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Attaining Scale in a Changing Market Update on the ACO and the Clinically Integrated Network Introducing…”Meridian Health Partners” Richard J. Scott MD.

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Presentation on theme: "Attaining Scale in a Changing Market Update on the ACO and the Clinically Integrated Network Introducing…”Meridian Health Partners” Richard J. Scott MD."— 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 Affairs Executive 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” – AMA CI 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 Collaborative Leadership Governance body Compliant legal structure Payer strategy Culture change Aligned Incentives Value based compensation Program infrastructure Physician leadership and support Clinical Programs Disease programs Care protocols/PCMH Clinical metrics Population health management Technology Infrastructure Health Information Exchange Disease registries Patient longitudinal record Patient portal to enable engagement Clinically Integrated Care

5 Collaboration: Current Options for Hospitals and Physicians

6 Meridian Accountable Care Organization Background and Strategy 6 A legal entity operated and governed by physicians and Meridian Health System under a 50/50 consensus governance model The 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 payers It 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 Admission –Emergency 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 8 Meridian ACO LLC First Year Key Metrics Effective Date: January 1, 2013 – Uniquely Attributed Medicare Lives (Original 39,705; Current 59,446) – Participating Physicians 874 – Participating PCP’s 250 – Medicare Spend $454,000,000 (on 39,705) – Average Age 74.3 years – Gender 57% Female 43% Male Year 1 infrastructure app. $1.3M Five Population health managers hired

9 Annual ACO Quality Audit N = 4,244 beneficiaries identified for quality data 5 high-risk care managers collected data with support from 3 others in department 89 unique physician practice locations visited –60% of practices had all or part of record on paper 12 nursing homes/other facilities visited –Only 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 9

10 Augmented Connectivity to Serve Clinical Integration- Jersey Health Connect Atlantic Health System Barnabas Health Centrastate Chilton Hospital Deborah Holy Name Medical Center Englewood Medical Center Trinitas Robert Wood Johnson St. Peters Univ. Hospital Hunterdon Healthcare Hackensack UMC Children’s Specialized Hospital The Valley Hospital St. Clare’s Health System Summit Medical Group Optimus Healthcare

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12 Meridian ACO Yr 1 Quality Performance vs 2012 ACOs (n=146) Meridian Accountable Care ACE or ARB Tx 72% HTN Control(<140/90) 72% HbA1c Control(<8.0) 77% Tobacco Non-use 78% ________________________ Challenges Depression Screening Falls risk Screening Medication reconciliation Physician/ACO Compare ACE or ARB 69% HTN Control 67% HbA1c Control 65% Tobacco Non-use 72% ________________________ All fall below the 30%tile- Will need improvement year Two (PFP years two and three)

13 30-Day All-Cause Readmissions/1,000 Discharges 13

14 Total Expenditures/Assigned Medicare Beneficiary 14

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 conditions Collaborate with provider offices designated as PCP Ensure services are deployed as needed across the continuum through collaboration with existing providers Makes visits to hospitals, rehabilitation facilities, homes, provider offices, and other locations as needed Experts in performance monitoring at multiple levels: patient, provider, practice, and ACO 15

16 Hypothetical Savings and Distributions Year 1 for a 462M MSSP Program If 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) Distributable to ACO (1) Total $ 0 to ACO $ 4.3M $ 5.9M $10.6M $22.1M (1) Based on 2013 Projected ACO Expenses of over $1.0M to be repaid before distributions. 16

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18 MSSP 2012 “Winners” (114 Original, 44 had savings, 29 qualify for bonus payments) 18

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 Health15,000 covered lives –CIGNA/Summit Medical Group10,000 covered lives Aetna partnering with Optimus for 11,900 covered Medicare Advantage lives in a shared savings model. 19

20 Financial Success From Patient Management Keep patient healthy, engaged with the system Avoid unnecessary higher-acuity, higher- cost spending Trade high-cost services for low- cost management High- Risk Patients Rising-Risk Patients Low-Risk Patients 60-80% of patients; any minor conditions are easily managed 15-35% of patients; may have conditions not under control 5% of patients; usually with complex disease(s), comorbidities Managing Three Distinct Patient Populations 20

21 Joint Venture: Advocate Physician Partners Advocate Physician Partners delivers services throughout Chicagoland and Downstate Illinois. Physician Membership –1,138 Primary Care Physicians –2,984 Specialist Physicians Total Membership Includes 1,300 Advocate-Employed Physicians 12 hospitals, encompassing 11 acute care hospitals and the state’s largest integrated children’s network Central Verification Office Certified by NCQA 250,000 Capitated Lives/ 700,000 PPO Lives/ 100,000 MSSP Lives 320,000 “Attributable” Lives One model for Governmental and commercial ACO-like Contracts

22 Changing Paradigms… FROM... TO... Silo Care ManagementEnterprise care management Episodes of CareCoordination of care DischargesTransitions Utilization ManagementRight Care, Right Place, Right Time Caring for the SickKeeping People Well Production (Volume)Performance (Value) Physicians membersPhysician partners AdvocateCare Model: changing the culture toward population health management

23 Clinical Integration at WellSpan.. “working as one” Like Advocate, have organized a pluralistic physician delivery system 660 employed and 600+ private practice physicians Coordinated continuum of services:90 sites Working as one“Working as one” to create healthy communities through exceptional care and lifelong wellness Three hospitals 65% market share 1.5 B in revenue Regional 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 other Have organized their physicians into a unified delivery system that includes facilities, services and physicians Are positioned as population health managers to provide value and accept risk

25 Possible Employee pilot: Inner Circle Network Meridian Health (2014) Partners, Inc. Clinically Integrated Network Meridian (2013) Accountable Care Organization, LLC Clinical Integration Steering Committee Medicare Shared Savings Program (ACO) Future Commercial Performance-based Opportunities These functions have been combined Effective Q

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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. 27

28 Vision Statement A fully integrated physician-health system enterprise, providing clinical quality and efficiency that is demonstrably better than its competitors A “pluralistic” model, providing efficient practice support, clinical integration, connectivity and network services to physicians in a variety of practice models A vehicle to ensure the availability of primary and specialty medical care services, ambulatory care, home care, long term care and ancillary services A platform to successfully integrate care and participate in pay for performance, quality and other value based initiatives with governmental and commercial payers 28

29 Value for Hospitals Creates Business Partnership with Key Physicians Focuses Physicians on coordinated care –Patient Safety –Controlling costs Creates alignment Physicians Drive Clinical Outcomes Positions for Health Care Reform –ACOs –Readmission Avoidance –Migration to Risk acceptance?

30 Access to and/or participation in “shared savings” and other contracts with payers- One interface Better alignment between primary care and specialists- Network integrity Marketplace recognition for quality care and excellent patient experience Support staff for chronic condition registries and QI initiatives Management/HIT expertise from system Value for Physicians

31 Shared Savings Contracting: Tenets for a workable Model In order to have a successful shared savings contract model 1.The Network must consistently perform better than the market 2.Improve quality and access to care 3.Reduce cost/decrease complications and readmissions 4.Promote network integrity/minimize medically unnecessary costly out migration 5.Increase volume to providers participating in Meridian Health Partners Enhance physician and patient satisfaction 31

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 other  Over 600 “system based” and contractually aligned physicians are already on board- including primary care, faculty practices and hospital based physicians  Actively seeking clinical pilots with health insurance companies that evolve the “shared savings model” focused on quality and efficiency Substantial payer interest in Meridian’s CIN

33 “Meridian Health Partners”  Shared Governance  Consensus decision making  Physicians comprise the majority of Board Members  The ACO and MHP initiatives share one combined board and committee structure  No 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 participate  Aligned Voluntary staff may “opt out” of any future fee schedule or global risk contract arrangements  Unlike the MSSP ACO- Participation is “non exclusive” for both Primary Care and Specialist physicians

35 Meridian Health Partners: Poised for Population Health Meridian’s Connected Continuum

36 Our system based physicians and the Meridian facilities are already committed to the effort Hospital based groups now joining the initiative bring enrollment to over 600 physicians Enrollment of aligned independent physicians will begin in June, giving them access to both shared savings/risk program opportunities as they arise Connectivity to Jersey Health Connect will be supported to successfully manage quality improvement and network performance 36 Next Steps….

37 Thank You !

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40 6 Hospitals: 1,700+ beds  Jersey Shore University Medical Center  K. Hovnanian Children’s Hospital  Ocean Medical Center Partner Companies  Post Acute Care: 6 facilities, 906 beds  At Home Nursing, Hospice, & Rehab: Serving all of Central New Jersey  Ambulatory Care: 19 facilities, including hospital based  Primary Care: 102 physicians  Ambulance/Medical transport: 100+ vehicles  Occupational Health: 6 centers  Rehabilitation and Fitness: 9 outpatient, 2 inpatient facilities  Behavioral Health: 5 outpatient, 2 inpatient facilities Meridian’s Powerful Continuum Key Health System Statistics  Over 100 Convenient Locations  $1.7 Billion in Annual System Revenues  12,000 Team Members  2,100 Physicians on Staff  Riverview Medical Center  Southern Ocean Medical Center  Bayshore Community Hospital

41  A 50/50 joint venture between Meridian and Geisinger  Enabled Meridian to enter the insurance market  Initially a 2-county Medicare Advantage offering  724 participating physicians Meridian Geisinger Gold  Superstorm Sandy disrupted 2012 open enrollment  Live January 1, 2013 with 875 members last year  Enrollment up nearly 5 fold to over 4,300 lives for 2014 Meridian is uniquely positioned for growth!

42 ACO Performance Domains Application of Rules for 2014 (Using Meridian ACO 2013 Data) DomainStatus/Issues of Ability to Share in Savings Patient/Caregiver Experience (7 measures)Unknown – survey conducted by CMS this year Care Coordination/Patient Safety (6 measures) Unknown - 4 of 6 measures provided by CMS 2 of the 6 are 30 th percentile, then 66.7%. Preventive Health (8 measures)None { "@context": "http://schema.org", "@type": "ImageObject", "contentUrl": "http://images.slideplayer.com/13/3941952/slides/slide_41.jpg", "name": "ACO Performance Domains Application of Rules for 2014 (Using Meridian ACO 2013 Data) DomainStatus/Issues of Ability to Share in Savings Patient/Caregiver Experience (7 measures)Unknown – survey conducted by CMS this year Care Coordination/Patient Safety (6 measures) Unknown - 4 of 6 measures provided by CMS 2 of the 6 are 30 th percentile, then 66.7%. Preventive Health (8 measures)None


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