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2016 MGMA Gulf Coast Business Plan Competition Value Through Unity
November 5th, 2016
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Executive Summary Physician Buy-in Finances Unified ACO PCMH PCSP
Value Based PCMH PCSP Unified ACO Finances Physician Buy-in Definitions MIPS: Merit-based Incentive Payment System PCMH: Patient Centered Medical Home PCSP: Patient Centered Specialty Practice Advanced APM: advancd Alternative Payment Model ACO: Accountable Care Organization FFS to Value based Two bonus structures: MIPS and aAPM aAPM: clnic and network levels PCMH PCSP ACO Finances Look forward to take advantage
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State of Healthcare Under FFS
Patients and physicians are isolated Fragmented healthcare market Wasteful operations Charting burden
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Misaligned Incentive Leads to Misaligned Care
US Federal Budget 2040 2014 1970 Value Volume Cost Source: Budget of United States Government 3 bins are: pharmaceutical, insurance, medical consumption
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Value Value Cost Cost Realigning Value
Healthcare Providers will integrate the new value structure. Value Cost Value Cost
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ACO Lays the Tracks for Success
Patient Guided PCP Guided
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Our ACO shelters the care network from administrative burden
Fragmentation of Care Accountable Care Organization PCMH PCSP Patients Physicians PCMH PCSP Patients Physicians
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Five Components in a Market Analysis
Rival Hospitals ACO Entrant Buyer Patient Substitute ER Care Self Care Supplier Physicians Insurance Rival Hospitals ACO Entrant Buyer Patient Substitute ER Care Self Care Supplier Physicians Insurance Coordinated Care
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Five Components in a Market Analysis
Rival Hospitals ACO Entrant Buyer Patient Substitute ER Care Self Care Supplier Physicians Insurance Rival Hospitals ACO Entrant Buyer Patient Substitute ER Care Self Care Supplier Physicians Insurance Coordinated Care Physician Focused
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New legislation proposes two models: MIPS and aAPMs.
Advanced APM
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ACO Finances PCMH Coordinated Care High Quality Physician Driven
Revenue Model Pro-Forma Margins Savings Bonus ACO Operations Integrated Structure Coordinated Care Innovative Beginning the ACO Phrase it in complete sentences, don’t read off slide
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No Gaps in Patient Care PCMH ACO Finances Coordinated Care
High Quality Physician Driven Intuitive EHR Patient portal Quality analytics Comprehensive care Primary care focused Preventive, Chronic Dz Care coordinator Continuity of care Patient accessibility Intuitive EMR Patient portal Simple interface Quality Analytics Continuity of care Patient accessibility Nurse Coordinator Comprehensive Care Primary + preventive care Chronic disease management Value through coordinated care
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Quality maintenance Continual progress Quality Maintenance
PCMH ACO Finances Coordinated Care High Quality Physician Driven Innovation Center Quality maintenance Synchronized IT Real-time metrics PCMH level metrics Continual progress Healthy competition Adopt what works Quality Maintenance Continual Improvements Real-Time Metrics Value through removing redundancy
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Value through intrinsic motivation
PCMH ACO Finances Coordinated Care High Quality Physician Driven Physician Friendly Autonomy Workflow efficiency (less bureaucracy/charting) Academic-friendly Aligned incentives Quality metrics Stakeholder Collaborative Minimized risk Administrative Burden Physician Autonomy Allusion to innovation center Workflow efficiency (less bureaucracy/charting) Value through intrinsic motivation
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SUMMARY GRPAHIC OF HOW ACO AND PCMH INTERACTS
Finances SUMMARY GRPAHIC OF HOW ACO AND PCMH INTERACTS Extended Network ACO Hospitals Labs PCMH PCSP
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Value through a strong ACO network
PCMH ACO Finances Network Strength Integrated Structure Coordinated Care Innovative Beginning the ACO Dual Governance PCMH and PCSP Hospital affiliates Tertiary care affiliates Governance Essential oversight Physician leadership - board Unified voice Bargaining power in marketplace PCMH, PCSP, & Affiliates Bargaining Power Network Strength Value through a strong ACO network
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PCMH ACO Finances Integrated Structure Integrated Structure
Coordinated Care Innovative Beginning the ACO Integrated Structure Coordinated Care Innovative Beginning the ACO Quality Coordination managers Nurse leadership IT Support for PCMH Synchronized HIE extends network Quality Set standards Metrics and feedback for system Set standards Feedback system EHR IT Coordination Managers Support for PCMH Synchronized HIE extends network Nurse leadership Value through strong cross-linking
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Innovation Center PCMH ACO Finances Innovation Center
Integrated Structure Coordinated Care Innovative Beginning the ACO Operations Ideas Innovation Center Operation – share information Research – academic Physician promotion Collaborative Innovation Research Platform Physician Promotion Value through internal improvement
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Value through removing barriers
PCMH ACO Finances Integrated Structure Coordinated Care Innovative Beginning the ACO Attract Membership Leadership Bonus Incentives Joint Ownership Growth Clinic Partnerships Commercial Payers Patient Volume Initial Strategy Attract membership Members joint ownership Private Equity Strong bonus incentives Growth Acquisition Commercial Payers Value through removing barriers
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30% 70% PCMH ACO Finances Revenue Model Pro-Forma Margins
Savings Bonus ACO Operations ACO and PCMH Financials and Cost Structure 5% 5% 5% 5%
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Immediate Profitability
PCMH ACO Finances PCMH within our ACO PCMH alone Immediate Profitability Revenue Model Pro-Forma Margins Savings Bonus ACO Operations ACO Model Staffing Reduction – 10% Technology Reduction – 30% Computer Reduction – 80% Increase Patient Volume – 1% Without ACO Staffing Increase – 3% Income Decrease – 2%
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PCMH ACO Finances Revenue Model Pro-Forma Margins Savings Bonus
ACO Operations Total Bonus Pool is modelled a large care organization ACO improves coordinated care ACO improves technology administration
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PCMH ACO Finances Revenue Model Pro-Forma Margins Savings Bonus
ACO Operations
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Restoring Doctor-Patient Relationships
Physicians treat patients
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Our Two Key Success Factors
Coordinated Care Physician Focused Questions?
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Appendix
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Pro Forma for One PCMH
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Pro Forma for Entire ACO
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Performance Incentives
ACO meets benchmark, and all physicians meet benchmark Minimum 105% + bonuses based on comparisons based on absolute value Incentives are preserved because increasing amount of cost-savings shared At a certain point of maximal value, clinic increases in volume Feedback loops and growth ACO meets benchmark, and one sector of physicians does not Baseline 105% for all. Bonuses still go to cost-saving physicians Feedback system in place ACO does not meet benchmark, and one sector is successful Bonuses come from savings and private equity to cost-saving physicians All physicians still get 105%. ACO does not meet benchmarks, and nobody meets benchmark Unlikely, as Houston healthcare market is very successful
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