Northern Colorado IPA: Laying the Groundwork for aPhysician-Driven Clinically Integrated Accountable Care Organization<br ...
Presentation Agenda	<br /><ul><li>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 </li></ul>May 12, 2011<br />2<br />
Market Trends, PPACA and Health Reform <br />PPACA is mostly about health insurance reform; it significantly impacts healt...
PPACA & Health Care Reform <br /><ul><li>Most substantive piece of legislation to affect the health care industry since th...
Goal: Increase the scope of insurance coverage and access to a greater number of Americans and reduce cost</li></ul>May 12...
Question<br /><ul><li>So, how does the government propose to increase access and at the same time reduce cost?</li></ul>Ma...
Start with Value & Triple Aim<br />VALUE = Quality/Cost … as compared to peers<br />TRIPLE AIM = Improved Outcomes, Lower ...
& add Payment System Change<br />May 12, 2011<br />7<br />
Payment Reform = New Ways to Deliver Care<br />If PPACA covers more lives, and payment reform is in place, what mechanisms...
ACO Defined<br /><ul><li>An integrated health care delivery system that relies on a network of primary care physicians, on...
Premier ACO Model<br />May 12, 2011<br />10<br />
Big ACO vs Small aco<br /><ul><li>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</li></ul>May 12, 2011<br />11<br />
Cornerstones of an  “aco”<br />May 12, 2011<br />12<br />
Basic Characteristics of Clinical Integration<br /><ul><li>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</li></ul>May 12, 2011<br />13<br />
Definition of Care Coordination<br />“Care coordination is the deliberate organization of patient care activities between ...
AHRQ Care Coordination Ring<br />May 12, 2011<br />Must have available <br />in all settings - -<br />Care Delivery & Care...
Screening and Prevention
Acute intervention and Referrals
Diagnosis and treatment
Chronic Disease management
Palliation and EOL Care</li></ul>15<br />
Information Technology<br /><ul><li>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</li></ul>May 12, 2011<br />16<br />
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Aco structure presented by hankwitz 5.12.11 meeting

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Aco structure presented by hankwitz 5.12.11 meeting

  1. 1. Northern Colorado IPA: Laying the Groundwork for aPhysician-Driven Clinically Integrated Accountable Care Organization<br />May 12, 2011<br />1<br />May 12, 2011<br />
  2. 2. Presentation Agenda <br /><ul><li>Market Trends, PPACA & Health Reform
  3. 3. NCIPA’S Current Situation
  4. 4. IPA Profile
  5. 5. SWOT
  6. 6. PVHS Offer to NCIPA re UMA
  7. 7. Scenarios of Future Vision, Roles and Functions
  8. 8. Group Discussion </li></ul>May 12, 2011<br />2<br />
  9. 9. Market Trends, PPACA and Health Reform <br />PPACA is mostly about health insurance reform; it significantly impacts health care delivery reform<br />For doctors and hospitals, the clearest aspects of PPACA spell out payment reduction schedules<br />Health Reform’s government payment schedules are not keeping pace with inflation <br />Providers must retain current commercial insurance base to ensure economic sustainability<br />Kaiser<br />May 12, 2011<br />3<br />
  10. 10. PPACA & Health Care Reform <br /><ul><li>Most substantive piece of legislation to affect the health care industry since the passage of Medicare in 1965
  11. 11. Goal: Increase the scope of insurance coverage and access to a greater number of Americans and reduce cost</li></ul>May 12, 2011<br />4<br />
  12. 12. Question<br /><ul><li>So, how does the government propose to increase access and at the same time reduce cost?</li></ul>May 12, 2011<br />5<br />
  13. 13. Start with Value & Triple Aim<br />VALUE = Quality/Cost … as compared to peers<br />TRIPLE AIM = Improved Outcomes, Lower Costs & Higher Patient Satisfaction<br />May 12, 2011<br />6<br />
  14. 14. & add Payment System Change<br />May 12, 2011<br />7<br />
  15. 15. Payment Reform = New Ways to Deliver Care<br />If PPACA covers more lives, and payment reform is in place, what mechanisms do we have to ensure quality care?<br />PPACA contemplates an Accountable Care Organization<br />
  16. 16. ACO Defined<br /><ul><li>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.</li></ul>May 12, 2011<br />9<br />Source: MedPAC<br />“ACOs have been compared to the unicorn: <br />Everyone seems to know what it looks like, but nobody’s actually seen one.”<br />
  17. 17. Premier ACO Model<br />May 12, 2011<br />10<br />
  18. 18. Big ACO vs Small aco<br /><ul><li>Big “A” Accountable Care Organization (ACO)
  19. 19. Medicare population
  20. 20. Draft Rules & Regs have not had positive reception
  21. 21. Small “a” accountable care organization (aco)
  22. 22. PVHS Employee & other ERISA Health Plans
  23. 23. Defined population
  24. 24. Self-funded
  25. 25. ERISA allows flexible plan design and reimbursement
  26. 26. Care coordination principles apply</li></ul>May 12, 2011<br />11<br />
  27. 27. Cornerstones of an “aco”<br />May 12, 2011<br />12<br />
  28. 28. Basic Characteristics of Clinical Integration<br /><ul><li>Careful selection of participating physicians
  29. 29. Significant contributions of financial and “sweat” capital by participating physicians
  30. 30. Development and adoption of clinical protocols
  31. 31. A performance-monitoring process
  32. 32. Care review based on the implementation of protocols
  33. 33. Mechanism to ensure adherence to the protocols
  34. 34. Use of common information technology to ensure an exchange of all relevant patient data
  35. 35. Aligned financial incentives</li></ul>May 12, 2011<br />13<br />
  36. 36. Definition of Care Coordination<br />“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.”<br />May 12, 2011<br />14<br />Source: AHRQ<br />
  37. 37. AHRQ Care Coordination Ring<br />May 12, 2011<br />Must have available <br />in all settings - -<br />Care Delivery & Care Coordination including:<br /><ul><li>Population Management & Outreach
  38. 38. Screening and Prevention
  39. 39. Acute intervention and Referrals
  40. 40. Diagnosis and treatment
  41. 41. Chronic Disease management
  42. 42. Palliation and EOL Care</li></ul>15<br />
  43. 43. Information Technology<br /><ul><li>Necessary to manage the services and costs of care for a population
  44. 44. Provide the right information, at the right time, in the right form
  45. 45. Appropriate infrastructure to assure security, maintenance, and use
  46. 46. Permit practitioners to make decisions based on current, comprehensive information and patient history
  47. 47. Ability to pay providers; redistribution of funds or claims processing</li></ul>May 12, 2011<br />16<br />
  48. 48. Key IT Functional Needs<br /><ul><li>Access to comprehensive patient data, viewed across service providers
  49. 49. Make established clinical guidelines available for all providers
  50. 50. Compliance reporting showing variations in care at the provider and network level
  51. 51. Track physician performance against benchmarks and peers
  52. 52. Clinical decision support based on network determined guidelines including point of care alerts
  53. 53. Secure mechanism for provider communication
  54. 54. Facilitate PCP and specialty coordination
  55. 55. Support care transitions</li></ul>May 12, 2011<br />17<br />
  56. 56. Financial Management<br /><ul><li>Need tools and data to support strong modeling
  57. 57. Must have complete physician data as well as hospital information
  58. 58. Typical payor data sets won’t be enough – incomplete and far too old to help manage care and COST of care</li></ul>May 12, 2011<br />18<br />
  59. 59. NCIPA Profile<br />Physician owned and operated Colorado corporation <br />Consists of 667 providers<br />168 Primary Care Physicians<br />328 Specialist Physicians<br />171 Other Contracted Providers<br />Holds multiple contracts<br />Health Plan <br />Direct ERISA<br />May 12, 2011<br />19<br />
  60. 60. NCIPA Membership<br />February 28, 2011<br />20<br />
  61. 61. Membership Breakdown<br />
  62. 62. 22<br />February 28, 2011<br />NCIPA Primary Care Profile<br />
  63. 63. 23May 12, 2011<br />NCIPA Specialist Profile<br />
  64. 64. Current Situation<br />May 12, 2011<br />24<br />Services:<br /> - Provider Network<br /> - Claims Adjudication<br /> and Payment<br />Customers:<br /> - PVHS <br /> - Poudre School<br /> District <br /> - Columbine (400 lives)<br />50 % ownership<br />50 % ownership<br />
  65. 65. PVHS Proposal<br />“We (PVHS) would purchase NCIPA’s fifty-percent (50%) interest (in UMA), becoming the sole owners of UMA.” <br />May 12, 2011<br />25<br />
  66. 66. How Can We Help PVHS Do This?<br />May 12, 2011<br />26<br />By collaborating with PVHS to become the physician driven vehicle through which UMA can quickly develop a Clinically Integrated <br />accountable care organization<br />
  67. 67. Infrastructure<br />May 12, 2011<br />27<br />
  68. 68. Administrative Driven Infrastructure Components<br />Third Party Administration<br />Financial Management<br />Healthcare Operations Management<br />Utilization Management<br />Quality Assurance<br />CVO<br />Case Management<br />Business Operations Management<br />IT Systems and Analysis <br />Payor Contracting & Contract Management<br />Legal<br />May 12, 2011<br />28<br />
  69. 69. Physician Driven Infrastructure Components &/or Committees<br />Clinical Integration<br />Care Coordination<br />Health Information Technology & IT Management<br />Credentialing<br />Network Development<br />Contracting and Finance<br />May 12, 2011<br />29<br />
  70. 70. Role & Functions to Consider<br />To be the physician driven vehicle through which UMA can:<br />Provide clinically integrated services<br />Perform Utilization Management<br />Develop, approve and implement EBM practice guidelines for all specialties (HealthTeam Works)<br />Monitor physician compliance to practice guidelines and report compliance to participating providers (Verisk Health – Sightlines Medical Intelligence) <br />Counsel non-compliant providers and discipline them if non-compliance continues<br />Implement and assist Systems of Care supporting patient centered medical homes and medical neighborhoods (CO Medical Society initiative)<br />May 12, 2011<br />30<br />
  71. 71. Role & Functions to Consider (continued)<br />To be the physician driven vehicle through which UMA can:<br />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<br />Ensure only high quality providers satisfying established criteria participate in the network (Credentialing)<br />Promote clinical HIE interconnectivity in collaboration with CORHIO<br />Establish compensation options such as P4P, bundled payments and shared savings arrangements (starting with PVHS as the Beta site) <br />May 12, 2011<br />31<br />
  72. 72. PHO vs ACO<br />May 12, 2011<br />32<br />
  73. 73. Examples of “aco” Models<br />Physician-only “aco” (Summit)<br />For Profit Corporation (HWHN modified)<br />Hospital Division or Single-Member LLC (LHP)<br />LLC Model (UMA?)<br />May 12, 2011<br />33<br />
  74. 74. May 12, 2011<br />34<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  75. 75. May 12, 2011<br />35<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  76. 76. May 12, 2011<br />36<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  77. 77. May 12, 2011<br />37<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  78. 78. May 12, 2011<br />38<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  79. 79. May 12, 2011<br />39<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  80. 80. May 12, 2011<br />40<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  81. 81. May 12, 2011<br />41<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  82. 82. May 12, 2011<br />42<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  83. 83. May 12, 2011<br />43<br />Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar<br />
  84. 84. Getting Ready…<br /><ul><li>Readiness Assessment
  85. 85. Convene a team
  86. 86. Inventory existing projects and initiatives that align with strategic goals
  87. 87. Identify strengths and gaps
  88. 88. Critically examine:
  89. 89. Structure
  90. 90. Governance
  91. 91. Financial alignment
  92. 92. Systems integration
  93. 93. Clinical integration</li></ul>May 12, 2011<br />44<br />
  94. 94. Getting Ready…<br /><ul><li>Identify operational infrastructure opportunities that are readily transferable to a Medicare ACO
  95. 95. Mitigation of unnecessary 30 day readmits
  96. 96. Expedient provision of meaningful clinical information to PCP upon patient admission or discharge
  97. 97. Identify ACE and Bundled Payment opportunities
  98. 98. Facilitate medical management of the ERISA health plans
  99. 99. Identify and manage the most costly disease categories
  100. 100. Manage the most costly ETG’s
  101. 101. Manage to appropriate site of service</li></ul>May 12, 2011<br />45<br />
  102. 102. Getting Ready…<br /><ul><li>WORK TOGETHER!
  103. 103. Create a Clinically Integrated Network
  104. 104. Success factors
  105. 105. High quality and appropriate utilization
  106. 106. Performance demonstrated through quality metrics
  107. 107. Care coordination and collaboration among hospitals, physicians, other providers
  108. 108. Data collection and data sharing
  109. 109. Implement – Just do it!</li></ul>May 12, 2011<br />46<br />
  110. 110. May 12, 2011<br />47<br />DISCUSSION<br />A Walter Hankwitz, MBA, FACHE, CMPE<br />Highlands Health Management, Inc.<br />awhankwitz@highlandshealth.com<br />B: 423/863-1363 C: 423/534-0212<br />

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