Creating change and transformation in general practice.

1. 1
ChenMed Care Model:
Creating Change and
Transformation in General
Practice
November , 6th, 2014

2. 2
Average per capita health care costs by
number of chronic conditions
Source: Medical Expenditure Panel Survey, 2006
Chronic conditions drive health care spending, especially
in Medicare
Medicare spending for patients with 5+
chronic conditions
52%
65%
76%
0% 20% 40% 60% 80%
1987
1997
2002

3. 3
Who we are: Privately held, primary care-led physician group
Our focus: Low to moderate income adults > 55 with multiple chronic
conditions in urban areas. Typical patient searches for a PCP every 18
months, often considered “frequent flyers” by other health systems.
Care model: 400-450 patients per PCP; on-site Rx, focus on culture,
patient relationships, decision making, customized information
technology, intensive care coordination
Scale: Designed to scale quickly; Growth from 5 centers in Miami market
in 2010E to 36 centers in 8 markets at 2013E . 40+k risk lives in 2014.
Payment: Global risk adjusted capitation from Medicare Advantage plans
Snapshot of ChenMed

4. 4
This approach is fundamentally different
ChenMed Typical ACO
Population focus
Low to moderate income
MA population
Commercial insurance,
multiple types
Payor Primarily one, capitated
Multiple, FFS economics
still preeminent
Strategy
Start with getting doctor-
patient relationship right
Evidence based guidelines,
operational processes
Governance Primary care led
Complex, multi-specialty,
multi-facility
Ability to scale High Low
Upfront integration
challenges
Low High

5. 5
Chen NMC National Difference
Consumer Net Promoter
Score
92 40-50 >100%
Medication Possession
Ratio
82 42 73%
Hospital Days per 1000 1058 1712 (38%)
Percent of Ambulatory
Encounters on Site
86% N/A
Patient Visits at Center
Per Year
13.3 N/A
PCP Visits with Same
Physician
92% 40-60% > 50%
Miami Outcomes in CY 2011 prior to scaling

6. 6
Designing the operations of a focused factory
One-stop shopping enhances coordination,
collaboration, convenience, and compliance
Reproducible layout resembles an Ambulatory ICU
• Primary care doctors lead the care team and do not have
private offices
• Onsite specialists to encourage physician to physician dialogue
• Onsite supportive services for convenience
• Capacity to keep patients out of hospital (e.g., IV Antibiotics,
Diuresis)
Door-to-doctor transportation to our clinical sites
improves access to care

7. 7
Focus creates the potential for strategic design
▪ Hire staff who are passionate about this patient segment with right skills
▪ Engineer tighter integration and links in every process
▪ Test multiple changes in different markets
▪ Streamlined organizational governance
▪ > 70% of Medicare costs driven by patients with > 4 conditions
▪ Changes in outcomes can be measured in months
Faster change
cycles
Impact easier
to measure
Payor
collaboration
▪ JV allows for rationalization of care programs between payor
and provider (e.g., analytics, care coordination, specialized
programs)
▪ Don’t focus on fee for service demands
▪ Operational challenges dramatically reduced
Specialized
staff and
processes
Reduces
complexity

8. 8
Manage across
transitions
▪ Build in continuity where possible; hospitalist follows patients to first
follow-up visit
▪ PCP and NP joint SNF decision-making
▪ Initial home assessment
▪ Interdisciplinary weekly team meetings by center
Design around
access
▪ One stop shop – most patients within 7 miles ; transportation
▪ On-site physician drug dispensing
▪ Wellness focused activities on-site
▪ Not looking to be a complete multi-specialty group, but invite external
specialists on-site as feasible and practical
Build up care
team
▪ Nurse case manager, social worker, transitions team
▪ Developing medical assistants as coaches
▪ Qualitative judgment – the worry index
▪ Develop relationships with trusted specialists over time
Integrating primary care decisions around the patient

9. 9
Physician culture is critical to get care right
“from the inside out”

10. 10
Building the right culture requires changing mindsets
and behaviors
Role-modeling
Behavior and
mindset shifts
Developing talent
and skills
Reinforcing with formal
mechanisms
Fostering understanding
and convictions
The McKinsey influence model
“I see superiors, peers,
and subordinates
behaving in the new way”
“I know what is
expected of me – I
agree with it, and it is
meaningful
“I have the skills and
competencies to
behave in the new
way”
“The structures, processes,
and systems reinforce the
change in behavior I am
being asked to make”
• Changes in mindsets and
behaviors need to happen at all
levels of the organization,
starting with
– Front-line physicians
– Clinical team
– Physician leadership
• None of the changes in
behaviors and mindsets can be
mandated or dictated – each
will require a coordinated set of
influencing tactics to ensure
traction in the organization

11. 11
CMS risk
scores
Real-time internal
HEDIS Metrics
Real-time patient flow
metrics (i.e. wait times)
Comprehensive
outpatient clinical data,
digitized and scanned
• Hospital Admissions
& Readmissions
• Real-time inpatient
clinical data
Claims Data
• Part A
• Part B
• Part D
Net Promoter Scores /
Customer Feedback
Predictive
Modeling data
from Envita
and Humana
Providing a suite of tools to optimise decision making in
the exam room

12. 12
Using
Visualization
Tools to help a
Physician
Manage Her
Panel of 450
High Risk
patients

13. 13
A care timeline is used to integrate claims, referrals and
hospital data for high cost case management

14. 14
Dash2Go

15. 15
▪ 3 times a week review of patient
care by the physician group
▪ Transparent review of outcomes
with all physicians
▪ Entire team owns the relationship
▪ Relationship evolves over time
▪ >85% of the touch-points
Focus on the
patient
relationship
Physician
decision-making
▪ Selection and culture
▪ Decision support at point of care
▪ Positive incentives – the “tuned” patient panel
Convenience
matters
▪ Redesigned system of on-site physician drug dispensing dramatically
improves adherence
▪ On-site behavioral health model coordination
Communication
▪ Coordination of care
▪ Specialist – PCP communication
in person
▪ Team conferences
What are the key drivers of success in integrated care?