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Early Lessons from an Accountable Care Organization

Scott D. BarlowChief Executive Officer

September 30, 2014

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Central Utah Clinic• Founded in 1969, largest independent medical group

in Utah. • Operate 101 offices - Utah, Mesquite NV and Paige,

AZ.• Currently employ over 1,400 professionals and staff.• Medical staff of 170+ physicians, 100+ midlevel

providers. • Completely paperless in all care locations since 2002. • Certified Medicare quality reporting registry. • Participating in the Medicare Accountable Care MSSP

program and five other commercial value based pilots.

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Operational Flows• Improving the reliability, safety and value of care is about

designing consistent operational flows - logistics.• An EHR is a tool to help create consistent designs, but is

not itself an answer.• Data sets mineable, relevant and actionable. • “HPN” – provider/system competency, manageable.• Sustained improvement does not rely on “I’ll remember

to do it the next time”, or hard work.• Design operational flows so the care we should provide

happens every time.

Primary Care Report Card

Cardiology Report Card

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MSSP Program Projections as of June 30, 2014N = 14,000

Meeting all 32 Quality Metrics.

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Payer 2 – NCQA Quality ScoresClinical Service Gen. Pop. Percentile Target Pop. Percentile Medicare Patients: n=347

Breast Cancer Screening 50th 90th

COL Screening 25th 50th

CMC – LDL Screening <10th 90th

CDC – LDL Screening 10th 10th

CDC – Eye Exam 25th 25th

CDC – Kidney Disease Monitor 10th 50th

CDC A1C Test 50th 75th

Commercial Patients: n=3,041

Breast Cancer Screening 75th 90th

COL Screening 50th 90th

CMC – LDL Screening <10th <10th

CDC – LDL Screening <10th 10th

CDC – Eye Exam 25th 50th

CDC – Kidney Disease Monitor <10th 25th

CDC A1C Test 25th <10th

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Payer 3 - Quality Measures• Population = 2,300

• Overall measures remained unchanged 2012 to 2013.

• Satisfaction survey scores improved:3Q = 87% 4Q = 94% Population = 89%

• Readmission rate (50% GI Diagnosis):Regular pop. = 14% Participating pop. = 8%

Savings generated above expected $986,724Savings $429 per member

Bonus Earned

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CY 2013 vs. CY 2012 Clinic Utilization Improvement over BenchmarkChange in Utilization/1000 Members

Util/1000 % Total Spend Util/1000 % Total SpendINPATIENT FACILITY PROFESSIONAL

Surgical 20.0% days 3.6% IP Professional -12.6% proc. 3.0%Medical, Non-Maternity -42.1% days 17.1% OP Surgical Professional -3.1% proc. 4.3%Maternity 4.3% days 2.6% PCP/Preventive -5.5% visits 7.0%Total IP Facility -12.9% days 23.3% Rad/Pathology -1.8% proc. 4.3%

All Other Professional 3.4% visits 12.3%OUTPATIENT FACILITY Total Professional -1.4% 30.9%

Surgical -9.2% cases 9.6%Emergency Room -4.8% cases 4.8% RX/OTHERRad/Pathology -3.9% cases 4.2% Prescription Drugs -4.0% scripts 14.8%Other OP Facilty -8.0% cases 9.2% Other Medical Benefits -6.6% units 2.8%Total OP Facility -6.4% cases 27.9% Ancillary Benefits -30.5% units 0.3%

TOTAL MEDICAL -3.1% 100.0%

• Data shows change in CY2013 vs .CY2012. Paid claims run-out through March 2014. • Utilization is on a risk-adjusted basis. • Observed trends can reflect many variables other than Program Impacts, random fluctuation and utilization changes due to other programs

Payer 3 - Impact

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Payer 4• N = 1,900 + 3,050 commercial

• No bi-directional data feed.

• Savings 7.8% of expected.

• Shared savings earned

• Missed quality targets so no payment.

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Payer 5N = 1,100

Measurement: PPO HMOAdmits per 1,000 213.4 166.8

TARGET 189 189

ER per 1,000 345.1 272.1TARGET 305 305

Readmit Rate 8.41% 16.13%TARGET 11.3% 11.3%

Bonus Earned = 2.3% of total claims costs saved!

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Payer 6• N = 11,300• Quality Measures:

Total Cost of Care – METBP Control of those with Hypertension – METCholesterol management, Cardiac patients – NOT MET

Bonus Earned

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Challenges• Patient attribution – who is accountable for whom?

Medicare claims review 1.79M beneficiaries:Beneficiaries saw a median of 2 PCP & 5 Specialists.Median level of 4 different entities or practices.Median of 35% of PCP visits with their attributed PCP.

(“Care Patterns in Medicare and Their Implications for Pay for Performance”, NEJM, March 15, 2007)(JAMA Internal Medicine, April 2014 – 145 ACO’s attribution, one-third switched 2010 to 2011)

• Past care challenges: Review period, SNF or Consulting Care, Validate and refresh process.

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Challenges• Patient attribution – who is accountable for whom?• Start with key partners (willing, capable, critical mass) – system of

care – LOGISTICS!• Data value – complete costs, mineable to the provider and

patient. • Data exchange to be bi-directional – 60%+ data missing.• Relevant data – complete, variation amongst peers, timely.• Golden Few – Care Management, Care Transitions.• Risk Stratification – Coding intelligence.• Patient & Family involvement/engagement?• Set and manage to targets – quality, budgets “VALUE”.• Maintaining the model? Improvements become new target?

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Lessons Learned• Aligning the interests of the payers, patients and

providers can improve Quality & Costs. • Models of success require a Holistic patient focus. • Providing enhanced information enables better care.• Need to start with a limited cohort of Providers. • Need critical mass to be a “system of care”.• Programs will be different, but need to be consistent and

relevant to the care model. • We can improve the system of care!

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Questions?

sbarlow@centralutahclinic.com

801-429-8034