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Achieving Clinical IntegrationWe’ll Take You There

Achieving Clinical IntegrationWe’ll Take You There

New Hope for Primary CareDeborah W. Robin, MD, MHCM

Medical Director, Lumeris

Tom Doerr, MD Accountable Primary Care Physician

Proprietary and Confidential. © 2013 Lumeris, Inc.

AGENDA

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• The Collaborative Payer® Model- White Paper Available: visit

booth 103• The Five Elements of Success• Triple Aim Plus One

- Population health management- Cost-effective care- Patient experience of care- Physician satisfaction (Plus One)

Business Transformation:• The Accountable Primary Care ModelSM

- Getting off the Hamster Wheel- Definition- Historical context- Development process- Outcomes- Metrics- Components

• Results: APC Model

Delivery Transformation:

JOURNEY TO AN ACCOUNTABLE DELIVERY SYSTEM

Proprietary and Confidential. © 2013 Lumeris, Inc. 3

SPEAKERS

Dr. Deborah Robin is board certified in Internal Medicine, Rheumatology and Geriatrics. Her expertise is focused on acute care of geriatric patients and their transitions along the care continuum. She also has extensive experience in post- acute care and long-term care. Dr. Robin recently completed her Master of Science in Health Care Management at the Harvard School of Public Health.

Dr. Tom Doerr is an accountable primary care physician practicing geriatric medicine at Innovare Health Advocates in St. Louis, and the vice president of clinical strategy for an IPA, Sennectus, II. He has successfully delivered value-based health care for nearly 20 years and helped co-found Essence Healthcare, a successful Medicare Advantage plan in St. Louis.

Tom Doerr, MDBoard Certified, Internal Medicine Innovare Health Advocates

Deborah W. RobinMD, MHCMMedical Director,Lumeris


BUSINESS TRANSFORMATION: COLLABORATIVE PAYER® MODEL


COLLABORATIVE PAYER MODEL

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• A care delivery innovation model jointly developed by a payer with providers in order to deliver value-based care

• Offers a framework with workflows, metrics and strategies necessaryto transition from volume-based to value-based care and achieve theTriple Aim Plus One:

• Patient focused• Fosters stewardship of health care resources while

achieving high quality• Built on:

- Aligned incentives- Shared control- Transparency- Reciprocal accountability


KEY PREMISES

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• Based on funding structure• Different from current state• Three key elements

1. Improve care through physician payment structure

2. Funding creates an alignment of interests- Payer- Provider- Patient

3. Micromanagement replaced by aligned incentives and commoninterest in improved performance and information sharing


FIVE ELEMENTS OF SUCCESS

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• Align patient incentives 1

• Identify provider readiness2

• Align physician incentives 3

• Support continuous improvement and behavior change4

• Use technology to identify improvement opportunities5


ALIGN PATIENT INCENTIVES

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Educate patients on importance of primary care and prevention

Align benefits with overall goals

1


IDENTIFY PROVIDER READINESS

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Organization structure

Payer and risk experience

Infrastructure

Likelihood of active physician participation

Quality and care management programs

Technology in use

Primary population served

Compensation structure

Cultural alignment

Clinical and administrative leadership

1 2 3 4 5Readiness Level

A multi-faceted understanding of a network provider’s capabilities is critical to successful engagement.

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ALIGN PHYSICIAN INCENTIVES 3

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SUPPORT CONTINUOUS IMPROVEMENT AND BEHAVIOR CHANGE4


USE TECHNOLOGY TO IDENTIFYIMPROVEMENT OPPORTUNITIES

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• Combine and normalize data from disparate sources • Support both a patient- and population-level view• Turn data into actionable information• Most EMRs are not designed for Population Management

Medical Evidence,Metrics, Benchmarks

Role-BasedSystems

Pharmacy/Lab Data

EMR Encounter Data

Claims Data


TOOLS TO ENABLE POPULATION HEALTH MANAGEMENT


• Accountable for:• Aligned incentive contracting• Collaboration and consultation• Value-added care management• Transparency – complete clinical and plan

financial information is made available• Clinically useful information – claims

information becomes a clinical resource• IT infrastructure – economies of scale• Education and training• Focus on customer service and

payer operations

STAKEHOLDER: COLLABORATIVE PAYER

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STAKEHOLDER: PROVIDER GROUP

Accountable for:

•Aligned group and internal incentives

•Information and analytics sharing

•Provider-based care management

•Leadership, culture and governance

•Provider mentorship

•Collaboration for best practices

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STAKEHOLDER: PROVIDER

Accountable for:•Focus on primary care•Shared risk•Providing the right care in the right place at the right time•Focus on

– Care coordination– Prevention– Flexibility

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Nine C’s of Accountable Primary Care:C1: First ContactC2: ComprehensiveC3: Continuous, longitudinalC4: Coordinated C5: CredibleC6: Collaborative LearningC7: Cost EffectiveC8: Capacity ExpansionC9: Career Satisfaction


CARE DELIVERY TRANSFORMATION: ACCOUNTABLE PRIMARY

CARE MODELSM


DEFINITION

• The Accountable Primary Care (APC) ModelSM

re-architects the way care is delivered at the practice level.

• The APC model offers a framework with workflows, metrics and strategies necessary to transition from volume-based to value-based care and achieve the Triple Aim Plus One.


NINE C’S: THE ACCOUNTABLE PRIMARY CARE MODEL

C1 First ContactC2 ComprehensiveC3 ContinuousC4 Coordinated C5 CredibilityC6 Collaborative LearningC7 Cost EffectiveC8 Capacity ExpansionC9 Career Satisfaction


- The blue line is PMPY spending in 5% FFS by decile.--The green dashes are the APC Model’s spend by decile.

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ACCOUNTABLE 1°CARE MODEL VS. FFS MEDICARE

PMPY

CO

ST

DECILE GROUPS


APC model spends significantly less on the higher deciles of patient cost groups, compared with FFS.

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PMPY

CO

ST

DECILE GROUPS


The bars are the APC spend divided by FFS spend for each decile. Scale is on the right.

Average APC spend = 70% of FFS

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PMPY

CO

ST

DECILE GROUPS


2010 encounters per thousand member years



EXCELLENT QUALITY AND PATIENT SATISFACTION

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• Star ratings are 50 quality metrics relating to the Triple Aim in five domains:- Outcomes – health improvement as a result of provided care- Intermediate Outcomes – assesses care related to specific diseases- Patient Experience – measures patient perspective about care provided- Access – reflects barriers to patients receiving needed care- Process – how healthcare is provided

• APC Model rated 4.5 Stars in 2011, 2012 and 2013- Based on performance in 2010, 2011 and 2012- 10 percent of health plans are rated 4.5 Stars or higher- 5 star ratings on “getting needed care” and “quality of care”

• Most PCPs were in shared global risk contracts with significant quality incentives

• A virtual integrated delivery network (vIDN)


THE PATIENT CENTERED MEDICAL HOME: SYSTEMATIC REVIEW

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Ann Intern Med, 2013;158:169-178.

Evidence suggested a reduction in emergency department visitsbut not in hospital admissions in older adults. There was no evidence for overall cost savings.


THE NINE C’S COMPONENTS

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• FFS-Plus methods and processes (on the left) may be used in global risk contracting• Global risk contracting methods and processes may not be feasible without substantial

global gain-sharing• Methods and processes in blue italics are NOT in the NCQA Medical Home model• Different elements for different practices

Global risk contracting

FFS plus incentives

• PA’s and Nurse Practitioners

• Panel Management Assistants1

• Teamlets, health coaches2

• PCP leadership assessments and training3

C8: CAPACITY EXPANSION

• Virtual Visits: email and telephone care

• PCP organizations: frail elderly and disease management programs

• PCP orgs may employ: case managers, nutritionists, social workers, home health nurse, care coordinators, certified coders


C1: FIRST CONTACT AND ACCESS TO CARE

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Global Risk Contracting•Advanced Access Scheduling•Virtual Visits: email and telephone care•Outreach to new and established patients not seen

FFS Plus Incentives(i.e. PCMH, MSSP ACO, etc.)

•Patient education handouts to define expectations•More same-day appointments•On-call access on evenings and weekends•Secure email for scheduling, communication•Offices open until 8:00 p.m., PCAT- AE #A1-A12 3

1 How SK et al Public Views on U.S. Health System Organization: A Call for New Directions, 2008 Commonwealth Fund.

2 Forrest CB and Starfield B. The effect of first-contact care with primary care clinicians on ambulatory health care expenditures J Fam Prac, 1996;43:40-8.

3 Lei et al. Validating the Adult Primary Care Assessment Tool JFP, 2001;50:161ffpatient.

In a nationally representative sample of over 20,000 episodes of care, episodes that began with visits to an individual's primary care clinician, as opposed to other sources of care, were associated with reductions in expenditures of 53 percent overall ($63 vs 134, P<.001). 2


C2: COMPREHENSIVE CARE

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FFS Plus Incentives•Proactive, anticipatory care•Chronic disease management•Self-management support•Community resources•Longer office visits

Global Risk Contracting•Expanded role of PCPs ("I am 80 percent of every specialist")•Greater range of procedures to serve the population

—

thorough evaluation—

documentation of high-risk conditions—

accurate coding—

preventive care and immunizations—

proactive care —

disease management—

teaching and assessing patients’ understanding

—

communication with families—

phone calls with specialists


C3: CONTINUOUS, LONGITUDINAL, PERSON-FOCUSED CARE

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1 Bodenheimer T, Abramowicz S. Helping Patients Help Themselves: How to Implement Self-Management Support. California Health Care Foundation, December 2, 2010.

FFS Plus Incentives•Advance care planning•Patient activation with self- management1

•Pre-visit work, post-visit work, between visit work

Global Risk Contracting•Enduring, personal relationships PCAT-AE: metrics C2-9•Following patients across care settings (inpatient, SNFs)•Following patients into hospice•Engaging the patient’s family

Person-focused care includes discussing expectations, discerning preferences, setting priorities, engaging with family, as well as the usual personalized prevention and screening goals and advance care planning.


C4: COORDINATED CARE

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FFS Plus Incentives•Active management of care transitions•Patient care plans•Medication reconciliations

Global Risk Contracting•PCPs follow their patients across care settings•Engagement in referrals: Referral pre-work solves the specialist’s dilemma •Low referral rates•PCP orgs employ case managers and/or care coordinators•Monitor, follow-up, adjust to changes and failures

After WWII:A dozen categories of health professionalsA half dozen specialties

2013:>200 categories of health professionals>100 specialties


C5: CREDIBILITY

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FFS Plus Incentives•PCP Credibility and Patient Trust

– Provision of the first four C’s– Address what patients care about,

answer their questions thoroughly– Honoring the patient’s perspective– Timely follow up of test results

Global Risk Contracting•PCP Credibility and Patient Trust

– PCPs build credibility with specialists

– Enduring, personal relationships. → beneficent persuasion1

– Management of supply-sensitive demands for care

– PCP sensitivity to creating expectations

1Swindell et al Beneficent Persuasion: Techniques and Ethical Guidelines to Improve Patients’ Decisions Ann Fam Med, 2010;8:260-264.

“If we don’t have credibility with patients, then we’re just referral clerks.”


C6: COLLABORATIVE LEARNING

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FFS Plus Incentives•Push care reminders into EMRs•Outreach work list and scores•Enhanced Encounters•ACT documents, MOTDs•Care consideration messages•Computer-based educational programs•Prevention and screening•Panel management assistants

Global Risk Contracting•Collaborative analytics wherein PCPs work on truing up shared payer database•Collaborative learning across organizational boundaries and institutional barriers


C7: COST-EFFECTIVE

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FFS Plus Incentives•Keep patients healthy•Teach patients to call PCP first•Hospice and palliative medicine

Global Risk Contracting•Right diagnosis, right care, right provider, right place, right time •PCPs "shop for health care” with their patients•Judicious selection of high-value specialists: facility charges, monthly PCP meetings•Active management of ancillary service providers (employed Home Health nurse)•Comprehensive care→ Low referral, ER, hospitalization rates“20 percent to 30 percent of health spending is

waste that yields no benefit to patients... much is done that does not help patients at all, and many physicians know it.”

Donald BerwickNew York Times , December 3, 2011

30% of $2.4T is wasteUnnecessary services $210BInefficiently delivered $130BExcess Admin costs $190BPrices too high $105BMissed prevention $ 55BFraud $ 75BTotal1 ~$750B

1 IOM, Best Care at Lower Cost, 2012.


C8: CAPACITY EXPANSION

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1 Bodenheimer T, Laing BY. The Teamlet Model of Primary Care Ann Fam Med, 2007;5:457-461. 2 Neuwirth EB et al. Understanding panel management: a comparative study of an emerging approach

to population care. Permanente Journal, 2007;11(3):12-20.3 Nutting, PA et al. Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home. Ann Fam Med, 2009;7:254-260.

FFS Plus Incentives•PA’s and nurse practitioners•Panel management assistants1

•Teamlets, health coaches2

•PCP leadership assessments and training3

Global Risk Contracting•Virtual visits: email and telephone care•PCP organizations: frail elderly and disease management programs•PCP groups may employ: case managers, nutritionists, social workers, home health nurse, care coordinators, certified coders


C9: CAREER SATISFACTION (PCPs)

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FFS Plus Incentives•Drivers of Career Satisfaction:

– Meaning in work/mindfulness– Control– Order– Work-life balance– Financial compensation

•Volume-based with bonuses (for quality, process)•How much gain sharing?

Global Risk Contracting•Global Risk Contracting

– Adequate compensation that enables longer visits

– PCPs capture the value they create

– Aligned incentives to decrease conflicts of interest

– Removes constraints on time, place and manner of care, enabling innovation


ACCOUNTABLE PRIMARY CARE MODEL PLAYBOOK

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GETTING OFF THE HAMSTER WHEEL

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n = 22 PCPs with average 270 M.A. members per PCP

Data includes all PCPs with full-time practices in 2000 and 2007 from a physician group in St. Louis. From 1999 to 2006, U.S. median F.M. and I.M. physician income rose 31-35% (AMGA survey data).


RESULTS: APC MODEL


APC MODEL: CASE STUDY

Payer collaboration with its virtual integrated delivery network (vIDN) of primary care physicians and specialists

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PAYER:

Medicare Advantage Plan

40,000 Members

OPPORTUNITY:


APC MODEL: READMISSIONS• The algorithms are used to trigger Patient Worklists for care managers

who are seeking to reduce the number of preventable re-admissions.

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10 Day Readmission Rate30 Day Readmission Rate60 Day Readmission Rate

PCP+ = (PCP took care of patient in the hospital)PCP- = (PCP did not take care of patient in the hospital)FUP+ = (PCP saw patient within 14 days of discharge)FUP- = (PCP did not see patient within 14 days of discharge)

Perc

enta

ge o

f Rea

dmis

sion

PCP Follow-Up in the Hospital and After Discharge


TRIPLE AIMPLUS ONE

APC MODEL: TRIPLE AIM PLUS ONE

• 70% MCR before provider bonuses

• 30% reduction costs compared to FFS Medicare

• 4.5 Star MA Plan for 3 years in a row

• Over 80% of providers consistently rate that they are satisfied with their collaborative payer partner

• Overall rating of Health Plan consistently above national average in CAHPS surveys• Largest market share for 3 years• Over 95% patients seen annually

COST QUALITY

PHYSICIAN SATISFACTIONPATIENT SATISFACTION

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