first year experience with a commerical aco - amga · first year experience with a commercial aco...
TRANSCRIPT
First Year Experience with a Commercial ACO
AMGA 2012 Annual Conference, March 9, 2012
Mark Shields, MD, MBA, FACP
Senior Medical Director
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
• APP Assumes No Responsibility for the Reliance by Conference Participants on Materials Presented at Today’s Session
2
Learning Objectives
Participants will be able to:
• Understand Challenges to ACO Development
• Understand How Clinical Integration Drives
Outcomes
• Describe Key Components of Clinical Integration
that Lead to Success
• Understand Early Results from a Large
Commercial Shared Savings Contract
3
• $4.5 Billion Annual Revenue• AA Rated• 12 Acute Care Hospitals
– 2 Children’s Hospitals – 5 Level 1 Trauma Centers– 4 Major Teaching Hospitals– 4 Magnet Designations
• Over 250 Sites of Care
– Advocate Medical Group– Dreyer Medical Clinic– Occupational Health– Imaging Centers– Immediate Care Centers– Surgery Centers– Home Health / Hospice
Advocate Health Care
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Advocate Physician Partners
• Physician Membership
– 1,085 Primary Care Physicians
– 2,889 Specialist Physicians
– Total Membership Includes 987 Advocate-Employed Physicians
• 10 Acute Care Hospitals and 2 Children’s Hospitals
• Central Verification Office Certified by NCQA
• 230,000 Capitated Lives/700,000 PPO Lives
• 215,000 “Attributable” Lives
Advocate Physician Partners delivers
services throughout Chicagoland and
Downstate Illinois.
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Clinical Integration: Definition
8
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.
Challenges of Health Reform
• 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
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Clinical Integration is the Foundation of an ACO• Provides Infrastructure for Integration of Small
Practices
• Overcomes Problems Seen Within the Fee-
for-Service Model
– Incentives to Providers Drive Improvement
• Creates Business Case for Hospital and
Doctors to Work for Common Goals
• Allows One Approach for Commercial and
Governmental Payers
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Creating a Culture of Engaged Physicians• Physician Engagement in Governance
• Physician Leadership Development
• Shared Identity and Values → “Membership”
• Infrastructure Investment to Enable Success
• Appeal to Pride and Sense of Excellence– Recognition for Quality and Efficiency
– Consistent Use of Evidence-based Medicine
– Power of the Outcomes of the Group
13
Total Physicians on Medical Staffs = 6,007
Total APP Physicians = 3,974
Independent Non-APP = 2,033
Independent APP = 2,987Employed /
Affiliated = 987
Affiliated (Dreyer) = 172AMG (Employed) = 815
Advocate’s Physician Platform
14
APP Board and Committee Composition
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Lee Sacks, M.D., Chief ExecutiveRobert Zimmanck, M.D ,Chairman
Marty Manning, President
Contract Finance Committee
Robert Raines, M.D., Chairman Pankaj Patel, M.D., Chairman
Advocate Physician PartnersBoard of Directors
Utilization Management Committee Quality Improvement Committee
Mark Shields, M.D., Chairman
Local Site Engagement in Governance
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APP Board and Committees
Condell
PHO
Christ
PHO
South
Suburban
PHO
Illinois
Masonic
PHO
BroMenn
PHO
Trinity
PHO
Good
Shepherd
PHO
Good
Samaritan
PHO
Lutheran
General
PHO
Health Plan Commitments
Includes All Major Payers in the Market
• Risk and Fee-for-Service Contracts
• Base and Incentive Compensation
• Same Measures Across All Payers
– Common Procedures at Practice Level for All
Contracted Plans
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2012 Performance Metrics
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• Physician Commitment to a Common Broad Set of Clinical Initiatives
– 60 Initiatives – Broad Area of Focus
– 159 Individual Performance Measures
• Primary Care and Specialty
– 4 AdvocateCare Measures
– 5 Performance Domains
• Clinical Outcomes
• Efficiency
• Medical and Technological Infrastructure
• Patient Safety
• Patient Satisfaction
Physicians Determine All New Performance Measures
Clinical Integration 3.0:Increasing Physician/System Integration
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Early Years:
2004 - 2006
Primary Care/
Ambulatory Measures Increasing
Specialist
Measures
Middle Years:
2007 - 2009
Maturing Years:
2010 - 2013
Increasing
Physician/
System
Integration
Clinical
Integration
to
Accountable
Care
Health Reform:
2013 -
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
2011 Care Management Software Plus Analytics
Advancing Technologies
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Advancing Evidence-Based Medicine and Care
Year
2004 Physician Reminders for Care
Chart Based Patient Management
2006 Patient Outreach
2007 Physician Office Staff Training
Pharmacy Academic Detailing Program
Generic Voucher Program
2008 Diabetes Collaborative
Patient Coaching Program
Hospitalists
2009 Diabetes Wellness Clinics
Asthma and HF/CAD Collaborative
2011 Access and COPD Collaborative
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• Web-Based Commercial Registry
• Integrates All Registries, Pharmacy, Labs, Claims and Performance Reporting
• Integrates Physicians
• Integrated with EMR
Clinical Integration Registry and Reporting Information System (CIRRIS)
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Clinical Integration Program Progress Reports: Background• Progress Reports are Compiled and Made
Available Quarterly
– 4th Quarter Progress Report is Reflective of Full
Reporting Year Performance
• Basis for Determining Physician’s Incentive Fund Payment
• Physicians Retrieve a Customized Progress
Report and Documentation Supporting
Measurement on Key Initiatives (Efficiency
Areas)
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Mechanisms to Increase Compliance
• APP QI/Credentials Committee
• Membership Criteria
• Peer Pressure/Local Medical Director
• Mandatory Provider Education/CME
• Physician’s Office Staff Training
• Financial Incentives/Report Cards
• Targeted Programs
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Advocate Physician Partners’ Incentive Fund Design
PHOs 1-9
Residual Funds
Individual Incentives (70%)
Individual Distribution
Based on Individual
Criteria
Residual Funds
Group/PHO Incentives (30%)
Group/PHO Distribution
Based on Group/PHO
Criteria
Tier 1(50%)
Tier 2(33%)
Tier 3(17%)
Tiering based on individual
MD scores
Residual funds are rolled over into general CI fund available for distribution in the following year
27
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 PHO
– Work Incentive Volume and Performance
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Aligning Physician and Hospital Incentives• 2009
– CPOE
– Core Measures
• 2010 – CPOE
– Core Measures
– Readmissions
– Length of Stay
• 2011– ED Efficiency
– Meaningful Use
– Core Measures
– Readmissions
– Length of Stay
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• 2012– ED Efficiency
– Core Measures
– Readmissions
– Length of Stay
– Transfusion Safety
– Elective Induction of Labor
Incentives for OutcomesCI 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 $50.0 Million
2011 $101.0 Million Est.
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230,000 Capitated Lives / 700,000 PPO Lives
215,000 “Attributable” Lives
Great Clinical Outcomes and Good Business
Transparency of CI Performance
• At Direction of APP Board of Directors,
Strategy Implemented to Increase
Transparency of CI Program Performance
• Statistics Shared with MDs for Them to See
How They Compare to Their Physician Peers
• All Individual Physician Performance Results
are Available for All to View and Compare
(Internally)
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• Generic Prescribing: 6-9% > Local Plans
• LDL Good Control in Patients with Diabetes:
43% > National Rate
• Childhood Immunizations: 55% > National
Rate
• Depression Screening: 85% > National Rate
• Diabetic Care: Exceeded National Rate on All
9 Measures
• Asthma Action Plans: 75% > National Rate
Highlights of 2010 CI Program“Moving the Dial on Quality”
33
2011 Value Report
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www.advocatehealth.com/valuereportor call 1-800-3-ADVOCATE
(1-800-323-8622)
Critical Success Factors• Physician Driven
• Same Metrics Across All
Payers
• Minimize Additional
Administrative Costs
• Additional Funds Recognize
Extra Work by Physicians and
Staff
• Infrastructure Necessary to
Support Improvement
• Physician/Hospital Alignment
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Value for Physicians
• Better Alignment with Hospital
• Marketplace Recognition
• Focus on Outcomes
• Incentives Compensate for Additional Work
• Interface with Multiple Payers
36
It’s a New Day
• Insurers 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
41
Industry Has Difficulty Controlling…
• Utilization of High End Imaging
• Readmissions
• Outpatient Trend
• New Drugs & Technologies
• Ambulatory Sensitive Conditions
42
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
43
Changing Paradigms
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FROM... TO...
Silo Care Management Enterprise Care Management
Episodes of Care Coordination of Care
Discharges Transitions
Utilization Management Right Care at the Right Place
at the Right Time
Caring for the Sick Keeping People Well
Production (Volume) Performance (Value)
Unicorn
The Accountable Care Organization is like a
unicorn, a fantastic creature that is vested with
mythical powers. But no one has actually seen
one.
Ian Morrison
45
AdvocateCare
• ACO-Like Contract
• Shared Savings Model
• Improved Health Care Outcomes
– Reductions in Waste, Duplications and
Inefficiencies
46
AdvocateCare - A Global Care Contracting Framework
• Global Cost Management Overlay On Top
of Existing FFS Structures
• Responsibility for Managing Comparative
Trend
• Method for Sharing Savings
• Involves Partnering With the Payer
• One Model for Governmental &
Commercial ACO-Like Contracts
47
Ranking of Respondent ACOs by Covered LivesAccountable Care Organizations
Year ACO Formed
Number of Covered Lives
Number of Physicians
Participating
Advocate Physician PartnersOak Brook, IL
2011 350,000 3,900
Bronx Accountable Healthcare NetworkNew York
1995 140,000 3,000
Pendulum HealthCare Development Corp.1
Rockford, IL2010 100,000 500
Southeast Texas Accountable Care OrganizationHouston
2011 60,000 30
Blue Shield of California1
San Francisco20102 41,500 520
AnewCare Collaborative3
Johnson City, Tenn.2011 10,000 1,500
Norton Healthcare1
Louisville, KY2011 6,026 176
Gonzaba Medical Group1
San Antonio2007 5,252 50
Castle Health Group1
Kailua, Hawaii19964 2,500 125
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Ranking of Respondent ACOs by Covered Lives (continued)
Accountable Care OrganizationsYear ACO Formed
Number of Covered Lives
Number of Physicians
Participating
Agnesian HealthCare1
Fond du Lac, WI2010 05 2,000
Atlantic ACOMorristown, NJ
2011 0 300
Southeast Michigan Accountable CareDearborn
2010 06 1247
Palmetto Health Quality CollaborativeColumbia, SC
2010 -- 210
1 Sponsoring organization.2 Memorandum of understanding signed in April 2009, launched Jan. 1, 2010.3 Mountain States Health Alliance affiliated company.4 Formed as a physician-hospital in 1996, currently evolving toward an ACO-type organization.5 No contracts for covered lives; estimate of 250,000 potential lives.6 No lives covered at this point; ACO was formed to participate in the Medicare Shared Savings Program.7 Primary-care providers are participating owners.
Source: Modern Healthcare’s 2011 Accountable Care Organizations Survey
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Shared Savings Model
50
$ Per
Attributed
Life Per Year
(Risk
Adjusted)
0 Yr 1 Yr 2 Yr 3 Yr 4 Yr 5
Shared
Savings
Summary Results of the Physician GroupPractice Demonstration Performance Years 1-4*
51
Physician Group Practice Percentage of Quality Goals Attained
YEAR 1 YEAR 2 YEAR 3 YEAR 4
Billings Clinic, Billings, MT 90.91 97.78 98.11 92.45
Dartmouth-Hitchcock Clinic, Lebanon, NH 95.45 97.78 92.45 94.34
Everett Clinic, Everett, WA 86.36 95.56 94.34 94.34
Forsyth Medical Group, Winston-Salem,NC 100.00 100.00 96.23 96.23
Geisinger Clinic, Danville, PA 72.73 100.00 100.00 100.00
Marshfield Clinic, Marshfield, WI 81.82 100.00 98.11 100.00
Middlesex Health System, Middletown, CT 86.36 95.56 92.45 94.34
Park Nicollet Clinic, St. Louis Park, MN 95.45 97.78 100.00 100.00
St. John’s Clinic, Springfield, MO 100.00 100.00 96.23 98.11
University of Michigan Faculty Group Practice, Ann Arbor
95.45 100.00 94.34 96.23
• Because the CMS applied different weights to each quality measure, the agency calculated the quality goals attained as percentages, rather than absolute numbers of measures. Data are from RTI International.
Published in NEJM, 364:198-200, Jan 20, 2011
51
Physician Group Practice Shared Savings Payments ($)
YEAR 1 YEAR 2 YEAR 3 YEAR 4
Billings Clinic, MT 0 0 0 0
Dartmouth-Hitchcock Clinic, NH 0 6,689,879 3,570,173 328,798
Everett Clinic, WA 0 129,268 0 0
Forsyth Medical Group, NC 0 0 0 0
Geisinger Clinic, PA 0 0 1,950,649 1,788,196
Marshfield Clinic, WI 4,565,327 5,781,573 13,816,922 16,154,242
Middlesex Health System, CT 0 0 0 0
Park Nicollet Clinic, MN 0 0 0 0
St. John’s Clinic, MO 0 0 3,143,044 8,185,757
University of Michigan Faculty Group Practice, Ann Arbor
2,758,370 1,239,294 2,798,006 5,222,852
Summary Results of the Physician GroupPractice Demonstration (continued)
52
Published in NEJM, 364:198-200, Jan 20, 2011
52
Attributed Patient Cost Concentration Supports Care Management Model
Person Years Predicted ExpendituresNumber Percent Mean $ Percent
Very Low Risk 54,398 30.5% $ 784 3%
Low Risk 78,520 44.1% $ 4,054 22%
Moderate Risk 24,906 14.0% $ 11,517 20%
High Risk 16,056 9.0% $ 24,054 27%
Very High Risk 4,270 2.4% $ 91,062 27%
Total 178,149 100.0% $ 7,987 100%
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Some Key Issues to Address
• Improving PCP Access
• Reducing Avoidable Admissions
• Intensive Outpatient Management
• Achieving “Hospitalism”
• Affecting “Perfect Transitions”
• Increasing Alignment with Private Practice
Physicians
• Real Time Clinical Decision Support
54
2011 ECM Infrastructure & Support
Outpatient Care Management
• Dedicated Outpatient CMs for High-Risk patients
Emergency/Acute Care Management
• Inpatient CMs
• ED CMs
• Hospitalists
• Physician-Partnered CM Model
Post Acute
• SNF CM Model
• SNF, LTACH, Inpatient Rehab Network
• Transition Coaches
Physician Office Performance
Coaches
Market Share Growth/Backfill
Data & AnalyticsCM
Risk/Reporting System
PCP Access/Virtual
Visits
Communication Strategies
55
Implications for Primary Care
• Renaissance of Primary Care
• Appropriate Incentive Structures
– Access/Avoidance of ER
– Medical Home
– Managing Ambulatory Sensitive Conditions
– Admission Rates & LOS
– Readmissions
– Specialist & Ancillary Efficiency
• Greater Alignment with Single System
56
Implications for Specialists
• Specialists are Integral to Success
• Structures Needed to Unlock Creativity
• “Pay for Work Done” Will Work for You
• Greater Transparency Around Efficiency
• Backfill Strategy Will Work for You
• Efficacious Specialists Will Thrive
57
Implications for IDNs
• Communicating a Complex Message
– Management & Physicians
• Building a Climate of Trust
• Ensuring Physician Access (Both Employed
& Private Practice)
• Less Volume from Existing Sources
• “Re-Purposing” Parts of the Enterprise
– Business Development, Physician Relations, UM,
Operations Management
58
Implementing ACOs: 10 Mistakes Singer and Shortell, JAMA, 8/9/11
Overestimate Organization Capabilities
• Manage Risk
• EHR
• Performance Measures
• Implement Protocols
Failure to Engage Stakeholders
• Balanced Governance
• Engage Patients
• Specialist Selection and Engagement
• Regulations/Legal
• Integrate Beyond Structures
Failure to Recognize Interdependencies
• Address All of Above
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Implementing ACOs
To Overcome These Mistakes:
• Adapt to Local Contexts
• Use Learning Systems Internally and
Externally
• Mature Measurement Systems Internally and
Externally
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Early Results
The Highlights Compare Key Utilization Metrics
for 200,000 Advocate-attributed Patients to
Identical Metrics for a Control Coup of
1,000,000 Non-Advocate-Attributed PPO
Patients.
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BCBS Data-1st Six Months
62
Utilization Metrics(PPO) AdvocateCare Market
Inpatient Admit Rate(Admit Rate/1000)
(10.6%) (8.8%)
Length of Stay (0.2%) (1.2%)
Days/1000 (10.8%) (9.8%)
% Days @ Advocate Hospitals
(12.9%) X
Outpatient ER Cases/1000 (5.4%) (4.6%)
OP Surgery/1000 (8.4%) (9.8%)
OP Other/1000 1.5% (2.0%)
Advance Imaging (6.7%) (7.5%)
Professional Office E and M/1000 (procedures/1000)
(5.9%) (6.1%)
Pharmacy Prescriptions/1000 1.3% (3.3%)
Figure 1: Utilization Dashboard-Q1 & Q2 2011 vs. 2010
Summary of Key Points
• Culture Evolves Over Time and Takes Effort
• Physician Engagement Requires Physician Involvement
• Technology Plays Important Role
• Evidence-based Management is Key
• The Need for Change – Preparing for the Future
63
Speaker:
Mark Shields, MD, MBA, FACPVice President, Advocate Health CareSenior Medical Director, Advocate Physician [email protected]