1. Bon Secours Virginia Medical Group’s Journey Bon Secours Health System’s Foundation for ACOs June 6, 2013 Payment and Delivery Reform Panel Virginia Chamber Health Care Conference

2. Presenter Tom Auer, MD, MHA CEO, Bon Secours Virginia Medical Group Contact Information: thomas_auer@bshsi.orgthomas_auer@bshsi.org Cell Phone: 804-572-0557 I have no real or apparent disclosures to report

3. Bon Secours means Good Help The Sisters of Bon Secours went to great lengths to meet the needs of their patients…among the first to go into patients’ homes to provide round the clock nursing care. The Sisters were innovators, guided by an unwavering commitment to their patients - a commitment we continue today.

4. Basic Delivery System is NOT WORKING Physicians are not happy – particularly PCPs Physician Workforce cannot keep up with Access Patients are not happy and not insured or underinsured Employers cannot continue to afford healthcare and compete in a global economy Fee-for-Service incentivizing volume not value

5. Healthcare Reform Requires Change We Know that We Have a Challenge We Know that There are Some Success Stories We Now Need to Push For the Changes That Work Physician Leadership is Critical

6. It is a New World

7. Bon Secours Virginia Medical Group Transforming our care in order to transform the lives of our patients and the health of our communities.

8. BSVMG Journey Electrify – Connect Care Grow - Strategically Re-engineer – PCMH Connect – My Chart Coordinate – Nurse Navigation, Geriatric MH Proactive – Registries Clinical Innovation – Hi Tech and Hi Touch Medical Group Culture - Synchronization Advanced Payment Models – ACOs Healthcare Without Walls – Returning to our Roots

9. Bon Secours Medical Group Virginia 460 Provider Multi-Specialty Group 100+ locations 45% PCP/55% Specialists 65% Richmond/35% Hampton Roads Experienced Medical Group Support Team Dyad Leadership Model Very Active Clinical Councils and Sub- Committees

11. TODAY’S CARE MEDICAL HOME CARE My patients are those who make appointments to see me Our patients are those who are registered in our medical home Patients’ chief complaints or reasons for visit determines care We systematically assess all our patients’ health needs to plan care Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet patient needs without visits Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients’ care I know I deliver high quality care because I’m well trained We measure our quality and make rapid changes to improve it It’s up to the patient to tell us what happened to them We track tests & consultations, and follow- up after ED & hospital Clinic operations center on meeting the doctor’s needs A multidisciplinary team works at the top of our licenses to serve patients Acute care is delivered in the next available appointment and walk-ins Acute care is delivered by open access and non-visit contacts *Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma 11

12. Patient-Centered Medical Home PCMH – Proactive Approach to Care PCMH – Building Blocks for an ACO PCMH – Philosophy of Care – Team Based PCMH – Grounded in Evidenced Based Medicine PCMH – Requires Nurse Navigators focused on Population Health PCMH – Expanded Capacity and Reduced Unnecessary Care PCMH – The Right Care, at the Right Time, for the Right Reasons This is VERY Different than what we do today

13. NCQA PCMH US32,976 NY 6,331 VA 671 PA 2,307 NC 2,364 TX 1,428 WI 939 CO 747 IL 384 MD 457

14. Advanced PCMH Outcomes 14 Inpatient Discharges Readmissions High-end Imaging ED Visits Quality/Clinical Outcomes

15. Facility Buffering Vectors 15 Aging Population Obesity Hi-Tech Market Share Appropriate Admissions Managed Care Contracting

16. One Of Our Experiences One Payer – One Year 9000 attributed patients $1.2 million in savings $10 pmpm savings compared to market 35% reduction in readmissions

17. Low Risk Moderate Risk High Risk AwarenessTargeted InterventionHigh-Risk Intervention Communication  Web-based information  Targeted messaging and emails reminders of prevention screenings and disease prevention  Weekly wellness tips and Bimonthly Good Life Newsletter Incentive Program  Complete the PHA and Wellness plan  Complete all age related recommended screenings. Examples: Physical with PCP, Annual Mammogram (or baseline for women 35-40) and Pap for women or Prostate Exam and PSA for men  Complete Self-care workshop and complete personal health record for future visits to PCP Same as low risk plus Communication Quarterly tailored messages, email and home mailing on specific risks such as hypertension. Incentive Program Group Coaching (Healthy Weigh, Compass to the Good Life) Complete 1-2 coaching Sessions either in person or telephonic Complete 2 Healthstream/Webinars based on wellness goals Same as low risk plus Communication Invitational letter from EWS mailed to home with a follow up phone call from CENVANET to those who have not responded. Incentive Program If Diabetic, Hypertensive, Asthma or Back (Ortho) complete 6 coaching sessions with CENVAT for disease and medication management or enroll into disease management program such as DTC or Cardiac Wellness. Other high risk employees not identified in the 4 groups above will work with the nurse navigator Weight Management: Referral into weight loss program based on BMI Physical Activity If you are Diabetic and/or Hypertension, Group exercise classes made available Physical Activity If you are Diabetic and/or Hypertension, Physical assessment and group training sessions available over a 3 month period then a reevaluation. Physical Activity Bon Secours Virginia Employee Wellness Model of Care Tobacco Cessation: Quitline or Freshstart in person class SeIf-Care/Health Care Consumerism 13

18. Advanced Payment Models Managed Care Contracting: Cigna Humana Conventry Aetna Optima* Anthem United* MSSP *Negotiations ongoing 18

19. Medicare Shared Saving Program 25,000 Medicare patients in Va. Shared savings for CMS 33 quality metrics Create a new delivery platform Partnering with Aetna

20. Our New Frontier and Mantra Healthcare Without Walls

21. Patient & Family Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation Building an ACO Patient Activation

22. Advanced Primary Care Patient & Family Advanced Primary Care Under Patient-Centered Medical Home Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation Prevention & Wellness Point of Care Analytics & Clinical Decision Support Gaps in Care Population Management & Chronic Care Registries Home Visiting Teams Generic Prescribing Program Embedded Nurse Navigation Cost Effective Medical Management & Utilization of Services (SCP, Ancillary) Access, Same Day Appointments, e-Visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction

23. New Health System Coordination Patient & Family Advanced Primary Care Under Patient-Centered Medical Home Medical Group & Health Care System Enterprise Level Activities PCP/SCP Incentives & Clinical Guidelines Pay for Performance Initiatives and Outcomes Measurements Hospitalists, Post Discharge Follow-Up Programs ER Avoidance Programs Urgent Care End of Life (Palliative Care) Patient Satisfaction & Loyalty Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation Prevention & Wellness Point of Care Analytics & Clinical Decision Support Gaps in Care Population Management & Chronic Care Registries Home Visiting Teams Generic Prescribing Program Embedded Nurse Navigators Cost Effective Medical Management & Utilization of Services (SCP, Ancillary) Access, Same Day Appointments, e- Visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction Care management (Acute, Chronic, Inpatient, SNF) Health Coaching (Shared Decision Making) Transition of Care Provider Satisfaction Behavioral & Mental Health

24. Patient & Family Advanced Primary Care Under Patient-Centered Medical Home Medical Group & Health Care System Enterprise Level Activities Accountable Care Organization Hospitals Service Line Integration Medical Staff Alignment Incentives for Efficiency & Lean Six Sigma Quality (SCIP, Leap Frog) Safety Medical Groups & Health Care System Enterprise Level Activities PC-MH Functions Skilled Nursing Facilities SNFists On-site Case Management Efficiency Rating Systems “Preferred Facilities” Ancillary Services Free-Standing ASC & Diagnostic Testing Centers Home Care Home Safety Visits Post Discharge Visits Home Health Coordinator of Services Hospice Transitions (CHF, COPD, Frailty Syndrome, Dementia) PCP/SCP Incentives & Clinical Guidelines Pay for Performance Initiatives and Outcomes Measurements Hospitalists, Post Discharge Follow-Up Programs DME Integration & Oversight with Care Management Outcomes & Evidence Based Medicine Call Coverage Consult Services (Stroke, STEMI) ER Avoidance Programs Urgent Care End of Life (Palliative Care) Patient Satisfaction & Loyalty Personal Health Record Patient Portal Health Risk Assessment Patient Engagement & Activation Prevention & Wellness Point of Care Analytics & Clinical Decision Support Gaps in Care Population Management & Chronic Care Registries Home Visiting Teams Generic Prescribing Program Cost Effective Medical Management & Utilization of Services (SCP, Ancillary) Access, Same Day Appointments, e- Visits Patient Satisfaction & Loyalty Provider & Office Staff Satisfaction Care management (Acute, Chronic, Inpatient, SNF) Health Coaching (Shared Decision Making) Transition of Care Provider Satisfaction Behavioral & Mental Health Maturing ACOs Payment Mechanism