Attaining Scale in a Changing Market Update on the ACO and the Clinically Integrated Network - PowerPoint PPT Presentation

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Attaining Scale in a Changing Market Update on the ACO and the Clinically Integrated Network

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  1. Attaining Scale in a Changing MarketUpdate on the ACO and the Clinically Integrated Network Introducing…”Meridian Health Partners” Richard J. Scott MD MBA FACS CPE SVP Clinical Effectiveness and Medical Affairs Executive Director, Meridian ACO LLC

  2. Special thanks to the members of the Steering Committee, ACO and Clinically Integrated Network

  3. “Clinical Integration” • “A means to facilitate the coordination of care across conditions, providers, settings and time in order to achieve care that is safe, timely, effective, efficient, equitable and patient focused” – AMA • CI is a continuous process of alignment between hospitals and all providers across the continuum that supports the triple aim of health care: Better care for individuals, better health for populations and lower per capita healthcare costs

  4. Four Pillars of Integrated care

  5. Collaboration: Current Options for Hospitals and Physicians

  6. Meridian Accountable Care OrganizationBackground and Strategy • A legal entity operated and governed by physicians and Meridian Health System under a 50/50 consensus governance model • The ACO is a low-risk laboratory wherein Meridian and its physician community can begin to learn population health and develop infrastructure to potentially assume risk contracting with payers • It is also a vehicle to build market share, and the prototype for other “bend the trend opportunities” • In each of the next 3 years, if MACO can decrease cost and document quality, savings are eligible to be shared between CMS and MACO. • MACO has received historical beneficiary claims information from CMS. The data show savings opportunities in: • Hospital Admission • Emergency Room Visits • “High Cost” Imaging

  7. Bending the trend…and sharing the savings Under the MSSP, up to 50% of the savings can be returned to the ACO for distribution to providers

  8. Meridian ACO LLC First Year Key Metrics Effective Date: January 1, 2013 Uniquely Attributed Medicare Lives (Original 39,705; Current 59,446) Participating Physicians 874 Participating PCP’s 250 Medicare Spend $454,000,000 (on 39,705) Average Age 74.3 years Gender 57% Female 43% Male Year 1 infrastructure app. $1.3M Five Population health managers hired

  9. Annual ACO Quality Audit • N = 4,244 beneficiaries identified for quality data • 5 high-risk care managers collected data with support from 3 others in department • 89 unique physician practice locations visited • 60% of practices had all or part of record on paper • 12 nursing homes/other facilities visited • Only one non Meridian nursing home had required information in electronic format (MHS locations had Sigmacare) • Numerous calls to non-ACO physicians to get required information (e.g., ejection fraction, mammograms, lipid values) 3,898 miles driven by team

  10. Augmented Connectivity to Serve Clinical Integration- Jersey Health Connect • Atlantic Health System • Barnabas Health • Centrastate • Chilton Hospital • Deborah • Holy Name Medical Center • Englewood Medical Center • Trinitas • Robert Wood Johnson • St. Peters Univ. Hospital • Hunterdon Healthcare • Hackensack UMC • Children’s Specialized Hospital • The Valley Hospital • St. Clare’s Health System • Summit Medical Group • Optimus Healthcare

  11. Meridian ACO Yr 1 Quality Performancevs 2012 ACOs (n=146) Meridian Accountable Care Physician/ACO Compare ACE or ARB 69% HTN Control 67% HbA1c Control 65% Tobacco Non-use 72% ________________________ All fall below the 30%tile- Will need improvement year Two (PFP years two and three) • ACE or ARB Tx 72% • HTN Control(<140/90) 72% • HbA1c Control(<8.0) 77% • Tobacco Non-use 78% ________________________ Challenges Depression Screening Falls risk Screening Medication reconciliation

  12. 30-Day All-Cause Readmissions/1,000 Discharges

  13. Total Expenditures/Assigned Medicare Beneficiary

  14. Meridian RN Population Health Managers • New role in 2013 to support the Medicare Shared Savings Program (MSSP) • Telephonic care management for high-risk patients and patients with multiple chronic conditions • Collaborate with provider offices designated as PCP • Ensure services are deployed as needed across the continuum through collaboration with existing providers • Makes visits to hospitals, rehabilitation facilities, homes, provider offices, and other locations as needed • Experts in performance monitoring at multiple levels: patient, provider, practice, and ACO

  15. Hypothetical Savings and DistributionsYear 1 for a 462M MSSP Program If the ACO “bent the trend” and collected/submitted data accurately and on time: - 2.0% = $9.24M Did not meet threshold - 2.3% = $10.6M (50% = $ 5.3M) - 3.0% = $13.8M (50% = $ 6.9M) - 5.0% = $23.2M (50% = $11.6M) - 10.0% = $46.2M (50% = $23.1M) • Distributable to ACO (1) • Total • $ 0 to ACO • $ 4.3M • $ 5.9M • $10.6M • $22.1M (1)Based on 2013 Projected ACO Expenses of over $1.0M to be repaid before distributions.

  16. MSSP 2012 “Winners” (114 Original, 44 had savings, 29 qualify for bonus payments)

  17. Commercial ACO Activity Across New Jersey • Horizon partnering with Central Jersey ACO, AtlantiCare ACO and the Optimus ACO on shared savings programs that include Medicare Advantage. • CIGNA has announced a national goal to have 1,000,000 CIGNA insureds in PCMH Pilots by 2014. In NJ: • CIGNA/Atlantic Health 15,000 covered lives • CIGNA/Summit Medical Group 10,000 covered lives • Aetna partnering with Optimus for 11,900 covered Medicare Advantage lives in a shared savings model.

  18. Financial Success From Patient Management Managing Three Distinct Patient Populations Trade high-cost services for low-cost management • 5% of patients; usually with complex disease(s), comorbidities Avoid unnecessary higher-acuity, higher-cost spending • 15-35% of patients; may have conditions not under control Keep patient healthy, engaged with the system • 60-80% of patients; any minor conditions are easily managed

  19. Joint Venture: Advocate Physician Partners • Physician Membership • 1,138 Primary Care Physicians • 2,984 Specialist Physicians • Total Membership Includes 1,300 Advocate-Employed Physicians • 12 hospitals, encompassing 11 acute care hospitals and the state’s largest integrated children’s network • Central Verification Office Certified by NCQA • 250,000 Capitated Lives/ 700,000 PPO Lives/ 100,000 MSSP Lives • 320,000 “Attributable” Lives • One model for Governmental and commercial ACO-like Contracts Advocate Physician Partners delivers services throughout Chicagoland and Downstate Illinois.

  20. AdvocateCare Model: changing the culture toward population health management Changing Paradigms…

  21. Clinical Integration at WellSpan.. “working as one” • Like Advocate, have organized a pluralistic 1200+ physician delivery system • 660 employed and 600+ private practice physicians • Coordinated continuum of services:90 sites • “Working as one” to create healthy communities through exceptional care and lifelong wellness • Three hospitals • 65% market share • 1.5 B in revenue • Regional leader in Trauma, Neurosciences, Cardiovascular

  22. Both WellSpan and Advocate Health… • Have invested in Information technology that links all elements of care (e.g. hospital, specialist, home health agency, nursing home) and the patient’s community (e.g. family) • Have connected their medical staff to the system, and each other • Have organized their physicians into a unified delivery system that includes facilities, services and physicians • Are positioned as population health managers to provide value and accept risk

  23. Clinical Integration Steering Committee These functions have been combined Effective Q1 2014 Meridian Health (2014) Partners, Inc. Clinically Integrated Network Meridian (2013) Accountable Care Organization, LLC Possible Employee pilot: Inner Circle Network Medicare Shared Savings Program (ACO) Future Commercial Performance-based Opportunities

  24. Building “Meridian Health Partners” Mission Statement A fully integrated partnership between Meridian Health and its physicians created to provide the highest quality, most accessible and most efficient health services in Monmouth, Ocean and our adjacent counties.

  25. Vision Statement A fully integrated physician-health system enterprise, providing clinical quality and efficiency that is demonstrably better than its competitors A “pluralistic” model, providing efficient practice support, clinical integration, connectivity and network services to physicians in a variety of practice models A vehicle to ensure the availability of primary and specialty medical care services, ambulatory care, home care, long term care and ancillary services A platform to successfully integrate care and participate in pay for performance, quality and other value based initiatives with governmental and commercial payers

  26. Value for Hospitals • Creates Business Partnership with Key Physicians • Focuses Physicians on coordinated care • Patient Safety • Controlling costs • Creates alignment • Physicians Drive Clinical Outcomes • Positions for Health Care Reform • ACOs • Readmission Avoidance • Migration to Risk acceptance?

  27. Value for Physicians • Access to and/or participation in “shared savings” and other contracts with payers- One interface • Better alignment between primary care and specialists- Network integrity • Marketplace recognition for quality care and excellent patient experience • Support staff for chronic condition registries and QI initiatives • Management/HIT expertise from system

  28. Shared Savings Contracting: Tenets for a workable Model In order to have a successful shared savings contract model • The Network must consistently perform better than the market • Improve quality and access to care • Reduce cost/decrease complications and readmissions • Promote network integrity/minimize medically unnecessary costly out migration • Increase volume to providers participating in Meridian Health Partners Enhance physician and patient satisfaction 31

  29. “Meridian Health Partners” • MHP will seek a higher level of clinical integration through enhanced connectivity with the system, regional health information exchange and eventually each other • Over 600 “system based” and contractually aligned physicians are already on board- including primary care, faculty practices and hospital based physicians • Actively seeking clinical pilots with health insurance companies that evolve the “shared savings model” focused on quality and efficiency Substantial payer interest in Meridian’s CIN

  30. “Meridian Health Partners” • Shared Governance • Consensus decision making • Physicians comprise the majority of Board Members • The ACO and MHP initiatives share one combined board and committee structure • No capital investment beyond time and expertise

  31. “Meridian Health Partners” Participation agreement provisions • Commitment to move toward an EMR will facilitate quality performance and point of care interventions. (Meridian’s IT Subsidy program currently being revised to support clinical integration and information exchange) • Initial contract opportunities parallel the ACO- Upside only “shared savings” or performance incentives for quality and efficiency measures- all would participate • Aligned Voluntary staff may “opt out” of any future fee schedule or global risk contract arrangements • Unlike the MSSP ACO- Participation is “non exclusive” for both Primary Care and Specialist physicians

  32. Meridian Health Partners: Poised for Population Health Meridian’s Connected Continuum

  33. Next Steps…. • Our system based physicians and the Meridian facilities are already committed to the effort • Hospital based groups now joining the initiative bring enrollment to over 600 physicians • Enrollment of aligned independent physicians will begin in June, giving them access to both shared savings/risk program opportunities as they arise • Connectivity to Jersey Health Connect will be supported to successfully manage quality improvement and network performance

  34. Thank You ! rscott@meridianhealth.com

  35. Meridian’s Powerful Continuum • Key Health System Statistics • Over 100 Convenient Locations • $1.7 Billion in Annual System Revenues • 12,000 Team Members • 2,100 Physicians on Staff • 6 Hospitals: 1,700+ beds • Jersey Shore University Medical Center • K. Hovnanian Children’s Hospital • Ocean Medical Center • Riverview Medical Center • Southern Ocean Medical Center • Bayshore Community Hospital • Partner Companies • Post Acute Care: 6 facilities, 906 beds • At Home Nursing, Hospice, & Rehab: Serving all of Central New Jersey • Ambulatory Care: 19 facilities, including hospital based • Primary Care: 102 physicians • Ambulance/Medical transport: 100+ vehicles • Occupational Health: 6 centers • Rehabilitation and Fitness: 9 outpatient, 2 inpatient facilities • Behavioral Health: 5 outpatient, 2 inpatient facilities

  36. Meridian Geisinger Gold • A 50/50 joint venture between Meridian and Geisinger • Enabled Meridian to enter the insurance market • Initially a 2-county Medicare Advantage offering • 724 participating physicians • Superstorm Sandy disrupted 2012 open enrollment • Live January 1, 2013 with 875 members last year • Enrollment up nearly 5 fold to over 4,300 lives for 2014 Meridian is uniquely positioned for growth!

  37. ACO Performance DomainsApplication of Rules for 2014 (Using Meridian ACO 2013 Data)