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New Risk and Collaboration Models for Providers Clinically Integrated Network January 2014.

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Presentation on theme: "New Risk and Collaboration Models for Providers Clinically Integrated Network January 2014."— Presentation transcript:

1 New Risk and Collaboration Models for Providers Clinically Integrated Network January 2014

2 Agenda 2 Objectives for Today  Provide a brief history and context  Share the vision, objectives, and strategies  Review the model of care  Review Physician Care Network’s clinical and administrative services  Provide a status of recent activities and upcoming milestones  Share the requirements and benefits of physicians joining the CIN

3 Background 3 Market & Competitive Pressures Hospitals  Consolidating; increasing negotiation strength  Employing primary care and specialty physicians Health Plans  Creating narrow networks and increasing price pressure  Implementing bundled episodic payments  Pushing risk based payment and shared savings models  Tying quality metrics to reimbursement levels  Requiring changes to protocols and treatment to improve outcomes  Demanding significant data compilation required to track and monitor Result: A serious threat to the long-term viability of physician owned practices

4 Addressing the Threat 4 Plan of Action  In 2013, the Northwest Medical Group Alliance initiated a study to determine the feasibility of creating a physician-led, Clinically Integrated Network (CIN)  Their network of over a dozen independent physician practices with more than 700 physicians is sufficient for limited network products  The proposed CIN delivery model is marketable and the timing is optimal  Hospital affiliation is not a priority  Member participation criteria can be met by most, if not all, medical groups in the Alliance and beyond  The right vehicle for the CIN is the Physicians Care Network (PCN)

5 Physicians Care Network 5 Overview  Formed in 1997, serves as a mechanism for sharing financial risk through clinical integration across multiple medical group practices  Contracts with various health plans on behalf of its Members and administers quality and care management programs in accordance with payer terms and conditions  Integration across care settings of standardized clinical protocols ‒Steerage of patient care to lower cost settings ‒Utilization management of high risk populations ‒Formularies that promote generic drug use  Develops the provider network for health plans ‒Billing, credentialing, administration of risk pools and other risk sharing arrangements ‒Management information services related to administration of those contracts

6 Physicians Care Network 6 Overview (continued)  Engaged with four Medicare Advantage (MA) health plans ‒PCN participates with three of the four MA health plans under full risk, fully delegated (care management, claims, credentialing) arrangements ‒Participates in the Medicare ACO Shared Savings Program with the Centers for Medicare and Medicaid Services (CMS) ‒Contracts with four health plans that focus on shared savings and reduction in the total cost of care delivered to plan beneficiaries

7 Vision & Business Aims Business Aim Develop and operate a clinically integrated network of independent physician practices that secures and supports performance of value-based contracts that reward practices for delivering high quality patient care in an efficient manner 7 Vision Enable independent physician practices in the Pacific Northwest to remain independent and thrive in the new healthcare environment

8 Strategies 8 Achieving the Business Aim  Create a robust and engaged clinically integrated network of independent physician practices  Identify, secure, and deploy an essential infrastructure to support CIN operations in a cost- effective manner  Engage physicians as leaders and full participants in the CIN's development and operations  Support participants’ practice transformation efforts  Identify, evaluate, and pursue network value-based payor contracting opportunities  Develop the capacity to accurately report the health status of defined patient population(s)  Ensure participants’ adherence to CIN-approved evidenced-based standards of care  Deliver "high-touch" care coordination for high-risk and patients who may become high risk  Deploy proven patient engagement tools to manage network patients  Develop metrics and measure outcomes for continuous quality improvement

9 Desired Outcomes 9 Outcomes  Engage a critical mass of independent physician practices as CIN participants  Create a sustainable business model to support essential CIN infrastructure and services to its participating practices  Transform participants’ practices to engage in population health management  Secure favorable value-based payor contracts for CIN participants  Demonstrate quality through participants’ achievement of specified standards  Reduce the total cost of care for defined population(s) by specified targeted amounts (percentage reductions)  Improve the overall patient experience of care

10 Model of Care Scalable Services to Meet Patient Needs 10 High risk – high cost, complex needs Cost Containment, support and coordination Rising risk – at least one chronic condition Motivational Interviewing, closing care gaps, strengthening relationship to PCP Low riskEngage, set the stage

11 Model of Care 11 Enhanced Care Model  Care coordination service delivery model with a focus on keeping patients healthy over time through screening and prevention, early intervention, health education, and meaningful management of chronic conditions  High risk / high cost patients actively managed and transitioned from high cost hospital based services to lower cost community based and home based care  Primary care providers rewarded based on the outcomes they achieve rather than by the number of exams they provide or tests they order  Evidence based clinical protocols, vetted by extensive research, and determined by experts to be most effective compared to other treatment options  Information sharing occurs across care settings to reduce duplication of unnecessary diagnostic and treatment orders and eliminate waste  Formularies that include step-therapy and increased use of generic drugs

12 PCN Services 12 Care Management Services  Train and coach providers on the Enhanced Care Model  Establish and disseminate CIN guidelines and protocols (in collaboration with Member groups)  Promote practice improvement, quality, and cost management goals  Collaborate with Member groups to establish quality and cost measures and clinical benchmarks that drive health system change  Extend risk identification and care management tools and processes to Members  Provide risk adjusted coding training and services

13 PCN Services 13 Administrative Services  Create the CIN, secure investors, and implement  Prepare legal documents for the joint venture: Bylaws, Articles of Incorporation, etc.  Develop Member participation agreements and negotiate contracts  Engage health plans and negotiate innovative payment models  Administer payment models  Develop prospective budgets and resource planning  Develop initial performance measures and baseline statistics  Brand, manage, and expand the network across the state  Manage CIN staff and liaison with in-kind services provided by Member groups  Credential Member physicians  Provide decision support and analytics tools and processes

14 PCN Systems 14 Primary Systems Phytel/Verisk – Concurrent and retrospective review  Stratify, validate, and manage risk  Identify care gaps  Assist with quality indicators; track and trend quality measures  Track population health around complex and chronic conditions  Aggregate disparate data sources into consistent data sets for analysis and comparison of quality and cost metrics  Assist staff in its patient outreach activities through a set of protocols that support preventive and chronic care follow-up EZ-Cap – Administration  Referral and Authorization Management  Customer Service  Encounter Submissions  Reporting

15 CIN Status 15 Recent Developments  Negotiated a term sheet with investors and gained agreement to move forward and engage provider groups  Developed milestones to ensure progress, safeguard ongoing capital investment, and provide investors with some assurance for their investments  Updated the Participation Agreement and created supporting materials for engaging prospective provider groups  Prioritized the list of potential provider groups

16 CIN Governance Model 16 Clinically Integrated Network Board of Managers Executive Director Medical Director (also supports MA business) Population Health Management Performance Improvement ContractsTechnology Business lead/controlled committees with physician participationPhysician lead/controlled committees

17 Revenue Model 17 Care management fee (e.g.PMPM) This approach…  Ensures there is immediate revenue to help offset operating costs  Provides an alternative to health plan contracts that only provide the potential for limited savings at the end of a contract period  Avoids the diminishing returns associated with continuously squeezing costs out of the system The CIN plans to charge a flat per member per month (PMPM) fee  A flat fee across the entire population is much simpler than charging a much higher fee for only the high-risk patients; it also provides a more predictable revenue stream  This approach is not unique; it is consistent with other PCN and standard industry arrangements  The up-front fee may have to work in conjunction with a shared savings arrangement

18 Next Steps 18 Upcoming Activities  Formally create the CIN enterprise ‒Execute the Term Sheet ‒Form the CIN legal entity (Operating Agreement, Articles of Incorporation, Bylaws, etc.) ‒Elect the Board of Directors; form and charge committees  Immediately kick off the next phase of provider group engagement  Execute contracts with health plan(s)  Complete the recruiting process and hire a Medical Director as soon as possible  Engage a CIN consulting firm to support implementation  Create a formal budget for 2015

19 Important Dates Milestones

20 Joining the CIN 20 Membership Participation Criteria  Use a certified electronic medical record system  Meet or be in the process of meeting Meaningful Use standards  Identify and track at least one patient population or chronic condition  Have experience tracking some patient costs  Have process in place for managing transitions of care  Use ePrescribing, CPOE or electronic results reporting  Agree to cost management and performance risk management protocols  Agree to share data transparently  Agree to adopt the new model of care

21 Joining the CIN 21 Member Benefits  The ability to remain independent as an alternative to large health system employment ‒With a number of quality focused provider groups, anchored by The Polyclinic and supported by Physicians Care Network, the CIN will enable independent physicians to participate in risk- based, total cost of care contracts that they would otherwise not have access to ‒This is critical to practice survival as health plan products are increasingly steering patients to narrow networks  Enhanced provider leadership over clinical decisions through selection and implementation of evidence based clinical protocols  Decision making seats on committees and influence to Board decisions  Innovative care delivery alternatives that enhance patient experience that, in turn, leads to growth in market share and revenue sharing opportunities  Access to population health management tools

22 Joining the CIN 22 Member Benefits (continued)  Training and administrative services that streamlines data compilation and extraction for health plan quality metrics management  Financial analysis capabilities  An environment where independent providers can support one another through referrals, team based care, and care coordination while reducing the total cost of care  Risk adjusted coding training and resources


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