collaborative healthcare models

Collaborative Healthcare Models

Objectives/Challenges Require Collaboration

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Common Objectives

• Need to demonstrate success and build awareness around quality, service and efficiency results

• Make it easy for members / patients to navigate the system

• Engage and motivate members through proactive on-boarding, outreach, and navigation resources

• Reduce network leakage

Common Challenge

• Consumers are skeptical • By definition, new models are generally unproven and

limited • Fragmented clinical decision making is still the norm

Countering Skepticism

• Collaboration model, resources, reputation, and data must support capabilities

• Care teams must engage patients through physician-driven population health programs and proactive member/beneficiary support services

• Early identification of at-risk patients by sharing data and delivering impactful disease management resources is key

Trends Supporting Collaborative Models

• Current trends are placing pressure on physicians to - Use health information

technology - Develop resource

intensive care management processes

- Seek help in groups - Retire

• Physicians are seeking help to alleviate administrative and financial challenges.

• Without infrastructure and support, physicians become the most qualified but the least equipped to lead.

• Volume, revenue, and physician relationships are at risk

• Hospitals must have engaged physician partners to drive sustainable clinical process improvement

• To date, some ACOs have achieved savings in part by excluding hospitals

• “Hospitals want to do robotic surgeries, heart catheterizations, PET scans, MRIs—all the expensive items. We actually felt that hospitals were part of the problem.” William Biggs, MD CEO Amarillo Legacy Medical ACO

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• Cigna, Aetna, Blues and others are increasingly looking to ACO physicians and aligned resources to manage chronic conditions, coordinate care and reduce costs

• Physicians are engaged in care management. We didn’t ask them in the past, and we didn’t pay for it either, Jill Hummel, WellPoint.

• When a patient hears from a physician versus an insurance company, you know there is a much better chance of changing the behavior, M. Murphy, CEO Iowa Health System ACO.

PHYSICIANS HOSPITALS PAYORS

Clinical Alignment

Mission and Cultural Alignment

Economic Alignment

Less Integration

More Integration

Employment - Fixed Comp

Co - Management

Gain - Sharing

Joint Ventures

Recruitment Assistance

Medical Directorships

Employment - Variable Comp

Call Coverage Agreements

Integration Framework

Population Mgmt /

CIN / ACO

Active Communication, Information Sharing, and Educational Connection Points

Confidential Working Draft 4

Presenter

Presentation Notes

Category 1: Business Services. The business services category includes services that physicians could purchase. Business services tools are typically implemented in arm’s-length relationships. Category 2: Contracts. Contracts generally include anything that is a payment for physician services. Similar to business services, contracts are typically implemented in arm’s-length relationships. Category 3: Structured Communications. This includes all types of one-on-one and group interactions initiated by the hospital leadership with the physicians beyond ad-hoc hallway conversations. Category 4: Employment. Employment includes all types of relationships covered by the legal definition of employment. Three factors are currently driving this category of tools to the forefront of hospitals’ alignment focus: the recent elimination of many of the previously permitted economic alignment tools; a desire by physicians to alleviate the administrative burdens and ongoing capital investment associated with running a professional practice; and ongoing reimbursement pressure, especially on selected physician specialties (cardiology, neurology and primary care). Category 5: Clinically Integrated Network (CIN) / ACO Model. Hospital and local physician partners working together to drive improved quality, efficiency and patient experience. CIN/ACO develops the necessary skills and resources to deliver/demonstrate high quality and efficient healthcare to defined populations through a network of highly integrated/aligned physicians with a common vision. This common vision includes clinical integration and accountability for the complete care of defined local populations. The DHR CIN/ACO model assumes local physician leadership around adopting and monitoring the use of applicable nationally accepted evidence based medicine protocols, clinical data sharing and reporting to demonstrate quality and clinical process improvement, patient centeredness culture to promote informed / engaged patients through education, care coordination, and enhanced access, and value based economic incentives that allow providers to gain upstream financial benefit.

Overlapping PCMH / CIN / ACO Framework

Requirements Medical Home

Clinical Integration

Accountable Care

Care Coordination X X X

Patient Centeredness X X X

Evidence-Based Guidelines X X X

Meaningful Use Requirements X X X

Coordinating Transitions of Care X X X

Financial Integration X X

Communication & Collaboration among Providers X X

Performance Metrics Selection & Reporting X X

Demonstration of Improved Quality & Cost Reduction X X

Population Health Management X

Greater Clinical Integration Across Care Continuum X

Population-Based Risk Management X 5

Population Health Priorities and Challenges Priority Programs

Primary Care • Medical Home • High risk stratification • Mental health

Specialty Care

• Clinical protocols • Referral management • Virtual visits • Bundles

Care Continuum

• Post acute networks • Mobile observation units • Urgent care

Patient Engagement

• Shared decision making • Virtual patient communities • Customized educational

materials

Infrastructure

• HIT, data sharing and analytics

• Infrastructure/program management

Implementation Challenges Clinical Management • Building comprehensive clinically integrated

network

• Reaching population health critical mass (lives)

• Risk adjustment and predictive modeling accuracy

• Developing, implementing and monitoring clinical protocols

Operational • Start-up costs

• Easy access/use by patients

• Clarity on where/who provides clinical and admin support services

• Consistent messaging from beneficiary enrollment to the physician’s office

• Provider incentives

• Reporting to demonstrate services and value

Legal • Anti-trust, Stark, civil monetary penalty

restrictions 6

• PCMH Operations Staff: Training and technical assistance to help physicians achieve Medical Home principles.

• Care Management and Coordination Staff: Support the PCMH/APCP practices and are operationally integrated with the Facility Based Case Management program.

• Other potential internal or contract resources include: - Disease management - Coding optimization - Patient education and self-management

• Medical Informatics Staff: Primary analytic resource supporting care management team, CPC physician leaders, PCMH Steering Committee, and PCMH PODs.

• Point Of Care Tool Set: Complete and timely information about patients at the point of care.

• Population Management Tool Set: Technology and skills for population management and coordination of care

Resource Considerations

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Standardized CDR

HIT - Data Extraction, Standardization and Reporting


HOSPITAL SYSTEMS - Clinical, Demographic

and Financial Data

PHYSICIAN SYSTEMS - Electronic Medical

Record (EMR)/PMS

ANCILLARY SYSTEMS - Additional Data Sources

(payer, Medication fulfillment, Ref Lab,

Registry, etc)

PAYOR SYSTEMS - Claims Data – Budgets, Utilization, and

Financial

External Entity Reporting (MSSP-GPRO, Commercial Payor - BTE, IPIP, QIO, etc.)

CCR/CCD (Standardized Clinical Coordination Data Sharing)

Evidence-based Clinical Guidelines PQRI Measures

Interface Engine

Clinical Protocol Engine

Point of Care / Gaps in Care Reports (patient specific, CDS)

Internal Reporting/Data Analyses (population registry)

Reporting Engine

Coordinated Message around and through PCP

• A sustained competitive advantage will require achieving and maintaining engaged and motivated members through:

• Consistent messaging from enrollment to the primary physician (Medical Home/APCP)

• Coordinated plan/provider member service resources • Easy access and use by members • Agreement / clarity on services included • Reporting results

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Connecting the dots between results and resources

Consistent message around care programs, service content, source, how to access, and value

Collaborative Network Navigation Aids

Onboarding Enrollment Resources • Find a Physician • BioScreening / Health Risk Assessment • Web Based Scheduling • Patient Portal • Data Sharing / HIE • Population Health Programs -Wellness -Care Coordination -Chronic Disease Management -24 Hour Nurse Line

• Pharmacy Benefits

Educate Members & Activate Navigation Aids

Payor Based Member Services

Member Onboarding and Navigation Aids

Population Health Programs

Provider Based Members Services and Network Referral Coordination / Scheduling

Ancillary

Specialist

Post Acute

Acute

Web Based Member Services

Engage Medical Home Relationship • Informed PCP Visit • Discuss BioScreen Results • Activate Indicated Population Health Programs

New Member

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DISCUSSION / NEXT STEPS

How do we work together?

9/3/2014

Sample WayPoint Case Study 1

• Advanced Primary Care Initiative (Patient Centered Medical Home) • Innovative population management payer contracting relationships • Patient quality and safety incentive programs • ACO Start-up • Medicare Shared Savings Program application and implementation • Strengthening health information technology and population management infrastructure

• Assessed existing clinical integration resources, evaluated existing incentive structures, and refined objectives to reflect market-specific priorities

• Developed enterprise scope, structure, governance and leadership • Developed provider network composition • Created reporting tools and processes • Created Physician and care team incentives tied to quality initiatives • Created health information technology resource plans • Created staffing plans and operating budget estimates

• PCMH implementation in 12 months with more than 100 physicians in various independent and employed practices certified to date

• CMS Medicare Shared Savings Program ACO approved • Multiple commercial payer ACO contracts • Among the largest ACOs nationally and named one of Becker’s “100 ACOs to Know” • Included in the 29 ACOs that experienced significant shared savings through the first quarter of 2013


Client Need

WayPoint Work

Results

Sample WayPoint Case Study 2

• Approval by Medicare to participate in the Medicare Shared Savings Program • ACO organizational structure and start up activities • Population health management technology implementation

– Analytics to identify, stratify and assess the patient’s risk – Analytics to improve provider performance and measure quality – Health Information Exchange

• Clinical process improvement and care management people, process and technology resources

• Drafted and submitted the ACO application for CMS approval • Facilitated the technology architecture of data sharing based on their selected technology vendors • Review and negotiation of selected technology contracts • Data submission for beneficiary data sharing claims feed • Project oversight for implementation of HIE, risk modeling application and physician performance application • Begun restructuring of clinical process improvement workflow and associated governance • Facilitated care management model discussion

• CMS Medicare Shared Savings Program ACO approved • Multiple commercial payer ACO contracts • Among the largest ACOs nationally and named one of Becker’s “100 ACOs to Know” • Included in the 29 ACOs that experienced significant shared savings through the first quarter of 2013


Client Need

WayPoint Work

Results