an integrated healthcare system’s approach to acos chuck baumgart, m.d., chief medical officer...
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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
San Juan Regional
Espanola Hospital Holy Cross Miners Colfax
St.Vincent
Union County
NortheasternRegionalMedical Ctr.
Los AlamosMed. Ctr.
RehobothMcKinley
CibolaGeneral Hosp. Guadalupe
City Hospital
Dan C. Trigg
RooseveltGeneralSocorro
GeneralLincoln CountyMedical Center
Eastern NMMedical Ctr.
Lea Regional
North LeaRegional
ColumbiaMedical Ctr.
ArtesiaGeneral
GeraldChampion
Sierra Vista
Gila Regional
MimbresMemorial
MemorialMedical
Mountain ViewMemorial
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
Adapted from: Presentation to the Health Plan Alliance by Neal C. Hogan, PhD – BDC Advisors, October 7, 2010
PATIENT
GROUP VISIT
WEB VISIT
TELE-VISIT
FACE TO FACE
RETAIL CLINIC
TEAM VISIT
UC/ER
PROVIDER
SELF MANAGEMENT SKILLS
HEALTH CARE TEAM
FAMILY COMMUNITY
CLINIC HEALTH SYSTEM
PHONE TRIAGE
HOMEVISIT
Generic Model of an ACO
Accountable Care Organization (ACO)
Adapted from: Presentation to the Health Plan Alliance by Neal C. Hogan, PhD – BDC Advisors, October 7, 2010
Healthy Lifestyle Model Chronic Care Model(Medical Home)
Evidence-BasedMedicine
Palliative Care Model
Innovation and Risk
Community Hospital
Community Hospital
PCP Practice
PCP Practice
Specialty Practice
Community Hospital PCP Practice
Specialty PracticePCP 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
2010 2011 2012 2013 2014 2015 2016 2017
Providers meeting criteria can be recognized as ACOs and can qualify for incentives bonus (January 2012 or July 2012)
Final CMS Regulations: summer 2011Interim 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
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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?
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