Payers and Accountable Care           Organizations                 Opportunities for A                 Value-Added Delive...
Challenges for an ACO       Unknown patient population (aligned        membership) and their underlying costs       No a...
Complementing ACO and Payer    Delivery Systems                      ACO                          Payer           Access t...
ACO and Payer Partnership             ACO Value                           Payer Value    • Organized business entity with ...
Risk Management = Medical Management    and Disease Management       Overall goal: provide best care at affordable cost  ...
ACO and Payer Collaboration and Sharing of    Clinical Data    • Utilizing paid claims data    • Identifying trends    • F...
Coordination of Care and Patient Outreach    Programs*       Establish clinical staff of care counselors       Conduct w...
IT Resource Needs*       Architecture of practitioner’s EMR/EHR        system       Capability to interconnect with othe...
Contact Us    Eagle Run MCC has the expertise and capability to:    • Construct and expand provider ACO networks for comme...
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ACO and Payer Partnership- Surviving Health Care Reform

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Health care reform initiatives offered through an ACO entity creates opportunities for both providers and payers to deliver affordable and high quality care for consumers. Each partner comes to the table with valuable resources to achieve common goals and outcomes.

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ACO and Payer Partnership- Surviving Health Care Reform

  1. 1. Payers and Accountable Care Organizations Opportunities for A Value-Added Delivery System1
  2. 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 management2
  3. 3. Complementing ACO and Payer Delivery Systems ACO Payer Access to payer contracts and broader network of care sites3
  4. 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. 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  ESRD5
  6. 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 performance6
  7. 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 ACO7
  8. 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 counseling8
  9. 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
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