Presented at the 35th Annual ABQAURP meeting, Atlanta 21APR12

1. wouldn’t it
be pan, mdmba
wayne
nice...
pacifcpartners

2. to have a great
healthcare
delivery
system ?

3. but we
don’t.

4. whynot?

5. some learnings from a commercial ACO...

6. who am i &
how did i
get
here?

10. orthopedic
hand
surgeon

11. medicaid
medicare
health
plans

12. ipa/mso
commercial
medicare
aco/ppo

13. healthcare
warrior

14. how about
you?

15. we are all
healthcare
warriors

16. who are
we
fighting
for?

17. the patient.

18. why?

19. i know
what you’re
thinking

20. takeaways

21. LISTEN TO
THE CHILD
WITHIN
YOU

22. WWABD?

23. HAVE FUN

25. discipleof

26. nancyduarte

29. bjfogg, phd
stanford

31. rogermartin
rotman, toronto

33. 2 business
processes:

34. 2 business
processes:
reliability

35. 2 business
processes:
validity

36. have to do
both

37. have to do
both
sustainable

38. have to do
both
obsolete

41. why?

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

47. some
basics

48. human
nature

49. human
nature
lazy

50. human
nature
social

51. human
nature
creaturesofhabit

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

57. doctor
nature

58. doctor
nature
competitive

59. doctor
nature
independent

60. doctor
nature
curious

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

67. leverage
our nature

68. leverage
our nature
4 behavior
change

69. michael
vanduren
mdmba
sutterhealth

70. michael
vanduren
mdmba
variationreduction

72. WWABD?

73. leverage
our nature
socialnorms

74. leverage
our nature
curious

75. leverage
our nature
competitive

76. leverage
our nature
competence

77. easy

78. easy
accessible

79. easy
accessible
design for failure

80. easy
accessible
design for failure
achievement

81. easy
accessible
design for failure
achievement
feedback

82. what got us here
marshall goldsmith

83. won't get us there
what got us here
marshall goldsmith

84. behavior
change

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 rights reserved
by garyhymes

91. beware of
shortcuts

92. remember
who & why

93. better for
patients?

94. easier for
patients?

96. ?

99. Who is
?

100. Individual Practice Association
Medical Group of
Santa Clara County

101. Individual Practice Association
Medical Group of
Santa Clara County

102. SCCIPA

103. largest IPA in Santa Clara County

104. Santa Clara County
size 1,304.01 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
80 Specialists
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)

108. 25,000
commercialACO

109. 40,000
commercialHMO

110. 5,000
MedicareHMO

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

115. partialrisk

116. managingDOFR

117. Division
Of
F inancial
Responsibility

118. outpatientservices

119. inpatientservices

120. capitatepcps

121. specialistspaidffs

122. performancebonus

123. IHAP4P&HCC

124. IPAcitizenship

125. roughroad

126. roughroad
4x4 healthcare

127. 4processes
x
4
dimensional
data

128. 4processes

129. communication

130. collaboration

131. Case
Managers
Patients PCPs
Specialists
coordination

132. anticipation

133. 4
dimensional
data

134. financial

135. administrative

136. clinical

137. retrospective
retrospective

138. reactivecare

139. $$$$$$

140. + behavioral

141. predictive

142. proactivecare

143. provideactionabledata

144. @pointofcare

145. @home

146. thecareteam

147. thecarecontinuum

148. peopleprocessesplatform

149. peopleprocessesplatform

150. peopleprocesses
hospitalists
available 24/7
evaluation of patients 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 of patients to reduce
rehospitalization
notification of PCP of admission/discharge
discharge summary faxed to PCP

152. peopleprocesses
onsite case managers
daily review 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
warm hand-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
all authorizations/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

155. people:physicians/staff
primary care physicians
specialists
ancillary providers

156. people:physicians/staff
primary care physicians
specialists
ancillary providers
front office staff

157. people:plan staff
case managers
disease managers
member outreach
benefit design

158. peopleprocessesplatform
communicate
collaborate
coordinate
anticipate

159. peopleprocessesplatform
common web-based communication platform
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 communication platform
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 communication platform
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

162. ourresults

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

169. managingACOpatients
inafee4serviceworld

170. challenge#1
managingproviderbehavior

171. challenge#2
managingpatientbehavior

172. challenge#3
alignincentives

173. HMOworld

174. patientsassignedPCP

175. PCPmanagesreferrals

176. patientsstayinnetwork

177. ACOworld

178. patientsnotassigned

179. physiciansendspatient

180. notrestrictedtonetwork

181. whataboutquality?

182. whoisaccountable?

183. carecoordination?

186. oursolution

187. make the newway...

188. feel just like the oldway

189. 1
trackingauths
> using the same auth system, have providers enter in
tracking auths for aco patients

190. keepspatientinnetwork

191. 2
providerselectiontool
> when selecting “referred to” providers, these providers are
listed in descending order of quality, efficiency, satisfaction

192. promotesquality

193. promotesefficiency

194. promotessatisfaction

195. 3
rewardaccountability
> referring physicians can be tracked to incentivize use of
provider network

196. 4
checkinbutton
> allows for real-time patient tracking, provides opportunity
for care coodination efforts

197. automatedtracking

198. alertingcasemanager

199. nocheck-inby_________

200. requestimmediatehelp

201. 5
qualityreminders
> @every encounter with the healthcare delivery system,
quality is reinforced

202. entireteamisaccountable

203. virtualpcmhmodel

204. air
trafffic
control
for patients

205. ibelieve...

206. ask
not...

208. cultural
revolution

210. thinkdifferent

211. LISTEN TO
THE CHILD
WITHIN
YOU

212. WWABD?

213. HAVE FUN

214. welcome to
healthcare2.0

215. Thank you!
wpan@ppmsi.com
slideshare.net/bonedoc97
WWW.SNOOPY.COM