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Listen to the playback of the Modern Healthcare webinar led byDell's Betsy Block (Director of Accountable Care Solution Strategies) and Dave Marchand (CTO): http://info.modernhealthcare.com/DellConsultingWebinarRegistrationPage.html
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ACOs for Real: Does it make sense for your organization?
Betsy Block Dave Marchand
Director of Accountable Care CTO Solution Strategies Healthcare & Life Sciences Services
Services 2
CMS timeline for reform
2010 2011 2012 2013 2014 2015
HIPAA 5010 ICD 10
PQRI PQRI (eRx) PQRS
Penalty for non
submission of PQRI
ARRA Meaningful Use Penalty for
non compliance
No Matching Payment
Hospital Acquired Conditions Reduced
Payment for HAC
Accountable Care Organizations
Penalties for High Rates of Readmissions
Inpatient Value Based Purchasing Program
Bundled Payment Pilot
Source: Kaiser Family Foundation Health Reform Source 11.10.2010
Services 3
Accountable Care Organizations: What are they
Under section 3022 of the Affordable Care Act, Medicare providers and suppliers participating in Accountable Care Organizations (ACOs) can continue to receive traditional FFS payments and are eligible for additional payments based on meeting specified quality and savings requirements.
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What Constitutes an ACO?
Who belongs to an ACO?
An ACO consists of a collection of providers in a given geography that can include primary care physicians, hospitals, specialists, home care, etc.
What are they Responsible for?
100% of the healthcare and costs for a defined group of patients
What Functions do they Perform?
• Coordination of all care activities between the providers in an ACO
• Measurement and improvement of outcomes and costs
• Financial management and distribution of cost savings across ACO
Services 5
Early Success in Clinical Integration
• Advocate Physician Partners, Chicago • 3400 physicians, 8 hospitals, 280,000 Capitated lives, 137
performance measures
Performance Year Incentive Funds
Distributed
2005 $12.4 million
2006 $16.7 million
2007 $25.0 million
2008 $28.2 million
2009 $32 million*
* Estimated from 2010 Value Report, Advocate Physician Partners
Services 6
Participants Region Organizational
Structure Number of Physicians
Part of Integrated Delivery
System?
Includes AMC?
Owns or Owned an
HMO?
Not For Profit?
Dartmouth-Hitchcock Clinic
Northeast Faculty/
Comm. Group Practice
907
Billings Clinic West Group Practice 232
Geisinger Clinic Northeast Group Practice 833
Middlesex Health System
Northeast Network Model 293
Marshfield Clinic Midwest Group Practice 1,039
Forsyth Medical Group South Group Practice 250
Park Nicollet Clinic Midwest Group Practice 648
St. John’s Clinic Midwest Group Practice 522
The Everett Clinic West Group Practice 250
University Of Michigan Faculty Group Practice
Midwest Faculty Practice
1,291
Source: CMS; Commonwealth Fund; WSJ, “Healthcare Overhaul Increases Rewards for Efficiency,” 11/2010
Organizational Characteristics of PGP Participants
PGP Demonstration
Services 7
The “secret sauce” of ACOs
• Clinical Integration is a physician and provider led effort
• Internally motivated to monitor themselves and deliver better quality and higher value – not something that is forced on them from the outside
• The “secret sauce” is the empowerment of the physicians
• Financial incentives are important but not the only motivating factor in a successful ACO
• Need to foster an entrepreneurial attitude and a desire to seek out novel solutions and accept the challenge to explore and learn how to make this work
Services 8
CMS ACO Development Timeline
Governance
• Legal organization
• Measures
• Incentives
• Participants and TINs
• Application
• Beneficiary representative
• Senior medical director
• Executive under governing body
• Marketing materials must be authorized
• PSA determination of ACO
Data Infrastructure
• Claims Data
• Quality Data
• Reporting
• Population ID
• Ancillary Data
• Disease Registries
• Pt Satisfaction (CAHPS)
• Summary of care documents
• Beneficiary access to med record
• Available to public using CMS format
Profiling
• Recruit members
• Establish connectivity
• Train on use of reporting tools
• Benchmarks
Analyzing
• Pull Reports
• Verify Data
• Care management: mechanism for care coordination
• Risk Management: ID high risk individuals and develop care plans
1/1/2012 7/1/2011
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Proposed CMS ACO guidelines ACOs can choose between 2 options:
Track 1
– Shared savings for Year 1 and 2, Year 3 is shared savings and shared losses (if any) over certain threshold
– Savings and Losses are capped
– Bonus for including a FQHC or RHC
– 50% shared savings up to 7.5% of benchmark
Track 2
– Shared savings and shared loss (if any) all 3 years
– Savings and losses are capped
– Bonus for including a FQHC or RHC
– 60% shared savings up to 10% of benchmark
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CMS Math: Estimates per ACO, based on 100 ACOs
Bonus Payout
$8,000,000
Cost $1,755,251 $1,265,897 $1,265,897 $4,287,075
Bonus left $3,712,925
• Source: CMS -1345-P Proposed Rule Medicare Shared Savings Program: Accountable Care 3. 31.2011 p.350
Year 1 Year 2 Year 3 Total 3 years
Services 11
Infrastructure Cost Estimates For ACO Prototype (ACO includes 200 beds, 80 PCPS, 150 SPC)*
Categories of Costs Start Up Ongoing
Network Development and Management $2,275,000 $2,900,000
Care Coordination, Quality Improvement and Utilization Management $405,000 $1,515,000
Clinical Information Systems $2,350,000 $1,500,000
Data Analytics $285,000 $385,000
Total $5,315,000 $6,300,000
* White Paper - THE WORK AHEAD: Activities and Costs to Develop an Accountable Care Organization, AHA
Services 12
Do we really need to do this?
As a small community hospital, you may wonder if you have to form an ACO or CI program
There are a number of reasons you should: – Commercial payers moving
to ACO model too – Competition for community
primary care physicians is on the rise
– Integrated delivery networks are forming
– Clinical integration principles are very successful in smaller hospitals
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Healthcare
Technology Infrastructure needed by ACOs
Healthcare 14
Healthcare Information Landscape is rapidly changing
ARRA/HITECH
HC REFORM
ICD-10/5010
CONSUMERISM
CONSOLIDATION
Healthcare 15
More Information is becoming DIGITAL
Genomics
Proteomics
Digital Pathology
Medical Images
Diet & Exercise
Medications
Results
Histories & Encounters
Procedures
Smart Medical Devices
Healthcare
Physicians
Health Plans
Long
Term
Care
Consumers
Other Medical
Intermediaries
Laboratories
Pharmacies
Public
Health
Agencies
Hospitals
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Data must be Shared, Aggregated, and Analyzed
Health Information needs
to be EXCHANGED within
Communities
Standardized Analytics &
Informatics solutions drive
improvements in QUALITY &
EFFICIENCY
Healthcare
8 Preventative
Health
10 At Risk Populations
Diabetes
7 At Risk Populations
Heart Failure
6 At Risk Populations
Coronary Artery Disease
2 At Risk Populations
Hypertension
3 At Risk Populations
COPD
3 At Risk Populations
Frail Elderly
2 Patient Safety
4 Care
Coordination / Transitions
5
Care Coordination /
Information Systems
7 Care
Coordination 7 Patient / Care
Giver Experience
Proposed Initial Quality Measures by Domain
Healthcare 18
Data + Analytics will drive Quality and Efficiency
Individual/Patient
• Care Gap Management • Preventative Health • Outreach/Education
Community
• Identified Data Analysis • Care Coordination • Financial Analysis
Population
• Disease Management • Care Improvement
Healthcare 19
Where does the Data come From?
Man
ual o
r A
uto
mate
d
• Targets for quality and care management standards
• Medical records • Clinical outcomes • Patient billing/Charge Master
• Labs, Rx • Encounters • Histories
• Historical patient data • “outside” treatment information • Reimbursement rules
• Surveillance data • Adverse drug events • Genomics/Imaging
EMR/PM/HIS
HIE
Payers
Quality Measures
Other
Healthcare
Dell’s Health Strategy – “In the Cloud”
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Healthcare Cloud Platform
Analytics Image
Archiving Reporting & Alerting
Portals
Electronic Medical Records
Revenue Cycle
Services
Payers Solutions
Healthcare Solutions
Data Management Interoperability Security Mobility
Simplifies use with interoperability that creates a true “healthcare system”
Hospitals Physicians Payers Life Science Other
Healthcare
Alerting Example
Patient Outreach Future Possibilities
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d JaneDoh Reminder to take 2 -100mg SOMA tablets
(sent at 8pm local time)
Medication Reminder Example
Pollen or Pollution
Patient List
Generic Alert
#AllergyAlert #HighPollenCount Plano, TX 5-12-2011
Patient Specific Alerts
d JaneDoh #HighPollenCount 5/12/11 take <med_name>
d JohnDoh #HighPollenCount 5/12/11 wear mask outside
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Wrap Up
• Whether the current rules for an ACO survive as is or are modified, the concept of clinical integration and shared cost savings will survive
• The infrastructure needed for an ACO consisting of separate provider entities in a community is the same infrastructure needed for a single provider entity, such as a health system, to improve quality and efficiency
• The key to improving quality and efficiency is consistent ways to gather the data, compare the results, and look for patterns of improvement
• A cloud based infrastructure enables a standard set of interoperability and analytics tools to be utilized across ACO’s resulting in further efficiencies and sharing of best practices and innovation
• Change is Inevitable
Thank You
23
Betsy Block Dave Marchand (317) 225-6244 (972) 577-5595 [email protected] [email protected]