1. Thursday, June 25, 2015 – 11am-12:45pm
New Models for Aligning Value-
based Incentives with Physicians,
Systems and Payers
PatrickAdams
President,Transcend

2. Humana and the Commitment to Population Health
Transcend Partnership Framework and Value-Based Reimbursement Models
Physician Perspective in Florida: Chauhan Medical Center
Saint Luke’s Health System: A fee-for-service market preparing for change
Interactive Session
3-7
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12-15
8-11
16-17
Agenda
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3. Humana launches wholly owned subsidiary Transcend
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4. Humana Background
 Health and well‐being company
focused on making it easy for
people to achieve their best health
with clinical excellence through
coordinated care
 #5 largest U.S. publicly-traded
health insurer with approximately
14.2 million medical members
nationwide as of March 2015
 #2 in Medicare Advantage
enrollment with approximately 3.2
million members as of March 2015
 $48.5 billion in revenue (2014)
 30+ years track record in Medicare
program
 Operator of 500+ medical centers
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5. Health care is moving from traditional care to integrated care
RESULT:
Dis-integrated. Episodic. Conflicted.
Traditional Healthcare
RESULT:
Patient-focused. Primary care-centric. Proactive.
Integrated Care
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6. Higher levels of provider integration across the integrated care
continuum result in improved quality and lower costs
1) Value-based relationships includes providers participating in Path to Risk and Shared Risk programs.
2) Humana Analysis on 2013 claims data for Individual MA only, including delegated risk
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7. Humana’s Integrated
Care Delivery Model
is the engine of a
consumer-focused
strategy
Providing integrated care
that makes it easy to
achieve best health through
clinical capabilities and a
personalized experience
– making healthcare easy
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8. 8
Making the transition to Population
Health Management possible
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9. Transcend delivers services to physicians supporting value-based
reimbursement models and population health
Population Health Service Model
Care ManagementPhysician Engagement
 Local Medical Director
• Committee leadership and
participation
• Peer education and coaching
• UM/QI/pharmacy oversight
 Nurse Care Managers/Care
Navigators
• Member outreach
• Coordinate PCP visits
• Post discharge follow-up
• Specialist follow-up back to PCP
 Quality Nurses
• HEDIS/quality, coordinate quality
initiatives with health plan
• Analyze access to specialty care
Clinical Integration
 Creation of Clinically Integrated
Network
 Medical Management Committee
 Data aggregation/analytics/reporting
• DataLink CareBook
• Patient stratification
 Health Information Exchange (HIE)
• Certify HealthLogix
• Community-wide patient view
Financial Risk Management
 MSO is physician’s partner in
population health
 Physician committee participation
 Richer value-based
reimbursement models
• QIP
• Shared Savings
 Provider Service Representatives
• Perpetual involvement
• Liaison with health plan –
problem solving
• Deliver actionable
information at the right time
• Provider office education
Patient-focused. Physician-centric.
 Risk aggregation and Stop Loss
 Documentation Consultants
• Risk adjustment support
• Chart reviews
• Diagnostic Action Forms
• PCP office coding education
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10. Fund flow structure
Solution: Partnership Framework
• The key differentiators are the
creation of a clinically integrated
network and payer ACO, and
management services that simplify
the population health process and
all the partnerships required to
create an aligned structure,
allowing movement from volume to
value.
• Physicians receive resources and
technology to proactively improve
health outcomes, patient
engagement and care affordability.
• Physician leadership, aligned
around population health tools and
resources, is core to the success of
value-based care.
Transcend
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11. • Churn and Burn
PCPs may need to see 35+ patients
daily to cover practice costs
• Reactive
Focus on individual patients’
presenting problems
• Hand on the doorknob
Visits may feel rushed to keep up
• Volume-driven
Reimbursement based on RVUs
generated
• Billing Limitations
PCPs generally provide and bill for a
lower level of services than specialists
• Not satisfying for some physicians
• Shift focus
Managing a population of patients
• Proactive management
Stratify and provide proactive treatment to
highest risk patients
• Close Gaps
Better data & enhanced ability to focus on
closing quality gaps
• Fewer, more thorough visits each day
• Increased opportunity
Reimbursement based on RVUs generated,
plus quality bonus & surplus distribution
• The “procedure” of Population Health
Management
Payers are willing to reimburse for the
“procedure” of population management
because of its proven value
Population health results in better quality and a more satisfying physician experience
Volume vs. Value-Based | APhysician’s Perspective
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12. PhysicianPerspectiveinFlorida: ChauhanMedicalCenter
Chauhan Medical Center – Primary care practice in
Orange City, east-central Florida (Volusia County)
 Practice with 15-year history in Orange City
 Residents age 65 and over: 29%
 Median household income: $29,050
 Persons per household: 2
*From census.gov
 Practice Panel—1500 Patients (unique, seen in the practice in the past 18 mos):
 1,000 are in a Population Health Management Model with Humana:
 ~650 are Humana Gold Plus® members (Humana Medicare Advantage
HMO/Health Maintenance Organization plan). Practice is exclusively
Humana Medicare Advantage Plans.
 Remaining patients are commercial fee-for-service patients under
ObamaCare.
 500 patients are traditional Fee for Service
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13. PhysicianPerspectiveinFlorida: ChauhanMedicalCenter
Chauhan Medical Center,
continued
 Practice Staffing
 Dr. Kevin Chauhan – Board Certified in Internal Medicine
• Special Interest in and focus on Chronic Condition Management
such as Diabetes and Cardiovascular Disease.
• Works closely with Transcend MSO and previously, MetCare
MSO—15-year relationship with same MSO team.
 Dr. Dorma Broome-Webster – Board Certified in Internal Medicine
• Associated with the practice for 10+ years.
• Special Interest in and focus on wellness and disease
prevention.
 Remainder of staff cross-trained to perform administrative work
such as referrals, care coordination, medication refills:
• Registered Nurse (retired military medic)
• Office Manager
• Receptionist
• Two Medical Assistants
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14. PhysicianPerspectiveinFlorida: ChauhanMedicalCenter
Chauhan Medical Center, continued
Typical Patient:
 Multiple medical conditions; taking four or more medications
 Congestive Heart Failure, Cardiovascular Disease, Diabetes, Hypertension, COPD
 Poor Nutrition, Non Compliance
With this patient profile:
 Even an engaged patient + best specialist = cost-prohibitive for patient.
 If the physician doesn’t find a way to take care of this patient, they’ll end up in the
ER over and over again.
 Working with Humana in the MSO structure, patients can come in more often—
daily if necessary—for monitoring and adjustment of their therapy until the
episode is resolved.
 Otherwise, within a two-week period, the same patient might be admitted to the
ER several times.
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15. PhysicianPerspectiveinFlorida: ChauhanMedicalCenter
A Collaborative Approach—MSO + Physician + Payer + More Engaged Patients = Greater Success
Partnership resulted in development of a Disease-State Management Program – educational
approach with diabetes patients:
 Focus-group-type model under guidance of the physician.
 ~10 diabetes patients met regularly at the practice to share stories and testimonials, and offer one
another support and encouragement.
 Support group setting helped patients learn to live better with diabetes and in compliance with therapy.
 MSO’s role expanded to support the program with additional resources.
The relationship with the MSO allowed the physician to focus on patients rather than finances—physician’s
interests and patients’ were the same:
 More affordable care for the patient and access to the practice.
 Improved quality of life for the patient and the physician.
 Better patient outcomes.
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16. SaintLuke'sHealthSystem: Afee-for-servicemarketpreparingforchange
Ben Harber, Chief Operating Officer, Physician Enterprise
Faith-based not-for-profit health system dedicated to enhancing
the physical, mental and spiritual health of communities served.
10-hospital system serving Kansas City metro and
throughout Kansas and Missouri; includes home care and
hospice, and behavioral health care.
 400 employed physicians
 130 APPs
 900 support staff at 60 locations
 Region’s only adult heart transplant program
 One of the nation’s leading cardiovascular disease
outcome research programs
 Treatment for complex brain and spinal cord diseases
 Nation’s leading stroke reversal program dedicated to
preventing and treating stroke
 An eICU, an innovative electronic intensive care
patient care and monitoring program spanning
multiple hospitals
 Nationally recognized children's behavioral health
center
 Level 1 trauma center
 Liver and kidney transplantation programs
 A Level IIIb Neonatal Intensive Care Unit
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17. SaintLuke'sHealthSystem: Afee-for-servicemarketpreparingforchange
Ben Harber, Chief Operating Officer, Physician Enterprise,
continued
 The match strike is imminent
Timing for a tipping point into a higher penetration
of risk-based contracts is a matter of when.
 Availability of right resources is key
Succeeding with risk deals takes more than the
typical finance/legal staff.
 PCPs want to treat
Navigating contract-specific requirements by
patient will not happen.
 No head of the table
Medical leadership, administration, legal, finance,
etc. must partner from initial stages to succeed.
 Shared-risk arrangements help train
Use of shared-risk contracting is key in order to
prepare for more complex arrangements.
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18. InteractiveSession
• Network of Care – Gaps vs. integrated clinical
care
• Organizational Foundation – Leader/staffing
capabilities; IT infrastructure
• Physician Engagement – E.g., regional variances
• Market Strength – Size, profits, brand
recognition
• Relationship with Business Partners – E.g.,
payers, data/analytics vendors
Questions
Audience participation
Using an interactive tool we will use the following
questions to role play a scenario of a medical
group examining where they are on the spectrum
of readiness to transform from volume to value.
We also will look at the approaches and partners
we need to succeed.
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