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ChenMed Care Model:

Creating Change and

Transformation in General

Practice

November , 6th, 2014

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Average per capita health care costs by

number of chronic conditions

Source: Medical Expenditure Panel Survey, 2006

Chronic conditions drive health care spending, especially

in Medicare

Medicare spending for patients with 5+

chronic conditions

52%

65%

76%

0% 20% 40% 60% 80%

1987

1997

2002

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Who we are: Privately held, primary care-led physician group

Our focus: Low to moderate income adults > 55 with multiple chronic

conditions in urban areas. Typical patient searches for a PCP every 18

months, often considered “frequent flyers” by other health systems.

Care model: 400-450 patients per PCP; on-site Rx, focus on culture,

patient relationships, decision making, customized information

technology, intensive care coordination

Scale: Designed to scale quickly; Growth from 5 centers in Miami market

in 2010E to 36 centers in 8 markets at 2013E . 40+k risk lives in 2014.

Payment: Global risk adjusted capitation from Medicare Advantage plans

Snapshot of ChenMed

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This approach is fundamentally different

ChenMed Typical ACO

Population focus Low to moderate income

MA population

Commercial insurance,

multiple types

Payor Primarily one, capitated Multiple, FFS economics

still preeminent

Strategy Start with getting doctor-

patient relationship right

Evidence based guidelines,

operational processes

Governance Primary care led Complex, multi-specialty,

multi-facility

Ability to scale High Low

Upfront integration

challenges Low High

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Chen NMC National Difference

Consumer Net Promoter

Score 92 40-50 >100%

Medication Possession

Ratio 82 42 73%

Hospital Days per 1000 1058 1712 (38%)

Percent of Ambulatory

Encounters on Site 86% N/A

Patient Visits at Center

Per Year 13.3 N/A

PCP Visits with Same

Physician 92% 40-60% > 50%

Miami Outcomes in CY 2011 prior to scaling

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Designing the operations of a focused factory

One-stop shopping enhances coordination,

collaboration, convenience, and compliance

Reproducible layout resembles an Ambulatory ICU

• Primary care doctors lead the care team and do not have

private offices

• Onsite specialists to encourage physician to physician dialogue

• Onsite supportive services for convenience

• Capacity to keep patients out of hospital (e.g., IV Antibiotics,

Diuresis)

Door-to-doctor transportation to our clinical sites

improves access to care

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Focus creates the potential for strategic design

▪ Hire staff who are passionate about this patient segment with right skills

▪ Engineer tighter integration and links in every process

▪ Test multiple changes in different markets

▪ Streamlined organizational governance

▪ > 70% of Medicare costs driven by patients with > 4 conditions

▪ Changes in outcomes can be measured in months

Faster change

cycles

Impact easier

to measure

Payor

collaboration

▪ JV allows for rationalization of care programs between payor

and provider (e.g., analytics, care coordination, specialized

programs)

▪ Don’t focus on fee for service demands

▪ Operational challenges dramatically reduced

Specialized

staff and

processes

Reduces

complexity

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Manage across

transitions

▪ Build in continuity where possible; hospitalist follows patients to first

follow-up visit

▪ PCP and NP joint SNF decision-making

▪ Initial home assessment

▪ Interdisciplinary weekly team meetings by center

Design around

access

▪ One stop shop – most patients within 7 miles ; transportation

▪ On-site physician drug dispensing

▪ Wellness focused activities on-site

▪ Not looking to be a complete multi-specialty group, but invite external

specialists on-site as feasible and practical

Build up care

team

▪ Nurse case manager, social worker, transitions team

▪ Developing medical assistants as coaches

▪ Qualitative judgment – the worry index

▪ Develop relationships with trusted specialists over time

Integrating primary care decisions around the patient

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Physician culture is critical to get care right

“from the inside out”

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Building the right culture requires changing mindsets

and behaviors

Role-modeling

Behavior and

mindset shifts Developing talent

and skills

Reinforcing with formal

mechanisms

Fostering understanding

and convictions

The McKinsey influence model

“I see superiors, peers,

and subordinates

behaving in the new way”

“I know what is

expected of me – I

agree with it, and it is

meaningful

“I have the skills and

competencies to

behave in the new

way”

“The structures, processes,

and systems reinforce the

change in behavior I am

being asked to make”

• Changes in mindsets and

behaviors need to happen at all

levels of the organization,

starting with

– Front-line physicians

– Clinical team

– Physician leadership

• None of the changes in

behaviors and mindsets can be

mandated or dictated – each

will require a coordinated set of

influencing tactics to ensure

traction in the organization

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CMS risk scores

Real-time internal HEDIS Metrics

Real-time patient flow metrics (i.e. wait times)

Comprehensive outpatient clinical data, digitized and scanned

• Hospital Admissions & Readmissions

• Real-time inpatient clinical data

Claims Data • Part A • Part B • Part D

Net Promoter Scores / Customer Feedback

Predictive Modeling data from Envita and Humana

Providing a suite of tools to optimise decision making in

the exam room

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Using

Visualization

Tools to help a

Physician

Manage Her

Panel of 450

High Risk

patients

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A care timeline is used to integrate claims, referrals and

hospital data for high cost case management

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Dash2Go

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▪ 3 times a week review of patient care by the physician group

▪ Transparent review of outcomes with all physicians

▪ Entire team owns the relationship

▪ Relationship evolves over time

▪ >85% of the touch-points

Focus on the patient

relationship

Physician decision-making

▪ Selection and culture

▪ Decision support at point of care

▪ Positive incentives – the “tuned” patient panel

Convenience matters

▪ Redesigned system of on-site physician drug dispensing dramatically improves adherence

▪ On-site behavioral health model coordination

Communication

▪ Coordination of care

▪ Specialist – PCP communication in person

▪ Team conferences

What are the key drivers of success in integrated care?