new risk and collaboration models for providers clinically integrated network january 2014
TRANSCRIPT
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Agenda
Objectives for Today
Provide a brief history and context
Share the vision, objectives, and strategies
Review the model of care
Review Physician Care Network’s clinical and administrative services
Provide a status of recent activities and upcoming milestones
Share the requirements and benefits of physicians joining the CIN
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Background
Market & Competitive Pressures
Hospitals
Consolidating; increasing negotiation strength
Employing primary care and specialty physicians
Health Plans
Creating narrow networks and increasing price pressure
Implementing bundled episodic payments
Pushing risk based payment and shared savings models
Tying quality metrics to reimbursement levels
Requiring changes to protocols and treatment to improve outcomes
Demanding significant data compilation required to track and monitor
Result: A serious threat to the long-term viability of physician owned practices
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Addressing the Threat
Plan of Action
In 2013, the Northwest Medical Group Alliance initiated a study to determine the feasibility of creating a physician-led, Clinically Integrated Network (CIN)
Their network of over a dozen independent physician practices with more than 700 physicians is sufficient for limited network products
The proposed CIN delivery model is marketable and the timing is optimal
Hospital affiliation is not a priority
Member participation criteria can be met by most, if not all, medical groups in the Alliance and beyond
The right vehicle for the CIN is the Physicians Care Network (PCN)
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Physicians Care Network
Overview
Formed in 1997, serves as a mechanism for sharing financial risk through clinical integration across multiple medical group practices
Contracts with various health plans on behalf of its Members and administers quality and care management programs in accordance with payer terms and conditions
Integration across care settings of standardized clinical protocols‒ Steerage of patient care to lower cost settings
‒ Utilization management of high risk populations
‒ Formularies that promote generic drug use
Develops the provider network for health plans‒ Billing, credentialing, administration of risk pools and other risk sharing arrangements
‒ Management information services related to administration of those contracts
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Physicians Care Network
Overview (continued)
Engaged with four Medicare Advantage (MA) health plans‒ PCN participates with three of the four MA health plans under full risk, fully delegated (care
management, claims, credentialing) arrangements
‒ Participates in the Medicare ACO Shared Savings Program with the Centers for Medicare and Medicaid Services (CMS)
‒ Contracts with four health plans that focus on shared savings and reduction in the total cost of care delivered to plan beneficiaries
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Vision & Business Aims
Business AimDevelop and operate a clinically integrated network of independent physician practices that secures and supports performance of value-based contracts that reward practices
for delivering high quality patient care in an efficient manner
VisionEnable independent physician practices in the Pacific Northwest toremain independent and thrive in the new healthcare environment
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Strategies
Achieving the Business Aim
Create a robust and engaged clinically integrated network of independent physician practices
Identify, secure, and deploy an essential infrastructure to support CIN operations in a cost-effective manner
Engage physicians as leaders and full participants in the CIN's development and operations
Support participants’ practice transformation efforts
Identify, evaluate, and pursue network value-based payor contracting opportunities
Develop the capacity to accurately report the health status of defined patient population(s)
Ensure participants’ adherence to CIN-approved evidenced-based standards of care
Deliver "high-touch" care coordination for high-risk and patients who may become high risk
Deploy proven patient engagement tools to manage network patients
Develop metrics and measure outcomes for continuous quality improvement
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Desired Outcomes
Outcomes
Engage a critical mass of independent physician practices as CIN participants
Create a sustainable business model to support essential CIN infrastructure and services to its participating practices
Transform participants’ practices to engage in population health management
Secure favorable value-based payor contracts for CIN participants
Demonstrate quality through participants’ achievement of specified standards
Reduce the total cost of care for defined population(s) by specified targeted amounts (percentage reductions)
Improve the overall patient experience of care
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Model of Care
Scalable Services to Meet Patient Needs
High risk – high cost, complex needs
Cost Containment, support and coordination
Rising risk – at least one chronic condition
Motivational Interviewing, closing care gaps, strengthening relationship to PCP
Low risk Engage, set the stage
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Model of Care
Enhanced Care Model
Care coordination service delivery model with a focus on keeping patients healthy over time through screening and prevention, early intervention, health education, and meaningful management of chronic conditions
High risk / high cost patients actively managed and transitioned from high cost hospital based services to lower cost community based and home based care
Primary care providers rewarded based on the outcomes they achieve rather than by the number of exams they provide or tests they order
Evidence based clinical protocols, vetted by extensive research, and determined by experts to be most effective compared to other treatment options
Information sharing occurs across care settings to reduce duplication of unnecessary diagnostic and treatment orders and eliminate waste
Formularies that include step-therapy and increased use of generic drugs
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PCN Services
Care Management Services
Train and coach providers on the Enhanced Care Model
Establish and disseminate CIN guidelines and protocols (in collaboration with Member groups)
Promote practice improvement, quality, and cost management goals
Collaborate with Member groups to establish quality and cost measures and clinical benchmarks that drive health system change
Extend risk identification and care management tools and processes to Members
Provide risk adjusted coding training and services
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PCN Services
Administrative Services
Create the CIN, secure investors, and implement
Prepare legal documents for the joint venture: Bylaws, Articles of Incorporation, etc.
Develop Member participation agreements and negotiate contracts
Engage health plans and negotiate innovative payment models
Administer payment models
Develop prospective budgets and resource planning
Develop initial performance measures and baseline statistics
Brand, manage, and expand the network across the state
Manage CIN staff and liaison with in-kind services provided by Member groups
Credential Member physicians
Provide decision support and analytics tools and processes
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PCN Systems
Primary Systems
Phytel/Verisk – Concurrent and retrospective review Stratify, validate, and manage risk Identify care gaps Assist with quality indicators; track and trend quality measures Track population health around complex and chronic conditions Aggregate disparate data sources into consistent data sets for analysis and comparison of quality
and cost metrics Assist staff in its patient outreach activities through a set of protocols that support preventive and
chronic care follow-up
EZ-Cap – Administration Referral and Authorization Management Customer Service Encounter Submissions Reporting
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CIN Status
Recent Developments
Negotiated a term sheet with investors and gained agreement to move forward and engage provider groups
Developed milestones to ensure progress, safeguard ongoing capital investment, and provide investors with some assurance for their investments
Updated the Participation Agreement and created supporting materials for engaging prospective provider groups
Prioritized the list of potential provider groups
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CIN Governance Model
Clinically Integrated NetworkBoard of Managers
Executive Director
Medical Director(also supports MA business)
Population Health Management
Performance Improvement Contracts Technology
Business lead/controlled committees with physician participationPhysician lead/controlled committees
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Revenue Model
Care management fee (e.g.PMPM)
This approach…
Ensures there is immediate revenue to help offset operating costs Provides an alternative to health plan contracts that only provide the potential for
limited savings at the end of a contract period Avoids the diminishing returns associated with continuously squeezing costs out of the
system
The CIN plans to charge a flat per member per month (PMPM) fee
A flat fee across the entire population is much simpler than charging a much higher fee for only the high-risk patients; it also provides a more predictable revenue stream
This approach is not unique; it is consistent with other PCN and standard industry arrangements
The up-front fee may have to work in conjunction with a shared savings arrangement
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Next Steps
Upcoming Activities
Formally create the CIN enterprise‒ Execute the Term Sheet‒ Form the CIN legal entity (Operating Agreement, Articles of Incorporation, Bylaws, etc.)‒ Elect the Board of Directors; form and charge committees
Immediately kick off the next phase of provider group engagement
Execute contracts with health plan(s)
Complete the recruiting process and hire a Medical Director as soon as possible
Engage a CIN consulting firm to support implementation
Create a formal budget for 2015
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Important Dates
2015 Milestones
1/1/2015 1/1/2016
4/1/2015 - 9/30/2015Implement
Model of Care
1/1/2016Members Enroll in
New Product(s)
1/1/2015Form and
Capitalize Entity
2/1/2015Operationalize
Committees
4/30/2015Health Plans
File 2016 Products
9/1/2015Population Health Systems
Available to Members
3/31/2015Health Care Authority
Selects 2016 ACO Partners
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Joining the CIN
Membership Participation Criteria
Use a certified electronic medical record system
Meet or be in the process of meeting Meaningful Use standards
Identify and track at least one patient population or chronic condition
Have experience tracking some patient costs
Have process in place for managing transitions of care
Use ePrescribing, CPOE or electronic results reporting
Agree to cost management and performance risk management protocols
Agree to share data transparently
Agree to adopt the new model of care
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Joining the CIN
Member Benefits
The ability to remain independent as an alternative to large health system employment‒ With a number of quality focused provider groups, anchored by The Polyclinic and supported
by Physicians Care Network, the CIN will enable independent physicians to participate in risk-based, total cost of care contracts that they would otherwise not have access to
‒ This is critical to practice survival as health plan products are increasingly steering patients to narrow networks
Enhanced provider leadership over clinical decisions through selection and implementation of evidence based clinical protocols
Decision making seats on committees and influence to Board decisions
Innovative care delivery alternatives that enhance patient experience that, in turn, leads to growth in market share and revenue sharing opportunities
Access to population health management tools
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Joining the CIN
Member Benefits (continued)
Training and administrative services that streamlines data compilation and extraction for health plan quality metrics management
Financial analysis capabilities
An environment where independent providers can support one another through referrals, team based care, and care coordination while reducing the total cost of care
Risk adjusted coding training and resources