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Wouldn't it be nice... 21APR12
The document discusses challenges in managing healthcare for patients in an Accountable Care Organization (ACO) model within a traditional fee-for-service system. It proposes a solution to make care coordination and quality accountability feel similar to a traditional HMO model by: 1) Tracking provider referrals and specialty visits, 2) Guiding provider selection based on quality/efficiency, 3) Incentivizing referring providers, 4) Allowing real-time patient tracking, and 5) Reinforcing quality at every patient encounter. The goal is to create a "virtual patient-centered medical home" model to manage ACO patients.
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Wouldn't it be nice... 21APR12
- 1. wouldn’t it be pan,mdmba wayne nice... pacifcpartners
- 2. to have agreat healthcare delivery system ?
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- 5. some learnings froma commercial ACO...
- 6. who am i& how did i get here?
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- 19. i know what you’re thinking
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- 42. From: Dan Roam,“American Healthcare: a 4-napkin explanation” www.slideshare.net/danroam/healthcare-napkins-all
- 43. From: Dan Roam,“American Healthcare: a 4-napkin explanation” www.slideshare.net/danroam/healthcare-napkins-all
- 44. ? From: Dan Roam,“American Healthcare: a 4-napkin explanation” www.slideshare.net/danroam/healthcare-napkins-all
- 45. insanity: doing the same thing over and over and expecting different results
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- 52. human lazy social nature habit notgood@ change
- 53. human lazy social nature habit socialnorms
- 55. human lazy social nature habit statusquo
- 56. human lazy social nature habit socialnorms
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- 61. doctor competitive nature independent curious formsilos
- 62. doctor competitive nature independent curious notgood@ cooperation
- 63. doctor competitive nature independent curious notgood@ collaboration
- 64. doctor competitive nature independent curious curious
- 65. doctor competitive nature independent curious competitive
- 66. doctor competitive nature independent curious competence
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- 82. what got ushere marshall goldsmith
- 83. won't get usthere what got us here marshall goldsmith
- 84.
- 86. from: A Gawande,“The Checklist,” The New Yorker (2007) (Artist: Yan Nascimbene)
- 87. from: A Gawande,“The Checklist,” The New Yorker (2007) (Artist: Yan Nascimbene)
- 89. © all rightsreserved by garyhymes
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- 99. Who is ?
- 100. Individual Practice Association Medical Group of Santa Clara County
- 101. Individual Practice Association Medical Group of Santa Clara County
- 102.
- 103. largest IPA inSanta Clara County
- 104. Santa Clara County size1,304.01 sqmiles pop 1,781,642 (2010) medianincome $74,335
- 105. THE Apr 21,2012 Price 75 FB C REDITS VIEW FROM THE VALLEY EUROPE ENGLAND RUSSIA ATLANTIC OCEAN NEW YORK CITY FLORIDA M DA EX NA IC C A CLEVELAND APPALACHIA O ILLINOIS the Mississippi River INFINITE LOOP SAND HILL ROAD
- 106. 5 PCP 80Specialists 173 PCP 343 Specialists 57 PCP 104 Specialists 11 PCP 30 Specialists SCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage) Anthem Commercial ACO pilot (2011)
- 107. urban/ suburban rural SCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage) Anthem Commercial ACO pilot (2011)
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- 111. no original Medicare, Medi-Cal, CHIP, uninsured
- 114. = managementservicesorganization medicalmanagement casemanagement networkmanagement providercontracting qualityimprovement credentialing memberservices claims&encounterprocessing clinicaldataanalytics&reporting marketingoutreach grievance&appeals compliance&auditing ITservices finance&riskmanagement
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- 126. roughroad 4x4 healthcare
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- 131. Case Managers Patients PCPs Specialists coordination
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- 137. retrospective retrospective
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- 140. + behavioral
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- 150. peopleprocesses hospitalists available 24/7 evaluation ofpatients for possible redirection to SNF aggressive use of observation status annual coding/documentation training for risk adjustment notification of PCP of admission/discharge discharge summary faxed to PCP
- 151. peopleprocesses SNFists ongoing evaluation ofpatients to reduce rehospitalization notification of PCP of admission/discharge discharge summary faxed to PCP
- 152. peopleprocesses onsite case managers dailyreview of patients based on Milliman guidelines actively involved with discharge planning all discharge needs authorized/arranged prior to discharge post-discharge follow-up on all patients with DME/HHC needs
- 153. peopleprocesses complex case managers warmhand-off between onsite and ccm use of clinical and non-clinical staff to assist patient and family caregivers with care coordination insure follow-up with PCP/specialist within 2 weeks
- 154. peopleprocesses utilization review staff allauthorizations/referrals reviewed using Milliman guidelines working closely with PCPs/specialists/ccm to facilitate care coordination compliance with regulatory guidelines generate member/provider letters regarding medical necessity decisions physician performance and quality reporting identification of potential quality issues continuous process improvement
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- 156. people:physicians/staff primary care physicians specialists ancillaryproviders front office staff
- 157. people:plan staff case managers diseasemanagers member outreach benefit design
- 158. peopleprocessesplatform communicate collaborate coordinate anticipate
- 159. peopleprocessesplatform common web-based communicationplatform facilitates administrative functions rules-based management of processes intuitive user-interface embed quality reminders into office/provider workflow provider feedback
- 160. peopleprocessesplatform common web-based communicationplatform facilitates administrative functions rules-based management of processes intuitive user-interface embed quality reminders into office/provider workflow provider feedback provide actionable clinical data at point of care allow patients to access their own data
- 161. peopleprocessesplatform common web-based communicationplatform facilitates administrative functions rules-based management of processes intuitive user-interface embed quality reminders into office/provider workflow provider feedback provide actionable clinical data at point of care allow patients to access their own data allow patients to provide feedback/enter their own data
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- 163. 80 Milliman - Loosely-Managed 70 Milliman - Moderately-Managed 60 Milliman - Well-Managed 50 SCCIPA 40 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > commercial admits/1000
- 164. 275 Milliman - Loosely-Managed 250 225 Milliman - Moderately-Managed 200 SCCIPA 175 Milliman - Well-Managed 150 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > commercial bed days/1000
- 165. 4.5 4.0 Milliman - Loosely-Managed 3.5 Milliman - Moderately-Managed SCCIPA 3.0 Milliman - Well-Managed 2.5 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > commercial average length of stay
- 166. 400 Milliman - Loosely-Managed 350 Milliman - Moderately-Managed 300 Milliman - Well-Managed SCCIPA 250 200 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > medicare admits/1000
- 167. 2,200 2,000 Milliman - Loosely-Managed 1,800 1,600 Milliman - Moderately-Managed 1,400 SCCIPA 1,200 Milliman - Well-Managed 1,000 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > medicare bed days/1000
- 168. 6.0 5.5 Milliman - Loosely-Managed 5.0 Milliman - Moderately-Managed 4.5 SCCIPA Milliman - Well-Managed 4.0 11 10 1 1 0 1 0 0 R1 N1 L1 L1 R1 N1 CT CT JU JU AP JA AP JA O O > medicare average length of stay
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- 188. feel just likethe oldway
- 189. 1 trackingauths > using thesame auth system, have providers enter in tracking auths for aco patients
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- 191. 2 providerselectiontool > when selecting“referred to” providers, these providers are listed in descending order of quality, efficiency, satisfaction
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- 195. 3 rewardaccountability > referring physicianscan be tracked to incentivize use of provider network
- 196. 4 checkinbutton > allows forreal-time patient tracking, provides opportunity for care coodination efforts
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- 201. 5 qualityreminders > @every encounterwith the healthcare delivery system, quality is reinforced
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- 204. air trafffic control for patients
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- 215. Thank you! wpan@ppmsi.com slideshare.net/bonedoc97 WWW.SNOOPY.COM