Physician Leader Perspective of ACO Transition Scott D. Hayworth, MD, FACOG President and CEO Mount Kisco Medical Group, PC

Multi-specialty group practice founded in 1946 and servicing Westchester, Dutchess and Putnam Counties in NYS 300 primary care and specialty physicians, 25 office locations servicing 300,000 patients Mount Kisco Medical Group, PC

Affiliated with 4 local community hospitals and academic affiliation with Massachusetts General Hospital Practice Data: o 760,000 patient visits o 2 million lab tests, 125K imaging tests o $425 million in gross revenue Recently implemented NextGen EMR; 3 rd EMR in over 15 years

Current Trends in Physician Practices Consolidation of small groups into larger group practices Acquisition of medical groups by hospitals & integrated delivery systems Imperative to capture market share

Current Trends in Physician Practices Risk-based contracting with payers Pay for performance growing as adjunct to usual payment Blurring of roles between payers and providers, i.e. groups become insurance plans and insurance companies are buying groups

Accountable Care Organizations (ACO) Established by federal government under Medical Shared Savings Program created by Section 3022 of Health Care Reform Law Initial guidelines published March 31, 2011 Final guidelines published October 20,2011

Accountable Care Organizations Definition: voluntary groups of physicians, hospitals, and other health care providers willing to assume responsibility for care of a clearly defined population of eligible beneficiaries attributed to them on the basis of patient’s use of primary care services

Accountable Care Organizations 3 Types Medicare Commercial Medicaid

Accountable Care Coalition of Mount Kisco (ACCMK) Signed “upside only” shared-risk contract with CMS in April, 2012 Established partnership with Universal American to provide consulting services through Collaborative Health Systems, a wholly owned subsidiary Currently 14,000 lives in the ACO

Collaborative Health Systems (CHC) Facilitated key management committees Provided requisite provider training Established compliance program Identified patient cohort and sent out “opt out” letters to patients Will provide necessary analytics to assist with managing population

Care Management Services Staffing: PT Medical Director and six FTE care coordination staff Activities: - Identify high risk patients through CHC analytics, hospital discharge/ER reports, PCP referrals, personal health assessments - Link with affiliated hospital discharge planning departments

Care Management Services Work with PCP offices to provide services to high risk patients and insure appropriate follow up visits Telephonic follow up with patients Facilitate appropriate point of service care: home care, transitional care, etc. Communicate with hospitalists re: discharge planning

Challenges to Group Adoption of ACO Model Understanding the definition of an “ACO patient” Explaining “opt out” process to patients Integrating ACO care management staff with existing physician nursing staff Involving physician staff in “transition of care” process post-hospital discharge

Challenges to Group Adoption of ACO Model (cont’d) Achieving “buy-in” to maximizing quality metrics, i.e. “standardization of care” Encouraging referrals from physicians to case management staff Integrating case management notes into EMR Distribution of savings to group participants Making move from “volume” to “value”

“Brave New World” of Value Volume Based Payment: Fee For Service Incentives: Volume Focus: Acute episodes Role of provider: single episodes Information: retrospective Value Based Outcomes Value Populations Care Continuum Real-time & predictible

How Should Groups React to “Value Proposition”? Develop integrated care models using care managers partnering with providers Develop or contract with continuum of care providers: home health, SNF’s, etc. Optimize radiology and lab test ordering Create patient-centered medical homes at primary care office sites

How Should Groups React to “Value” Proposition Standardize care: evidence-based guidelines Rationalize/consolidate clinical assets Build Care Management Department with imbedded case managers, transitions of care coordinators and telephonic outreach

What Do I Do If I Am In a Small Group?

Ethical Issues Associated with ACO Patient autonomy v. referral patterns within the ACO, i.e., leakage Unintended financial effects re: market share growth of ACO Distribution of savings fairly Where to focus quality improvement efforts, i.e. those closest or furthest from targets? Potential loss of physician autonomy

Ethical Issues Associated with ACO Impact on risk management of reduced resource utilization Role of beneficiary on the ACO Governance Board: independence and strength of the role Comfort level with ACO referral patterns

Summary Points ACO’s with shared risk will be a significant venue for reimbursement in the future Medical groups must prepare for the transition from “pay for volume” to “pay for value” in the near future Group practices will need to standardize care, incorporate care coordination and respond to pay for performance metrics Medical groups must be prepared to address the ethical issues associated with ACO adoption

Thank you…questions?