Thursday, June 25, 2015 – 11am-12:45pm

New Models for Aligning Value-based Incentives with Physicians, Systems and Payers

Patrick Adams President, Transcend

Humana and the Commitment to Population Health

Transcend Partnership Framework and Value-Based Reimbursement Models

Physician Perspective in Florida: Chauhan Medical Center

Saint Luke’s Health System: A fee-for-service market preparing for change

Interactive Session

3-7

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12-15

8-11

16-17

Agenda

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Humana launches wholly owned subsidiary Transcend

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Humana Background Health and well‐being company

focused on making it easy for people to achieve their best health with clinical excellence through coordinated care

#5 largest U.S. publicly-traded health insurer with approximately 14.2 million medical members nationwide as of March 2015

#2 in Medicare Advantage enrollment with approximately 3.2 million members as of March 2015

$48.5 billion in revenue (2014)

30+ years track record in Medicare program

Operator of 500+ medical centers

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Health care is moving from traditional care to integrated care

RESULT: Dis-integrated. Episodic. Conflicted.

Traditional Healthcare

RESULT: Patient-focused. Primary care-centric. Proactive.

Integrated Care

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Higher levels of provider integration across the integrated care continuum result in improved quality and lower costs

1) Value-based relationships includes providers participating in Path to Risk and Shared Risk programs. 2) Humana Analysis on 2013 claims data for Individual MA only, including delegated risk

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Humana’s Integrated Care Delivery Model is the engine of a consumer-focused strategy

Providing integrated care that makes it easy to achieve best health through clinical capabilities and a personalized experience – making healthcare easy

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Making the transition to Population Health Management possible

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Transcend delivers services to physicians supporting value-based reimbursement models and population health

Population Health Service Model

Care ManagementPhysician Engagement

Local Medical Director• Committee leadership and

participation• Peer education and coaching• UM/QI/pharmacy oversight

Nurse Care Managers/Care Navigators• Member outreach• Coordinate PCP visits• Post discharge follow-up• Specialist follow-up back to PCP

Quality Nurses• HEDIS/quality, coordinate quality

initiatives with health plan• Analyze access to specialty care

Clinical Integration

Creation of Clinically Integrated Network

Medical Management Committee Data aggregation/analytics/reporting

• DataLink CareBook• Patient stratification

Health Information Exchange (HIE)• Certify HealthLogix• Community-wide patient view

Financial Risk Management

MSO is physician’s partner in population health

Physician committee participation Richer value-based

reimbursement models• QIP• Shared Savings

Provider Service Representatives• Perpetual involvement• Liaison with health plan –

problem solving• Deliver actionable information

at the right time• Provider office education

Patient-focused. Physician-centric.

Risk aggregation and Stop Loss Documentation Consultants

• Risk adjustment support• Chart reviews• Diagnostic Action Forms• PCP office coding education

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Fund flow structure

Solution: Partnership Framework

• The key differentiators are the creation of a clinically integrated network and payer ACO, and management services that simplify the population health process and all the partnerships required to create an aligned structure, allowing movement from volume to value.

• Physicians receive resources and technology to proactively improve health outcomes, patient engagement and care affordability.

• Physician leadership, aligned around population health tools and resources, is core to the success of value-based care.

Transcend

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• Churn and Burn PCPs may need to see 35+ patients daily to cover practice costs

• Reactive Focus on individual patients’ presenting problems

• Hand on the doorknob Visits may feel rushed to keep up

• Volume-driven Reimbursement based on RVUs generated

• Billing Limitations PCPs generally provide and bill for a lower level of services than specialists

• Not satisfying for some physicians

• Shift focus Managing a population of patients

• Proactive management

Stratify and provide proactive treatment to highest risk patients

• Close Gaps Better data & enhanced ability to focus on closing quality gaps

• Fewer, more thorough visits each day• Increased opportunity

Reimbursement based on RVUs generated, plus quality bonus & surplus distribution

• The “procedure” of Population Health Management

Payers are willing to reimburse for the “procedure” of population management because of its proven value

Population health results in better quality and a more satisfying physician experience

Volume vs. Value-Based | A Physician’s Perspective

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Physician Perspective in Florida: Chauhan Medical Center

Chauhan Medical Center – Primary care practice in Orange City, east-central Florida (Volusia County) Practice with 15-year history in Orange City

Residents age 65 and over: 29% Median household income: $29,050 Persons per household: 2

*From census.gov Practice Panel—1500 Patients (unique, seen in the practice in the past 18 mos):

1,000 are in a Population Health Management Model with Humana: ~650 are Humana Gold Plus® members (Humana Medicare Advantage

HMO/Health Maintenance Organization plan). Practice is exclusively Humana Medicare Advantage Plans.

Remaining patients are commercial fee-for-service patients under ObamaCare.

500 patients are traditional Fee for Service

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Physician Perspective in Florida: Chauhan Medical Center

Chauhan Medical Center, continued Practice Staffing

Dr. Kevin Chauhan – Board Certified in Internal Medicine• Special Interest in and focus on Chronic Condition Management

such as Diabetes and Cardiovascular Disease.• Works closely with Transcend MSO and previously, MetCare

MSO—15-year relationship with same MSO team. Dr. Dorma Broome-Webster – Board Certified in Internal Medicine

• Associated with the practice for 10+ years.• Special Interest in and focus on wellness and disease

prevention. Remainder of staff cross-trained to perform administrative work

such as referrals, care coordination, medication refills:• Registered Nurse (retired military medic)• Office Manager • Receptionist• Two Medical Assistants

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Physician Perspective in Florida: Chauhan Medical Center

Chauhan Medical Center, continued

Typical Patient: Multiple medical conditions; taking four or more medications Congestive Heart Failure, Cardiovascular Disease, Diabetes, Hypertension, COPD Poor Nutrition, Non Compliance

With this patient profile: Even an engaged patient + best specialist = cost-prohibitive for patient. If the physician doesn’t find a way to take care of this patient, they’ll end up in the

ER over and over again. Working with Humana in the MSO structure, patients can come in more often—

daily if necessary—for monitoring and adjustment of their therapy until the episode is resolved.

Otherwise, within a two-week period, the same patient might be admitted to the ER several times.

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Physician Perspective in Florida: Chauhan Medical Center

A Collaborative Approach—MSO + Physician + Payer + More Engaged Patients = Greater Success

Partnership resulted in development of a Disease-State Management Program – educational approach with diabetes patients:

Focus-group-type model under guidance of the physician. ~10 diabetes patients met regularly at the practice to share stories and testimonials, and offer one another

support and encouragement. Support group setting helped patients learn to live better with diabetes and in compliance with therapy. MSO’s role expanded to support the program with additional resources.

The relationship with the MSO allowed the physician to focus on patients rather than finances—physician’s interests and patients’ were the same:

More affordable care for the patient and access to the practice. Improved quality of life for the patient and the physician. Better patient outcomes.

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Saint Luke's Health System: A fee-for-service market preparing for changeBen Harber, Chief Operating Officer, Physician EnterpriseFaith-based not-for-profit health system dedicated to enhancing the physical, mental and spiritual health of communities served.

10-hospital system serving Kansas City metro and throughout Kansas and Missouri; includes home care and hospice, and behavioral health care. 400 employed physicians 130 APPs 900 support staff at 60 locations Region’s only adult heart transplant program One of the nation’s leading cardiovascular disease

outcome research programs Treatment for complex brain and spinal cord diseases Nation’s leading stroke reversal program dedicated to

preventing and treating stroke An eICU, an innovative electronic intensive care

patient care and monitoring program spanning multiple hospitals

Nationally recognized children's behavioral health center

Level 1 trauma center Liver and kidney transplantation programs A Level IIIb Neonatal Intensive Care Unit

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Saint Luke's Health System: A fee-for-service market preparing for changeBen Harber, Chief Operating Officer, Physician Enterprise, continued

The match strike is imminentTiming for a tipping point into a higher penetration of risk-based contracts is a matter of when.

Availability of right resources is key Succeeding with risk deals takes more than the typical finance/legal staff.

PCPs want to treat

Navigating contract-specific requirements by patient will not happen.

No head of the table Medical leadership, administration, legal, finance, etc. must partner from initial stages to succeed.

Shared-risk arrangements help train

Use of shared-risk contracting is key in order to prepare for more complex arrangements.

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Interactive Session

• Network of Care – Gaps vs. integrated clinical care

• Organizational Foundation – Leader/staffing capabilities; IT infrastructure

• Physician Engagement – E.g., regional variances• Market Strength – Size, profits, brand

recognition• Relationship with Business Partners – E.g.,

payers, data/analytics vendors

Questions

Audience participation

Using an interactive tool we will use the following questions to role play a scenario of a medical group examining where they are on the spectrum of readiness to transform from volume to value. We also will look at the approaches and partners we need to succeed.

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