the unc health care system & bluecross blueshield of … · a blueprint for successful...
TRANSCRIPT
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The UNC Health Care System & BlueCross BlueShield of North Carolina
Model Medical Practice: A Blueprint for Successful Collaboration
January 26, 2012
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Session Overview
Partners in Innovation and Service
Carolina Advanced Health
BCBSNC – Ensuring Quality Care
UNCHCS – Challenges and Opportunities
Lessons Learned
Questions?
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Part I: Partners in Innovation and Service
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North Carolina’s changing landscape
Changing demographics creating varied market pressures for new services
Unstable financial landscape spurring hospital acquisitions of physician practices, greater collaboration between providers and insurers
Federal focus on care coordination, disease management, and quality
Emergence of alternative reimbursement models to change provider incentives
Growing demand for value purchasing
One constant: costs continuing to climb …4
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BlueCross BlueShield of North Carolina
Largest health insurer in North Carolina and one of the 25 largest health insurers in the nation - 4,600 employees serving over 3.7 million customers
Serving customers for almost 80 years
Commitment to quality and patient satisfaction
Commitment to community services - BCBSNC Foundation invested almost $70 million in local communities in 2010
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BCBS Experience
BCBSNC– Blue Quality Physician Program
– Highest level of NCQA accreditation
BlueCross BlueShield of Massachusetts Alternative Quality Contract
BlueShield of California Pilot Program
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The UNC Health Care System
Chartered to provide patient care, educate physicians and other providers, conduct research, and promote the health and well-being of the citizens of North Carolina
U.S. News & World Report: Best Hospitals 2010-11
Almost 40,000 inpatients and 800,000 outpatients each year
UNC Hospitals - 803 licensed beds
UNC Physicians & Associates - 1,100 UNC School of Medicine faculty members
Triangle Physician Network - Almost 100 employed physicians
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UNC Health Care System Experience
NCQA PCMH Recognition
Carolina ACCESS
Town of Chapel Hill Wellness@Work
Community Based Clinics
Triangle Physician Network
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A unique partnership
Develop new relationship between UNC Health Care and BCBSNC to promote partnership and integration across industries
Explore financing and delivery models that provide greater value in the changing healthcare environment
Create clinical laboratories to test new models and concepts and gain hands-on experience with ACO principles
Improve access, delivery, quality, and efficiency by coordinating care across settings
Assure sustainability, suitability, and scalability in rural and urban settings
Improve the health and wellbeing of North Carolinians
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Collaboration offers increased value for stakeholders
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Patient
Improved health and wellbeing
Better, more confident self-management of chronic conditions
Payer
Demonstrate leadership in changing the healthcare system
Aligning incentives
Creating a sustainable, replicable model
Provider
More time to fully engage patients in
their care
Focus on outcomes
Information and tools to provide
quality care
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Part II: Carolina Advanced Health
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What is Carolina Advanced Health?
First project through NC Healthcare Innovation, LLC
– Joint governing board (3 UNC HCS & 3 BCBSNC members) and implementation teams
– BCBSNC and UNC HCS contribute equally to NCHI
– NCHI provides oversight and guidance to practice
Practice is run through Triangle Physician Network, LLC (UNC HCS affiliate), with financial support from NCHI
Three-year pilot project beginning on December 1, 2011
– Newly-recruited providers and staff
– Unique data sharing between health plan and provider
– BCBSNC Onsite Provider Associate integrated into practice
Triangle Physician Network practice with unique branding
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Sublease and Asset LeaseNC Healthcare Innovation, LLC
(NCHI)
Lease
Independent Contractor Agreements
Fees
Rent
Provider ContractClaims Payments of:
• FFS• Shared savings
Triangle Physician
Network (TPN)Contribution Agreement
BCBSNC
BCBSNC Subsidiary
UNCHCS Subsidiary
Landlord
Outside Vendors
• Practice management• Physician / staff employment• Care delivery
Funding of net loss
Service Agreement
Expense reimbursement
Operating Agreement
ASO Groups
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Test a fundamentally new model for organizing, funding and delivering “primary care” that is sustainable and can be replicated
Build evidence-based care model beyond Level 3 Patient-Centered Medical Homes (PCMHs)
Align financial incentives to shared savings
Design with a patient-centered orientation & team approach
Expected OutcomesPrimary Objectives
Improved Patient Health
Improved Patient Health
Increased Patient
Satisfaction
Increased Patient
Satisfaction
Increased Operational Efficiency
Increased Operational Efficiency
Reduced Healthcare Expenses
Reduced Healthcare Expenses
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Who will Carolina Advanced Health serve?
Practice open to select BCBSNC members:
– North Carolina State Health Plan
– BCBSNC ASO
– Underwritten BCBSNC
5,000 patient panel enriched with chronically-ill adult population (e.g., Coronary Artery Disease; Hypertension; Diabetes; Obstructive Lung Disease; Depression; Asthma; etc.).
Patients recruited through targeted mailings and other joint efforts.
Patients retained through excellent service, case management, and individualized care plans and follow up.
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Carolina Advanced Health Floor Plan
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What makes Carolina Advanced Health different?
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Access and Convenience Extended hours
Open scheduling
Telehealth visits
Small patient‐to‐provider ratio
Effective Encounters Pre‐visit planning
Decision support
Evidence‐based protocols
Outcome orientation
One‐Stop Shopping Primary Care
Behavioral Health
Pharmacist
Phase 2 – select Specialists
Coordination of Care Case management
Transition‐of‐care program
Technological Support Sharing of claims data
Disease registries
Patient risk stratification
Self‐Management Support Lifestyle / health coach
Decision aids and educational materials
Home monitoring
Patient
Team based care and active care management (delegated from BCBSNC)
Leveraged IS systems
Reserved provider time for care management, telephone and e-visits
Practice providers and staff incented on quality metrics only
Embedded behavioral health and select specialty referral network
BCBSNC onsite provider associate integrated into practice
Talented providers and staff recruited and trained specifically for practice
Unique data sharing between health plan and provider (15 month history for all new patients and alerts for admissions)
What will Carolina Advanced Health provide?
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Part III: BCBSNC – Ensuring Quality Care While Reducing Healthcare Costs
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Goal: Better manage medical cost trend and improve health care quality
Multifaceted approach includes:
– New payment models
– New network structures
– New pharmacy and care delivery programs
– And more
Quality emphasis: Rewarding outcomes over volume of procedures
Collaborating with providers and leading change
Strategic Response to Escalating Healthcare Costs
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The Quality Threshold
Meeting a stringent quality threshold is required for either party to participate in shared savings.
If quality standards are not met, any gainshare will be donated to a charity dedicated to improving healthcare in NC.
Quality metrics include:
– Submission of application to NCQA for PCMH recognition
– Meet the following elements from BCBSNC’s BQPP program:
• Each physician uses electronic prescribing software
• Claims submitted electronically
• Completion of training focused on cultural competency in medical practice.
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The Quality Threshold, con’t.
Score at/above at least 5 out of following 7 measures:
1. Mammograms for women (appropriate/eligible) 40-62 w/in past
2 years.
2. Cholesterol management for patients with cardiovascular conditions.
3. Diabetic (type 1 and type 2) patients with acceptable LDL levels.
4. A1c for type 1 and type 2 diabetics at acceptable levels.
5. Diabetic (type 1 and type 2) patients age 18-62 with eye exam within
last 24 months.
6. Nephropathy assessment urine microalbumin w/in past 12 months.
7. Aspirin or other anti-thrombotic use in past 12 months.
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The Quality Threshold, con’t.
Score at/above at least 3 out of following 4 measures: 1. BMI assessments with nutritional counseling for
score >30.
2. Smoking assessment and cessation counseling of patients seen in past 12 months.
3. Depression screening. All patients within past 12 months.
4. Implement at least one patient-centered metric and track for first year.
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Medical Expense Savings
Medical Expense Savings Overview
– Savings will be based on the difference in Total Claims Cost during each of the three evaluation periods.
– Savings Payment will require meeting a minimum sample size for group membership for statistical and measurement validity.
– Savings Payment will be tied to the practice meeting specific quality measures.
– Outliers will be excluded in an uncomplicated manner.
Timing
– Demonstration will take place over 3 years (2012 through 2014) with an option to continue based upon outcomes and partner agreement.
– Calculation will occur on a yearly basis during the Demonstration.
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Carolina Advanced Health3 Year Model Practice Demonstration
Evaluation Period 12012
Evaluation Period 12012
Evaluation Period 22013
Evaluation Period 22013
Evaluation Period 32014
Evaluation Period 32014
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Medical Expense Savings
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Carolina Advanced HealthModel Practice Group
Matched Control Group
ComparisonComparison
Methodology Goal– Calculate the Medical Expense Savings for the Model Practice Group as compared to a Matched
Control Group during the demonstration.
Model Practice Group– Model Practice Group will be based on an attribution methodology, additional qualifying criteria
and successful matching to the Control Group.
Control Group– Control Group creation will be based on qualifying criteria and a statistical method known as
Propensity Score Matching.
Comparison Process– Comparison is performed retrospecively based upon concurrent data for the Model Practice
Group and the Matched Control Group.
– Example: 2012 comparison completed in spring of 2013 using 2012 data for both groups.
Medical Expense Savings
Model Practice Group– Eligibility Group
• BCBSNC Underwritten, BCBSNC ASO Employees and Select ASO Groups
– Attribution Group• Members must attend the practice, but only a subset will be considered attributed to the
model practice.
• The eligible model practice members are not required to attend the practice.
– Savings Calculation Group• Members must have sufficient BCBSNC membership history to be included.
• The medical expense savings calculation is based upon this group.
Matched Control Group– Control Group Eligibility
• Members must experience at least one encounter during the evaluation year and have sufficient membership history to be included.
– Control Group Matching• Matching the Control Members to the Model Practice Members will be based on a
statistical method known as Propensity Score Matching.30
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Medical Expense Savings and Payment
Medical Expense Savings– Total Medical Expenses
• Calculation is a comparison of the Total medical expenses for each group.
• Includes all episodes of care and places of service during the evaluation period; not only those episodes and locations associated with model practice.
– Actual Values and Not Trend• Calculation is a comparison of actual expenses and not a prospective
evaluation or a trend analysis.
Medical Expense Savings Payment– If savings are produced, the payment calculation identifies the
payment amounts due to the Model Practice from eligible groups for the savings achieved.
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Part IV: UNCHCS – Challenges and Opportunities
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Strategic Response to New Reimbursement Models
Acknowledging that the health care cost curve is unsustainable and that payment purely for volume is not good for anyone
Redesigning a care model that is value driven:
– Constraining costs, eliminating waste
– Measuring quality, outcomes, cost
– Transitioning from a focus on isolated episodes of care to population health management
Embracing Patient-Centered Medical Homes
Building an IS infrastructure that includes EMR, private UNC health information exchange, data warehouse, patient and referral portals
Taking risks on alternative payment agreements
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What happens if you build the perfect practice and no one shows up?
Build a patient panel with target prevalence of chronic illness
Market to potential patients Manage physician resentment Get the right incentives:
– Attract patients with chronic diseases
– Comply with state and federal regulations
– Create an environment where patients will allow their care to be coordinated by the practice in a PPO setting with no “gate-keeping”?
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How can we simplify the provider/payer interaction?
Do we really have to submit claims?
What else can we do to simplify the process?– Eligibility
– Prior authorizations
– Claims submission
– Denials
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How do you attract the most talented providers?
What should the financial incentive plan for providers look like?– Based on what factors (productivity, quality, both)?
– Individual v. group?
Should we have an incentive plan for staff?– Based on what factors?
What metrics can be measured reliably?
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How do you get the right information to the right people?
IS infrastructure - from the ground up or use existing resources?
Share care utilization data with the practice
Manage the sheer volume of utilization data, in addition to existing data (e.g., systemwide EMR; data warehouse quality metrics; registries; etc.)
Patient portals and non-traditional visits
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Part V: Lessons Learned
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Lessons Learned
Executive sponsorship and direction with physician leadership Building on previous relationships and partnerships
– Building trust for common goal of patient-centered, quality, affordable care
– Springboard for other innovations
Shifting the negotiation paradigm to move past historical relationships– Shifts discussion from “us vs. them” mentality in contract
negotiations
Moving forward while worrying about the details Gaining confidence of internal and external stakeholders Shared savings gained from greater efficiencies
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Lessons Learned (cont.)
Defining and agreeing on the roles and operational responsibilities for each partner
Educating each partner on unique business practices
Navigating state and federal regulatory obstacles
Designing and implementing new financing models
Coordinated care model leads to better health outcomes, lower costs− Will help answer question in North Carolina of whether highly
resourced, high-performing medical home can improve outcomes while lowering total cost of care
Strategies for reducing administrative costs
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Vision to reality– Providing enhanced clinical care through information availability
and data enrichment
– Demonstrating successful relationship between insurer and health care provider
– Aligning financial incentives for improving quality outcomes and medical expense savings
Future initiatives built on relationship and synergies
Looking Forward
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Part VII: Questions?
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Mr. Lotchin is a member of Arnold & Porter LLP’s FDA and Healthcare practice group and counsels a broad range of clients, including hospitals and academic medical centers; physician practices; ambulatory service providers; and pharmaceutical and medical device companies, on healthcare regulatory, transactional, and litigation matters. His experience includes developing Accountable Care Organizations (ACOs) and other network affiliation projects.
Robert G. Cimo, [email protected]
Mr. Cimo is the Senior Managing Counsel for Corporate Law and Governance at Blue Cross and Blue Shield of North Carolina. He directs transactional matters for BCBSNC and provides counsel on intellectual property, tax and finance, insurance, real estate, election law, HIPAA privacy and security and e-commerce issues. Mr. Cimo heads BCBSNC’s Vendor Contract Analysis and Negotiation unit and is lead counsel to BCBSNC’s Strategic Development, Legislative Affairs, Diversified Products and Ancillary Markets groups.
Gina [email protected]
Ms. Bertolini is an Assistant General Counsel with the UNC Health Care System and the Legal Director and General Counsel for Triangle Physician Network.
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