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

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?