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Charting Your Course Towards Accountable Care6/14/2011
Agenda
ACO Market Momentum: Payer/Provider ImplicationsKelly Rakowski Senior Executive, Health and Public Service Practice AccentureAndrew Ziskind, MDSenior Executive, Health and Public Service Practice Accenture
Enterprise Solutions to Facilitate New Models of Care Carrie RaffaelliSenior Product Manager, Health Solutions Group, Microsoft
Q&A
ACOs: Market Momentum, Payer/Provider Implications
Kelly Rakowski Accenture
Andrew Ziskind, MDAccenture
Our Perspective of the Market
1) There is increasing momentum around Payment & Delivery Reform and ACO formation:• Extent of activity varies by market/geography and based on the perceived level of competitive
threat and/or opportunity• Primary focus is optimizing care delivery to improve clinical outcomes and reduce medical
costs and aligning reimbursement for the right financial incentives• While CMS’ proposed rule for shared savings has significant implications for providers, with many
potentially delaying participation in the shared savings program, market leaders are pursuing ACOs in the commercial space and building “ACO-like” competencies that improve quality and reduce costs.
2) For those taking action now, 3 key areas of activity are occurring:• Strategy Development• Capability Assessment, Design, Development• Provider-Payer Contracting & Collaboration / Joint Venture Opportunities
3) The key functional and IT capability needs include: • Provider Network Strategy, Management and Governance• Integrated Care Delivery Model• Information Technology / “Connected Health”• Data Management and Analytics• Payment Methodology and Management
4Copyright © 2011 Accenture. All Rights Reserved.
ACOs are increasingly viewed as a cornerstone of Payment & Delivery reform, though momentum varies by market . . .
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ACN ACO Activity Underway
Key Market Influences:• Threat of competing market ACO initiatives• Extent of Physician Alignment
– Employed physician base– Presence of large physician groups– Strength of alignment (both employed
and affiliated MDs)• Degree of payer competition• History of payer‐provider collaboration• Provider experience with financial risk arrangements
• Breadth and depth of provider organizational capabilities and infrastructure to manage increased financial risk
• Cultural acceptance of evidence‐based medicine and standard care practices
Copyright © 2011 Accenture. All Rights Reserved.
. . . and the perceived threats and opportunities.Providers Payers
Improved Quality & Clinical Outcomes
Reward / Performance Payments for High Quality
Increased Patient “Centeredness” & Care Coordination
Strengthened Provider Alignment
Increased Growth / Market share
Strengthened Core Competencies
Payment & Delivery Reform
Improved Quality & Clinical Outcomes
Decreased Utilization
Reduced Medical Costs & Risk for Total Cost of Care
Strengthened Provider Network
Reduced Administrative Spend
New Revenue Streams (e.g., Provider Services, new ACO Products)
Providers Payers
Thre
ats
Opp
ortu
nitie
s
6Copyright © 2011 Accenture. All Rights Reserved.
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These perceptions are driving a spectrum of market “responsiveness” among our clients, ranging from those “acting now” to those who prefer to “wait and see.”
Copyright © 2011 Accenture. All Rights Reserved.
Act Now!Wait & See . . .
Large, Academic Health Systems
National / Regional, Independent Hospitals / Health Systems
For-Profit IDNs
Large, National For-ProfitHealth Plans
Not-for-Profit, Community-Based Hospitals / Health Systems
Managed Medicaid
Health Plans Providers
Already There. . .
Geisinger
Regional Blues Health Plans
Health System –Owned Health Plans
Kaiser
Group Health Large group practices / IPAs
Small, independent MD practices
Shared Savings Program:Implications of CMS’ Proposed Rule
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1. The proposed rule poses significant challenges to providers seeking to contract with CMS, including:
• Limitations of PCP Participation to one ACO• Retrospective Patient Attribution• Frequency of (Claims) Data Provided to ACOs• Inclusion of IME and DSH payments in calculating spending benchmarks
2. CMS has come under considerable pressure to address these challenges before the final rule is issued in the fall, leaving providers little time to adequately prepare if they wish to participate January 2012.
3. As a result, a number of capable providers (in conjunction with other suppliers) may choose not to apply to Medicare for 2012 participation.
4. However, we believe that market leaders will continue to move forward with the formation of ACOs, with particular focus on building the requisite provider network, capabilities, and infrastructure, in order to:
• Serve the commercial ACO market;• Participate in the Medicare ACO / Shared Savings Program at a later date; and• Adopt ACO-like competencies to optimize quality and cost-effectiveness in the face of pressure to
deliver greater healthcare value.
Copyright © 2011 Accenture. All Rights Reserved.
Payer-Provider collaboration is a key element of success, though several challenges need to be addressed:
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Industry Perspectives & Insights
Challenges
• Historically adversarial payer-provider relationships in some markets
• Harder to innovate when contract negotiations underway / anticipated
• Contract negotiations still dominate the payer-provider dialogue
• Providers fear greater risk with dominant payer due to greater financial risk
• Providers that reduce utilization will see lower revenue from FFS contracts
• As physician employment increases, harder to selectively target them as incentivized decision-makers
Potential Solutions
•Pursue partnerships based on strong payer-provider relationships and/or increased transparency
•Partnership layered upon contract stability• Lower rates offset by subsidy of
services / infrastructure
•Models that provide financial alignment• Strongly data driven• Phased downside risk to providers• Preferential physician targeting
•Redefining the relationship and enhancing interdependence
• New insurance products• Payers as capital/capital avoidance
partners
Copyright © 2011 Accenture. All Rights Reserved.
Data Management &
Analytics
Payment Methodology& Management
Provider Network
Strategy & Management
Integrated Care Delivery Model
Information Technology/ “Connected
Health”
Payment & Delivery Reform
COLLABORATIONCOLLABORATION
COLL
ABOR
ATIO
N COLLABORATION
COLLABORATION
Critical Success Factors
•Position in the local market•Relationship with existing health plans / providers•Ability to achieve consensus among stakeholders:
- Clinical model- Performance measures- Comp/reimbursement distribution
- Risk accountability / management
- Quality measures- Team based care delivery
•Delivery on core competencies
Payment & Delivery Reform Core Capabilities
To reap the benefits and address the challenges of effectively performing as an ACO, collaboration is required to build the complex and interconnected capabilities
10Copyright © 2011 Accenture. All Rights Reserved.
Robust IT and connectivity are foundational to the other core capabilities and supporting ACO business needs.
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Primary Care Specialty Care Acute Care Post‐Acute /Home Health
Integrated Care Delivery
Health Management
Provider Network Management
Payment Setting & Management
PatientEngagement
Contracting
(Re)Credentialing
Network Dev. & Optimization
Participation Terms
Customer Relationship Management
Customer Service & Contact Management
Appointments & SchedulingCare Experience / Satisfaction
Patient Attribution
Incentive Model Design
Financial Risk Management
Transaction Processing
Core Administrative Functions
Patient Enrollment Patient Financial Management Claims Processing Billing & Collections
Supply Chain Management
Enterprise Resource Management Accounting Product Management
RemediationFunds Flow
Care Coordination & Transition Management
Campaign ManagementProgram Referral Management
Clinical CoachingConsumer Health Services & Engagement
Quality Management
Utilization Management
Analytics & Rep
ortin
g
Efficiency & Effe
ctiven
ess A
nalysis
of C
are Processes a
cross T
ime & Settin
gs
Clinical Outcome Mon
itorin
g & Quality Issue Ro
ot Cause Analysis
Patie
nt Risk
Stratificatio
n and Ca
re Team Notificatio
n
Actuarial and
Financial Outcomes M
onito
ring & Risk
Managem
ent
Popu
latio
n Segm
ent M
odeling to Sup
port Con
tractin
g and Ca
re Delivery
Enterprise Solutions to Facilitate New Models of Care
Carrie RaffaelliMicrosoft
What if You Could..
Solve Today’s Complex Problems
Our clinicians need a faster way to access
their critical systems.
I want to use my patient data to proactively
manage patient care
We can’t share information between patients and providers to coordinate care.
I need to more effectively identify and manage patients at risk across the continuum.
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Need to Streamline Operations within the Enterprise
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15
Need to Coordinate Careacross Organizational Boundaries
15
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Need to Engage Patients
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EHR
Hospital System
LIS PACS LABS
Long Term Care
Device LABSPACS BillingEMR
PCPs & Specialists Skilled Nursing
DeviceEHRLABEMR
Pharmacy
PHR Devices
Home Care
Health Intelligence for Accountable Care Needs
Health Intelligence Platform(Integrated Patient Record)
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Continuous Improvement Through Clinical Integration
Integrated Clinical
Information System
Financial System
Lab AnatomicPatholog
y
EMPI
Dictation Interface Engines
Ambulatory
Specialty
HospiceAdvancedVisualizati
on
Budgeting
Labor andDelivery
Time and Attendan
ce
Ambulatory
EMR
AnesthesiaPACS
Patient Monitorin
g System
Laboratory
Blood Bank
CT Ultrasound
Other MedicalDevices
Ventilators
Fetal Monitors
30-Day ReadmissionsCharge & Payment AnalysisChronic Disease ManagementQuality MeasuresAttribution & Risk Analysis
PHR & Device IntegrationPatient & Family Engagement
Care TransitionsManage Patient Leakage
Infection Tracking
1919
Engage Providers & Patients Across Care Settings
Integrated Patient Record
EMR
Meds
PACS
Surgery
Claims
Orders
Dictation
Labs
ADT
Patient & FamilyPCPs & Specialists
Post-Acute Care FacilityCare Management Team
Vitals
PCP & Specialists
ACO Network Services
Patient & Family
Hospital Clinicians
Amalga
Time
Preventive Care
At Risk Population Identification•Proactive population management•Attribution/ risk analysis
Proactive Patient Screening & Coordination•Chronic disease management needs•Patient P4P compliance•Scheduling & Referrals
Follow-up & Post-Acute Care
Patient Engagement •Patient wellness applications •Home devices and monitoring
Administrative Needs •P4P compliance reviews, readmission analysis, audits, and referral tracking
Care Management Across the Continuum
Acute Episode Begins
Patient Admitted•Readmission analysis•At Risk Surveillance of adverse events •Cross-hive analysis of labs, meds, orders, etc.
PCP Informed of Acute Care Admission•Near real-time access to longitudinal patient record
Care Transitions
Transition Planning •Predictive Modeling of Patient Readmissions•Post acute care follow-up & record transfer•Scheduled PCP visit
Patient Engagement•Electronic Discharge Instructions •Patient education & outreach
PCP Outreach•Longitudinal patient view•Portal access •Patient scheduling
Microsoft Amalga creates the foundation for improved care management of chronic disease patients across the continuum.
Patient Surveillance & Screening•Chronic disease management needs•Patient P4P compliance•Scheduling & Referrals
Patient Engagement•Patient wellness & portal use •Patient education and outreach
Health Intelligence Platform
Health Intelligence Platform
Devices Apps
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Engaging patients
Coordinating care
Streamlining operations
Health Intelligence
Platform
Capabilities and Functionalities to Support new Models of Care
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DESIGNED FOR:
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© 2011 Microsoft Corporation. All rights reserved. This material is provided for informational purposes only. Microsoft makes no warranties, express or implied.
