A Conversation About MGO and Physician Driven Clinical Integration

1. A Conversation About MGOand Physician Driven Clinical Integration Who/What is MGO? What is Clinical Integration? Why is MGO Clinically Integrating? When/How is MGO Clinically Integrating? What’s it to you? John Schmeling, MD VP Physician Development jschmeling@theMGO.com 614-223-3333 www.theMGO.com

2. Who? MGO is… 640 practices/groups in 32 Ohio counties 501 (78%) of groups comprised of 1-3 physicians 2,001 physicians 659 (33%) primary care physicians 1342 (67%) specialists – all specialties • > 150 Physicians engaged in leadership roles • MGO Physicians responsible for > 90% of • OhioHealth’s revenue

3. What ? MGO’s Mission The Medical Group of Ohio (MGO) is an organization of health care professionals working together, as a business, to improve the process of delivering health care and to enhance the professional satisfaction of its members. • A physician business for • Quality • Enhancing Satisfaction • A physician business for • Quality • Enhancing Satisfaction • Obtain Fair Reimbursement Increase Efficiency • Reduce Hassles Reduce Overhead • Obtain Fair Reimbursement Increase Efficiency • Reduce Hassles Reduce Overhead

4. What ? Business Services MGO Practice Resources (MGO PR) Billing/claims processing, coding, collections, group purchasing, PMS and EMR, and more Communications Written: MGO Update, Quality Matters, Business Matters, Burgundy Book Electronic: www.theMGO.com, MGOE-news Professional Liability by Physicians for Physicians (PLPP) Physician owned and controlled professional liability program Long term stability with rates based on MGO physician’s experience

5. 50/50 Ownership and Governance OhioHealth Group OhioHealth Group A Physician-Hospital Organization and Facilities Physicians to the Market Aetna, Cigna, Great West, and others What ? Contracting – via OHG 5

6. What ? Clinical IntegrationA Definition and a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs. Clinical Integration is characterized by an active and ongoing program to evaluate and modify practice patterns 6

7. Why ? Clinical Integration To meet your needs in fulfillment of MGO’s Mission • Purchaser’s/Market’s Expectations • Legal considerations • Prove, Improve and be Fairly Reimbursed for • the Quality Care you deliver

8. Why ? Purchaser’s Expectations What do you consider when you purchase something important? Quality/Cost =Value • Quality • Cost • Service As a purchaser, You want value!

9. Why ? Purchaser’s Expectations The purchasers of health care want value too!

10. The Purchasers of healthcare are increasing their expectation / pressure for providers to: Prove and improvequality Decreasecost (or reduce the rate of rise) Improveservice / access Why ? Purchaser’s Expectations (government, employers, patients, and plans)

11. Evidence based care processes Support for prevention and wellness Effective management of chronic diseases Measure/prove, communicate and improve our performance Why ? Purchaser’s Expectations - Quality -

12. Reduce waste and needless repetition Right service, right time, every time Support prevention and wellness Primary and secondary Coordinated with employer driven programs Increase efficiency Why ? Purchaser’s Expectations - Cost -

13. Utilize Information Systems Enhance communication Provide better, more timely information Provide Patient Centered Care Comprehensive, Coordinated, Convenient and Compassionate Across many conditions, services and settings Why ? Purchaser’s Expectations - Service -

14. Why ? Clinical Integration Conclusion 1: The best way for Physicians to meet the purchasers’/market’s expectations is by collaborative clinical efforts

15. Why ? Clinical Integration To meet your needs in fulfillment of MGO’s Mission Purchaser’s/Market’s Expectations Legal considerations Prove, Improve and be Fairly Reimbursed for the quality care you deliver

16. Why ? Legal Considerations- Anti-Trust - For the FTC to allow “competitors” to jointly negotiate as one, there must be a compelling Benefit i.e. new product/service that meets market needs • Two legal standards – at least one must be met • Clinical Integration • Financial Integration

17. 2002 - sold the HMO no longer financially integrated not clinically integrated Why ? Legal Considerations Financial Integration (financial risk) • 1995 – 2001 MGO was financially integrated via 50% ownership of HealthPledge HMO • MGO negotiated contracts utilizing a single signature contracting model

18. MGO delivers the payers, terms/rates, the message, to the physicians and then delivers the physicians’ individual responses back to the payer Why ? Legal Considerations Messenger Model • Negotiation (even commenting on the terms • of the offer) is NOT allowed

19. While the FTC doesn’t provide a precise definition or checklist for Clinical Integration, there are a growing number of organizations the FTC has recognized as clinically integrated. Why ? Legal Considerations MGO has been learning from them!

20. New systems and programs to improve quality and efficiency Why ? Legal Considerations Characteristics of FTC Recognized Programs • Physician Standards of Care - develop, measure, provide feedback and assure compliance • Commitment by physicians to participate in the systems and programs • Investment of human and monetary capital

21. Why ? Legal Considerations Every organization the FTC has recognized as Clinically Integrated has found collective negotiations to be necessary in order to achieve these characteristics.

22. Why ? Legal Considerations Conclusion 2: Physicians’ ability to attain fair reimbursement is related to their ability to negotiate Conclusion 3: To achieve Clinical Integration it may be necessary to negotiate on behalf of physicians

23. Why ? Clinical Integration To meet your needs in fulfillment of MGO’s Mission Purchaser’s/Market’s Expectations Legal considerations Prove, Improve, and be Fairly Reimbursed for the quality care you deliver

24. What ? Clinical Integration A Definition and a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs. Clinical Integration is characterized by an active and ongoing program to evaluate and modify practice patterns

25. How ? Prove, Improve, Reward Programs to Evaluate and Modify Practice Patterns Pay for Quality (P4Q) Pilot Program

26. An employer, OhioHealth, wanted to work with MGO physicians to assure that a high percentage of their associates / insureds received prevention and wellness services. How ? Prove, Improve, Reward

27. Cervical Cancer Colo-rectal Cancer 80% 70% 68% 43% 35% 29% The proportion of female OHIPs age 18-64 having received a Pap test during the last 3 years.. Reference: U.S. Preventive Services Task Force Recommendation 2003 Reference: U.S. Preventive Services Task Force Recommendation (modified) 2002 Asthma 90% 78% 63% Preventive Health Visits The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma last year. The proportion of OHIPs having received at least one coded preventive health service visit last year. Reference: HEDIS – modified 2007 2008 Baseline for Rewards Quality of Care Measures for the OhioHealth Insured Patients (OHIPs) P4Q Pilot Breast Cancer 67% 68% 67% The proportion of female OHIPs age 40-64 having received a mammogram in the last 2 years. Reference: U.S. Preventive Services Task Force Recommendation 2002 A1C in Diabetics 88% 53% 44% 40% 44% For every 1% reduction in blood sugar level, the risk of developing eye , nerve or kidney disease is reduced by 40%

28. Cervical Cancer 80% 70% 68% The proportion of female OHIPs age 18-64 having received a Pap test during the last 3 years.. Quality of Care Measures for the OhioHealth Insured Patients (OHIPs) P4Q Pilot 28

29. Cervical Cancer Colo-rectal Cancer 80% 70% 68% 43% 35% 29% The proportion of female OHIPs age 18-64 having received a Pap test during the last 3 years.. Reference: U.S. Preventive Services Task Force Recommendation 2003 Reference: U.S. Preventive Services Task Force Recommendation (modified) 2002 Asthma 90% 78% 63% Preventive Health Visits The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma last year. The proportion of OHIPs having received at least one coded preventive health service visit last year. Reference: HEDIS – modified 2007 2008 Baseline for Rewards Quality of Care Measures for the OhioHealth Insured Patients (OHIPs) P4Q Pilot Breast Cancer 67% 68% 67% The proportion of female OHIPs age 40-64 having received a mammogram in the last 2 years. Reference: U.S. Preventive Services Task Force Recommendation 2002 A1C in Diabetics 88% 53% 44% 40% 44% For every 1% reduction in blood sugar level, the risk of developing eye , nerve or kidney disease is reduced by 40%

30. Actionable

31. Baseline Measures Forming the Standards of Eligibility for Rewards for MGO Physicians Caring for OhioHealth Insured Patients (OHIPs) P4Q Pilot Cervical Cancer Breast Cancer Colo-rectal Cancer $8.43 70 % $11.80 $22.62 68 % 35 % The proportion of female OHIPs age 40-64 having received a mammogram in 2006 or 2007. The proportion of female OHIPs age 18-64 having received a Pap test during 2005-2007. The proportion of OHIPs age 50-64 having received either a fecal occult blood test in the last year, or barium enema, flexible sigmoidoscopy or colonoscopy since 2004 Reference: U.S. Preventive Services Task Force Recommendation 2002 Reference: U.S. Preventive Services Task Force Recommendation 2003 Reference: U.S. Preventive Services Task Force Recommendation (modified) 2002 Asthma Diabetes Preventive Health Visits $21.37 78 % 38 % 44 % $20.57 $9.82 The proportion of adult diabetic OHIPs having received all 3 of the following last year: 1) HBA1c test at least 2/year 2) annual LDL level and 3) annual urine microalbumin or prescribed an ACE/ARB The proportion of OHIPs having received at least one coded preventive health service visit in 2007. (99381 thru 99396) The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma in the previous year. Reference: HEDIS – modified 2007

32. Baseline Measures Forming the Standards of Eligibility for Rewards for MGO Physicians Caring for OhioHealth Insured Patients (OHIPs) P4Q Pilot Cervical Cancer 70 % $8.43 The proportion of female OHIPs age 18-64 having received a Pap test during 2005-2007. Reference: U.S. Preventive Services Task Force Recommendation 2003

33. Baseline Measures Forming the Standards of Eligibility for Rewards for MGO Physicians Caring for OhioHealth Insured Patients (OHIPs) P4Q Pilot Cervical Cancer Breast Cancer Colo-rectal Cancer $8.43 70 % $11.80 $22.62 68 % 35 % The proportion of female OHIPs age 40-64 having received a mammogram in 2006 or 2007. The proportion of female OHIPs age 18-64 having received a Pap test during 2005-2007. The proportion of OHIPs age 50-64 having received either a fecal occult blood test in the last year, or barium enema, flexible sigmoidoscopy or colonoscopy since 2004 Reference: U.S. Preventive Services Task Force Recommendation 2002 Reference: U.S. Preventive Services Task Force Recommendation 2003 Reference: U.S. Preventive Services Task Force Recommendation (modified) 2002 Asthma Diabetes Preventive Health Visits $21.37 78 % 38 % 44 % $20.57 $9.82 The proportion of adult diabetic OHIPs having received all 3 of the following last year: 1) HBA1c test at least 2/year 2) annual LDL level and 3) annual urine microalbumin or prescribed an ACE/ARB The proportion of OHIPs having received at least one coded preventive health service visit in 2007. (99381 thru 99396) The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma in the previous year. Reference: HEDIS – modified 2007

34. P4Q Pilot MGO Physician Performance Preventive and Wellness Measures(based on claims paid through 10/31/08) Multi-Year Measures

35. Comparison of Compliance Rates for Preventive and Wellness MeasuresBased on claims paid through 12/31/2008

36. How ? Clinical Integration Prove, Improve, Reward Conclusion 4: The pilot program is demonstrating marketable quality improvement results Conclusion 5: Clinical Integration program can work well for physicians – both in quality and fair reimbursement

37. What ? Clinical Integration A Definition and a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs. Clinical Integration is characterized by an active and ongoing program to evaluate and modify practice patterns

38. How ?Prove, Improve, Reward Programs to Evaluate and Modify Practice Patterns Clinical Guidelines

39. Evidence based How ? Clinical Guidelines • Developed/modified by MGO physicians • Accountable, via measurement

40. How ? Clinical Guidelines • First 5 have been established • Asthma and Diabetes Management • Cancer Screening – Breast, Cervical and Colo-rectal • Many more to follow • Broad clinical array • Specialty and Primary Care • Inpatient, Ambulatory and Office related • Market and data driven

41. Add other Data Sources, potentials include Physician Office 100% of your patients Hospital, ………. How ? Clinical Guidelines It’s ALL about DATA • Data Warehouse • Start with Claims Data • Employer (OhioHealth) 20,000 patients • Payer (Aetna) 60,000+ patients

42. How ? Clinical Guidelines Conclusion 6: Clinical guidelines and their supporting data are a framework around which MGO physicians can Prove, Improve, and be Fairly Reimbursed for the Quality care we deliver Conclusion 7: Clinical Integration provides MGO physicians the opportunity to distinguish themselves in the market based on quality and value

43. What ? Clinical Integration A Definition and a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs. Clinical Integration is characterized by an active and ongoing programs to evaluate and modify practice patterns

44. How ?Prove, Improve, Reward Interdependence and Cooperation Among Physicians Non-clinical Metrics and Rewards

45. How ? Non-Clinical Metrics • Develop interdependence and cooperation • Build infrastructure - to support quality/cost initiatives • Metrics/rewards for physicians in specialities where clinical metrics are not yet developed MGO’s Clinical Integration is available to ALL MGO physicians • Data capture

46. How ? Non-Clinical Metrics Examples being considered • High speed internet; ORB use • Secure messaging through a common web portal, etc. • Use of E-prescribing or Disease Registries • Intra-MGO referrals And get rewarded for meeting non-clinical metrics

47. How ? Non-Clinical Metrics Conclusion 8: Non-Clinical metrics can build infrastructure that supports the ongoing development and implementation of Clinical Integration Conclusion 9: Non-Clinical metrics allow all MGO physicians to participate in and be rewarded by our Clinical Integration program from the outset

48. What ? Your Role? Participate now by: • Remain attentive to communications • Engage in developing/utilizing MGO practice guidelines • Reinforce the importance of and your commitment to Clinical Integration • Refer to other MGO physicians More steps in the future

49. When ?Timeline • Steps in Progress • Spring - Summer 2009 • Finalize initial criteria for participation • Communicate our pilot results to the market • Summer - Fall 2009 • Be prepared to deliver our new Clinically Integrated product to the market

50. When ?Timeline Conclusion 10: Clinical Integration is attainable for me and my practice Conclusion 11: Clinical Integration is a realistic goal and has an achievable timeline for initial implementation