Transformation of Health Care Delivery: Navigating the Challenges and Opportunities

1. Transformation of Health Care Delivery: Navigating the Challenges and Opportunities Barbara Spivak, M.D. Mount Auburn Cambridge Independent Practice Association, Inc. (MACIPA) November 1-3, 2011

2. MACIPA Mission Statement MACIPA is an organization that leads its physician members by education and supporting them, representing their interests so that they delivery the highest quality care at appropriate cost in a manner that maximizes physician and patient satisfaction

3. Mount Auburn Cambridge IPA(MACIPA) • Founded in 1985 to organize physicians and negotiate managed care contracts • 513 physician members who admit to Mount Auburn Hospital and/or Cambridge Health Alliance • MACIPA takes full risk capitation from three major local health plans since mid 90’s • Blue Cross Blue Shield of MA • Tufts Health Plan and Tufts Medicare Preferred • Harvard Pilgrim Health Care • 48 employees • 40,000 capitated lives

4. MACIPA Membership Practice Statistics • MAPS (Hospital owned) 166 • Private Practices 250 • Cambridge Health Alliance 103 • Belmont Medical 20 • ________________________________________________ • PCPs 98 • Specialists 403 • PCP/Specialist 18 • _________________________________________________ 180 Physicians Practices Total Number of Office Sites

5. MACIPA & Mount Auburn Hospital • Managed Care partners since 1985 • Long history of investment in systems and programs to manage costs • Teaching level hospital care without the costs of a major academic medical center • Systems established to prevent leakage to costlier hospital care • Active and engaged leadership at hospital and IPA willing to partner with payers to achieve mutual goals

6. MACIPA & Mount Auburn Hospital • Independent entities - no legal structure joining them. • Contracts with payers are signed as 3-way agreements, signed independently. • Risk sharing between Hospital and IPA is defined and agreed-to outside the agreements with payers. • Service agreements are in place between Hospital and IPA defining: • Who provides service (e.g. MACIPA provides data warehousing; Mount Auburn administers reinsurance program) • Compensation to be provided for each service • Terms of the service to be provided

7. MACIPA Structure • Board Committees involve over 50 physicians • Primary Care Centric-touching every PCP monthly through Pod system • Focus on education and quality • Data driven • Physician leaders all practice medicine at least 50% of time

8. MACIPA Pod Structure • Topics discussed at Pod Meetings: • New physicians & services • Pharmacy management and medication recommendations • Data & reports • New programs/initiatives • Pod meetings attended by MACIPA case managers, other staff • Quality improvement programs-focus on preventive care

9. MACIPA Infrastructure • Case Management • Medical Management • Referral Management • Pharmacy Management • Data and Reporting • Contracting • Quality Improvement • EHR Department • IT Department

10. Keys to Success • Leadership believes that Managed Care is better care • IPA brings value to physicians & improves care for patients • Hospital believes in and supports the model • Focus on Quality, Education, Rewards not cost & before penalties • Hospital, PCP & Specialists benefit

11. What makes MACIPA successful? • Culture of collaboration among PCPs & Specialists • Board and Committee are very engaged in MACIPA activities • Larger infrastructure-more services supplied by MACIPA than the typical IPA • PCPs have a strong voice in the operation of the organization • PCPs & Specialists split the surplus earned 50/50

12. Challenges • Culture changes for physicians & administrators take time to develop • Managing “leakage” delivered outside the system • Patient & Physician acceptance of the team approach • Getting to “yes” on a contract with the payor, the Hospital and the physicians all feeling positive

13. Challenges • Need for capital investment for infrastructure and IT before payouts • Years before rewards are seen • Need for reserves and reinsurance • Tax implications • Leadership void • Getting to win/win with less funds available • Difficulty evaluating program efficiency, planning services and developing programs