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Payers and Accountable Care
           Organizations


                 Opportunities for A
                 Value-Added Delivery
                 System




1
Challenges for an ACO
       Unknown patient population (aligned
        membership) and their underlying costs
       No assigned membership- freedom to self-
        refer (Medicare fee-for-service)
       Little or no formal process for directing
        patients through health care system or
        resource consumption
       Requires lots of coaching by primary care
        practitioner (medical home and care
        coordinator role)
       Must manage risk through care
        coordination, education and collaboration
        with partner providers for cost efficiency
       Quality metrics requires disease-specific
        and individual case management


2
Complementing ACO and Payer
    Delivery Systems




                      ACO                          Payer




           Access to payer contracts and broader
           network of care sites
3
ACO and Payer Partnership

             ACO Value                           Payer Value
    • Organized business entity with     • Existing IT resources
       shared governance                 • Ability to provide:
    • Internal performance structure           Claims payment & data

      and oversight                            Population demographics
    • Common goals established                 Actuarial & underwriting support
    • Knowledge of delivery system       • Medical cost management techniques
      and practice relationships               On-site UM/case mgmt
    • Adoption of practice protocols           Pre-certification
    • Willingness to accept risk or            Alternative care settings
      shared-risk contracts              • Tracking and reporting outcomes data
    • Basis for care collaboration and         Performance feedback from data
      patient-centeredness               • Access to broader health care delivery
    • Ease in payer contracting            system (Payer’s contracts)
4                                        • Access to payer’s clients and marketing
Risk Management = Medical Management
    and Disease Management

       Overall goal: provide best care at affordable cost
        in most appropriate setting
       Adopt health plan-like utilization management
        practices:
         –   Pre-authorization
         –   Concurrent review with Interqual® criteria
         –   Discharge planning and follow up
       Seek lower cost care settings
       Utilize network of providers under contract at
        predetermined prices and conformance
       Adopt health plan-like disease management
        programs for high risk and chronic care
        population:
            CAD               COPD/emphysema
            Diabetes          CHF
            Hypertension      ESRD

5
ACO and Payer Collaboration and Sharing of
    Clinical Data

    • Utilizing paid claims data
    • Identifying trends
    • Focus on areas of improvement
    • Consulting on care plans and alternatives
    • Conducting patient experience surveys
    • Evaluate quality and cost performance standards across
      ACO delivery system (based on benchmark cost
      management goals and clinical outcomes)
    • Reporting/feedback on non-ACO (payer) network provider
      performance



6
Coordination of Care and Patient Outreach
    Programs*

       Establish clinical staff of care counselors
       Conduct welcome calls and introductions for
        identified patient population
       Conduct risk assessment surveys from
        prospective data and patient base
       Enroll targeted patients in disease
        management and education programs
       Follow up with post-discharge patients
        (inpatient and select outpatient procedures)
       Conduct periodic assessment and adherence
        calls for high risk/chronic care patients
       Invest in home monitoring devices for at-risk
        patients

                                   * Shared role between payer and ACO
7
IT Resource Needs*

       Architecture of practitioner’s EMR/EHR
        system
       Capability to interconnect with other ACO
        participants (e.g. specialists, hospitals,
        labs etc.)- providing results and care plan
        histories
       Medical informatics (data mining) capability
        and technical help:
          – For identifying and flagging high
            risk/at-risk patients from prospective
            data for targeted interventions
          – Conducting cost (expenditure) trend
            analysis
       Tracking referrals across ACO practices
        and outside the delivery system                * Payer support role
       Capability for secure internet patient
        contact and counseling
8
Contact Us
    Eagle Run MCC has the expertise and capability to:
    • Construct and expand provider ACO networks for commercial and
    government requirements.

    • Negotiate contracts on behalf of providers and the ACO entity and
    monitor contractual performance measures between providers and
    payers.

    • Provide medical and patient management techniques to improve
    performance and produce desired clinical and cost outcomes.

    • Provide access to low cost, leading-edge, cloud-based EMR, practice
    management and revenue cycle management services to increase
    productivity, profitability and health information exchange capability
    among provider practices and the ACO network.
9

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ACO and Payer Partnership- Surviving Health Care Reform

  • 1. Payers and Accountable Care Organizations Opportunities for A Value-Added Delivery System 1
  • 2. Challenges for an ACO  Unknown patient population (aligned membership) and their underlying costs  No assigned membership- freedom to self- refer (Medicare fee-for-service)  Little or no formal process for directing patients through health care system or resource consumption  Requires lots of coaching by primary care practitioner (medical home and care coordinator role)  Must manage risk through care coordination, education and collaboration with partner providers for cost efficiency  Quality metrics requires disease-specific and individual case management 2
  • 3. Complementing ACO and Payer Delivery Systems ACO Payer Access to payer contracts and broader network of care sites 3
  • 4. ACO and Payer Partnership ACO Value Payer Value • Organized business entity with • Existing IT resources shared governance • Ability to provide: • Internal performance structure  Claims payment & data and oversight  Population demographics • Common goals established  Actuarial & underwriting support • Knowledge of delivery system • Medical cost management techniques and practice relationships  On-site UM/case mgmt • Adoption of practice protocols  Pre-certification • Willingness to accept risk or  Alternative care settings shared-risk contracts • Tracking and reporting outcomes data • Basis for care collaboration and  Performance feedback from data patient-centeredness • Access to broader health care delivery • Ease in payer contracting system (Payer’s contracts) 4 • Access to payer’s clients and marketing
  • 5. Risk Management = Medical Management and Disease Management  Overall goal: provide best care at affordable cost in most appropriate setting  Adopt health plan-like utilization management practices: – Pre-authorization – Concurrent review with Interqual® criteria – Discharge planning and follow up  Seek lower cost care settings  Utilize network of providers under contract at predetermined prices and conformance  Adopt health plan-like disease management programs for high risk and chronic care population:  CAD  COPD/emphysema  Diabetes  CHF  Hypertension  ESRD 5
  • 6. ACO and Payer Collaboration and Sharing of Clinical Data • Utilizing paid claims data • Identifying trends • Focus on areas of improvement • Consulting on care plans and alternatives • Conducting patient experience surveys • Evaluate quality and cost performance standards across ACO delivery system (based on benchmark cost management goals and clinical outcomes) • Reporting/feedback on non-ACO (payer) network provider performance 6
  • 7. Coordination of Care and Patient Outreach Programs*  Establish clinical staff of care counselors  Conduct welcome calls and introductions for identified patient population  Conduct risk assessment surveys from prospective data and patient base  Enroll targeted patients in disease management and education programs  Follow up with post-discharge patients (inpatient and select outpatient procedures)  Conduct periodic assessment and adherence calls for high risk/chronic care patients  Invest in home monitoring devices for at-risk patients * Shared role between payer and ACO 7
  • 8. IT Resource Needs*  Architecture of practitioner’s EMR/EHR system  Capability to interconnect with other ACO participants (e.g. specialists, hospitals, labs etc.)- providing results and care plan histories  Medical informatics (data mining) capability and technical help: – For identifying and flagging high risk/at-risk patients from prospective data for targeted interventions – Conducting cost (expenditure) trend analysis  Tracking referrals across ACO practices and outside the delivery system * Payer support role  Capability for secure internet patient contact and counseling 8
  • 9. Contact Us Eagle Run MCC has the expertise and capability to: • Construct and expand provider ACO networks for commercial and government requirements. • Negotiate contracts on behalf of providers and the ACO entity and monitor contractual performance measures between providers and payers. • Provide medical and patient management techniques to improve performance and produce desired clinical and cost outcomes. • Provide access to low cost, leading-edge, cloud-based EMR, practice management and revenue cycle management services to increase productivity, profitability and health information exchange capability among provider practices and the ACO network. 9