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Aco structure presented by hankwitz  5.12.11 meeting
 

Aco structure presented by hankwitz 5.12.11 meeting

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Aco structure presented by hankwitz  5.12.11 meeting Aco structure presented by hankwitz 5.12.11 meeting Presentation Transcript

  • Northern Colorado IPA: Laying the Groundwork for aPhysician-Driven Clinically Integrated Accountable Care Organization
    May 12, 2011
    1
    May 12, 2011
  • Presentation Agenda
    • Market Trends, PPACA & Health Reform
    • NCIPA’S Current Situation
    • IPA Profile
    • SWOT
    • PVHS Offer to NCIPA re UMA
    • Scenarios of Future Vision, Roles and Functions
    • Group Discussion 
    May 12, 2011
    2
  • Market Trends, PPACA and Health Reform
    PPACA is mostly about health insurance reform; it significantly impacts health care delivery reform
    For doctors and hospitals, the clearest aspects of PPACA spell out payment reduction schedules
    Health Reform’s government payment schedules are not keeping pace with inflation
    Providers must retain current commercial insurance base to ensure economic sustainability
    Kaiser
    May 12, 2011
    3
  • PPACA & Health Care Reform
    • Most substantive piece of legislation to affect the health care industry since the passage of Medicare in 1965
    • Goal: Increase the scope of insurance coverage and access to a greater number of Americans and reduce cost
    May 12, 2011
    4
  • Question
    • So, how does the government propose to increase access and at the same time reduce cost?
    May 12, 2011
    5
  • Start with Value & Triple Aim
    VALUE = Quality/Cost … as compared to peers
    TRIPLE AIM = Improved Outcomes, Lower Costs & Higher Patient Satisfaction
    May 12, 2011
    6
  • & add Payment System Change
    May 12, 2011
    7
  • Payment Reform = New Ways to Deliver Care
    If PPACA covers more lives, and payment reform is in place, what mechanisms do we have to ensure quality care?
    PPACA contemplates an Accountable Care Organization
  • ACO Defined
    • An integrated health care delivery system that relies on a network of primary care physicians, one or more hospitals, and subspecialists to provide care to a defined population.
    May 12, 2011
    9
    Source: MedPAC
    “ACOs have been compared to the unicorn:
    Everyone seems to know what it looks like, but nobody’s actually seen one.”
  • Premier ACO Model
    May 12, 2011
    10
  • Big ACO vs Small aco
    • Big “A” Accountable Care Organization (ACO)
    • Medicare population
    • Draft Rules & Regs have not had positive reception
    • Small “a” accountable care organization (aco)
    • PVHS Employee & other ERISA Health Plans
    • Defined population
    • Self-funded
    • ERISA allows flexible plan design and reimbursement
    • Care coordination principles apply
    May 12, 2011
    11
  • Cornerstones of an “aco”
    May 12, 2011
    12
  • Basic Characteristics of Clinical Integration
    • Careful selection of participating physicians
    • Significant contributions of financial and “sweat” capital by participating physicians
    • Development and adoption of clinical protocols
    • A performance-monitoring process
    • Care review based on the implementation of protocols
    • Mechanism to ensure adherence to the protocols
    • Use of common information technology to ensure an exchange of all relevant patient data
    • Aligned financial incentives
    May 12, 2011
    13
  • Definition of Care Coordination
    “Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.”
    May 12, 2011
    14
    Source: AHRQ
  • AHRQ Care Coordination Ring
    May 12, 2011
    Must have available
    in all settings - -
    Care Delivery & Care Coordination including:
    • Population Management & Outreach
    • Screening and Prevention
    • Acute intervention and Referrals
    • Diagnosis and treatment
    • Chronic Disease management
    • Palliation and EOL Care
    15
  • Information Technology
    • Necessary to manage the services and costs of care for a population
    • Provide the right information, at the right time, in the right form
    • Appropriate infrastructure to assure security, maintenance, and use
    • Permit practitioners to make decisions based on current, comprehensive information and patient history
    • Ability to pay providers; redistribution of funds or claims processing
    May 12, 2011
    16
  • Key IT Functional Needs
    • Access to comprehensive patient data, viewed across service providers
    • Make established clinical guidelines available for all providers
    • Compliance reporting showing variations in care at the provider and network level
    • Track physician performance against benchmarks and peers
    • Clinical decision support based on network determined guidelines including point of care alerts
    • Secure mechanism for provider communication
    • Facilitate PCP and specialty coordination
    • Support care transitions
    May 12, 2011
    17
  • Financial Management
    • Need tools and data to support strong modeling
    • Must have complete physician data as well as hospital information
    • Typical payor data sets won’t be enough – incomplete and far too old to help manage care and COST of care
    May 12, 2011
    18
  • NCIPA Profile
    Physician owned and operated Colorado corporation
    Consists of 667 providers
    168 Primary Care Physicians
    328 Specialist Physicians
    171 Other Contracted Providers
    Holds multiple contracts
    Health Plan
    Direct ERISA
    May 12, 2011
    19
  • NCIPA Membership
    February 28, 2011
    20
  • Membership Breakdown
  • 22
    February 28, 2011
    NCIPA Primary Care Profile
  • 23May 12, 2011
    NCIPA Specialist Profile
  • Current Situation
    May 12, 2011
    24
    Services:
    - Provider Network
    - Claims Adjudication
    and Payment
    Customers:
    - PVHS
    - Poudre School
    District
    - Columbine (400 lives)
    50 % ownership
    50 % ownership
  • PVHS Proposal
    “We (PVHS) would purchase NCIPA’s fifty-percent (50%) interest (in UMA), becoming the sole owners of UMA.”
    May 12, 2011
    25
  • How Can We Help PVHS Do This?
    May 12, 2011
    26
    By collaborating with PVHS to become the physician driven vehicle through which UMA can quickly develop a Clinically Integrated
    accountable care organization
  • Infrastructure
    May 12, 2011
    27
  • Administrative Driven Infrastructure Components
    Third Party Administration
    Financial Management
    Healthcare Operations Management
    Utilization Management
    Quality Assurance
    CVO
    Case Management
    Business Operations Management
    IT Systems and Analysis
    Payor Contracting & Contract Management
    Legal
    May 12, 2011
    28
  • Physician Driven Infrastructure Components &/or Committees
    Clinical Integration
    Care Coordination
    Health Information Technology & IT Management
    Credentialing
    Network Development
    Contracting and Finance
    May 12, 2011
    29
  • Role & Functions to Consider
    To be the physician driven vehicle through which UMA can:
    Provide clinically integrated services
    Perform Utilization Management
    Develop, approve and implement EBM practice guidelines for all specialties (HealthTeam Works)
    Monitor physician compliance to practice guidelines and report compliance to participating providers (Verisk Health – Sightlines Medical Intelligence)
    Counsel non-compliant providers and discipline them if non-compliance continues
    Implement and assist Systems of Care supporting patient centered medical homes and medical neighborhoods (CO Medical Society initiative)
    May 12, 2011
    30
  • Role & Functions to Consider (continued)
    To be the physician driven vehicle through which UMA can:
    Prove that value to those who are paying for healthcare is critical to receiving fair reimbursement for services rendered in that receiving fair reimbursement is essential to achieving the professional satisfaction of NCIPA providers
    Ensure only high quality providers satisfying established criteria participate in the network (Credentialing)
    Promote clinical HIE interconnectivity in collaboration with CORHIO
    Establish compensation options such as P4P, bundled payments and shared savings arrangements (starting with PVHS as the Beta site)
    May 12, 2011
    31
  • PHO vs ACO
    May 12, 2011
    32
  • Examples of “aco” Models
    Physician-only “aco” (Summit)
    For Profit Corporation (HWHN modified)
    Hospital Division or Single-Member LLC (LHP)
    LLC Model (UMA?)
    May 12, 2011
    33
  • May 12, 2011
    34
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    35
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    36
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    37
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    38
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    39
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    40
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    41
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    42
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • May 12, 2011
    43
    Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar
  • Getting Ready…
    • Readiness Assessment
    • Convene a team
    • Inventory existing projects and initiatives that align with strategic goals
    • Identify strengths and gaps
    • Critically examine:
    • Structure
    • Governance
    • Financial alignment
    • Systems integration
    • Clinical integration
    May 12, 2011
    44
  • Getting Ready…
    • Identify operational infrastructure opportunities that are readily transferable to a Medicare ACO
    • Mitigation of unnecessary 30 day readmits
    • Expedient provision of meaningful clinical information to PCP upon patient admission or discharge
    • Identify ACE and Bundled Payment opportunities
    • Facilitate medical management of the ERISA health plans
    • Identify and manage the most costly disease categories
    • Manage the most costly ETG’s
    • Manage to appropriate site of service
    May 12, 2011
    45
  • Getting Ready…
    • WORK TOGETHER!
    • Create a Clinically Integrated Network
    • Success factors
    • High quality and appropriate utilization
    • Performance demonstrated through quality metrics
    • Care coordination and collaboration among hospitals, physicians, other providers
    • Data collection and data sharing
    • Implement – Just do it!
    May 12, 2011
    46
  • May 12, 2011
    47
    DISCUSSION
    A Walter Hankwitz, MBA, FACHE, CMPE
    Highlands Health Management, Inc.
    awhankwitz@highlandshealth.com
    B: 423/863-1363 C: 423/534-0212