New Risk and Collaboration Models for - PowerPoint Presentation

Slide1

New Risk and Collaboration Models for

ProvidersClinically Integrated Network

January 2014Slide2

Agenda2

Objectives for TodayProvide a brief history and contextShare the vision, objectives, and strategies

Review the model of care

Review Physician Care Network’s clinical and administrative services

Provide a status of recent activities and upcoming milestones

Share the requirements and benefits of physicians joining the CINSlide3

Background3

Market & Competitive PressuresHospitalsConsolidating; increasing negotiation strength

Employing primary care and specialty physiciansHealth Plans

Creating narrow networks and increasing price pressure

Implementing bundled episodic payments

Pushing risk based payment and shared savings models

Tying quality metrics to reimbursement levels

Requiring changes to protocols and treatment to improve outcomes

Demanding significant data compilation required to track and monitor

Result

:

A serious threat to the

long-term viability of physician owned practicesSlide4

Addressing the Threat4

Plan of ActionIn 2013, the Northwest Medical Group Alliance initiated a study to determine the feasibility of creating a physician-led, Clinically Integrated Network (CIN)

Their network of over a dozen independent physician practices with more than 700 physicians is sufficient for limited network products

The proposed CIN delivery

model is marketable and the timing is optimal

Hospital affiliation is not a priority

Member participation criteria can be met by

most,

if not

all,

medical groups in the

Alliance and beyond

The

right vehicle for the CIN is the Physicians Care

Network (PCN)Slide5

Physicians Care Network5

OverviewFormed in 1997, serves as a mechanism for sharing financial risk through clinical integration across multiple medical group practices

Contracts with various health plans on behalf of its Members and administers quality and care management programs in accordance with payer terms and conditionsIntegration across care settings of standardized clinical protocols

Steerage of patient care to lower cost settings

Utilization management of high risk populations

Formularies that promote generic drug use

Develops the provider network for health plans

Billing, credentialing, administration of risk pools and other risk sharing arrangements

Management information services related to administration of those contractsSlide6

Physicians Care Network6

Overview (continued)Engaged with four Medicare Advantage (MA) health plans

PCN participates with three of the four MA health plans under full risk, fully delegated (care management, claims, credentialing) arrangements

Participates

in the Medicare ACO Shared Savings Program with the Centers for Medicare and Medicaid Services (CMS)

Contracts with four health plans that focus on shared savings and reduction in the total cost of care delivered to plan beneficiariesSlide7

Vision & Business Aims

Business AimDevelop and operate a clinically integrated network of independent physician practices that secures and supports performance of value-based contracts that reward practicesfor delivering high quality patient care in an efficient manner7

Vision

Enable independent physician practices in the Pacific Northwest

to

remain

independent and thrive in the new healthcare

environmentSlide8

Strategies8

Achieving the Business AimCreate a robust and engaged clinically integrated network of independent physician practices

Identify, secure, and deploy an essential infrastructure to support CIN operations in a cost-effective manner

Engage

physicians as leaders and full participants in the CIN's development and operations

Support

participants’ practice transformation efforts

Identify

, evaluate, and pursue network value-based payor contracting opportunities

Develop

the capacity to accurately report the health status of defined patient population(s)

Ensure

participants’ adherence to CIN-approved evidenced-based standards of care

Deliver

"high-touch" care coordination for high-risk and patients who may become high risk

Deploy

proven patient engagement tools to manage

network patients

Develop

metrics and measure outcomes for continuous quality improvementSlide9

Desired Outcomes9

OutcomesEngage a critical mass of independent physician practices as CIN participants

Create a sustainable business model to support essential CIN infrastructure and services to its participating practicesTransform

participants’ practices to engage in population health management

Secure

favorable value-based payor contracts for CIN participants

Demonstrate

quality through participants’ achievement of specified standards

Reduce

the total cost of care for defined population(s) by specified targeted amounts (percentage reductions)

Improve

the overall patient experience of careSlide10

Model of Care

Scalable Services to Meet Patient Needs10

High risk –

high cost,

complex needs

Cost Containment, support and coordination

Rising risk

–

at least one chronic condition

Motivational Interviewing, closing care gaps, strengthening relationship to PCP

Low risk

Engage, set the stageSlide11

Model of Care11

Enhanced Care ModelCare coordination service delivery model with a focus on keeping patients healthy over time through screening and prevention, early intervention, health education, and meaningful management of chronic conditions

High risk / high cost patients actively managed and transitioned from high cost hospital based services to lower cost community based and home based care

Primary care providers rewarded based on the outcomes they achieve rather than by the number of exams they provide or tests they order

Evidence based clinical protocols, vetted by extensive research, and determined by experts to be most effective compared to other treatment options

Information sharing occurs across care settings to reduce duplication of unnecessary diagnostic and treatment orders and eliminate waste

Formularies that include step-therapy and increased use of generic drugsSlide12

PCN Services12

Care Management ServicesTrain and coach providers on the Enhanced Care ModelEstablish and disseminate CIN guidelines and protocols (in collaboration with Member groups)

Promote practice improvement, quality, and cost management goals

Collaborate with Member groups to establish quality and cost measures and clinical benchmarks that drive health system change

Extend risk identification and care management tools and processes to Members

Provide risk adjusted coding training and servicesSlide13

PCN Services13

Administrative ServicesCreate the CIN, secure investors, and implementPrepare

legal documents for the joint venture: Bylaws, Articles of Incorporation, etc.Develop Member participation agreements and negotiate contracts

Engage

health plans

and negotiate innovative payment models

Administer payment models

Develop prospective budgets and resource planning

Develop initial performance measures and baseline statistics

Brand, manage, and expand the network across the state

Manage CIN staff and liaison with in-kind services provided by Member groups

Credential Member physicians

Provide decision support and analytics tools and processesSlide14

PCN Systems14

Primary SystemsPhytel/Verisk – Concurrent and retrospective reviewStratify, validate, and manage risk

Identify care gaps

Assist with

quality indicators;

t

rack

and trend quality measures

Track population health around complex and chronic conditions

Aggregate disparate data sources into consistent data sets for analysis and comparison of quality and cost metrics

Assist staff in its patient outreach activities through a set of protocols that support preventive and chronic care follow-up

EZ-Cap – Administration

Referral and Authorization Management

Customer Service

Encounter Submissions

ReportingSlide15

CIN Status15

Recent DevelopmentsNegotiated a term sheet with investors and gained agreement to move forward and engage provider

groupsDeveloped milestones to ensure progress, safeguard ongoing capital investment, and provide

investors with

some assurance for their investments

Updated the Participation Agreement and created supporting materials for engaging prospective provider groups

Prioritized the list of potential provider

groupsSlide16

CIN Governance Model16

Clinically Integrated NetworkBoard of Managers

Executive Director

Medical Director

(also supports MA business)

Population Health Management

Performance Improvement

Contracts

Technology

Business lead/controlled committees with physician participation

Physician lead/controlled committeesSlide17

Revenue Model17

Care management fee (e.g.PMPM)This approach…

Ensures there is immediate revenue to help offset operating costsProvides an alternative to health plan contracts

that only provide the potential for limited savings at the end of a contract period

Avoids the diminishing returns associated with continuously squeezing costs out of the system

The CIN plans

to charge a flat per member per month (PMPM

) fee

A flat fee across the entire population is much simpler than charging a much higher fee for only the high-risk patients; it also provides a more predictable revenue stream

This approach is not unique; it is consistent with other PCN and standard industry arrangements

The

up-front fee may have to work in conjunction with a shared savings

arrangementSlide18

Next Steps18

Upcoming ActivitiesFormally create the CIN enterpriseExecute the Term Sheet

Form the CIN legal entity (Operating Agreement, Articles of Incorporation, Bylaws, etc.)

Elect the Board of Directors; form and charge committees

Immediately kick off the next phase of provider group engagement

Execute contracts with health plan(s)

Complete the recruiting process and hire a Medical Director as soon as possible

Engage a CIN consulting firm to support implementation

Create a formal budget for 2015Slide19

Important Dates19

2015 MilestonesSlide20

Joining the CIN20

Membership Participation CriteriaUse a certified electronic medical record system

Meet or be in the process of meeting Meaningful Use standardsIdentify and track at least one patient population or chronic condition

Have experience tracking some patient costs

Have process in place for managing transitions of care

Use

ePrescribing

, CPOE or electronic results reporting

Agree to cost management and performance risk management protocols

Agree to share data transparently

Agree to adopt the new model of careSlide21

Joining the CIN21

Member BenefitsThe ability to remain independent as an alternative to large health system employment

With a number of quality focused provider groups, anchored by The Polyclinic and supported by Physicians Care Network, the CIN will enable independent physicians to participate in risk-based, total cost of care contracts that they would otherwise not have access to

This is critical to practice survival as health plan products are increasingly steering patients to narrow networks

Enhanced provider leadership over clinical decisions through selection and implementation of evidence based clinical protocols

Decision making seats on committees and influence to Board decisions

Innovative

care delivery alternatives that enhance patient experience that, in turn, leads to growth in market share and revenue sharing opportunities

Access to population health management

toolsSlide22

Joining the CIN22

Member Benefits (continued)Training and administrative services that streamlines data compilation and extraction for health plan quality

metrics management Financial analysis capabilities

An

environment where independent providers can support one another through referrals, team based care, and care coordination while reducing the total cost of care

Risk

adjusted coding training and

resources