2013-01 Building a Framework for Sustainable ACO Enablement

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Insurers and Providers must first agree on how to share risk. After that, begins the hard part. For ACOs to last, unlike managed care in the 90's, they will need a sustainable framework to achieve cost, quality, and patient experience.

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  • I will be giving a talk at the ACOs Summit in Austin, TX on January 16, 2013 at 8:55 am entitled “A framework for sustainable ACO enablement”. You can find more about it here. http://healthmodelinnovation.com/speaking-on-aco-enablement/
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2013-01 Building a Framework for Sustainable ACO Enablement

  1. 1. Building a Framework for Sustainable ACO Enablement a presentation by Kevin Riley for the Opal 2013 ACOs Summit January 15, 2013
  2. 2. Synopsis Topic: A framework for sustainable ACO enablement Insurers and Providers must first agree on how to share risk. After that, begins the hard part. For ACOs to last, unlike managed care in the 90s, they will need a sustainable framework to achieve cost, quality, and patient experience. In this session, learn about the essential ingredients in a value-based ACO framework that support your risk-sharing contracts long-term. Key takeaways include: • What is the role of informatics in ACOs? • What does improved care delivery mean? • Can you create a winning care consumption experience?
  3. 3. Who am I? Principal at Kevin Riley & Associates | Health Model Innovation • former chief innovation officer of Florida Blue (Blue Cross Blue Shield of Florida) and founder and former president/CEO of GuideWell • entrepreneur, health care executive, business model innovator, and pursuer of experiences that drive behavior, and ultimately action Kevin started Kevin Riley & Associates | Health Model Innovation consultancy in 2006 to help companies with the convergence of health care and the consumer. He founded and was CEO of a national health care retail company, played leadership roles for several national retail health start-ups, and served as the first Chief Innovation Officer of a major insurance plan. Kevin holds a Masters of Business in entrepreneurship and marketing from Rice University. follow me on @kevineriley, linkedin, slideshare
  4. 4. What is Health Model Innovation? Producing value though profitable and sustainable business models made by creating and/or realigning the activity systems that improve member experience, boost provider performance, and enable payer cost control.
  5. 5. What is value? “Value” is the patient health outcome achieved per healthcare dollar spent. So more value is achieved when you get: 1. improved patient engagement 2. improved patient experience 3. reduces aggregate cost of careSource: Porter ME. What is value in health care? N Engl J Med 2010; 363:2477-81. (10.1056/NEJMp1011024).http://www.nejm.org/doi/suppl/10.1056/NEJMp1011024/suppl_file/nejmp1011024_appendix1.pdf.
  6. 6. What is the problem? Health care reform, while providing access to more consumers, does not address the underlying problems of escalating costs. How do we create better value? Mass. medical spend increased ~ 7% YOY” Source: Forbes “53% of consumers are oblivious to costs” Source: Deloitte Center for Health Solutions
  7. 7. What is the premise? 1. ACOs are necessary for the sustainably of healthcare 2. ACOs start with good risk-sharing 3. ACOs require investment in enabling capabilities for: • Patient engagement (consumption) • Practice workflow management (care delivery) • Data collection and analysis (data analytics)
  8. 8. Minimal Traditional Fee-for-Service Episodic Cost Pay-for-Performance Bundled Payments Shared Savings AccountabilityShared Savings Continuum of Payment Models Partial Capitation Total Cost Full Capitation Substantial
  9. 9. Healthcare Care LoopPatient Need Provider Engaged Diagnosis Communicate Solution Resolved? Resolved? No Care Management Yes Rewards & Incentives Prevention & Wellness
  10. 10. 1. Create a positive consumption experience Think of it as patient relationship management, or creating engagement models that uses carrots and sticks to get members to comply with evidence based protocols, and enrich ties with their provider.
  11. 11. 2. Focus on improving care delivery This is not just the view of the plan, this means the provider believes they are practicing better medicine, and most importantly the patient confirms it.
  12. 12. 3. Start with a foundation of data analytics At the heart of risk control is intense investment in informatics. Imagine a hedge fund with the same level of risk tools and insight as payers and providers have now?
  13. 13. Questions Kevin Riley & AssociatesBusiness Model Innovation for Healthcare kevin@healthmodelinnovation.com www.healthmodelinnovation.com

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