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Clinical Integration a Strategy for Physician Alignment Better Quality and Collective Payer Contracting John Marren Thomas Babbojpmhmltdcom tjbhmltdcom
Hogan Marren Ltd Chicago Illinois
(312) 946-1800March 2009
Agenda
1 Update on Clinical Integrationmdashthe national health care perspective
2The FTC perspective3MGOrsquos efforts to date4What it takes to be Clinically Integrated5Contracting with payors
2
Letrsquos be specific
bull Physicians can align with each other and hospitals to ndash(1) distinguish themselves in the
market on the basis of qualityndash(2) justify higher reimbursement ndash(3) conduct collective negotiations
with health plans
3
4
What do we know about todayrsquos health care environment
5
The solution is physician alignment
bull Through employment
bull Through management models
bull Through clinical integrationclinical integration
Combining the efforts of employed managed and independent doctors
6
bull Fosters collaboration among doctors and hospitals in a way that increases the quality and efficiency of patient care
bull Presents doctors and hospitals a powerful business and clinical strategy to thrive in the advent of consumerism pay-for-performance and quality report cards
bull Allows physician networks to assert themselves forthrightly in collective negotiations with health plans andor employers
What does CI achieve
What do we know about CIIf Clinical Integration is defined ashellip
7
ldquo an active and ongoing program to evaluate and modify practice patterns by the networks physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure
quality rdquo
hellip then we know at least three things
8
bull The ldquomessenger modelrdquo
bull Risk contracting redux
bull Payor-driven ldquoP4Prdquo
What do we know
First CI is not hellip
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Agenda
1 Update on Clinical Integrationmdashthe national health care perspective
2The FTC perspective3MGOrsquos efforts to date4What it takes to be Clinically Integrated5Contracting with payors
2
Letrsquos be specific
bull Physicians can align with each other and hospitals to ndash(1) distinguish themselves in the
market on the basis of qualityndash(2) justify higher reimbursement ndash(3) conduct collective negotiations
with health plans
3
4
What do we know about todayrsquos health care environment
5
The solution is physician alignment
bull Through employment
bull Through management models
bull Through clinical integrationclinical integration
Combining the efforts of employed managed and independent doctors
6
bull Fosters collaboration among doctors and hospitals in a way that increases the quality and efficiency of patient care
bull Presents doctors and hospitals a powerful business and clinical strategy to thrive in the advent of consumerism pay-for-performance and quality report cards
bull Allows physician networks to assert themselves forthrightly in collective negotiations with health plans andor employers
What does CI achieve
What do we know about CIIf Clinical Integration is defined ashellip
7
ldquo an active and ongoing program to evaluate and modify practice patterns by the networks physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure
quality rdquo
hellip then we know at least three things
8
bull The ldquomessenger modelrdquo
bull Risk contracting redux
bull Payor-driven ldquoP4Prdquo
What do we know
First CI is not hellip
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Letrsquos be specific
bull Physicians can align with each other and hospitals to ndash(1) distinguish themselves in the
market on the basis of qualityndash(2) justify higher reimbursement ndash(3) conduct collective negotiations
with health plans
3
4
What do we know about todayrsquos health care environment
5
The solution is physician alignment
bull Through employment
bull Through management models
bull Through clinical integrationclinical integration
Combining the efforts of employed managed and independent doctors
6
bull Fosters collaboration among doctors and hospitals in a way that increases the quality and efficiency of patient care
bull Presents doctors and hospitals a powerful business and clinical strategy to thrive in the advent of consumerism pay-for-performance and quality report cards
bull Allows physician networks to assert themselves forthrightly in collective negotiations with health plans andor employers
What does CI achieve
What do we know about CIIf Clinical Integration is defined ashellip
7
ldquo an active and ongoing program to evaluate and modify practice patterns by the networks physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure
quality rdquo
hellip then we know at least three things
8
bull The ldquomessenger modelrdquo
bull Risk contracting redux
bull Payor-driven ldquoP4Prdquo
What do we know
First CI is not hellip
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
4
What do we know about todayrsquos health care environment
5
The solution is physician alignment
bull Through employment
bull Through management models
bull Through clinical integrationclinical integration
Combining the efforts of employed managed and independent doctors
6
bull Fosters collaboration among doctors and hospitals in a way that increases the quality and efficiency of patient care
bull Presents doctors and hospitals a powerful business and clinical strategy to thrive in the advent of consumerism pay-for-performance and quality report cards
bull Allows physician networks to assert themselves forthrightly in collective negotiations with health plans andor employers
What does CI achieve
What do we know about CIIf Clinical Integration is defined ashellip
7
ldquo an active and ongoing program to evaluate and modify practice patterns by the networks physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure
quality rdquo
hellip then we know at least three things
8
bull The ldquomessenger modelrdquo
bull Risk contracting redux
bull Payor-driven ldquoP4Prdquo
What do we know
First CI is not hellip
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
5
The solution is physician alignment
bull Through employment
bull Through management models
bull Through clinical integrationclinical integration
Combining the efforts of employed managed and independent doctors
6
bull Fosters collaboration among doctors and hospitals in a way that increases the quality and efficiency of patient care
bull Presents doctors and hospitals a powerful business and clinical strategy to thrive in the advent of consumerism pay-for-performance and quality report cards
bull Allows physician networks to assert themselves forthrightly in collective negotiations with health plans andor employers
What does CI achieve
What do we know about CIIf Clinical Integration is defined ashellip
7
ldquo an active and ongoing program to evaluate and modify practice patterns by the networks physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure
quality rdquo
hellip then we know at least three things
8
bull The ldquomessenger modelrdquo
bull Risk contracting redux
bull Payor-driven ldquoP4Prdquo
What do we know
First CI is not hellip
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
6
bull Fosters collaboration among doctors and hospitals in a way that increases the quality and efficiency of patient care
bull Presents doctors and hospitals a powerful business and clinical strategy to thrive in the advent of consumerism pay-for-performance and quality report cards
bull Allows physician networks to assert themselves forthrightly in collective negotiations with health plans andor employers
What does CI achieve
What do we know about CIIf Clinical Integration is defined ashellip
7
ldquo an active and ongoing program to evaluate and modify practice patterns by the networks physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure
quality rdquo
hellip then we know at least three things
8
bull The ldquomessenger modelrdquo
bull Risk contracting redux
bull Payor-driven ldquoP4Prdquo
What do we know
First CI is not hellip
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
What do we know about CIIf Clinical Integration is defined ashellip
7
ldquo an active and ongoing program to evaluate and modify practice patterns by the networks physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure
quality rdquo
hellip then we know at least three things
8
bull The ldquomessenger modelrdquo
bull Risk contracting redux
bull Payor-driven ldquoP4Prdquo
What do we know
First CI is not hellip
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
8
bull The ldquomessenger modelrdquo
bull Risk contracting redux
bull Payor-driven ldquoP4Prdquo
What do we know
First CI is not hellip
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
What do we know
the FTC has said a lot about Clinical Integration
9
Second
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
10
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
bull The FTC staff hellip considered the explicit admission by GRIPA that one objective of the plan was to contract at higher fee levels for the services of physician-members
11
bull Ordinarily such an objective would raise concerns that higher prices would result from the exercise of market power the FTC staff said
bull Here however GRIPAs higher fee levels are anticipated as part of a program that seeks and through the participants integration appears to have significant potential to achieve greater overall efficiency and improved quality in the provision of medical care to covered personsrdquo
bull Based on the information provided the FTC staff letter said it appeared that GRIPAs joint negotiation of contracts including price terms with payers on behalf of its physician members who will be providing medical services to payers enrollees under those contracts is subordinate to reasonably related to and may be reasonably necessary for or to further GRIPAs ability to achieve the potential efficiencies that appear likely to result from its member physicians integration through the proposed program
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
12
May 28 2008
FTC Conference Center601 New Jersey Avenue NWWashington DC 20001
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
antitrust laws forbid collective negotiationshellip
13
In other words
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
hellipunless yoursquore really clinically integrated
An analysis of any physician networkrsquos clinical integration program is essentially a three-part test which asks
1 whether the networkrsquos clinical integration program is ldquorealrdquo
containing authentic initiatives actually undertaken by the network which involve all physicians in the network and apply to the physiciansrsquo practice patterns relative to patients who obtain health benefits under fee-for-service health plans
2 whether the initiatives of the program are designed to achieve likely improvements in health care quality and efficiency and
3 whether joint contracting with fee-for-service health plans is ldquoreasonably necessaryrdquo to achieve the efficiencies of the clinical integration program
14
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
What else do we know
many lawful well-constructed CI programs have and are being developed across the country
15
Third
So we need to get going
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Current Successful CI Modelsbull Advocate Physician
Partnersbull Brown amp Toland
Medical Groupbull Greater Rochester IPAbull MedSouthbull St Lukersquos Magic Valleybull Memorial Hermann HNPbull Covenant Health
Partnersbull Etc
16
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Achieving CI a phased approach
bull Evaluate CI Readiness bull Build Physician amp Hospital Consensus
bull Establish Network Organizationbull Develop CI Initiativesbull Select amp Deploy CI Infrastructurebull Engage Regulatorsbull Implement CI Programbull Commence CI Contracting 17
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12
Establish Organization
Develop CI Initiatives
Select amp Deploy CI Infrastructure
Implement CI Program
Engage Payors
Maintain Legal Compliance
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
19
Health System
CI Operations Company
Physicians
Payors Employer Community
Health Systems
A wholly-owned subsidiary of Health System Governance is predominated by physicians along with a number of key hospital representatives (and possibly important purchasersstakeholders)
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
20
Health
CI Operations Company
Payors Employer Community
A joint venture Physician Hospital Organization (PHO) A 50=50 partnership both in governance and equity
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
21
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Examples of CI initiatives MGO is considering
Non- Clinicalbull Electronic Connectivity ndash high speed internet amp e-mailbull Attendance at CI information meetingsbull Completion of on-line assessments and courses
23
Clinicalbull Readmission within 30 days of patients discharged with a
diagnosis of heart failurebull Prophylactic antibiotic selection for surgical patientsbull Ambulatory management of patients with GERD
All of these can be measured now
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
wwwadvocatehealthcom
Search for 2008 Value Report
(httpwwwadvocatehealthcomphyspartnersaboutemployersvalue_reporthtml)
Or call 1800 3ADVOCATE24
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Infrastructure building on a solid foundation
bull Networks of independent physicians that are affiliated with hospitals or health systems enjoy a distinct advantage in the development of CIndash Existing OhioHealth QI and patient safety initiativesndash Established MGOOHG medical management activitiesndash MGOOhioHealthOHG investments in advanced clinical
technologies and information systems
bull The presence of such infrastructure greatly accelerates the implementation of a comprehensive CI programndash The CI activities of the MGOOHG entail reorientation and
realignment of this infrastructure rather than building basic CI competencies
25
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Ambulatory ClaimsHospital SystemsbullMIDASbullMIDAS + DataVisionbullEMRCPOEbullORBbullExisting QI Programs
Med3000 Data Warehouse
Ambulatory EMR(good to have but not necessary)
26
bull MGO billing programbullMed3000 PMSbullAetna claimsbullOhioHealth benefits
Physician Profiling and Actionable Reports
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Food for thoughthellipldquoThough creating clinically
integrated organizations is difficult and expensive physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patientsrdquo
Lawrence P Casalino MD PhD University of Chicago ldquoThe Federal Trade Commission Clinical Integration and the
Organization of Physician Practicerdquo Journal of Health Politics Policy and Law 2006 Duke University Press 31(3)569-585 DOI10121503616878-2005-007
27
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
MGO efforts to dateA brief history -2005 - bull Representatives from OHC and MGO began meeting to
discuss PHO contracting and market changes bull Clinical Integration was adopted as the ldquogo to marketrdquo
strategy of the PHObull The OHG Board formed a PHO Strategy Team with
representatives from OHG MGO and OHC
2006 - bull The PHO Strategy Team developed a clinical integration
implementation plan bull A pilot program with OhioHealth as the employer was
proposed7
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
MGO efforts to date(continued)
2007 - bull OHG populated a data warehouse with three years of OhioHealth
employee and dependent claims databull A pilot pay for quality (P4Q) program that incentivizes MGO
physicians to support OhioHealthy initiatives was planned
2008 - bull The MGO Board adopted clinical integration as the organizationrsquos
primary strategic initiativebull The pilot pay for quality program focused on OhioHealth
associates and dependents was implementedbull Aetna a payer agreed to provide claims data for the data
warehouse to expand the pay for quality program in 2009bull The PHO Strategy Team transitioned to the Clinical Integration
Development and Implementation Team (CI DIT)8
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Clinical Integration Development amp Implementation Team
INFORMATICS
- Data Warehouse- Results- Reporting
INFORMATION TECHNOLOGY
- Connectivity- Data Acquisition- Electronic Medical Records- E-prescribing
METRICS DEVELOPMENT
QUALITY COMMUNICATION
MANAGED CARE CONTRACTING LEGAL
OHIOHEALTH PILOT
PROGRAM
Work Groups
ChairAllen Heilman
VPOHG
ChairMichael Krouse
CIOOH
ChairBob Thompson MD
Assc Medical DirectorMGO
Chair Kitty Martin
COOMGO
ChairJohn Kontner
System VP Mgd CareOH
ChairBob McAdamsLegal Counsel
OHG
ChairTom Thompson
COOOHG
Chair Dr ____________ CMO MGOOHGVice Chair Bruce Vanderhoff MD CMO OH
Interim Chair Tom Thompson COO OHG
OH Reps Mike Louge Exec VP and CFO Paul Patton VP Human Resources - Interim
MGO Reps John Burns MD Ben Humphrey MD
CI DIT
Core Committee
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
What it takes to be CI
bull Network of physicians committed to Clinical Integration
bull A set of initiatives that impacts allbull An infrastructure that supports CI
And most importantly--the proper narrative
31
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
Next steps for MGO
bull Ask physicians to participate in the clinically integrated network
bull Begin marketing the program to employers and payers
32
bull Develop a strategy for engaging payors
Aetna Anthem Cigna Medical Mutual UHC
