ACO Webcast What you need to know - April 25, 2011

8/7/2019 ACO Webcast What you need to know - April 25, 2011

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Accountable Care: A New Delivery Model

Is Your Organization Ready to Participate

in Accountable Care?

Copy Right 2011 JHD Group, EpsteinBeckerGreen and KPMG


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Todays Speakers

David MatyasMember

EpsteinBeckerGreenwww.ebglaw.com KPMG Healthcarewww.kpmginstitutes.com

JHD Groupwww.jhdgroup.com

Jack GleasonMember

Brad BentonParrtner

Joe KuehnPartner

Hank DuffyPresident


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Recapping Our Three Part Webinar Series Overview of the MSSP proposed rules from CMS, DOJ, FTC, AND IRS

ACO Structure and Governance Primary-Care Centric

Shared Savings Models Two Tracks

Beneficiary Attribution and Choice

65 Quality Measures

Antitrust Issues

Fraud and Abuse

IRS Issues

Timing and Comment Period

Business considerations

Identifying the strategic options

Building a business case

Operational challenges Todays conversation

Responses to polling questions

Getting ready A coordinated approach

Introduction


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Great audience response

Accountable care focus is all payers

Providers dominate

Support concept of shared savings

Equal number of watchers andwaiters as players

Polling Responses

My organization`s current position on MedicareACO is:

Our accountable care orientation is:

4%

1%

36%

2%

Medicare only

Medicaid only

All payers (in an "accountable carelike" arrangement)

All payers except Medicare

8%

9%

17%

5%

We're a first wave player

We're building; expect to file later

We'll be watching and waiting

We don't expect to be a participant


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Were not ready yet

ROI will be delayed

Question how accountable care fits

with current organizational strategy

Data systems/EHR is a majorconcern

Physician buy in is the greatestchallenge

Polling Responses (continued)

What do you see as the greatest challenge towardlaunching an ACO?

How long do you believe the creation of an ACOwill take?

1%

11%

24%

27%

13 to 18 months

19 to 24 months

25 to 30 months

More than 30 months (not in theforeseeable future)

25%

18%

7%

27%

Cost

Staff and or skill sets

Management buy-in

Physician buy-in


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Determining the right approach to accountable care depends on themarket, the culture of the organization, and your overall businessstrategy

Becoming a CMS ACO near term is just one option

Not a Cookie Cutter solution

Local markets and specific organizational circumstances are too different

Private or local market solutions with slower migration to clinical integration may precede CMS

ACO participation

Requires a transition of the entire business model of traditional care delivery

Change is here; Are you ready?

Getting Ready and Moving Forward


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Achieving the Three Part Aim Multi-dimensional OrganizationalChallenges

Pulling All The Pieces Together

Better Care for Individuals

Better Health for Populations

Lower Growth in Expenditures

Providers

Employers

Payors

Go

vernment


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An organizations state of readiness can be assessed by consideringquestions across a number of disciplines

How Complex Is It?

Strategy

How to increasemarket

competitiveness?

What is thepopulationopportunity?

Go with aClosed Networkor Partnerships?

Participate inCMS Pilots orthe CMSprogram?

What is theCase to act?

Legal

How shouldparties be

organized?

How should it begoverned?

Is special statelicensurerequired?

Are therecontracts withproviders?

How to complywith variousregulatoryconcerns?

What are theantitrustconsiderations?

Care Delivery

What toapproach clinical

integration?

How to assure arobust PCPresource?

How to movetoward PCMHaccreditation?

How to includeDiseaseManagement andPreventive Care?

How to managecomplex cases?

How to assureeffective EHRuse?

Is the physicianleadershipready?

Operations

What is the bestmanagement

structure foraccountability?

How to structurecompensationand incentives?

How to create asingle ClinicalTeam culture?

How to integratePracticemanagement?

How to developtraining around

patientmanagement?

How to align non-employedphysicians

Financial

What is theeconomic case

for movingtoward an ACO?

Do we pursueperformanceincentives, gainsharing, or riskcontracting?

What investmentis required?

What are thefinancialprojections?

What are the tax

considerations?

Technology

Whatinfrastructure is

needed tosupport:

IT Systems

Portals

Data/Reporting

Supportingfunctions

How to expediteMeaningful Use

How to get toand manage theMeasuresdata?

How to link thepartners?


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A multi-step phase process involving multiple disciplines

Addressing the Challenge

Create Design Monitor Results Implement SolutionsDevelopInsight

Discipline Develop Insight Create Design Implement Monitor

Business Strategy

Care Delivery

Operations

Financial

Technology

Legal and Organization

Communications

Change management

MoreBlue =

MoreEffort

Most

Least

Assess your readiness

Manage and monitor thetransition

Evaluate your options Develop a specific and tangible

course of action


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When it comes to moving forward, there are Six Disciplines to bedeveloped and integrated

Six Integrating Disciplines

Business

Strategy

Operations

FinancialLegal and

Organization

Technology

Care Delivery


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BusinessStrategy

What is our strategy to become Accountable CareCapable?

Specific near term actions should include:

1. Determine Goals: Market Mover, performance advantage, or positioning for healthcaretransformation

2. Assess market footprint versus population needs; competitor, payor, and employerpositioning;owned/community physician cohort; and antitrust considerations

3. Develop analytical data baseline

4. Involve physician leadership

5. Assess alternative strategies and care models

6. Model the Business Case

7. Develop tangible strategy

Expected Result: A plan that determines if and how to move to an accountable care capableoperation in a sustainable manner



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What is the optimal threshold of investment,complexity, and readiness?

Determining What is Right for Your Organization

Degree of Medical Integration and ACO-Readiness

Single DiseaseState

Medicare ACO Total PopulationACO

Level ofOperational

Complexity

Low

High

Incrementalinvestment

Incrementalinvestment

BusinessStrategy


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How to reinvent the care delivery model?


1. Establishing broad internal recognition that the key to success will be effective clinicalintegration and that:


Clinical Integration is NOT Clinical Integration IS

Employing physicians

An IPA or PHO

A Network

Multiple Joint Ventures

Physician (PCP) ledclinical teaming

Patient centeredcoordinatedcare/continuity-of-care

The full range of clinical

services in the best setting

Preventive, acute, andchronic management ofhealth

Care Delivery


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How to reinvent the care delivery model?

2. Develop understanding of population and utilization efficiency benchmarks

3. Assess PCP and specialist capacity and continuum participants (i.e. SNFs, Home Health, etc.)

4. Identify and start educating/training physician leaders on Top of Licensure role

5. Assess readiness for Dynamic Access, Level 3 PCMH, coordinated care, preventive care,patient experience monitoring, and Demand Chain Management

6. Begin development of Medical Management to support diversion programs, outreach, complexcase management, disease management, etc.

7. Identify Impactable populations with actuarial and clinical analytics, and build a Care TeamModel around clinically integrated dashboards (possibly using all 65 measures)

Expected Result: A disciplined migrating program to a population and metric based care deliverymodel


Care Delivery


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OperationsHow to build the team and define the roles andresponsibilities?


1. Develop process to collect clinical, financial and quality data

2. Create communications processes that stitch together actuarial, clinical management, caredelivery/collaboration, and reimbursement processes

3. Establish documented roles, governance, and organizational protocols

4. Develop the Management Dyad to promote accountability and team work

5. Build a change management and communications team to oversee internal cultural transitionand external communications

6. Elevate organization awareness of the granularity needed to satisfy functional responsibilitiese.g. finance, clinical, actuarial

7. Ensure the critical components of medical management, provider contracting, quality and costreporting, and financial management all come together

Expected Result: Operational capabilities to effectively manage the health and wellness of adefined population



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FinancialHow are the economics going to work and what isthe investment?


Build/Test Business Case

1. Define the role of Finance in shaping strategy, partnerships, and transactions

2. Develop cost benchmarks and probable cost growth curve

3. Validate patient aggregation, costs of services, and utilization expectation assumptions

4. Financially model alternative scenarios and strategies (i.e. Accountable Care Capable, Track 1,Track 2)

5. Quantify and source the investment required for infrastructure development and working capital

6. Perform actuarial and clinical analysis

7. Develop expanded physician compensation models

8. Develop and confirm target performance

9. Create financial projections: assess risks; stress test and analyze ROI



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How are the economics going to work and what isthe investment?

Financial Operations

10. Identify and capture transactional data at the source; clinical information as well as qualitybased data and resource consumption

11. Develop processes and governance structure so that data can be collected and storedaccurately, and with sufficient granularity

12. Provide timely and accurate reporting, to enable sound decision making on a clinical as well

as operational/process level

13. Develop shared savings programs, compensation models and allocations in a clear andunderstandable way Transparency is key

14. Leverage the lessons learned from failed capitation deals of the 90s

Expected Result: A robust finance function capable of addressing the complexity of the requisiteplanning and reporting needs


Financial


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IT Support Requirements

Electronic Health Records and Meaningful Use

Post Discharge Reporting

Real Time Reporting

Data aggregation across care sites

Quality Reporting

Normalization of disparate data

Business Intelligence Analytics

Predictive Modeling

Tools Build vs. Buy

Information Management Clinical, Financial, andOperational

Revenue Cycle system enhancements

Cost Accounting system enhancements

Provider Network Management

Contract Management

Risk Management

Access to data Electronic Health Records/Health Information Exchange

Evidence Based Care (guidelines and protocols)

Clinical Decision Support (rules and alerts)

Provider connectivity and mobility

Clinical Information

Exchange and MedicalManagement

Member access to personal health data and health maintenance content

Enrollment and Membership applications

Connection to remote home monitoring devices

Clinician contact (social media, call center, secure messaging)

Membership Engagementand Personal HealthManagement


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How to address legal hurdles and structure anorganization?


1. Establish the organizational, management and governance structure2. Develop the risk and incentives distribution methodology in a legally compliant manner

3. Identify the necessary members/participating providers and negotiate contracts (oramendments to existing contracts)

4. Enter into (or modify existing) contractual arrangements with third party payors (either

government or private)

5. Explore potential antitrust issues and evaluate market share considerations

6. Address IT Legal Issues (Privacy and Security)

Expected Result: Legal entity formed that has developed contracts to be paid under anaccountable care methodology and shares the financial rewards (and risks) with other membersin a legally compliant manner


Legal andOrganization


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Progress results and speed can be assessed as each stage of theHealth Care Value Curve is achieved

Expected Result

Stage I: DataRetrieval

Improved

EncounterCapture

Access toPatient Data

Stage II: ClinicalDecision support

Data frommultiplesources

Improved erroravoidance

Improved

Continuity ofCare

Improvedclinicalworkflow

Stage III:Integrated Care

Management

Holistic view

of patient Coordination of

Care

Patient accessto Data

Consistent use

of registries Evidence

based bestpractices

Stage IV:Structured

HealthManagement

Protocol basedcare plans

AdvancedChronicDisease

Preventivehealthmanagement

Value basedreimbursement

Clinicalpopulationmanagement


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The KPMG Healthcare Transformation Agenda 3 Pillars

Changes the practice of medicine and,therefore, the business of healthcare.

Viewed through the lens of ever-more-sophisticated healthcare informationtechnology..

The granular clinical data capturedthrough the ICD-10 code set.

An Example of One ICD-9-CM code beingrepresented by Multiple ICD-10-CM Codes

2 5 0 6 1

E 1 0 4 0

E 1 0 4 1

E 1 0 4 4

E 1 0 4 9

Diabetes mellitus with neurologicalmanifestations type I not stated as

uncontrolled

Type 1 diabetes mellitus with diabetic neuropathy, unspecified

Type 1 diabetes mellitus with diabetic mononeuropathy

Type 1 diabetes mellitus with diabetic amyotrophy

Type 1 diabetes mellitus with other diabetic neurological complication

Enterprise BI Framework

Integrated Information

Management

Governance

Business Strategy

Alignment

Infrastructure

Business Intelligence

Platform (Translation)

Performance

Management Process

and Reporting

Business

Technical

Stakeholdersthroughout thehealthcare lifecycle

will need assistancewith interpretationand reporting onclinical events

The healthinformationexchanges that willbe implemented ineach state will drivedata integration andsharing across adiverse set oftechnical

environments

InterconnectedHealth

Eco-System

Physician

Research

Pharma/Device

Public

Health

Providers

Payor

Cost andEfficiencies

Effective

Health

Management

Coordinate Itemsand Services

Manage toQuality

Standards

Components of an ACO


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An approach to making the transition Manageable

Addressing the Challenge

Gap AssessmentStrategy and

Business CaseDevelopment

Glide PathDevelopment

Execution

Quickassessment ofACO CapableCare readiness

Addresses key

questions Identifies major

gaps andpriorities

Assesses theCase to Act

About 30calendar daysto complete

Specifiesmarket andperformancegoals

Identifies

alternativestrategies

Develops thepreferredstrategy

Documents the

BusinessCase

Requires 2 3months

Addresses howto manage thetransition toACO CapableCare

Details theindividualprojects withmilestones

Prioritizes LowFruit

opportunities Requires 2 3

months

Managetransition tomilestones andfinancialtargets

Often requires2 3 years


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There may be many reasons for not moving forward, but there are fourcompelling reasons to start acting

The reimbursement system is changing

As CMS goes, so does the private sector and other payers

It takes time to make the move to being accountable care capable classic turning the

battleship

It makes sense and is going to happen

Concluding Thoughts


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Concluding Thoughts (continued)

It is neither the strongest of the species thatsurvive, nor the most intelligent, but the one most

responsive to changeCharles Darwin


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Contact Information:

David Matyas

Epstein Becker & Green1227 25th St NW

Suite 700Washington, DC 20037-1175

Office: 202-861-1833

E-Mail: [email protected]

www.ebglw.com

John H. (Hank) Duffy

JHD Group5055 Keller Springs Road

Suite 240Addison, TX 75001

Office: 214-674-5240


Joe Kuehn

KPMG, LLP1305 Walt Whitman Road

Suite 200Melville, NY 11747-4302

Office: 631-425-6021

E-Mail:[email protected]

www.kpmg.com

John F. Gleason

Epstein Becker & Green250 Park Avenue

New York, NY 10177Office 212 -351-4500

E-Mail:[email protected]

Brad Benton

KPMG, LLP303 Peachtree Street

Suite 2000Atlanta, GA 30308

Office: 404- 222-3166


Copy Right 2011 JHD Group, EpsteinBeckerGreen and KPMG

ACO Webcast What you need to know - April 25, 2011

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