An Integrated Healthcare System’s Approach to ACOs Chuck Baumgart, M.D., Chief Medical Officer Presbyterian Health Plan David Arredondo, M.D., Executive Medical Director Presbyterian Medical Group

Presbyterian Healthcare Services (PHS) 8 Hospitals 650+ Physician multi- specialty group 43 clinic locations 400,000 member health plan

Presbyterian Healthcare Services PHS is a nonprofit integrated health care system that has served the state of New Mexico for over 100 years Over 37% of New Mexicans rely on PHS for the financing and/or delivery of health care services PHS is comprised of Presbyterian Health Plan (PHP) and the Presbyterian Delivery System (PDS) PHP is the largest health plan in the state with approximately 400,000 Commercial, Medicare and Medicaid members

Overview of PPACA US Health Care Reform Insurance Reform Coverage Expansion Medicaid Insurance Exchanges Individual Mandate Tax Credits & Subsidies Penalties Delivery System Reform New Org Structures Accountable Care Organizations Patient Centered Medical Home Payment Reform Value-Based Payments Bundled Payments Adapted from: Presentation to the Health Plan Alliance by Neal C. Hogan, PhD – BDC Advisors, October 7, 2010

Generic Model of an ACO Staying Healthy Living with Chronic Disease Getting Better (Acute Care) End of Life Care Accountable Care Organization (ACO) Adapted from: Presentation to the Health Plan Alliance by Neal C. Hogan, PhD – BDC Advisors, October 7, 2010 Healthy Lifestyle ModelChronic Care Model (Medical Home) Evidence-Based Medicine Palliative Care Model

Innovation and Risk Community Hospital PCP Practice Specialty Practice Community Hospital PCP Practice Specialty Practice PCP Practice Fee-for-Service Accountable Care Organization $ $ Community Hospital Source: 2010 Center for Healthcare Quality and Payment Reform, Network for Regional Healthcare Improvement

9 ACO Participation Requirements Providers eligible to participate in ACOs: –Hospitals employing ACO professionals –ACO professionals in group practice arrangements –Networks of individual practices of ACO professionals –Partnerships or joint venture arrangements between hospitals and ACO professionals –Other groups of providers that the Secretary deems appropriate ACOs must meet certain quality thresholds: –Clinical processes and outcomes –Patient and caregiver perspectives on care –Utilization and costs Providers meeting criteria can be recognized as ACOs and can qualify for incentives bonus (January 2012 or July 2012) Final CMS Regulations: summer 2011 Interim CMS Regulations: March 31, 2011

ACO Requirements Eligible entities Legal Structure and Governance Leadership and Management structure Accountability for Beneficiaries Agreement Requirements Shared Savings Program – Distribution of Savings Sufficient Number of Primary Care Providers and Beneficiaries. Required Reporting on Participating ACO professionals Process to promote Evidence-based Medicine, Patient Engagement, Reporting, and Coordination of Care 10

Will ACOs work? Key Success Factors –Process to keep efforts to improve totally aligned –Clear Financial alignment –Open Sharing of information – data availability –Give and Take on all sides –Its all about relationships Value-based purchasing –Alignment of incentives to improve care Clinical Quality outcomes Patient Experience Affordability

Presbyterian’s Transformation Plan Goal: develop a network of providers that delivers clinically integrated and coordinated care –Develop new care models – patient centered care, care management, alternative venues of care, transitions of care, performance reporting Model for the primary care delivery system components: –Employed primary care group –Aligned groups and other independents Leverage all lessons learned including experience with roll-out of Medical Home model

Presbyterian Medical Group - the Integrated Approach Large group, integrated, organized approach PCMH pilot started in July 2009 Alternative Venues of Care and Care Team Portions of PCMH deployed in 10 clinic sites –Data supported move to tailored approach for each site NCQA application for PCMH recognition submitted

Presbyterian Medical Group - the Integrated Approach Key Points Truly a new care delivery model Ensure process efficiency is addressed –Access, patient panel size, productivity –Patient focused – no shows, ED and inpatient follow-up Establish measurable outcomes - align with the Triple Aim

Patient Centered Medical Home (PCMH) Core Concepts –Information sharing via Electronic Medical Record –Use of technology to drive quality –Evidence-based guidelines - Algorithms

The Challenge…. How to develop a program that meets the needs of the primary care group, the integrated system and the ACO? Realized that - “When you’ve seen one PCMH Program, you’ve seen one PCMH Program”

One Solution…. “Medical Home Lite” A program that engages primary care practices to start “down the path” Grant funds from the health plan, associated with our state Medicaid program requirements Application for participation –Specific “ask” required –Measure of impact required Targeted areas of care model deployment –ED visits –Hospital readmits –Generic medication usage Support –Patient registry software –Hire staff to do patient outreach, care coordination (or use health plan staff) –Population data for the group – “care opportunities” in clinical quality and utilization

Lessons Learned Need for “gradual engagement” model – not all primary care practices will be in the position to fully embrace patient-centered care and medical home. Measures of success are a key to show value Start with focus on targeted areas – ED utilization, transitions of care, generic prescribing – understandable, actionable and can show more immediate impact Align with other requirements – EHR implementation, “meaningful use”, PQRI Most groups glad to have support – had no idea where to start

Questions?