Network physicians, hospitals, and other care continuum providers work collaboratively in active clinical process improvement programs across service lines and specialties to define, establish, implement, monitor, evaluate and periodically update the processes of: - Evidence-based medicine - Beneficiary engagement - Care coordination - Conservation of healthcare resources - Clinical data reporting

1. Collaborative Healthcare Models

2. Objectives/Challenges Require Collaboration
2
Common Objectives
•
Need to demonstrate success and build awareness around quality, service and efficiency results
•
Make it easy for members / patients to navigate the system
•
Engage and motivate members through proactive on-boarding, outreach, and navigation resources
•
Reduce network leakage
Common Challenge
•
Consumers are skeptical
•
By definition, new models are generally unproven and limited
•
Fragmented clinical decision making is still the norm
Countering Skepticism
•
Collaboration model, resources, reputation, and data must support capabilities
•
Care teams must engage patients through physician- driven population health programs and proactive member/beneficiary support services
•
Early identification of at-risk patients by sharing data and delivering impactful disease management resources is key

3. Trends Supporting Collaborative Models
•
Current trends are placing pressure on physicians to
-
Use health information technology
-
Develop resource intensive care management processes
-
Seek help in groups
-
Retire
•
Physicians are seeking help to alleviate administrative and financial challenges.
•
Without infrastructure and support, physicians become the most qualified but the least equipped to lead.
•
Volume, revenue, and physician relationships are at risk
•
Hospitals must have engaged physician partners to drive sustainable clinical process improvement
•
To date, some ACOs have achieved savings in part by excluding hospitals
•
“Hospitals want to do robotic surgeries, heart catheterizations, PET scans, MRIs—all the expensive items. We actually felt that hospitals were part of the problem.” William Biggs, MD CEO Amarillo Legacy Medical ACO 3
•
Cigna, Aetna, Blues and others are increasingly looking to ACO physicians and aligned resources to manage chronic conditions, coordinate care and reduce costs
•
Physicians are engaged in care management. We didn’t ask them in the past, and we didn’t pay for it either, Jill Hummel, WellPoint.
•
When a patient hears from a physician versus an insurance company, you know there is a much better chance of changing the behavior, M. Murphy, CEO Iowa Health System ACO.
PHYSICIANS
HOSPITALS
PAYORS

4. Clinical Alignment
Mission and Cultural Alignment
Economic Alignment
Less Integration
More Integration
Employment - Fixed Comp
Co - Management
Gain - Sharing
Joint Ventures
Recruitment Assistance
Medical Directorships
Employment - Variable Comp
Call Coverage Agreements
Integration Framework
Population Mgmt / CIN / ACO
Active Communication, Information Sharing, and Educational Connection Points Confidential Working Draft 4

5. Overlapping PCMH / CIN / ACO Framework
Requirements
Medical Home
Clinical Integration
Accountable Care
Care Coordination
X
X
X
Patient Centeredness
X
X
X
Evidence-Based Guidelines
X
X
X
Meaningful Use Requirements
X
X
X
Coordinating Transitions of Care
X
X
X
Financial Integration
X
X
Communication & Collaboration among Providers
X
X
Performance Metrics Selection & Reporting
X
X
Demonstration of Improved Quality & Cost Reduction
X
X
Population Health Management
X
Greater Clinical Integration Across Care Continuum
X
Population-Based Risk Management
X 5

6. Population Health Priorities and Challenges
Priority Programs
Primary Care
•
Medical Home
•
High risk stratification
•
Mental health
Specialty Care
•
Clinical protocols
•
Referral management
•
Virtual visits
•
Bundles
Care Continuum
•
Post acute networks
•
Mobile observation units
•
Urgent care
Patient Engagement
•
Shared decision making
•
Virtual patient communities
•
Customized educational materials
Infrastructure
•
HIT, data sharing and analytics
•
Infrastructure/program management
Implementation Challenges
Clinical Management
•
Building comprehensive clinically integrated network
•
Reaching population health critical mass (lives)
•
Risk adjustment and predictive modeling accuracy
•
Developing, implementing and monitoring clinical protocols
Operational
•
Start-up costs
•
Easy access/use by patients
•
Clarity on where/who provides clinical and admin support services
•
Consistent messaging from beneficiary enrollment to the physician’s office
•
Provider incentives
•
Reporting to demonstrate services and value
Legal
•
Anti-trust, Stark, civil monetary penalty restrictions 6

7. •
PCMH Operations Staff: Training and technical assistance to help physicians achieve Medical Home principles.
•
Care Management and Coordination Staff: Support the PCMH/APCP practices and are operationally integrated with the Facility Based Case Management program.
•
Other potential internal or contract resources include:
-
Disease management
-
Coding optimization
-
Patient education and self-management
•
Medical Informatics Staff: Primary analytic resource supporting care management team, CPC physician leaders, PCMH Steering Committee, and PCMH PODs.
•
Point Of Care Tool Set: Complete and timely information about patients at the point of care.
•
Population Management Tool Set: Technology and skills for population management and coordination of care
Resource Considerations
7

8. Standardized CDR
HIT - Data Extraction, Standardization and Reporting
Confidential Working Draft 8
HOSPITAL SYSTEMS - Clinical, Demographic and Financial Data
PHYSICIAN SYSTEMS - Electronic Medical Record
(EMR)/PMS
ANCILLARY SYSTEMS - Additional Data Sources (payer, Medication fulfillment, Ref Lab, Registry, etc)
PAYOR SYSTEMS - Claims Data – Budgets, Utilization, and Financial
External Entity Reporting (MSSP-GPRO, Commercial Payor - BTE, IPIP, QIO, etc.)
CCR/CCD (Standardized Clinical Coordination Data Sharing)
Evidence-based Clinical Guidelines PQRI Measures
Interface Engine
Clinical Protocol Engine
Point of Care / Gaps in Care Reports (patient specific, CDS)
Internal Reporting/Data Analyses (population registry)
Reporting Engine

9. Coordinated Message around and through PCP
•
A sustained competitive advantage will require achieving and maintaining engaged and motivated members through:
•
Consistent messaging from enrollment to the primary physician (Medical Home/APCP)
•
Coordinated plan/provider member service resources
•
Easy access and use by members
•
Agreement / clarity on services included
•
Reporting results 9
Connecting the dots between results and resources
Consistent message around care programs, service content, source, how to access, and value

10. Collaborative Network Navigation Aids
Onboarding Enrollment Resources
•
Find a Physician
•
BioScreening / Health Risk Assessment
•
Web Based Scheduling
•
Patient Portal
•
Data Sharing / HIE
•
Population Health Programs
-
Wellness
-
Care Coordination
-
Chronic Disease Management
-
24 Hour Nurse Line
•
Pharmacy Benefits Educate Members & Activate Navigation Aids
Payor Based Member Services
Member Onboarding and Navigation Aids
Population Health Programs
Provider Based Members Services and Network Referral Coordination / Scheduling
Ancillary
Specialist
Post Acute
Acute
Web Based Member Services
Engage Medical Home Relationship
•
Informed PCP Visit
•
Discuss BioScreen Results
•
Activate Indicated Population Health Programs
New Member 10

11. DISCUSSION / NEXT STEPS
How do we work together?
9/3/2014

12. Sample WayPoint Case Study 1
•
Advanced Primary Care Initiative (Patient Centered Medical Home)
•
Innovative population management payer contracting relationships
•
Patient quality and safety incentive programs
•
ACO Start-up
•
Medicare Shared Savings Program application and implementation
•
Strengthening health information technology and population management infrastructure
•
Assessed existing clinical integration resources, evaluated existing incentive structures, and refined objectives to reflect market-specific priorities
•
Developed enterprise scope, structure, governance and leadership
•
Developed provider network composition
•
Created reporting tools and processes
•
Created Physician and care team incentives tied to quality initiatives
•
Created health information technology resource plans
•
Created staffing plans and operating budget estimates
•
PCMH implementation in 12 months with more than 100 physicians in various independent and employed practices certified to date
•
CMS Medicare Shared Savings Program ACO approved
•
Multiple commercial payer ACO contracts
•
Among the largest ACOs nationally and named one of Becker’s “100 ACOs to Know”
•
Included in the 29 ACOs that experienced significant shared savings through the first quarter of 2013 Confidential Working Draft 12
Client Need
WayPoint Work
Results

13. Sample WayPoint Case Study 2
•
Approval by Medicare to participate in the Medicare Shared Savings Program
•
ACO organizational structure and start up activities
•
Population health management technology implementation
–
Analytics to identify, stratify and assess the patient’s risk
–
Analytics to improve provider performance and measure quality
–
Health Information Exchange
•
Clinical process improvement and care management people, process and technology resources
•
Drafted and submitted the ACO application for CMS approval
•
Facilitated the technology architecture of data sharing based on their selected technology vendors
•
Review and negotiation of selected technology contracts
•
Data submission for beneficiary data sharing claims feed
•
Project oversight for implementation of HIE, risk modeling application and physician performance application
•
Begun restructuring of clinical process improvement workflow and associated governance
•
Facilitated care management model discussion
•
CMS Medicare Shared Savings Program ACO approved
•
Multiple commercial payer ACO contracts
•
Among the largest ACOs nationally and named one of Becker’s “100 ACOs to Know”
•
Included in the 29 ACOs that experienced significant shared savings through the first quarter of 2013 Confidential Working Draft 13
Client Need
WayPoint Work
Results