Your SlideShare is downloading. ×
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.


Saving this for later?

Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime - even offline.

Text the download link to your phone

Standard text messaging rates apply



Published on

Published in: Business, Economy & Finance

  • Be the first to comment

  • Be the first to like this

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 1. High Performance Clinically Integrated Organization (HPCIO) sm Prepared by: Mark Tozzio, MA-IHHS, FACHE President Hospital and Physician Practice Development Consulting, Inc. Overview of HPCIO Program Development … in a nutshellAugust 1, 2011 1
  • 2. High Performance Clinically Integrated Organization (HPCIO) sm Commercial Insurers are Embracing Pay-For-Performance Incentive Programs:  WellPoint  United Healthcare  Blue Cross Blue Shield of Illinois  Advocate Physician Partners (Chicagoland) was established as a Clinically Integrated model ten years ago – today the program includes 3,800 physicians that focus on key clinical and financial initiatives in these areas:  Clinical outcomes improvement (including generic prescribing)  Enhancement of operational efficiency (ambulatory and acute care settings)  Robust medical and technological infrastructure  Patient safety  Patient experience FTC-compliant Clinically Integrated Organizations must demonstrate that they meet the three principal testsResources: established by the Department of Justice (DOJ) andAdvocate Physician Partners, “The 2011 Value Report: Benefits from Clinical Federal Trade Commission (FTC) outlined in the 1996Integration,", June 6, 2011. policy statement:Web.Great Boards, “Clinically Integrated Physician-Hospital Organizations,” Winter 1) The network’s program of clinical integration is likely to2009, Vol. IX, No. 4. Print. achieve “real” integration of providers; 2) The initiatives of the program are designed to achieve likely improvements in healthcare cost, quality and efficiency; and 3) Joint contracting with health plans is “reasonably necessary” to achieve the efficiencies of the clinical integration program. 2 Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468,
  • 3. High Performance Clinically Integrated Organization (HPCIO) sm Lee B. Sacks, M.D., Advocate’s Executive Vice President and Chief Medical Officer, and CEO of Advocate Physician PartnersNetwork of 3,800Physicians and 10hospitals and 2integrated children’shospitalsPhysician Led CIOrganizationalGovernance57 key quality and costinitiatives carried outin 2010Pay-For-Performancebonuses paid to APPphysicians fromcommercial insurersreportedly totaled =$60 million in 2010 Resource: Advocate Physician Partners, “The 2011 Value Report: Benefits from Clinical Integration,", June 6, 2011. Web. Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 3
  • 4. High Performance Clinically Integrated Organization (HPCIO) smAnd here comes the ACO… Share Savings Program to Reward Accountable Care “It is in the public interest to harmonize the eligibility criteria for ACOs that wish to participate in the Shared Saving Program with the similar antitrust criteria on clinical integration. As discussed in more detail in section II.I. of this proposed rule, competition between ACOs is expected to have significant benefits for Medicare beneficiaries, by improving the quality of care they receive, protecting their access to a variety of providers, and helping to sustain the Medicare program by controlling costs. Furthermore, because ACOs that operate in the Shared Savings Program are likely to use the same organizational structure and clinical care practices to serve both Medicare beneficiaries and consumers covered by commercial insurance, the certainty created by harmonizing our eligibility criteria with antitrust requirements will help to ensure that an ACO organization participating in the Share Saving Program willCFR Vol. 76, No. 67, April 7, 2011, page 19542 not subsequently face an antirust challenge that its conduct is per se illegal, which could prevent the ACO from fulfilling the 3-year term of its agreement und the Shared Savings Program” [emphasis added). Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 4
  • 5. High Performance Clinically Integrated Organization (HPCIO) sm CMS published their 412-page proposed guidelines for ACOs on March 31, 2011:  Providers must sign up with CMS for a minimum of three years to participate as an ACO  Primary care groups must be the driving force of ACOs – specialists and hospitals/other providers can participate (in the clinical integration process)  Participating ACOs must serve at least 5,000 Medicare beneficiaries in a region  Medicare beneficiaries will be assigned to ACOs retrospectively – freedom to move in and out of ACOs is preserved  ACOs will bear risk for covered Medicare beneficiaries (two ACO payment tracks offered)  Bonus incentive payments will depend on demonstrated cost savings and quality metrics to Medicare (65 quality measures; significant transparency of ACO operations and financial performance)  Unprecedented cooperation between DHHS/CMS, FTC, DOJ, and IRS to create “safety zones” to address anti-trust and physician inurement concerns  Final Regulations will be published after the comment period ending June 6th of this year  ACO Program enrollment is set to start on January 1, 2012Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 5
  • 6. High Performance Clinically Integrated Organization (HPCIO) sm Stages of healthcare transformation:  Healthcare reform will move providers along a transformational pathway within 3 main groups over the next decadeLevel of provider integration Stage 3 – Some providers will be able to achieve: >New collaboration models that truly/fully integrate the continuum of provider care >Allocation of substantial resources to develop sophisticated business intelligence IT solutions >Formation of HPCIO and ACO partnerships to capture P4P/Shared Savings/Bundled Payment Stage 2 – Many providers will have to achieve: >Formal medical staff development – physician recruitment, retention, loyalty enhancement and leadership training >Clinical integration initiatives along service lines that expand market share and stabilize positive revenue streams >Robust IT and HR infrastructure to support “value-based purchasing” and P4P programs - commercial and CMS >Consolidation of affiliate hospitals and physicians along mission, values, and vision horizons >Chronic care management and preventive care delivery systems throughout the health service area Stage 1 – All providers will need to achieve: >Control over escalating operating costs and increase productivity (do more with less) >Superb customer satisfaction (patients, physicians, vendors, donors, etc.) >Optimized quality outcomes (CORE measures; PQRS, SCIP, etc.), and improve safety (HAI, errors, complication rates, etc.) >Efficiency of operations at all levels of healthcare delivery >Expanded care coordination before, during and after hospitalization involving physicians along the healthcare continuum Adapted from: Gelineau, Stephen, “Hospital of the Future: Strategies in an Era of Healthcare Reform," ACHE Presentation, June 6, 2011. Print. Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 6
  • 7. High Performance Clinically Integrated Organization (HPCIO) sm Medical Center Physician- Led Governance Independent Employed Physicians Physicians Commercial Insurance Focus CMS Medicare / Medicaid Focus Clinically Accountable Integrated Care Organization Organization (CI) (ACO) The HPCIO negotiates with payers for incremental P4P and bonus payments on top of the fee schedule on behalf of all members based on demonstrated improvements in quality and cost effectiveness of care rendered to patients under the care of the organizationMark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 7
  • 8. High Performance Clinically Integrated Organization (HPCIO) PSCI Solutions’ Quality Organization Maturity Model:  There are four distinct phases of quality maturation in hospitals and health systems; at present, very few organizations reach Phase IV performancePHASE I PHASE II PHASE III PHASE IV “Processes & “Institutionalize “Reporting” “Compliance” Variance” Quality” Laggards Followers Leaders Innovators 1. Focus on external 1. Focus on quality 1. Focus on internal 1. Focus on hospital quality reporting compliance quality improvement margin improvement 2. Measures 2. Cross-functional projects 2. Pay-for-performance, department quality alignment 2. Facilitate change patient satisfaction, productivity 3. Ad-hoc physician management clinical-financial 3. Data collection integration 3. Monitor and report alignment, integration efficiencies 4. Minimize QI project success 3. Link quality of care to measurement errors 4. Process-driven cost, report impact of physician integration quality improvement on margin 4. Physician scorecards Maximize Improve Productivity Improve Quality Scores Link Cost-Quality Quality-Revenue Curve ● Tactical ● Project orientation ● Process orientation ● Strategic orientation ● Director of Quality ● VP Quality ● Chief Quality Officer ● Chief Quality Officer ● Facility cost center ● Shared service center ● Shared Service Center ● Revenue Center 8 sm Image © Copyright 2011 PSCI Solutions, Inc. All rights reserved [Reproduced with approval of PSCI Solutions] 8
  • 9. High Performance Clinically Integrated Organization (HPCIO) sm The key to clinical integration involves serious commitment to:  Development of enhanced infrastructure and technological enablers  Shared governance organizational structure with strong physician leadership and broad participation  Contractual relationships between HPCIO members and payers in order to align clinical and financial incentive across the continuum of care environment Alignment of Collaboration Technological Incentives Effectiveness Provider Share performance metrics across the  Operate a physician-led governance structure with  Negotiate on behalf of HPCIO organization – ambulatory, inpatient, strong leadership representing both independent and members for performance-based post-acute settings, and community employed providers across all specialties with the incentive payments with commercial health status support of the health system’s management team and governmental payers Implement real-time business  Establish relevant participation criteria that encourages  Promote accountable care intelligence solutions (BI) reporting involvement of quality-driven physicians (30 to 40% of  Tie community health status organization-wide accomplishments medical staff initially) improvement to financial incentives (dashboards, trend monitoring, etc.)  Include a remediation process for non-compliant  Expand HPCIO to include additional Publish report cards that clearly members providers beyond the initial core demonstrate added value to patients  Adopt interdisciplinary clinical and financial metrics and and payers initiatives to improve outcomes and control costs Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 9
  • 10. High Performance Clinically Integrated Organization (HPCIO) sm HPCIO implementation process:  Phase 1 – HPCIO Readiness Assessment involves a comprehensive analysis of the health system and physician leaders, employed and independent physicians, that indicates that the medical community is able and willing to become clinically integrated (approximately 45 days to complete the Phase 1 study once the Client’s key information is obtained)  Go / No-Go decision by stakeholders and commitment to invest time and resources into the program  Phase 2 – Implement HPCIO – entails establishing a physician-led organizational structure for the HPCIO in partnership with the health system (six to seven months from the date that an agreement is signed with consultancy to move to Phase 2)  Create HPCIO’s legal entity  Identify key transformational metrics  Implement robust IT infrastructure (ambulatory and inpatient)  Seek regulatory confirmation that program is structured appropriately as a clinically integrated entity and meet the “safe harbor” conditions  Negotiate with payers regarding performance objectives  Establish incentive pay program for providers in the ACO  Apply for CMS ACO certification (if it makes business sense)Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 10
  • 11. High Performance Clinically Integrated Organization (HPCIO) sm1 Develop Market Profiles & Trends, Competitive Intensity, Technology and Clinical Trends; Snapshot Market Performance Review: Inpatient and Ambulatory settings Assessment2 Organizational Assess Organization & Service Line Alignment Options, 3 YR capital needs; Complete For Key Performance Services And Facilities, Projected baseline EBIDA 3 YR Returns & reimbursement impacts Assessment3 Foundations Of Complete Clinical Integration Prospects and Design Roadmap with Physician & Health Clinical Integration System Leader ship Stakeholders4 Physician Companion for CI, evaluate optional structures, and evolving mix of PCP & specialists; Integration Options assess impact of trending practice reimbursement conflicts5 Organizational Criteria for independent models applied to decision scenarios and impacts; Based on physician alignment, regulatory, and payer performance driven leverage; culture-driven Structure performance indicators applied for feasibility6 Network Payers Relative contracting positions vs. Medicare assessed; market impact for specific service Analysis & Strategies line bundles and overall evaluated7 Community Health Develop joint programs with public health, community leaders and establish pilot & Service Bundling metrics for population health program; coordinate with Payers & evolving CMS rules.8 Tactical Plans For Based on service line quality & operating cost savings, develop continuum action plansHPCIO Implementation with aligned physicians & stabilized margins Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 11
  • 12. High Performance Clinically Integrated Organization (HPCIO) sm HPCIO Assessment and Implementation Road Map ROI Assessment Phase – 45 days Researching Establishing the High Developing Hospital- Assessing Performance Clinically Physician- Enhancing Physician HPCIO Integrated Led High Performance Integration Feasibility Organizational Performance Improvement Alternatives Structure Metrics InfrastructurePre-Assessment Implementation Phase – 6 to 7 monthsPeriod Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 12
  • 13. High Performance Clinically Integrated Organization (HPCIO) sm The HPCIO implementation team delivers results – on time and on budget  Our multi-specialty leadership team delivers the highest quality consultative services at affordable rates for our Clients  The expertise of our leadership team provides effective guidance and knowledge transfer to our clients so they can operate independently once the HPCIO program is operational  We implement the HPCIO program over a shorter period of time compared to our competitors – nearly half the time of other consultancies specializing in the Affordable Care initiative with excellent results (6 to 7 months implementation schedule)  Our guaranteed maximum “program investment” is very competitive with fees charged by other recognized firms because of our efficient delivery process and breadth of expertise among our delivery team  Our team prides itself in providing a personalized (not a canned) program that is physician-led, and involves key stakeholders that drive the program’s long term success  Our team of experts will also be available to assist with the preparation of application documents necessary for acceptance by regulatory agencies and commercial insurers  The HPCIO organizational structure/governance and clinical integration program is designed to meet the requirements for participation in the CMS’ Shared Savings Program and other performance-based incentive programs offered by selected commercial insurance companies and self-insured plans – this dual approach saves our Clients time and money when compared to other alternativesMark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 13
  • 14. High Performance Clinically Integrated Organization (HPCIO) smHPCIO Advisory Team: Mark Tozzio, Masters Health and Human Services Administration, FACHE - Healthcare Program/Services Development and Clinical Integration (35 years of healthcare management experience with large and small hospital systems and physician groups) Rich Miller, MPH - Strategy, Project Management and Performance Analysis Expert (32 years of healthcare strategy and development; including 20 years of consulting for clients nationwide) David Woodrum, FAAHA, FACHE - Board/Leadership and Services Line Management Development (40 years of in- hospital, physician owned facilities, and consulting expertise; served as Vice President of the American Hospital Association and Chairman of Woodrum Ambulatory System Development) Steve Dobbs, MHA, FACHE - Executive Officer for Integrated Health Systems and Key Participant in the CMS Bundled Payment Prototype at Ardent’s Hillcrest Medical Center in Tulsa, OK (35 years of healthcare management experience and program innovation/physician partnerships development) Jay Reddy, MBA - Co-Founder and President of PSCI, a leading Business Information and Advanced Technologies firm specializing in quality analytics and decision support solutions for healthcare organizations (20 years of innovation in information technology systems to enhance quality and operational performance) Dennis Dvorak, Bachelors Business Administration - Physician Practice Administration (32 years of progressive management experience with multispecialty groups and integrated organizations as large as 120 providers) Steve Money, JD, MD - Medical-Legal Advisor Services (20 years of legal practice combined with medical training; corporate law and compliance expertise) Carolyn Davies, CPA – Physician practice management consultant with over 25 years of healthcare experience with small and large groups (financial performance improvement, benchmarking, contract negotiations, cash flow management, etc.); Carolyn has worked for national managed care companiesDepending on your specific needs, we will assign additional clinical support consultants for Phase 1 and Phase 2 Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 14
  • 15. High Performance Clinically Integrated Organization (HPCIO) sm • Don’t have a CI/AC91% program • Are planning to develop64% a program • Will implement a39% program in 2012Mark Tozzio, FACHE, HPPD, Inc., 918-521-7468, 15