ACO, PCMH, PCSP The Ingredients for a Medical Neighborhood

Presented by:

Cindy Friend, RN, BSN, MSN, MBA/HCA

Executive Consultant

November 8, 2013

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• Healthcare Reform

• Future of Healthcare

• PCMH

• PCSP

• ACO

• Payment Reform

• Healthcare Organization Fundamentals

• Organize, Prioritize & Strategize

Agenda

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Heading – Ariel 40Healthcare Reform

ACO

PCMH

ARRA/MU

PQRS/eRx

HIPAA

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HIPAA, PQRS &

eRx

Meaningful Use

PCMH

ACO

Medical Neighborhoods

The Future of Healthcare

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Heading – Ariel 40The Medical Neighborhood

Hospital

Home Health

PayersLTC/

Rehab

Lab/Rad

Pharmacy

Physicians/Clinics

Employers

Government

Patients

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Heading – Ariel 40The Name Means the Same

• ACO• PHO• CIN• IDN• ICO• CCO

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• PCMH – Patient Centered Medical Home

• PCSP – Patient Centered Specialty Practice

• ACO – Accountable Care Organization

Medical Neighborhood Foundation

Medical Neighborhood

ACO

PCSPPCMH

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Heading – Ariel 40Today vs. TomorrowToday vs. Tomorrow

My patients are those who make appointments to see me

Our patients are everyone in our patient population

A patient’s chief complaint or reason for the visit determines care

We systematically assess all our patient’s health needs to plan care

Care is determined by today’s problem and available time

Care is determined by a proactive plan to meet patient needs

Patients are responsible for coordinating their own care

Care is standardized according to evidence-based guidelines

I know I deliver high quality care because I am well trained

A prepared team of professionals coordinates all of the patient’s care

Acute care needs met through next available visit and walk-ins

We continuously measure our quality and make rapid changes to improve our performance

It’s up to the patient to tell us what happened to them

We track test results and referrals, and follow-up, including ED visits and hospitalizations

Operations center on meeting the doctor’s needs

A multidisciplinary team works together and has defined roles and responsibilities

Source: The University of Oklahoma-Tulsa (revised)

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• Primary Care Providers

• Recognition programs

• NCQA 2011Standards

• Includes Stage 1 Meaningful Use Requirements

PCMH

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• Started with 38 in 2008

• Over 6,000 medical practices

• Almost 30K clinicians

• 49 States

• ~15% of all primary care practices

PCMH Numbers

Source: Market Watch, Business Wire, 2013

Source: The Commonwealth Fund

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Heading – Ariel 40PCMH Standards

Source: NCQA

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• Specialty practices

• NCQA recognition program

• Launched end of 3/2013

• Includes Stage 1 and Stage 2 Meaningful Use Requirements

PCSP

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Heading – Ariel 40PCSP Standards

Source: NCQA

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• Community collaborations

• Almost 500 ACOs among private and public payers

• Accreditation available

ACO

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Q4 2010

Q1 2011

Q2 2011

Q3 2011

Q4 2011

Q1 2012

Q2 2012

Q3 2012

Q4 2012

Q1 2013

Q2 2013

Q3 2013

0

100

200

300

400

500

600

4267 84 100

144 154

215

341 363

464 484 493

Number of ACOs

Source: Levitt Partners, 2013

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Heading – Ariel 40Medicare Reimbursement

Source: Dartmouth Atlas, 2010

%

20%

20%

18%

20%

22%

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Heading – Ariel 40Medicare ACOs

Source: RUPRI Center for Rural Health Policy Analysis, 2013

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Heading – Ariel 40ACO by State

Source: Levitt Partners, 2013

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Heading – Ariel 40ACO Standards

Source: NCQA

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• Aetna and WellSpan form ACO (10/11/13)

• River Health applies for MSSP (8/30/13)

• Memorial Hermann Physician Network and BCBS of Tx (9/18/13)

• Rutgers and Robert Wood Johnson Medical School form ACO (10/16/13)

• More than 300 Physicians Join Brown & Toland’s ACO with Cigna (10/15/13)

The Effort Continues

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Heading – Ariel 40Payment Reform

Source: United Healthcare

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Heading Ariel 40Fundamental Components

Healthcare

Organization

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• Shared Governance

• Legal, Policy & Compliance

• Operations

• Finance

• Population Management

• Risk Management

• Performance Reporting

Business

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• IT Infrastructure

• Clinical Systems & Tools

• Regulations

• Data Analytics

• Reporting Requirements

• ACO Connectivity

• Patient Connectivity

• Health Information Exchange

Technical

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• Staff Assessment, Engagement & Education

• Population Management• Evidenced-Based Care Management• Care Coordination• Care Transitions• Care Planning

Clinical

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• Clinical Workflow• Patient Engagement• Quality Measures• Performance Analysis• Quality Improvement• PCMH Practice/ Recognition

Clinical

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Heading – Ariel 40The Subcomponents

Healthcare Organization

Business

Shared Governa

nce

Legal, Policy & Complia

nce

Operations

Finance

Population

Management

Risk Manage

ment

Performance

Reporting

Technical

IT Infrastru

cture

Clinical Systems & Tools

Regulations

Data Analytics

Reporting

Requirements

ACO Connecti

vity

Patient Connecti

vity

Health Informati

on ExchangeCl

inical

Staff Assessme

nt, Engageme

nt & Education Populatio

n Managem

ent

Evidenced-Based

Care Managem

ent

Care Coordinati

on

Care Transition

sCare

PlanningClinical

Workflow

Patient Engageme

nt

Quality Measures

Performance

Analysis

Quality Improvem

ent

PCMH Practice/

Recognition

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• Initiate stakeholder outreach and education• Establish a separate entity with authority

and accountability• Conduct organizational assessments,

improve deficiencies, and obtain recognition• Improve medical management• Identify technology requirements and

implement systems• Establish performance evaluation,

reporting, and improvement process• Develop a strategic plan and execute!

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Organize, Prioritize & Strategize

1.800.4BEACON │ BeaconPartners.com

BOSTON · CLEVELAND · SAN FRANCISCO · TORONTO

Thank You

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For more information, please contact:

Cindy Friend, RN, BSN, MSN, MBA/HCA

cfriend@beaconpartners.com

443.413.6901