patients who have not been seen during the year for their AWVs.

HCMA has extensive experience and understands how healthcare services should be delivered in the home setting to improve patient outcomes, adopting the Triple Aim model of care. The call team is trained to discuss the benefits of the AWV with patients, as having a good understanding is key to their consenting to the visit.

The advantages of conducting a comprehensive AWV include reducing costs by providing preventive services to keep the patient healthy. The yearly visit can be used as an opportunity to not only offer preventive services but also address existing chronic conditions. Additionally, the AWV provides an opportune time to capture the ICD-9 codes necessary for the CMS risk adjustment payment model and outcomes data. Capturing HCC codes is important not only for the groups but also for the health plan’s

BY V IV IEN TRAN, MPH, D IRECTOR OF STRATEGIC PROGRAMS, COAST HEALTHCARE MANAGEMENT, LLC

continued on page 29


From our WellMed doctors, nurses and physician assistants to our medical assistants and technicians, we have the same focus; to provide the best, most attentive healthcare for our senior patients.

WellMed wants to create partnerships that offer physicians who share our vision with the freedom, support, and opportunity for professional growth.

Call our recruitment partner Provenir today (210) 479-3444. We can help you strengthen your medical practice future.

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Top Business Risks for Medical PracticesBY MIKE ROSENTHAL, V ICE PRESIDENT, THE DOCTORS COMPANY INSURANCE SERVICES

In today’s changing healthcare environment, the challenges of running a medical practice are complex. Practices face business exposures beyond malpractice that can lead to high defense costs and significant fines and penalties.

DATA BREACH RISKS

A full 51 percent of all data breaches occur in healthcare entities.1 The healthcare industry is targeted because healthcare organizations fail to upgrade their cybersecurity as quickly as other businesses and because cyber criminals are paid $20 for health insurance credentials, compared to only $1 or $2 for credit card numbers.2

In one incident, an employee of a county health center had his laptop and mobile phone stolen from his car. The devices were not password-protected, and both devices contained personal health information of the center’s patients. The total costs for this HIPAA violation are expected to exceed $150,000.

It’s not a question of whether a practice will get hacked, but a question of when. To mitigate this risk:

� Develop a data recovery and/or disaster plan.

� Create, document, and use enforceable cyber and data breach procedures.

� Train your staff on your procedures.

� Encrypt all computers and devices with passwords that are composed of numbers, letters, and symbols.

� Protect your facilities by securing building access, shredding documents, and installing firewalls.

� Have separate office and guest Wi-Fi networks in your office and/or practice.

� Install endpoint security software, including antivirus, antispyware, and antimalware.

RISKS OF BEING A HEALTHCARE EMPLOYER

The most severe exposure for a practice, outside of malpractice suits, is employment-related claims. In a

five-year period, 6 out of 10 employers can expect a claim of harassment, discrimination, retaliation, wrongful termination, or wage and overtime practices, among a host of actions.3 The median award in employment practices lawsuits was $325,000 in 2012,4 and defense costs are incurred even for frivolous claims. Doctors are a particular target for this type of lawsuit because they are viewed as having deep pockets.

In one case, an office manager for a dermatology group went on medical leave. During the leave, the group discovered significant performance issues and decided to terminate the employee. The employee was offered a $5,000 severance package, rejected it, and was terminated anyway. Subsequently, the employee alleged age and disability discrimination, retaliation, and wrongful termination against the practice. The case was eventually settled in mediation for $85,000, with the practice incurring additional legal expenses totaling close to $15,000.

To mitigate your risk and exposure:

� Create, document, and use enforceable employment procedures.

� Have a lawyer or human resources professional review your employment procedures at least every two years.


� Train your managers and supervisors on your procedures.

� Adopt an equitable format and policy for administering evaluations.

BILLING ERRORS AND OMISSIONS

All healthcare providers who submit bills for reimbursement to the government or private payers could face an audit, which can lead to significant fines and penalties. On average, it costs $80,000 for healthcare organizations to defend themselves.5 In addition, fines and penalties can be hundreds and thousands of dollars, even if the provider is found not guilty.

In one case, a provider contracted with a software vendor to develop and maintain an online appointment scheduling system. However, the vendor did not properly secure the website and the patient information was viewable by unauthorized users visiting the site. The patient filed a complaint against the provider, and the vendor corrected the mistake—however, the provider had to pay $42,000 in defense costs.

Here’s what you can do to mitigate your risk:

� Establish compliance standards, and conduct internal monitoring and auditing of those standards.

� Stay current on coding rules and federal regulation by reading Federal Register and Health and Human Services bulletins.

� Identify billing issues, track denied claims, look for patterns, and take necessary corrective actions to avoid improper payments.

� Conduct appropriate training for your staff.

into this benefit. As the paradigm shifts to wellness and prevention, it is becoming clear that AWVs and health risk assessments can play a key role in the future of patient care.

Coast Healthcare Management is an MSO providing management services to independent physician groups serving more than 80,000 members. Together the groups contract with over 700 primary and specialty care physicians who practice throughout Los Angeles and Orange Counties.

HouseCall Medical Associates, managed by Medical Home Center (MHC), is a healthcare management company whose care model embraces collaboration among diverse providers to deliver comprehensive, quality healthcare in patients’ homes. o

revenue, thus providing significant value. Population health management and care coordination starts with the AWV.

Although AWVs are a great benefit for the Medicare population, patients are still reluctant to take advantage of them. Of the population our groups have reached out to, less than 40 percent agreed to an AWV. Many preferred having an AWV with their PCP rather than having someone come to their home, while others did not think it was necessary since they see their PCP regularly.

This points to the need for primary care physicians to make AWVs a priority and take time to discuss their importance with patients. Better education and engagement are needed so that patients are tapping

� Use updated coding standards, including Current Procedural Terminology, a Healthcare Common Procedure Coding System, and new ICD-10 codes.

� Consider using a medical coding and billing software program.

Be sure your practice has adequate insurance coverage for all these risks, and review your insurance portfolio regularly.

To learn more about protecting your practice—including additional case studies that illustrate these exposures—view the video playlist “Medical Practices: Be Aware of Top Business Risks” at www.youtube.com/doctorscompany. o

References

1Visser S, Osinoff G, Hardin B, et al. Information security & data breach report—March 2014 update. Navigant. March 31, 2014. http://www.navigant.com/~/media/WWW/Site/Insights/Disputes%20Investigations/Data%20Breach%20Annual%202013_Final%20Version_March%202014%20issue%202.ashx. Accessed December 16, 2014.

2Cybercrime and the healthcare industry. EMC. July 2013. http://www.emc.com/collateral/white-papers/h12105-cybercrime-healthcare-industry-rsa-wp.pdf. Accessed December 16, 2014.

3Employment practices liability insurance. The Hartford. http://www.thehartford.com/commercial-insurance-agents/small-business-employment-practices-liability-insurance. Accessed December 19, 2014.

4Employment practice liability jury award trends hit new high. HR that Works. January 17, 2013. http://www.hrthatworksblog.com/2013/01/17/employment-practice-liability-jury-award-trends-hit-new-high/. Accessed December 19, 2014.

5Smigel T. The facts about billing errors & omissions insurance. Oregon HealthCare News. www.orhcnews.com. Accessed July 2014.

Annual Wellness Visits...continued from page 26

30 l CAPG HEALTH September/October 201430 l CAPG HEALTH Winter 2015

before,” said Dan Osterweil, MD, FACP, vice president and medical director for SCAN Health Plan. “Central to that is the sharing of ideas and programs that are making a difference in one community and providing support to other organizations so they can adopt these best practices as well.”

HERITAGE PROVIDER NETWORK, TRINITY HEALTH TO EXPAND RISK-BASED CARE

Southern California–based Heritage Provider Network has signed an agreement with Trinity Health, an 86-hospital Catholic system based in Livonia, Michigan, to advance coordinated care for specific groups of patients. Under the joint venture—Trinity Health Partners – the organizations will partner to create care networks similar to ACOs and contract with health plans for full-risk capitated payments for the networks. The collaboration will emphasize technology, using Heritage’s patented Q-ACO software for patient tracking and health records.

According to the organizations, the partnership will help their systems move more quickly from fee-for-service reimbursement toward their shared goal of a “people-centered health system.” Both organizations have been deeply involved in population health efforts. Heritage has participated in Medicare’s Pioneer ACO demonstration since the program began, and Trinity has established Medicare Shared Savings Program ACOs in all Trinity markets.

WILLIAMS JOINS STANFORD HEALTH CARE

Tom Williams has joined Stanford Health Care as vice president and general manager of accountable care operations and strategy. Williams previously had served since 2004 as president and CEO of the Integrated Healthcare Association (IHA) in Oakland, California. In the newly created position at Stanford, Williams will oversee the Stanford Health Care Alliance health plan, along with its Medicare Advantage HMO and activities with independent practice associations. IHA is a California quality improvement advocacy group known for its statewide medical group performance ratings and its Pay for Performance program, the largest nongovernmental U.S. physician quality incentive program.

CEDARS-SINAI MEDICAL CENTER OPENS COMPREHENSIVE TRANSPLANT CENTER

Cedars-Sinai Medical Center (CSMC) has opened a new Comprehensive Transplant Center that consolidates four transplant programs into one building. Designed by SmithGroupJJR, the 36,500-square-foot center unites liver, kidney, lung, and pancreas transplant programs that formerly resided in several locations across the campus. Patients now can have nearly all their medical needs addressed at one location. Working with the transplant clinic team and CSMC, the architects developed a plan that incorporates all services through a single-line patient flow spanning from entry to check out. The workflow model improves the patient experience and reduces wait time, while enhancing staff efficiency. “Improving the quality of life for patients who have received an organ transplant, or are waiting for one, was the organizing principle for the design of this new facility,” said Center director Andrew S. Klein, MD.

CAHP NAMES VP, LEGISLATIVE AFFAIRS AND DIRECTOR, STATE PROGRAMS

The California Association of Health Plans (CAHP) has named longtime Director of Legislative Affairs Nicholas Louizos as Vice President of Legislative Affairs. Athena Chapman, formerly Director of Legal and Regulatory Affairs, is now the new Director of State Programs.

Over the past eight years, Louizos’ advocacy has focused on improving quality of care while maintaining affordability, expanding coverage, and ensuring sufficient funding for public programs protecting access to care. Louizos led CAHP’s legislative advocacy work on the implementation of the Affordable Care Act in California and leads legislative outreach on all Medi-Cal issues, including the state budget.

As Director of State Programs, Chapman leads CAHP’s unit dedicated to public health coverage programs, namely Medi-Cal. She will direct CAHP’s regulatory response to proposals, state budget issues, and new policies impacting public programs and health plan operations with the Department of Health Care Services (DHCS) and CMS. Prior to joining CAHP, Chapman worked in the Medi-Cal Managed Care Division at DHCS and also spent six years at CMS. o

Names in the News...continued from page 6

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The healthcare industry has been moving from “volume to value,” placing more emphasis on coordinating care and delivering better outcomes in the most appropriate and cost effective settings.

That’s a good thing. Improving quality and reducing costs is not a trend at Brown & Toland Physicians. It’s part of our DNA. As one of the first medical groups in the country to implement electronic health records in our physicians’ offices, and develop system-wide population health management programs, we’ve learned that every population and every individual is not the same and does not require the same level of care.

Taking a team approach, our professional care managers work closely with our physicians to develop successful programs and education for specific patient groups. These programs have helped improve preventive screening rates, reduced hospital stays, and have resulted in fewer hospital readmissions.

Using predictive population health analytics, Brown & Toland Physicians has advanced care for patients in our Pioneer Medicare ACO and commercial ACOs. We will continue to provide proprietary solutions that help our physicians deliver value-based care, as this type of care is good for our patients today, as well as tomorrow.

To learn more about Brown & Toland Physicians, please visit our website at www.brownandtoland.com.

Value-Based Care: Today and Tomorrow

Keeping the San Francisco Bay Area healthy for more than 20 years

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