What is an Accountable Care Organization?

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  • Dollars in each bubble represent FY09 budgeted revenue
  • Operational and professional integration Physicians  Hospitals Primary care  Specialty care Clinic  Home ( MyGeisinger ) Provider  Payer (GHP) Enterprise-Wide Clinical Decision Support (via the EHR) Real-time, universally accessible clinical data Point-of-care and population-based targeting of patient “care gaps” Rules-based automation/delegation of routine care Accountability, Transparency, Incentives and Market Focus Performance data Geisinger Health Plan Geisinger Ventures
  • Phase 1 October 2006-May 2007 Phase 2 & 2B November 2007-May 2008 Phase 3 August 2008-January 2009 Phase 4 July 2009-November 2009
  • What is an Accountable Care Organization?

    1. 1. What is an Accountable Care Organization? Geisinger as an Exemplar March 17, 2010 Bruce H. Hamory, MD, FACP Executive Vice President, Chief Medical Officer, Emeritus
    2. 2. Heal • Teach • Discover • Serve Organized Delivery System “ A network of organizations that provide or arrange to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served.” SM Shortell, RR Gillies and DA Anderson (1996)
    3. 3. Heal • Teach • Discover • Serve Characteristics of High-Performing Integrated Delivery Systems • Strong physician leadership • Organizational culture • Clear, shared aims • Governance • Accountability and transparency • Selection and workforce planning • Patient-centered teams Tollen, LA The Commonwealth Fund (2008)
    4. 4. Heal • Teach • Discover • Serve Six Attributes of a High Performing Health System • Clinical information at point-of-care through EHR • Patient care coordinated • Providers share accountability and collaborate • Easy access to care for patients • Clear accountability for total care of patient • System continually innovates and learns Shih et al Organizing the U.S. Health Care Delivery System for High Performance (2008)
    5. 5. Heal • Teach • Discover • Serve Exhibit 1. Continuum of Delivery System Organization in the United States • Single MDs • Small Groups • Single Hospitals • Single Specialty Groups • Hospital Chains • Hospital Staffs • Some Faculty Practices MORE INTEGRATED SYSTEMS LESS INTEGRATED SYSTEMS Multispecialty Group Practices +/- Hospital Affiliation • Marshfield Clinic • Harvard Vanguard • Vanderbilt Univ. • Hill Physicians • Dean Health System Integrated Delivery Systems • Henry Ford Health System • Mayo Clinic • Geisinger Health System • Ochsner Clinic Fully Integrated Systems • Kaiser Permanente • Group Health Cooperative
    6. 6. Heal • Teach • Discover • Serve Accountable Care System “An entity that can implement organized processes for improving the quality and controlling the costs of care and be held accountable for the results.” Shortell and Casalino JAMA (2008) 300:95-97
    7. 7. Heal • Teach • Discover • Serve Accountable Care Organization (ACO) “A provider organization…clinically and financially accountable for their patients and the care they provide.” Crosson, et al The Commonwealth Fund (Nov. 2009)
    8. 8. Heal • Teach • Discover • Serve Accountable Care Organization Definition: A group of physicians with a hospital willing to be accountable for the quality and cost of care they deliver to a population of patients.
    9. 9. Heal • Teach • Discover • Serve Accountable Care Organization • An aggregation of sufficient advanced medical homes to meet required threshold of 5,000 patients managed • Robust HIT across all sites of care to influence and directly measure outcomes and quality metrics • Legal structure and governance to accept money and distribute it to all parties involved in care • Will involve specialists, nursing home contracts and others
    10. 10. What is an ACO? “An organization that is accountable for the quality and cost of care delivered to a population.” Fisher and Casalino “A set of providers responsible for the healthcare of a population of Medicare beneficiaries.” CMMS
    11. 11. What does an ACO do? • Sets and achieves standards for access, quality, safety, and patient-centeredness of care • Ensures coordination of care across multiple sites and providers • Delivers above while controlling costs
    12. 12. What is needed for an ACO? • Governance • Physician leadership • Ability to receive money • Ability to pay providers for care • Health information technology (EMR w/CPOE) • Arrange for all needed care (home, office, hospital, etc.) • Ability to track/meet patient needs
    13. 13. Heal • Teach • Discover • Serve “Make my hospital right, make it the best.” Abigail Geisinger 1827-1921 “Geisinger Quality – Striving for Perfection”…2006 - 2011 The Legacy
    14. 14. Heal • Teach • Discover • Serve Geisinger Health System Provider Facilities Physician Practice Group Managed Care Companies An Integrated Health Service Organization • Multispecialty group • ~800 physicians • ~370 advanced practitioners • ~60 primary and specialty clinic sites (36 community practice sites) • ~1.8 million outpatient visits • ~270 residents and fellows • Geisinger Medical Center with Janet Weis Children’s Hospital • Geisinger Northeast (2 campuses) - Geisinger Wyoming Valley Medical Center with Heart Hospital, Henry Cancer Center, Level II Trauma Center - Geisinger South Wilkes-Barre Ambulatory Surgery, Adult & Pediatric Urgent Care, Pain Medicine, Sleep Medicine • Marworth Alcohol & Chemical Dependency Treatment Center • Ambulatory surgery centers • >37K admissions • ~725 licensed in-patient beds • ~229,000 members (incl. 39,000 Medicare Adv.) • Diversified products • >18,000 contracted physicians • 90 Non-Geisinger hospitals • 43 PA counties Note: Numerical references based on fiscal 2010 budget.
    15. 15. Heal • Teach • Discover • Serve Geisinger Health System Careworks Convenient Healthcare Non-Geisinger Physicians With EHR Last updated 11/12/09 Geisinger ProvenHealth Navigator Sites Contracted ProvenHealth Navigator Sites Geisinger Medical Groups Geisinger Specialty Clinics Geisinger Inpatient Facilities Ambulatory Care Facility Geisinger Health System Hub and Spoke Market Area Geisinger Health Plan Service Area
    16. 16. Heal • Teach • Discover • Serve Geisinger Population-Based Care CY 2009 70% to 89% 40% to 70% 20% to 40% 10% to 20% 0% to 10% *All MRNs are defined as inpatient and outpatient for GMC, GWV, GSWB and GC Strategy & Business Development 1/10
    17. 17. Heal • Teach • Discover • Serve What is an Integrated Health System? A care model that is focused on the patient and includes both inpatient and outpatient experience. The model aligns all care providers to deliver the right care in the right place at the right time.
    18. 18. Heal • Teach • Discover • Serve • > $120M invested (hardware, software, manpower, training) • Running costs: ~4.4% of annual revenue of > $2.3B • Fully-integrated EHR: 36 community practice sites; 2 hospitals; 2 EDs; 6 Careworks Retail-based and worksite clinics – Acute and chronic care management – Optimized transitions of care • Networked PHR - 133,000 active users (27% of ongoing patients) – Patient self-service (self-scheduling, kiosks) – Home monitoring integrated with Medical Home • “Outreach EHR” - 2,300 non-Geisinger physician users – Regional image distribution • Regional Health-Information Exchange (KeyHIE) – 11 hospitals, 90+ practices, 2.5 M patients Electronic Health Record (EHR)
    19. 19. Heal • Teach • Discover • Serve he Geisinger Advantage • Our physicians and professional staff • Our market • Vision and leadership • Operational and professional integration • Enterprise-wide clinical decision support (via the EHR) • Accountability, transparency, incentives – all aligned • Our insurance/provider “sweet spot”
    20. 20. Heal • Teach • Discover • Serve ProvenHealth NavigatorSM (Advanced Medical Home)
    21. 21. Heal • Teach • Discover • Serve ProvenHealth NavigatorSM (Advanced Medical Home) • Partnership between primary care physicians and GHP that provides 360-degree, 24/7 continuum of care • “Embedded” nurses • Assured easy phone access • Follow-up calls post-discharge and post-ED visit • Telephonic monitoring/case management • Group visits/educational services • Personalized tools (e.g., chronic disease report cards)
    22. 22. Heal • Teach • Discover • Serve 150 200 250 300 350 Jan-Aug 06 Jan-Aug 07 Jan-Aug 08 Jan-Aug 09 GHS Phase 1 GHS Phase 2 & 2B GHS Phase 3 Medicare Control Group Risk-adjusted acute admits/1000 (Medicare population) 1/07 1/08 Acute admissions continue to show improvement 1/09
    23. 23. Heal • Teach • Discover • Serve ProvenHealth NavigatorSM significantly expanded since 2007 Date Sites Gold members Commercial members PGP members Phase 1 October 2006 May 2007 2 GHS 1 non-GHS 3,000 100 800 Phase 2 & 2B November 2007 May 2008 10 GHS 7,300 6,000 10,200 Phase 3 August 2008 January 2009 9 GHS 3 non-GHS 4,200 400 4,500 1,400 6,200 Phase 4 July 2009 November 2009 11 GHS and 1 non-GHS 4,300 12,300 4,700 Total 32 GHS and 5 non-GHS 19,300 25,000 21,100
    24. 24. Heal • Teach • Discover • Serve ProvenHealth NavigatorSM (Advanced Medical Home) • Currently serves 40,000 Medicare recipients and 25,000 commercial patients • Results from best primary care sites: • 25% patients’ admissions • 23% days/1000 • 53% readmissions following discharge • Significant benefit to patients and families, avoiding multiple hospital admissions
    25. 25. Heal • Teach • Discover • Serve
    26. 26. Heal • Teach • Discover • Serve The Physician Group Practice Demonstration Project: 4/05-3/10 Goal: To determine whether multispecialty group practices deliver higher quality care at lower cost than private practice physicians.
    27. 27. Heal • Teach • Discover • Serve Participants • Dartmouth • Everett Clinic • Forsyth Medical Group (Novant) • Geisinger • IRMA • St. John’s Medical Group • University of Michigan
    28. 28. Heal • Teach • Discover • Serve Conclusions Year 1 – Some dollars saved (2 paid) – Quality improved Year 2 – More dollars saved – Quality further improved Year 3 – More dollars saved (4 paid) – 2 groups hit all quality metrics
    29. 29. Heal • Teach • Discover • Serve What do you need to do this? • Physicians to lead the process • Governance to set goals and adjudicate issues • Lots of motivated PCP’s (it’s a population game!) • A hospital partner (access to capital/HIT) • A robust HIT system • Some joint financial system (? insurance partner)
    30. 30. Heal • Teach • Discover • Serve Issues • Legislation not passed • Regulations unwritten – ? 2% threshold – ? Cap on savings • Impact of state insurance rules on “risk- bearing” entity • Who’s in? – (? any willing provider)
    31. 31. Heal • Teach • Discover • Serve Health Insurance Reform • Adds 31-35 million people to insurance (many Medicaid) • Does not “bend the cost curve” • Offers “pilot projects” – Bundled Payments – Medical Home – Accountable Care Organizations • Will place downward pressure on payments
    32. 32. Heal • Teach • Discover • Serve Requirements for Integrated Delivery System • Common governance • Common mission, vision, values • Hospitals • Tightly affiliated physicians – Employed physician group practice – Other aligned physicians • Common financials • Robust clinical information system • Common metrics for success – 4 quadrant value proposition
    33. 33. Heal • Teach • Discover • Serve Design of Primary Care for Basic Medical Home • Continuity of care • Clinical information systems = EHR • Decision support: – EBM protocols for chronic/acute disease • Delivery system design: – Open access model • Patient/Family engagement • Coordination of care

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