1. How Physicians Can Achieve Success in the Arriving Population Health Model Thursday, September 26 th 2013

2. LEGAL CAVEAT The Advisory Board Company has made efforts to verify the accuracy of the information it provides to members. This report relies on data obtained from many sources, however, and The Advisory Board Company cannot guarantee the accuracy of the information provided or any analysis based thereon. In addition, The Advisory Board Company is not in the business of giving legal, medical, accounting, or other professional advice, and its reports should not be construed as professional advice. In particular, members should not rely on any legal commentary in this report as a basis for action, or assume that any tactics described herein would be permitted by applicable law or appropriate for a given member’s situation. Members are advised to consult with appropriate professionals concerning legal, medical, tax, or accounting issues, before implementing any of these tactics. Neither The Advisory Board Company nor its officers, directors, trustees, employees and agents shall be liable for any claims, liabilities, or expenses relating to (a) any errors or omissions in this report, whether caused by The Advisory Board Company or any of its employees or agents, or sources or other third parties, (b) any recommendation or graded ranking by The Advisory Board Company, or (c) failure of member and its employees and agents to abide by the terms set forth herein. The Advisory Board is a registered trademark of The Advisory Board Company in the United States and other countries. Members are not permitted to use this trademark, or any other Advisory Board trademark, product name, service name, trade name, and logo, without the prior written consent of The Advisory Board Company. All other trademarks, product names, service names, trade names, and logos used within these pages are the property of their respective holders. Use of other company trademarks, product names, service names, trade names and logos or images of the same does not necessarily constitute (a) an endorsement by such company of The Advisory Board Company and its products and services, or (b) an endorsement of the company or its products or services by The Advisory Board Company. The Advisory Board Company is not affiliated with any such company. IMPORTANT: Please read the following. The Advisory Board Company has prepared this report for the exclusive use of its members. Each member acknowledges and agrees that this report and the information contained herein (collectively, the “Report”) are confidential and proprietary to The Advisory Board Company. By accepting delivery of this Report, each member agrees to abide by the terms as stated herein, including the following: 1. The Advisory Board Company owns all right, title and interest in and to this Report. Except as stated herein, no right, license, permission or interest of any kind in this Report is intended to be given, transferred to or acquired by a member. Each member is authorized to use this Report only to the extent expressly authorized herein. 2. Each member shall not sell, license, or republish this Report. Each member shall not disseminate or permit the use of, and shall take reasonable precautions to prevent such dissemination or use of, this Report by (a) any of its employees and agents (except as stated below), or (b) any third party. 3. Each member may make this Report available solely to those of its employees and agents who (a) are registered for the workshop or membership program of which this Report is a part, (b) require access to this Report in order to learn from the information described herein, and (c) agree not to disclose this Report to other employees or agents or any third party. Each member shall use, and shall ensure that its employees and agents use, this Report for its internal use only. Each member may make a limited number of copies, solely as adequate for use by its employees and agents in accordance with the terms herein. 4. Each member shall not remove from this Report any confidential markings, copyright notices, and other similar indicia herein. 5. Each member is responsible for any breach of its obligations as stated herein by any of its employees or agents. 6. If a member is unwilling to abide by any of the foregoing obligations, then such member shall promptly return this Report and all copies thereof to The Advisory Board Company.

3. © 2013 THE ADVISORY BOARD COMPANY How Physicians Can Achieve Success in the Arriving Population Health Model Presented to: University of Virginia Health System Presented by: John A. Deane CEO, Southwind Division Lisa Bielamowicz, M.D. Executive Director & CMO The Advisory Board Company September 26, 2013

4. © 2013 THE ADVISORY BOARD COMPANY National Trends Driving Physician Alignment 4

5. © 2013 THE ADVISORY BOARD COMPANY Meet Your Newest Medicare Beneficiaries 5 Happy 65 th Birthday! Steven TylerOzzy Osbourne Kathy Bates Al Gore James TaylorTerry Bradshaw

6. © 2013 THE ADVISORY BOARD COMPANY A Population More Predisposed to Comorbidity 6 Worsening Case Mix Not Just Due to Aging Obesity Rate Among U.S. Adults 1 1988 Obesity Rate Among U.S. Adults 1 2009 Source: Centers for Disease Control Behavioral Risk Factor Surveillance System, available at: http://www.cdc.gov/brfss/, accessed May 4, 2011; Health Care Advisory Board interviews and analysis. 1)Body Mass Index ≥ 30, or 30 pounds overweight for 5’ 4” person. No Data 30%

7. © 2013 THE ADVISORY BOARD COMPANY Chronic Disease Growth Outpacing Population Growth 7 Source: Milken Institute, available at: http://www.milkeninstitute.org/ pdf/chronic_disease_report.pdf, accessed April 27, 2011; Health Care Advisory Board interviews and analysis. Projected Increase in Chronic Disease Cases 2003-2023 19%: Projected population growth, 2003- 2023

8. © 2013 THE ADVISORY BOARD COMPANY Getting Paid Less to Do Less 8 New Payment Models Calling Old Imperatives Into Question Accountable Payment Models Cost of Care Quality of Care Volume of Care Performance RiskUtilization Risk Bundled Pricing Bundled Payments for Care Improvement program Commercial bundled contracts Shared Savings Medicare Shared Savings Program Pioneer ACO Program Commercial ACO contracts Pay-for-Performance Value-Based Purchasing Readmissions penalties Quality-based commercial contracts Source: Health Care Advisory Board interviews and analysis.

9. © 2013 THE ADVISORY BOARD COMPANY Health Care Defects Occurring at an Alarming Rate 9 Growing Demand for Higher Value Source: Modified from Buck, CR, General Electric; Health Care Advisory Board interviews and analysis; Southwind. Health Care Quality Defect Defects per Million 1,000,000 1,000 1 10,000 100,000 100 10 1 (69%) 2 (31%) 3 (7%) 4 (.6%) 5 (.002%) 6 (.00003%) σ Level (% Defects) Anesthesia-related fatality rate Hospitalized patients injured through negligence Adverse drug events Breast cancer screening (65-69) Post-MI beta-blockers Overall health care in U.S. Hospital- acquired infections Airline baggage handling U.S. industry best-in-class

10. © 2013 THE ADVISORY BOARD COMPANY Bridging the Transition Between Payment Paradigms 10 Mitigating Incentive Disconnect Between FFS, Value Based Payment Time Revenue Generated Through Incentive Model Fee for Service 100% 0% Total Cost Accountability Can increase FFS rates Stabilizes physician economics Improves performance on key quality and cost initiatives Can increase market share Creates infrastructure for care coordination, management Builds physician comfort with performance focus Realizing Returns Today Preparing for Tomorrow

11. © 2013 THE ADVISORY BOARD COMPANY 11 Forcing Tighter Ties Payment Reforms Place Greater Burden on Care Coordination Strategic Responses to New Payment Methodologies Pay-for- Performance Hospital-Physician Bundling Episodic Bundling Shared- Savings Model Degree of Management Challenge Engage active medical staff Standardize care processes Track and analyze performance Leverage physician incentives Standardize devices Reduce orders and consults Partner with post- acute providers Standardize care site transitions Partner with PCPs Invest in chronic disease management Reduce utilization Actions needed under all payment reforms Provider Cost Accountability

12. © 2013 THE ADVISORY BOARD COMPANY Organize "Integrated Practice Units" or "IPUs" around patient conditions Organize primary and preventative care to serve distinct patient segments Measure outcomes & cost Offer bundled pricing arrangements Integrate delivery across separate facilities Expand geographic coverage by excellent providers Build and enable information technology Creating a Value-Based Health Care Delivery System The Strategic Agenda 12 Michael Porter, Harvard University, 2013

13. © 2013 THE ADVISORY BOARD COMPANY This Is Not a Cup of Coffee 13 Source: Health Care Advisory Board interviews and analysis.

14. © 2013 THE ADVISORY BOARD COMPANY An Absurdly Fragmented Market Offering 14 Dozens of Businesses, Thousands of Products Source: Accreditation Council for Graduate Medical Education, http://www.acgme.org/acWebsite/RRC_sharedDocs/ACGME- Accredited_Specialties_and_Subspecialties.pdf, accessed May 14, 2012; Health Care Advisory Board interviews and analysis. 1)Medicare Severity-Diagnosis Related Group. 2)Healthcare Common Procedure Coding System. 3)Accreditation Council for Graduate Medical Education. Quite a Lot on the Menu 745 MS-DRGs 1 ~15,000 HCPCS 2 Codes 26 ACGME 3 - Accredited Specialties Emergency Department Office VisitsImaging Outpatient Procedures Rehab Long-Term Care Lab Tests Inpatient Procedures Pharmacy Typical Silos in Health Care Delivery

15. © 2013 THE ADVISORY BOARD COMPANY In Consumers’ View, Only Two Products 15 Individual Services Merely Inputs; System’s Role is in Assembly Health Care Production Model Inputs Office Visits Imaging Lab Emergency Care Inpatient Procedures Outpatient Procedures Rehabilitation Long-Term Care Pharmacy Health System Acute Care Episodes Longitudinal Management High-quality, low-cost treatment of acute illness Includes pre-acute, post- acute services, readmission Ongoing, comprehensive health management Includes chronic disease care, wellness, prevention Value-Added Products Planning Coordination Delivery Source: Health Care Advisory Board interviews and analysis.

16. © 2013 THE ADVISORY BOARD COMPANY Physicians at the Nexus 16 Physicians Essential to Generating Value from Systemness 1)Independent Practice Association. Care Planning Care Delivery Care Coordination Payers Integrating Physicians Examples: Texas Health Resources acquires Medical Edge St. Thomas forms 1,600-strong IPA 1 in two years MemorialCare acquires 400-physician Nautilus Examples: UnitedHealth acquires Monarch HealthCare Humana acquires Concentra WellPoint acquires CareMore Hospitals Integrating Physicians Source: Health Care Advisory Board interviews and analysis. Value-Added Processes

17. © 2013 THE ADVISORY BOARD COMPANY Moving Beyond “Us and Them” 17 True Systemness Requires Demolition of Individual, Group Silos 1)Clinically integrated. New Ambition for Hospital-Physician Relations Traditional Goal: Strengthen ties within medical group/CI 1 network Traditional Goal: Strengthen individual practice ties to hospital center Today’s Goal: Align priorities, strategies, and efforts of system leadership with those of broader physician network Collaborative Care Enterprise Source: Health Care Advisory Board interviews and analysis. Words Matter “The language hospital leaders use to describe physician alignment—‘how do we get them to work with us’— reveals how deeply rooted this sense of separateness is.” Health System Executive ”

18. © 2013 THE ADVISORY BOARD COMPANY The New Hospital-Physician Compact 18 Collaborating to Deliver Value to Patients Patient Demands, System Responsibilities Timely Access Source: Health Care Advisory Board interviews and analysis. Principled Referrals Unified Care Experience Top-Quality Care Open Communication Cost-Effective Care Physicians build schedules around patient needs, connect to other providers to expand options System invests in alternative access points and needed capacity Physicians build and utilize evidence-based care standards Clinical decisions prioritize quality All providers accept, respond to transparent performance data Physicians, care teams respond promptly to patient inquiries Providers proactively engage patients in care management Referral decisions based on quality and cost, not habit Physicians coordinate with peers to ensure safe and effective transitions Care transitions appear seamless to patients Information is a system asset, updated and utilized by all to streamline care experience Physicians actively work to reduce cost, unnecessary utilization System encourages use of low- cost care pathways

19. © 2013 THE ADVISORY BOARD COMPANY Executing Strategy in the Accountable Care Era 19 Tactics for Evolving Primary Care to Support Accountable Care Strategy Align clinical, operational and financial goals Manage inappropriate utilization of high- risk patients Reduce costs through quality improvement, care coordination Leverage business intelligence systems to identify core competencies Consider value-based contracts across payers Tailor interventions for population health management Securing Physician Alignment Care Transformation Reducing Costs, Advancing Quality Managing Total Population Risk Evaluate, secure and stabilize primary care base “Clinically Integrate” the network Engage physicians in leadership, governance Promote adoption of evidence-based care standards with aggressive quality targets Start medical home transformation Foster seamless data exchange across sites of care

20. © 2013 THE ADVISORY BOARD COMPANY Start by Segmenting Medical Staff by Role in ACO 20 The Accountable Physician Enterprise Community Contractors Hospital-Based Non Admitting Specialists Proceduralists Primary Care Community-Based Medical Specialists Dermatology Ophthalmology Radiology Anesthesiology Pathology ED Physicians General Surgery Cardiac Surgery Neurosurgery Orthopedics Internal Medicine Pediatrics Family Medicine Hospitalist Cardiology Medical Oncology Endocrinology OB/GYN Effective Care Management EnterpriseEfficient Procedural Enterprise “ACO Partners” “ACO Collaborators” “ACO Principals” Minimal Relationship

21. © 2013 THE ADVISORY BOARD COMPANY More Than Just Great Clinicians 21 Ideal Partners Willing to Demonstrate Cultural Compatibility Information-PoweredValue-Conscious Open to TransparencySystem-Oriented Instinctively pursues system goals Prioritizes system needs over individual ambitions Trusts that decisions made with interest of patients, not politics, in mind Understands benefit of full data transparency Accepts results as validated, unbiased, accurate Views release of performance data as opportunity to improve Supplements personal experience with communal knowledge resources Actively contributes to expanding body of knowledge on care standards, patient records Source: Health Care Advisory Board interviews and analysis. Four Attributes of the Ideal Physician Partner Acknowledges continuous cost pressures within system Actively works to improve patient care in cost-effective manner

22. © 2013 THE ADVISORY BOARD COMPANY Address Physician Concerns About Team-Based Care 22 Key Responses to Common Physician Pushback Source: Innovations Center interviews and analysis. Fear of “Losing” Patients Medical Home is a physician-led team of providers Key relationship built around maximizing patient-physician interaction Physician actively engaged in overall patient care Protecting “Physician-Required” Tasks Best practices are standardized, maximizing physician time “Triggers” to engage physician can be built into care processes Physician-required tasks are not offloaded to team Imposition on Physician Time, Productivity Role and goals of physician defines how team is used Team extends time available to patient, without requiring additional physician time Cost of Creating the Care Team More efficient visits improve financial performance of practice More cost-effective to minimize physician time spent on non-physician tasks Allows team members to operate at the top of their licenses

23. © 2013 THE ADVISORY BOARD COMPANY Finding the Right Physician Leaders 23 Best Ambassadors Are Eager, Committed, Humble Source: Intermountain Healthcare, “How to Run Your Own Clinical Quality Improvement Training Program,” available at: http://intermountainhealthcare.org/, accessed May 14, 2012; Health Care Advisory Board interviews and analysis. Disruptively Opposed Grudgingly Obedient Willingly Cooperative Passionately Leading Distractingly Over-Enthused Best suited to spearhead change, disseminate system vision Putting Our Best Foot Forward “Even today, we still have people within our system who viscerally oppose our ongoing shift to clinical process management and improvement. Change is hard. However, we have enough people who “get it”—and are deeply convinced of and committed to it— that we can move vigorously ahead.” Dr. Brent James Chief Quality Officer, Intermountain Healthcare ” Spectrum of Physician Engagement with System Strategy Least EngagedMost Engaged Great majority of physicians willing to support system strategy but need strong physician leadership

24. © 2013 THE ADVISORY BOARD COMPANY Building an Effective Ambassador Corps 24 Small Groups of Leaders Make Large Impact Source: Intermountain Healthcare, “How to Run Your Own Clinical Quality Improvement Training Program,” available at: http://intermountainhealthcare.org/, accessed May 14, 2012; Health Care Advisory Board interviews and analysis. How Much is “Critical Mass”? Rule of thumb from change management research: The number of leaders necessary to spearhead organizational change is equal to the square root of n, where n is the total number of individuals in an organization Ambassador Corps Rank-and-File Physicians Respected clinicians Ethic of trust and stewardship Effective communicators Skilled at resolving conflict Natural problem-solvers Attributes of Effective Physician Ambassadors

25. © 2013 THE ADVISORY BOARD COMPANY Funneling Patients Through A Siloed Enterprise 25 Individual Components Strong But Disconnected Traditional Clinical Enterprise Source: Health Care Advisory Board interviews and analysis. 1)Fee-for-Service. Primary care practices serve as feeders to specialty service lines Each practice as individual point of care, not comprehensive network Specialty service lines serve as core business under FFS 1 model Care, services streamlined within each specialty but not across service lines Ambulatory space serves as driver of volumes to inpatient setting, treatment Hospital as nexus of clinical enterprise rather than node on care continuum Primary Care Specialty Service Lines Acute Care Hospital

26. © 2013 THE ADVISORY BOARD COMPANY A Week in the Life of a Diabetic 26 Fragmented Pathways, Poor Coordination Threaten Outcomes Source: Health Care Advisory Board interviews and analysis. Typical Diabetic Complication Pathway Call to PCP Office ED Visit Med/Surg Admission Surgery Consult Wound Team Intervention Discharge Urgent Care Visit Typical Typical Failure Practice closes early on Friday, unable to see patient No access to chart; patient sent to ED for wound care ED unable to contact wound care specialist, admits patient Hospitalist unclear about Parkinson’s medications, gives wrong dose Diagnostics delayed due to mental status changes; surgeon refuses to see patient Clinicians determine care plan without consulting outpatient team LOS two days longer than needed Lack of coordination, interfacing across service lines, specialties Primary care pathways, providers fractured across care continuum Lines of control fail to converge at any actionable level Root Causes of Care Management Breakdowns

27. © 2013 THE ADVISORY BOARD COMPANY Patient Problems Often Span Multiple Specialties 27 Source: Health Care Advisory Board interviews and analysis. Specialists Required to Generate Post-Op Wound Prevention Standards Even Simple Problems Require Broad Specialist Collaboration Surgical Specialists Guarantee pre-, post-op care order consistency 7 Total number of specialists required for comprehensive wound care Infectious Disease Specialist Ensures appropriate antibiotic use Wound Care Specialist Supervises wound therapy pre-, post-discharge Hospitalists, Intensivists Manage general post-op care

28. © 2013 THE ADVISORY BOARD COMPANY Meeting Clinical Needs Head On 28 Organizing Quality Around Patient Issues Source: Health Care Advisory Board interviews and analysis. 1)Congestive Heart Failure. 2)Chronic Obstructive Pulmonary Disorder. Quality Committee Characteristics Nine quality committees organized around initiatives rather than specialties All physicians required to spend two hours per month on a committee Physicians not compensated for time Case in Brief: MissionPoint Health Partners 1,400-physician clinically integrated population management network affiliated with St. Thomas Health located in Nashville, Tennessee Mandates multidisciplinary physician participation on quality committees;18 percent of physicians participate on a committee at any given time MissionPoint Quality Committees Cardiac – CHF 1 and Chest Pain Diabetes Mellitus Respiratory – Asthma/COPD 2 Sepsis Preventive Care Depression Joint Pain (including back pain) Women/Newborn Health Weight Loss

29. © 2013 THE ADVISORY BOARD COMPANY Evolving to a New Physician Leadership Bench 29 New Crop of Leaders Rising To Meet Tomorrow’s Challenges Traditional Hospital Physician Leadership Source: Health Care Advisory Board interviews and analysis. VP of Medical Affairs Chief Medical Officer Tomorrow’s Health System Leaders Roles largely limited to inpatient quality management, standards Legacy of independent medical staff model, responsible for credentialing Limited authority to enact true change across organization Chief Clinical Officer Chief Medical Information Officer VP of Care Transformation Leads transition to evidence-based practice Sets unified quality standards across care continuum Chief Quality Officer Bridges communications gap between IT staff, physicians Provides guidance on realities of clinical practice as IT systems are deployed Applies systematic analysis to pilot effective population health programs Tailors offerings, rolls out stratified risk programs Holds management jurisdiction, authority over entire clinical enterprise Bridges stakeholder relationships

30. © 2013 THE ADVISORY BOARD COMPANY Patient-Focused Culture Not an Overnight Change 30 Transforming Personal Relationships, Attitudes Takes Time Source: Health Care Advisory Board interviews and analysis. Shifting Perspectives “Comfort Zone”New Expectation Clinical Practice Model Physician makes treatment decisions unilaterally Main responsibility to advance patient to next stage of care continuum Physician collaborates with colleagues, adheres to evidence-based standards Responsibility extends to coordination across entire care continuum Understanding of Success Personal financial performance paramount Profit potential proportional to volume Individual success closely linked to system objectives Financial return dependent on quality, coordination Relationship to Hospital Physician refers to, practices at hospital Relationship based on convenience, financial ties Physician engages with hospital as strategic partner Relationship based on common culture, patient focus

31. © 2013 THE ADVISORY BOARD COMPANY Tough Decisions Require New Paradigms 31 Successful Physician Alignment Must Be Redefined Difficult (But Necessary) Transformations New Measures of Success Restrict network participation to culturally-aligned, performance-focused physician partners Empower physicians with meaningful influence in system strategic planning Restructure reporting relationships to emphasize unified, coordinated patient care over parochial interests Physician satisfaction Network size Physician “buy-in” to hospital-led strategy Minimized losses on employed practices Stronger physician engagement with system Network integrity, compatibility with payer contracting objectives Physician contribution to jointly-led strategy Physician impact on quality, cost of care Traditional Goals Source: Health Care Advisory Board interviews and analysis.

32. © 2013 THE ADVISORY BOARD COMPANY Value Proposition of Systemness Broadening 32 Attracting Physicians to New Model Requires Making Benefits Clear Traditional Physician Benefits of Systemness Additional Value Proposition Stronger negotiating position with payers Affiliation with larger, respected brand Access to investment capital Efficiency through shared services Collaboration with network peers Coordination across care continuum Comprehensive IT infrastructure Stronger negotiating position with payers Affiliation with larger, respected brand Access to investment capital Efficiency through shared services Patient-focused care model Source: Health Care Advisory Board interviews and analysis.

33. © 2013 THE ADVISORY BOARD COMPANY Three Fundamental Principles 33 Recalling the Tenets of True Systemness Source: Health Care Advisory Board interviews and analysis. Hospital leaders, physicians must move beyond “us vs. them” mentality to one of system unity, shared purpose An End to Factionalism System leaders need not be physicians, but must have collegial, productive relationships with physician partners Physician-Oriented Leadership All stakeholders must understand that system value derives from serving patient needs through high- quality, cost-effective care Patients at the Center

34. © 2013 THE ADVISORY BOARD COMPANY Questions 34