This webinar discusses the ACO Assessment Toolkit, an example of Intel's ACO, and how to improve ACO measures.

1. Purchaser Value Network
ACO Assessment Toolkit
JUNE 19, 2017

2. Agenda
• PVN ACO assessment toolkit—Kristof (10 mins)
• Intel’s ACO story—Angela (20 mins)
• Improving ACO measures—Emma (10 mins)
• Q&A (20 mins)
Kristof Stremikis
Associate Director for Policy,
PBGH
Emma Hoo
Director
PBGH
Angela Mitchell
Manager, Connected Care
Intel

3. Logistics
• Line muted.
• Questions in chat box throughout.
• Email kklaas@pbgh.org for slides.

4. Employer Direct Contracting (PBGH Members)

6. 1. Leadership, Governance, Organization & Experience
2. Member Identification and Engagement
3. Provider Engagement, Support & Feedback
4. Care Management and Population Health
5. Quality Measurement and Improvement
6. Network Management, Contract & Financial Model
7. Prescription Drug Management and Optimization
8. Health IT, Data Integration & Reporting
Domains

7. 4. Care Management and Population Health
Definition: Approach to patient risk identification, care coordination and member
engagement in care management and support services, including integration of behavioral
health services.
Best Practice
• Patients with chronic condition or behavioral health needs are proactively identified and engaged through patient-
centered approaches.
• Gaps in care are prioritized based on clinical significance and tailored to patients’ readiness and health goals.
• Patients are routinely screened for behavioral health needs.
• Using a defined process and criteria, medically complex and at-risk patients are proactively identified and receive direct
outreach and face-to-face contact, coordinated by or with the primary care physician.
• Community resources are leveraged to address psychosocial needs and environmental barriers to self-care and health risk
reduction.
• Patient’s caregiver is engaged in education and care coordination as needed.

8. 8. Health IT, Data Integration & Reporting
Definition: Health IT infrastructure and degree of data integration and exchange with
providers.
Best Practice
• Real-time clinical information is captured and communicated between treating providers.
• Real-time reporting through electronic medical record and/or two-way participation in regional health information
exchange (HIE).
• Frequent (at least monthly; daily where feasible) data exchange with health plans, pharmacy benefit managers and
relevant data suppliers.
• Electronic medical record or clinical decision support system provides timely information at the point of care to help
inform decisions about a patient’s care, facilitate treatment decision support, and improve outcomes.
• Data reporting categories include quality, cost and utilization metrics, using biometric and clinical lab values,
medical claims and pharmacy information.
• Analytics include risk stratification and predictive modeling – particularly high-cost high-need patients, gaps in care,
adherence to evidence-based medicine and care pathways, provider-level utilization and cost variation.
• Participation in community or other health information exchange networks reduces duplication

9. Angela Mitchell
Manager - US Connected Care
Intel Global Health and Wellness
Connected Care @ Intel

10. Intel Corporation TodayThe World’s Largest Semiconductor Manufacturer
Who we Are
Approximately 100,000 Employees worldwide / 50,000 US
• ~170 Sites in >70 Countries
• Major US sites: California,Oregon,Arizona,New Mexico
Our Business
 $59.4B in Annual Revenues
 $690M in US health care spend for 2016
 Data Center and Internet of Things are growing business segments
 Corporate vision that all of our business driven from a connected data growth
Our Brand
 1st World’s Most Admired Semiconductor Company by Fortune
 Forbes.World’s Most Reputable Companies & Most Valuable Brand (#17 - 2016)
 Gartner.Top 25 Supply Chains - 4th overall (global)
2

11. Measuring
Performance Pay for PerformanceDirect Contracting Member-Centric
Design
What is Connected Care?
Experience Quality Value

12. Performance Incentive Model

13.  Helping Intel innovate in healthcare
 A live person answers the phone!
 Ability to email providers, set appointments, see lab results, etc.
 Up to $1,000 into Health Savings Account
 Lower deductible w/ 5% coinsurance vs. 10%
 Do I Need to change doctor(s)?
Is this right for me?

14. New Mexico -
2013
Oregon - 2015
Arizona- 2016
California- 2017
Going Local and Connecting Care

15. Employer-Driven ACO Model
 Improving experience
• Concierge approach
• Dedicated teams with navigators
• Improved access/alternative venues of care
• Innovative technology/tools
 Improving heath outcomes
• Targets are set on access metrics,patient satisfaction
with experience, and clinical outcomes
• High-touch chronic disease management programs
 Reducing cost; increasing value
• Accountability for cost - PMPM
• High-preforming providers – access vs. quality
• EHRinteroperability
• No referrals or prior authorizations
• Focused on preventive care
VALUE
QUALITY
Member
EXPERIENCE
EMR Interoperability

16. • Exchange and reconciliation of structured clinical data within PCMHs and
Neighborhood providers
• Including onsite primary care clinics at Intel campuses in NM, OR and AZ
• Enhance the patient and provider experience through interoperable
systems
• Leverage nationally recognized health data and information exchange
standards
 eHealth Exchange (Sequoia Project)
 Direct Messaging
 IHEData Interoperability Standards
 CDAdocument family (e.g. C-CDA)
• Develop IT utilization reports to track and monitor matching rates and
evolve the model
Connected Care Interoperability Requirements

17. Medical Neighborhood
Specialists,Hospitals & Facilities
Patient Centered
Medical Home Clinics
Health for Life Centers
Intel Connected
Care Member
eHealth
Exchange
Connected
Care
Concierge
Dedicated Care
Teams
Interoperability w/ Intel’s Onsite Clinics
Direct
messagin
g
“It is incredibly exciting to hear about exchange happening in
the way we have always imagined.”
Lee Stevens,
U.S. Dept. of Health & Human Services

18. 48200
42366
81147
80000
60000
40000
20000
0
2015 2016
eHealth Exchange - Query/Retrieve
Volume
Number of queries via eHealth Exchange
2474
6215
0
1000
2000
3000
4000
5000
7000
2015 2016
CCDs pushed via Direct messaging
2016 Highlights
• 2016: 87,362 CCDs exchanged by all DSPs
• 2015-2016:132,202 CCDs exchanged since Connected Care-Oregon launched
• Volume Increase:2016 data exchange volume increases 53% over 2015
• Query SuccessRate: 90.2% of queries resulted in a retrieved CCD
*Ratio of queries vs. number of CCDsretrieved
Data Exchange Volume Overview - 2015 vs 2016

19. Retention
90%
91%
Member
Satisfactio
n
Enrollment
31%
 Connected Care is
more cost efficient
than national plans,
after adjusting for
age/gender/risk-
adjusted
 $1.7M in cost
avoidance
 Higher-risk members
are the most cost
efficient
0.82
1
1.07
CCPlans
(N=30,277)
Intel US National Plans
Average (N=100,706)
(N=130,983)
Cost Efficiency Ratio by
Plan, 2016
Cost Efficiency Ratio (<1 is good)
How’s it working?

20. •Connected Care Depression Management
• Connected Care members receive a mental health diagnosis from
family practice, general medical doctors and pediatricians more
often
• Non-CC US members are more likely to receive a mental health
diagnosis from a psychologist or psychiatrist
• Connected Care members are treated with a medication less often

21. Member
Experience Engagement
Health
Trends
Return on
Investment
Program
Vision
It’s a Journey
True disruptive care
Cost
Healthcare is Local
Copy Exactly
Challenges/Learnings

22. Intel & Providence Health & Services
Case Study

25. 2016 Pay for Performance
Results

26. •8% increase in diabetics with A1c in control
•5% increased in hypertensive patients with BP under
140/80
•Screened 75% of the population for depression in PCMH
•Screened 71% of population for substance abuse in
PCMH
Evidence Based
Medicine

27. •91% of calls for medical advice
returned within 4 hours
•Had 3 available appointments
within 4 days 92% of the time
•Had over 450 visits at alternative
venues (video, telephone, email)
Right Time Right Setting

28. •Would you recommend this provider office?
+4% increase
•Patients scoring their providers at a 9 or 10.
+4% increase
Member Experience

29. •A simple magnet reminder outside
of exam room to re-check BP at end
of visit
•Chart audit showed 75% of patients
within 5 degrees of goal
•Spread best practice to all clinics
Improving Outcomes

30. • Annual cost savings of $225 per
person compared to traditional
diabetic education
• Results: Patients had high
satisfaction, lost weight, and
lowered A1c
Online Diabetic Education
Pilot

31. • Mailed postcard to
homes post open
enrollment
•Average visits to virtual
care increased 65%
•Average visits to retail
increased 9%
Alternative venues for care

32. EMR Interoperability via direct
messaging

33. Healthy
(N=11,0
13)
Stable
(N=8,02
3)
At Risk
(N=4,83
7)
Strugglin
g
(N=2,32
5)
In Crisis
(N=356)
Actual PMPM $60 $190 $508 $1,462 $5,515
Expected PMPM $69 $253 $635 $1,534 $6,275
Ratio 0.88 0.75 0.80 0.95 0.88
0.88
0.75 0.80
0.95
0.88
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0.80
0.70
1.00
0.90
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
CC Cost Efficiency

34. Measurement

35. Meaningful Measures
GOAL: Use a concise set of quality measures that are outcomes-oriented and patient-centered
Why?
• Multiple sets of measures: CMS Medicare Shared Savings Program, CMS-AHIP Core Quality Measures, PBGH-CPR ACO
Toolkit measures, IHA Pay for Performance measures, health plan ACO measures, etc.
• Need to prioritize and focus provider accountability and improvement efforts
What?
• Targeted measures where a change in performance reflects demonstrable outcomes improvement and reduction in the
total cost of care
Who?
• PBGH, Catalyst for Payment Reform and Integrated Healthcare Association plus other stakeholder input
How?
• Improve capacity to capture lab values, biometric data and EMR-based information
• Leverage disease registry and other sources of information
• Increase use of patient-reported information

37. Contact Us:
Kristof Stremikis, Associate Director of Policy
kstremikis@pbgh.org
Emma Hoo, Director
ehoo@pbgh.org
Kelly Klaas, Purchaser Value Manager
kklaas@pbgh.org
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