This document discusses considerations for healthcare organizations looking to participate in accountable care models. It outlines a multi-step process involving multiple disciplines to assess an organization's readiness for accountable care and develop an integrated strategy. Specific near-term actions are proposed for disciplines like business strategy, care delivery, operations, finance, technology, and legal/organization. The expected results of addressing each discipline are described as developing a strategic plan, reinventing the care delivery model, building operational capabilities, assessing financial requirements, evaluating technology needs, and establishing a compliant legal structure.

1. Accountable Care: A New Delivery Model
Is Your Organization Ready to Participate
in Accountable Care?
Copy Right © 2011 JHD Group, EpsteinBeckerGreen and KPMG

2. Today’s Speakers
EpsteinBeckerGreen KPMG Healthcare
www.ebglaw.com www.kpmginstitutes.com
Jack Gleason David Matyas Brad Benton Joe Kuehn
Member Member Parrtner Partner
JHD Group
www.jhdgroup.com
Hank Duffy
President
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3. Introduction
Recapping Our Three Part Webinar Series
Overview of the MSSP proposed rules from CMS, DOJ, FTC, AND IRS
– ACO Structure and Governance – Primary-Care Centric
– Shared Savings Models – Two Tracks
– Beneficiary Attribution and Choice
– 65 Quality Measures
– Antitrust Issues
– Fraud and Abuse
– IRS Issues
– Timing and Comment Period
Business considerations
– Identifying the strategic options
– Building a business case
– Operational challenges
Today’s conversation
– Responses to polling questions
– Getting ready – A coordinated approach
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4. Polling Responses
Great audience response Our accountable care orientation is:
Accountable care focus is “all payers” All payers except Medicare 2%
Providers dominate All payers (in an "accountable care
like" arrangement)
36%
Support concept of shared savings Medicaid only 1%
Equal number of “watchers and Medicare only 4%
waiters” as “players”
My organization`s current position on Medicare
ACO is:
We don't expect to be a participant 5%
We'll be watching and waiting 17%
We're building; expect to file later 9%
We're a first wave player 8%
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5. Polling Responses (continued)
“We’re not ready yet” How long do you believe the creation of an ACO
will take?
ROI will be delayed
More than 30 months (not in the
27%
foreseeable future)
Question how accountable care fits
with current organizational strategy 25 to 30 months 24%
Data systems/EHR is a major 19 to 24 months 11%
concern
13 to 18 months 1%
Physician buy in is the greatest
What do you see as the greatest challenge toward
challenge launching an ACO?
Physician buy-in 27%
Management buy-in 7%
Staff and or skill sets 18%
Cost 25%
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6. Getting Ready and Moving Forward
Determining the right approach to accountable care depends on the
market, the culture of the organization, and your overall business
strategy
Becoming a CMS ACO near term is just one option
Not a “Cookie Cutter” solution
Local markets and specific organizational circumstances are too different
Private or local market solutions with slower migration to clinical integration may precede CMS
ACO participation
Requires a transition of the entire business model of “traditional” care delivery
Change is here; Are you ready?
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7. Pulling All The Pieces Together
Achieving the Three Part Aim – Multi-dimensional Organizational
Challenges
Government
Payors
Employers
Better Care for Individuals
Providers
Better Health for Populations
Lower Growth in Expenditures
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8. How Complex Is It?
An organization’s “state of readiness” can be assessed by considering
questions across a number of disciplines
Strategy Care Delivery Operations Financial Technology Legal
How to increase What to What is the best What is the What How should
market approach clinical management economic case infrastructure is parties be
competitiveness? integration? structure for for moving needed to organized?
What is the How to assure a accountability? toward an ACO? support: How should it be
population robust PCP How to structure Do we pursue – IT Systems governed?
opportunity? resource? compensation performance – Portals Is special state
Go with a How to move and incentives? incentives, gain licensure
sharing, or risk – Data/
“Closed Network” toward PCMH How to create a Reporting required?
or Partnerships? accreditation? single “Clinical contracting?
– Supporting Are there
Participate in How to include Team” culture? What investment contracts with
is required? functions
CMS Pilots or Disease How to integrate providers?
the CMS Management and Practice What are the How to expedite
“Meaningful Use” How to comply
program? Preventive Care? management? financial with various
What is the How to manage How to develop projections? How to get to regulatory
“Case to act”? complex cases? training around What are the tax and manage the concerns?
patient considerations? “Measures”
How to assure data? What are the
effective EHR management? antitrust
use? How to align non- How to link the considerations?
employed partners?
Is the physician
leadership physicians
ready?
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9. Addressing the Challenge
A multi-step phase process involving multiple disciplines
Develop
Create Design Implement Solutions Monitor Results
Insight
Assess your readiness
Evaluate your options
Develop a specific and tangible
course of action
Manage and monitor the
transition
Discipline Develop Insight Create Design Implement Monitor
Business Strategy
Care Delivery
Most
Operations
More
Financial Blue =
More
Technology Effort
Legal and Organization Least
Communications
Change management
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10. Six Integrating Disciplines
When it comes to moving forward, there are “Six Disciplines” to be
developed and integrated
Business
Strategy
Legal and
Financial
Organization
Operations Technology
Care Delivery
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11. Six Integrating Disciplines
Business What is our strategy to become Accountable Care
Strategy Capable?
Specific near term actions should include:
1. Determine Goals: “Market Mover”, performance advantage, or “positioning” for healthcare
transformation
2. Assess market footprint versus population needs; competitor, payor, and employer
positioning;“owned”/community physician cohort; and antitrust considerations
3. Develop analytical data baseline
4. Involve physician leadership
5. Assess alternative strategies and care models
6. Model the “Business Case”
7. Develop tangible strategy
Expected Result: A plan that determines if and how to move to an accountable care capable
operation in a sustainable manner
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12. Determining What is Right for Your Organization
Business What is the optimal threshold of investment,
Strategy complexity, and readiness?
High
Incremental
Level of investment
Operational
Complexity
Incremental
investment
Low
Single Disease Medicare ACO Total Population
State ACO
Degree of Medical Integration and ACO-Readiness
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13. Six Integrating Disciplines
How to reinvent the care delivery model?
Care Delivery
Specific near term actions should include:
1. Establishing broad internal recognition that the key to success will be effective clinical
integration and that:
Clinical Integration is NOT Clinical Integration IS
– Employing physicians – Physician (PCP) led
– An IPA or PHO clinical teaming
– A Network – Patient centered
– Multiple Joint Ventures coordinated
care/continuity-of-care
– The full range of clinical
services in the best setting
– Preventive, acute, and
chronic management of
health
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14. Six Integrating Disciplines
How to reinvent the care delivery model?
Care Delivery
2. Develop understanding of population and utilization efficiency benchmarks
3. Assess PCP and specialist capacity and continuum participants (i.e. SNFs, Home Health, etc.)
4. Identify and start educating/training physician leaders on “Top of Licensure” role
5. Assess readiness for “Dynamic Access”, Level 3 PCMH, coordinated care, preventive care,
patient experience monitoring, and Demand Chain Management
6. Begin development of Medical Management to support diversion programs, outreach, complex
case management, disease management, etc.
7. Identify “Impactable” populations with actuarial and clinical analytics, and build a Care Team
Model around clinically integrated dashboards (possibly using all 65 measures)
Expected Result: A disciplined migrating program to a population and metric based care delivery
model
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15. Six Integrating Disciplines
How to build the team and define the roles and
Operations
responsibilities?
Specific near term actions should include:
1. Develop process to collect clinical, financial and quality data
2. Create communications processes that stitch together actuarial, clinical management, care
delivery/collaboration, and reimbursement processes
3. Establish documented roles, governance, and organizational protocols
4. Develop the “Management Dyad” to promote accountability and team work
5. Build a change management and communications team to oversee internal cultural transition
and external communications
6. Elevate organization awareness of the granularity needed to satisfy functional responsibilities
e.g. finance, clinical, actuarial
7. Ensure the critical components of medical management, provider contracting, quality and cost
reporting, and financial management all come together
Expected Result: Operational capabilities to effectively manage the health and wellness of a
defined population
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16. Six Integrating Disciplines
How are the economics going to work and what is
Financial
the investment?
Specific near term actions should include:
Build/Test Business Case
1. Define the role of Finance in shaping strategy, partnerships, and transactions
2. Develop cost benchmarks and probable cost growth curve
3. Validate patient aggregation, costs of services, and utilization expectation assumptions
4. Financially model alternative scenarios and strategies (i.e. Accountable Care Capable, Track 1,
Track 2)
5. Quantify and source the investment required for infrastructure development and working capital
6. Perform actuarial and clinical analysis
7. Develop expanded physician compensation models
8. Develop and confirm target performance
9. Create financial projections: assess risks; stress test and analyze ROI
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17. Six Integrating Disciplines
How are the economics going to work and what is
Financial
the investment?
Financial Operations
10. Identify and capture transactional data at the source; clinical information as well as quality
based data and resource consumption
11. Develop processes and governance structure so that data can be collected and stored
accurately, and with sufficient granularity
12. Provide timely and accurate reporting, to enable sound decision making on a clinical as well
as operational/process level
13. Develop shared savings programs, compensation models and allocations in a clear and
understandable way – Transparency is key
14. Leverage the lessons learned from failed capitation deals of the 90’s
Expected Result: A robust finance function capable of addressing the complexity of the requisite
planning and reporting needs
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18. Six Integrating Disciplines
How to build and deliver the necessary technology
Technology
infrastructure?
Specific near term actions should include:
1. Identify ACO participants and develop inventory of applications, infrastructure, connectivity,
etc…
2. Define technology support requirements (applications, infrastructure, integration)
3. Identify additional data sources (i.e. payers) and the ability to manage granular clinical,
operating, and population data, and how to integrate into dashboards
4. Identify gaps in capabilities
5. Assess timeline relative to “Meaningful Use”, ICD-10, and EHR
6. Determine role of EMR Stark Safe Harbor and approach to EMR integration amongst
participants
7. Assess ability to support PCMH with necessary reports and metrics
8. Develop a three year technology plan for Accountable Care Support
Expected Result: An assessment of technology requirement gaps and infrastructure needs
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19. IT Support Requirements
Member access to personal health data and health maintenance content
Membership Engagement Enrollment and Membership applications
and Personal Health
Management Connection to remote home monitoring devices
Clinician contact (social media, call center, secure messaging)
Access to data – Electronic Health Records/Health Information Exchange
Clinical Information Evidence Based Care (guidelines and protocols)
Exchange and Medical
Management Clinical Decision Support (rules and alerts)
Provider connectivity and mobility
Electronic Health Records and Meaningful Use
Post Discharge Reporting
Quality Reporting
Real Time Reporting
Data aggregation across care sites
Normalization of disparate data
Information Management Business Intelligence Analytics
– Clinical, Financial, and
Operational Predictive Modeling
Tools – Build vs. Buy
Revenue Cycle system enhancements
Cost Accounting system enhancements
Risk Management
Provider Network Management
Contract Management
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20. Six Integrating Disciplines
Legal and How to address legal hurdles and structure an
Organization organization?
Specific near term actions should include:
1. Establish the organizational, management and governance structure
2. Develop the risk and incentives distribution methodology in a legally compliant manner
3. Identify the necessary members/participating providers and negotiate contracts (or
amendments to existing contracts)
4. Enter into (or modify existing) contractual arrangements with third party payors (either
government or private)
5. Explore potential antitrust issues and evaluate market share considerations
6. Address IT Legal Issues (Privacy and Security)
Expected Result: Legal entity formed that has developed contracts to be paid under an
“accountable care” methodology and shares the financial rewards (and risks) with other members
in a legally compliant manner
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21. Expected Result
Progress results and speed can be assessed as each stage of the
“Health Care Value Curve” is achieved
Stage IV:
Structured
Stage III: Health
Integrated Care Management
Management Protocol based
Stage II: Clinical care plans
Decision support Holistic “view”
of patient Advanced
Data from Chronic
multiple Coordination of
Care Disease
sources Preventive
Stage I: Data Improved error Patient access
to Data health
Retrieval avoidance management
Improved Improved Consistent use
of registries Value based
Encounter Continuity of reimbursement
Capture Care Evidence
based best Clinical
Access to Improved
practices population
Patient Data clinical management
workflow
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22. The KPMG Healthcare Transformation Agenda – 3 Pillars
An Example of One ICD-9-CM code being
represented by Multiple ICD-10-CM Codes E 1 0 4 0
Type 1 diabetes mellitus with diabetic neuropathy, unspecified
The granular clinical data captured E 1 0 4 1
Type 1 diabetes mellitus with diabetic mononeuropathy
through the ICD-10 code set…. 2 5 0 6 1
Diabetes mellitus with neurological E 1 0 4 4
manifestations type I not stated as Type 1 diabetes mellitus with diabetic amyotrophy
uncontrolled
Public
Health E 1 0 4 9
Type 1 diabetes mellitus with other diabetic neurological complication
Providers
Pharma/
Device Interconnected
Health
“Eco-System”
Payor
Research
Viewed through the lens of ever-more-
Physician
Enterprise BI Framework sophisticated healthcare information
Business Strategy
technology…..
Business
Alignment Stakeholders
throughout the
healthcare lifecycle Components of an ACO
Governance
will need assistance
with interpretation
Performance and reporting on
clinical events
Management Process
The health
and Reporting
Integrated Information information
exchanges that will
Management
be implemented in Manage to
Coordinate Items
Technical
Business Intelligence
each state will drive Quality
and Services
Platform (Translation) data integration and Standards
sharing across a
Infrastructure
diverse set of Effective
technical Health
environments Management
Changes the practice of medicine and,
Cost and
therefore, the business of healthcare. Efficiencies
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23. Addressing the Challenge
An approach to making the transition “Manageable”
Strategy and
“Glide Path”
Gap Assessment Business Case Execution
Development
Development
Quick Specifies Addresses how Manage
assessment of market and to manage the transition to
ACO Capable performance transition to milestones and
Care readiness goals ACO Capable financial
Addresses key Identifies Care targets
questions alternative Details the Often requires
Identifies major strategies individual 2 – 3 years
gaps and Develops the projects with
priorities preferred milestones
Assesses the strategy Prioritizes “Low
“Case to Act” Documents the Fruit”
About 30 “Business opportunities
calendar days Case” Requires 2 – 3
to complete Requires 2 – 3 months
months
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24. Concluding Thoughts
There may be many reasons for not moving forward, but there are four
compelling reasons to start acting
The reimbursement system is changing
As CMS goes, so does the private sector and other payers
It takes time to make the move to being accountable care capable – classic “turning the
battleship”
It makes sense and is going to happen
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25. Concluding Thoughts (continued)
“It is neither the strongest of the species that
survive, nor the most intelligent, but the one most
responsive to change”
Charles Darwin
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26. Contact Information:
Brad Benton John H. (Hank) Duffy John F. Gleason
KPMG, LLP JHD Group Epstein Becker & Green
303 Peachtree Street 5055 Keller Springs Road 250 Park Avenue
Suite 2000 Suite 240 New York, NY 10177
Atlanta, GA 30308 Addison, TX 75001 Office 212 -351-4500
Office: 404- 222-3166 Office: 214-674-5240
E-Mail: jgleason@ebglaw.com
E-Mail: bbenton@kpmg.com E-Mail: hduffy@JHDGroup.com
www.ebglw.com
www.kpmg.com www.jhdgroup.com
Joe Kuehn David Matyas
KPMG, LLP Epstein Becker & Green
1305 Walt Whitman Road 1227 25th St NW
Suite 200 Suite 700
Melville, NY 11747-4302 Washington, DC 20037-1175
Office: 631-425-6021 Office: 202-861-1833
E-Mail: jkuehn@kpmg.com
E-Mail: Dmatyas@ebglaw.com
www.kpmg.com
www.ebglw.com
Copy Right © 2011 JHD Group, EpsteinBeckerGreen and KPMG
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