Presentation on theme: "Introducing…”Meridian Health Partners”"— Presentation transcript:
1 Attaining Scale in a Changing Market Update on the ACO and the Clinically Integrated Network Introducing…”Meridian Health Partners”Richard J. Scott MD MBA FACS CPE SVP Clinical Effectiveness and Medical AffairsExecutive Director, Meridian ACO LLC
2 Special thanks to the members of the Steering Committee, ACO and Clinically Integrated Network
3 “Clinical Integration” “A means to facilitate the coordination of care across conditions, providers, settings and time in order to achieve care that is safe, timely, effective, efficient, equitable and patient focused” – AMACI is a continuous process of alignment between hospitals and all providers across the continuum that supports the triple aim of health care:Better care for individuals, better health for populations and lower per capita healthcare costs
4 Four Pillars of Integrated care Clinically Integrated CareCollaborative LeadershipGovernance bodyCompliant legal structurePayer strategyCulture changeAligned IncentivesValue based compensationProgram infrastructurePhysician leadership and supportClinical ProgramsDisease programsCare protocols/PCMHClinical metricsPopulation health managementTechnology InfrastructureHealth Information ExchangeDisease registriesPatient longitudinal recordPatient portal to enable engagement
5 Collaboration: Current Options for Hospitals and Physicians
6 Meridian Accountable Care Organization Background and Strategy A legal entity operated and governed by physicians and Meridian Health System under a 50/50 consensus governance modelThe ACO is a low-risk laboratory wherein Meridian and its physician community can begin to learn population health and develop infrastructure to potentially assume risk contracting with payersIt is also a vehicle to build market share, and the prototype for other “bend the trend opportunities”In each of the next 3 years, if MACO can decrease cost and document quality, savings are eligible to be shared between CMS and MACO.MACO has received historical beneficiary claims information from CMS. The data show savings opportunities in:Hospital AdmissionEmergency Room Visits“High Cost” Imaging
7 Bending the trend… and sharing the savings Under the MSSP, up to 50% of the savings can be returned to the ACO for distribution to providers
8 First Year Key Metrics Meridian ACO LLC Effective Date: January 1, 2013Uniquely Attributed Medicare Lives (Original 39,705; Current 59,446)Participating PhysiciansParticipating PCP’sMedicare Spend $454,000,000 (on 39,705)Average Age yearsGender 57% Female 43% MaleYear 1 infrastructure app. $1.3MFive Population health managers hired
9 Annual ACO Quality Audit N = 4,244 beneficiaries identified for quality data5 high-risk care managers collected data with support from 3 others in department89 unique physician practice locations visited60% of practices had all or part of record on paper12 nursing homes/other facilities visitedOnly one non Meridian nursing home had required information in electronic format (MHS locations had Sigmacare)Numerous calls to non-ACO physicians to get required information (e.g., ejection fraction, mammograms, lipid values)3,898 miles driven by team
10 Augmented Connectivity to Serve Clinical Integration- Jersey Health Connect Atlantic Health SystemBarnabas HealthCentrastateChilton HospitalDeborahHoly Name Medical CenterEnglewood Medical CenterTrinitasRobert Wood JohnsonSt. Peters Univ. HospitalHunterdon HealthcareHackensack UMCChildren’s Specialized HospitalThe Valley HospitalSt. Clare’s Health SystemSummit Medical GroupOptimus Healthcare
12 Meridian ACO Yr 1 Quality Performance vs 2012 ACOs (n=146) Meridian Accountable CarePhysician/ACO CompareACE or ARB Tx %HTN Control(<140/90) 72%HbA1c Control(<8.0) 77%Tobacco Non-use %________________________ChallengesDepression ScreeningFalls risk ScreeningMedication reconciliationACE or ARB %HTN Control %HbA1c Control %Tobacco Non-use 72%________________________All fall below the 30%tile-Will need improvement year Two (PFP years two and three)
14 Total Expenditures/Assigned Medicare Beneficiary
15 Meridian RN Population Health Managers New role in 2013 to support the Medicare Shared Savings Program (MSSP)Telephonic care management for high-risk patients and patients with multiple chronic conditionsCollaborate with provider offices designated as PCPEnsure services are deployed as needed across the continuum through collaboration with existing providersMakes visits to hospitals, rehabilitation facilities, homes, provider offices, and other locations as neededExperts in performance monitoring at multiple levels: patient, provider, practice, and ACO
16 Hypothetical Savings and Distributions Year 1 for a 462M MSSP Program Distributable to ACO (1)Total$ 0 to ACO$ 4.3M$ 5.9M$10.6M$22.1MIf the ACO “bent the trend” and collected/submitted data accurately and on time: - 2.0% = $9.24M Did not meet threshold - 2.3% = $10.6M (50% = $ 5.3M) - 3.0% = $13.8M (50% = $ 6.9M) - 5.0% = $23.2M (50% = $11.6M) % = $46.2M (50% = $23.1M)(1)Based on 2013 Projected ACO Expenses of over $1.0M to be repaid before distributions.
18 MSSP 2012 “Winners” (114 Original, 44 had savings, 29 qualify for bonus payments)
19 Commercial ACO Activity Across New Jersey Horizon partnering with Central Jersey ACO, AtlantiCare ACO and the Optimus ACO on shared savings programs that include Medicare Advantage.CIGNA has announced a national goal to have 1,000,000 CIGNA insureds in PCMH Pilots by In NJ:CIGNA/Atlantic Health 15,000 covered livesCIGNA/Summit Medical Group 10,000 covered livesAetna partnering with Optimus for 11,900 covered Medicare Advantage lives in a shared savings model.
20 Financial Success From Patient Management Managing Three Distinct Patient PopulationsHigh Risk PatientsRising-Risk PatientsLow-Risk PatientsTrade high-cost services for low-cost management5% of patients; usually with complex disease(s), comorbiditiesAvoid unnecessary higher-acuity, higher-cost spending15-35% of patients; may have conditions not under controlKeep patient healthy, engaged with the system60-80% of patients; any minor conditions are easily managed
21 Joint Venture: Advocate Physician Partners Physician Membership1,138 Primary Care Physicians2,984 Specialist PhysiciansTotal Membership Includes 1,300 Advocate-Employed Physicians12 hospitals, encompassing 11 acute care hospitals and the state’s largest integrated children’s networkCentral Verification Office Certified by NCQA250,000 Capitated Lives/ 700,000 PPO Lives/ 100,000 MSSP Lives320,000 “Attributable” LivesOne model for Governmental and commercial ACO-like ContractsAdvocate Physician Partners delivers services throughout Chicagoland and Downstate Illinois.
22 AdvocateCare Model: changing the culture toward population health management Changing Paradigms…FROM ...TO ...Silo Care ManagementEnterprise care managementEpisodes of CareCoordination of careDischargesTransitionsUtilization ManagementRight Care, Right Place, Right TimeCaring for the SickKeeping People WellProduction (Volume)Performance (Value)Physicians membersPhysician partners
23 Clinical Integration at WellSpan.. “working as one” Like Advocate, have organized a pluralistic physician delivery system660 employed and 600+ private practice physiciansCoordinated continuum of services:90 sites“Working as one” to create healthy communities through exceptional care and lifelong wellnessThree hospitals65% market share1.5 B in revenueRegional leader in Trauma, Neurosciences, Cardiovascular
24 Both WellSpan and Advocate Health… Have invested in Information technology that links all elements of care (e.g. hospital, specialist, home health agency, nursing home) and the patient’s community (e.g. family)Have connected their medical staff to the system, and each otherHave organized their physicians into a unified delivery system that includes facilities, services and physiciansAre positioned as population health managers to provide value and accept risk
25 Clinical Integration Steering Committee These functions have been combinedEffective Q1 2014Meridian Health (2014) Partners, Inc.Clinically Integrated NetworkMeridian (2013) Accountable Care Organization, LLCPossible Employee pilot: Inner Circle NetworkMedicare Shared Savings Program(ACO)Future Commercial Performance-based Opportunities
27 Building “Meridian Health Partners” Mission Statement A fully integrated partnership between Meridian Health and its physicians created to provide the highest quality, most accessible and most efficient health services in Monmouth, Ocean and our adjacent counties.
28 Vision StatementA fully integrated physician-health system enterprise, providing clinical quality and efficiency that is demonstrably better than its competitorsA “pluralistic” model, providing efficient practice support, clinical integration, connectivity and network services to physicians in a variety of practice modelsA vehicle to ensure the availability of primary and specialty medical care services, ambulatory care, home care, long term care and ancillary servicesA platform to successfully integrate care and participate in pay for performance, quality and other value based initiatives with governmental and commercial payers
29 Value for Hospitals Creates Business Partnership with Key Physicians Focuses Physicians on coordinated carePatient SafetyControlling costsCreates alignmentPhysicians Drive Clinical OutcomesPositions for Health Care ReformACOsReadmission AvoidanceMigration to Risk acceptance?
30 Value for PhysiciansAccess to and/or participation in “shared savings” and other contracts with payers- One interfaceBetter alignment between primary care and specialists- Network integrityMarketplace recognition for quality care and excellent patient experienceSupport staff for chronic condition registries and QI initiativesManagement/HIT expertise from system
31 Shared Savings Contracting: Tenets for a workable Model In order to have a successful shared savings contract modelThe Network must consistently perform better than the marketImprove quality and access to careReduce cost/decrease complications and readmissionsPromote network integrity/minimize medically unnecessary costly out migrationIncrease volume to providers participating in Meridian Health PartnersEnhance physician and patient satisfaction31
32 “Meridian Health Partners” MHP will seek a higher level of clinical integration through enhanced connectivity with the system, regional health information exchange and eventually each otherOver 600 “system based” and contractually aligned physicians are already on board- including primary care, faculty practices and hospital based physiciansActively seeking clinical pilots with health insurance companies that evolve the “shared savings model” focused on quality and efficiencySubstantial payer interest in Meridian’s CIN
33 “Meridian Health Partners” Shared GovernanceConsensus decision makingPhysicians comprise the majority of Board MembersThe ACO and MHP initiatives share one combined board and committee structureNo capital investment beyond time and expertise
34 “Meridian Health Partners” Participation agreement provisions Commitment to move toward an EMR will facilitate quality performance and point of care interventions. (Meridian’s IT Subsidy program currently being revised to support clinical integration and information exchange)Initial contract opportunities parallel the ACO- Upside only “shared savings” or performance incentives for quality and efficiency measures- all would participateAligned Voluntary staff may “opt out” of any future fee schedule or global risk contract arrangementsUnlike the MSSP ACO- Participation is “non exclusive” for both Primary Care and Specialist physicians
35 Meridian’s Connected Continuum Meridian Health Partners: Poised for Population HealthMeridian’s Connected Continuum
36 Next Steps….Our system based physicians and the Meridian facilities are already committed to the effortHospital based groups now joining the initiative bring enrollment to over 600 physiciansEnrollment of aligned independent physicians will begin in June, giving them access to both shared savings/risk program opportunities as they ariseConnectivity to Jersey Health Connect will be supported to successfully manage quality improvement and network performance
40 Meridian’s Powerful Continuum Key Health System StatisticsOver 100 Convenient Locations$1.7 Billion in Annual System Revenues12,000 Team Members2,100 Physicians on Staff6 Hospitals: 1,700+ bedsJersey Shore University Medical CenterK. Hovnanian Children’s HospitalOcean Medical CenterRiverview Medical CenterSouthern Ocean Medical CenterBayshore Community HospitalPartner CompaniesPost Acute Care: 6 facilities, 906 bedsAt Home Nursing, Hospice, & Rehab: Serving all of Central New JerseyAmbulatory Care: 19 facilities, including hospital basedPrimary Care: 102 physiciansAmbulance/Medical transport: 100+ vehiclesOccupational Health: 6 centersRehabilitation and Fitness: 9 outpatient, 2 inpatient facilitiesBehavioral Health: 5 outpatient, 2 inpatient facilities
41 Enrollment up nearly 5 fold to over 4,300 lives for 2014 Meridian Geisinger GoldA 50/50 joint venture between Meridian and GeisingerEnabled Meridian to enter the insurance marketInitially a 2-county Medicare Advantage offering724 participating physiciansSuperstorm Sandy disrupted open enrollmentLive January 1, 2013 with 875 members last yearEnrollment up nearly 5 fold to over 4,300 lives for 2014Meridian is uniquely positioned for growth!
42 ACO Performance Domains Application of Rules for 2014 (Using Meridian ACO 2013 Data) Status/Issues of Ability to Share in SavingsPatient/Caregiver Experience (7 measures)Unknown – survey conducted by CMS this yearCare Coordination/Patient Safety(6 measures)Unknown - 4 of 6 measures provided by CMS2 of the 6 are <CMS 30th percentileCorrective Action Plan (CAP) Activation since 70% of all measures in a domain do not score above minimum attainment level. If unknown 4 are >30th percentile, then 66.7%.Preventive Health (8 measures)None <CMS 30th percentileAt-Risk Populations (12 measures)