Utilizing Clinical Integration to Align Physicians and Increase Market Share

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1 Utilizing Clinical Integration to Align Physicians and Increase Market Share Timothy J. Quinn, MD & Daniel J. Marino DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure Timothy J. Quinn, MD Daniel J. Marino Have no real or apparent conflicts of interest to report. DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

3 Learning Objectives Attendees will: 1. Analyze 5 keys to creating a quality clinical integration infrastructure 2. Identify complex questions that guide clinical integration 3. Define success criteria of clinical integration 4. Develop a plan for clinical integration based on the 4 Pillars approach 5. Identify how to track clinical outcomes starting with Meaningful Use data

4 Healthcare is Going Through Dramatic Changes

5 What is Driving the Cost of Healthcare? Technologic Advances Prescription Drugs Aging Population Administrative Costs 7% of total spending Chronic Disease Account for over 75% of healthcare spending Preventable diseases consume 80% of spending

6 Reimbursement for Service is Changing Never Events In 2008, CMS stopped reimbursing healthcare providers for never events: serious adverse events that should never occur or are reasonably preventable through adherence to evidence-based guidelines. Value-Based Purchasing Program Beginning in October 2012, CMS s value-based purchasing program will provide incentives to hospitals that exceed certain quality measures relating to clinical care processes and patient experience, while hospitals that fall short on these measures compared with their peers will receive reduced payments.

7 Reimbursement for Service is Changing ACOs The ACA calls for the development of ACOs which will link providers together in risk-based structures Bundled Payment System Coalitions of Providers and Payers testing bundled payment systems on evidence informed case rates

8 What does this Mean for the Physician? Physicians must provide value in everything they do!

9 What is Clinical Integration? Coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused To achieve clinical integration: Promote changes in provider culture Redesign payment methods and incentives Incorporate technical support tools Focus on chronic disease management Measure clinical outcomes Focus placed on creating a organization-wide quality Source: AHA description of clinical integration infrastructure

10 Where Do We Begin in Clinically Integrating Care? Establish a burning platform for change Identify programs for care coordination and quality tracking Physicians must lead the care coordination initiatives The goal is to coordinate patient care and position physicians and Hospitals for success by leveraging quality.

11 Options for Physicians & Organizations Physician s Level of Collaboration High Create Provider-Driven Medical Home Model Coordinate care within practice s population Establish value around chronic disease outcomes Use outcomes to create value with payers Do Nothing Maintain FFS Model Negotiate contracts under current strategy Tolerate fee schedule reductions Clinically Integrate Care Track quality across continuum Establish a patient longitudinal record Prepare for value-based contracting Develop Hospital Coordinated Care Model Focus on cost reduction Invest in health information technology Connect providers to acute care setting Low Organization s Level of Collaboration High

12 Moving an Organization Forward Build the Infrastructure and Make the Case for Change Develop Primary Care Participation First Critical Features/Ground Rules Physician defined measures Meaningful incentives Timely feedback Embed in system governance

13 Physician Committee Participation Hourly rate for participation System Support for Pay for Performance IT presence in the committee, especially during design process Audit process defined

14 Cultural Transformation with CI Develop Primary Care Initiatives First Coincide with Medical Home, ACO, Meaningful Use, PQRS/GPRO, Wellmark Expand Specialty specific measures and measures of care coordination in a system Develop opportunity for unifying record

15 Develop System Quality and Governance Predominantly primary care Coincides with ACO governance Drives organizational strategic plan initiatives Key driver of system coordination of care measures and central discussion for value-based purchasing

16 Continuous Improvement Program Lean/Six Sigma Team involved in identifying weaker areas Improvement projects measure and modify the process

17 How do Physicians Get Paid? As the clinically integrated network begins to develop, the CI entity negotiates value-based contracts with payers Incentive Only Contracts vs. Full Contracts Full Contracts Include Base FFS Rates Group Contract Shared Savings vs. Performance Base Rates Physicians continue to bill and collect from insurance company under group contract rates & terms Incentives paid to CI entity, then distributed per program measures, weighting and physician performance

18 Questions that Guide Clinical Integration How can the Governance structure be organized to successfully lead the process? What are the key cultural changes that need to be addressed? How can the Clinical Integration initiative be coordinated with other health system priorities? What technology is required to build Clinical Integration? Why should community physicians participate in Clinical Integration (what s the value)?

19 Thought Process Toward Building CI Organization s Why Statement Areas of Program Focus Measures Supporting Focus Areas Build Technical Support Solutions Align Incentives to Drive Results

20 Four Pillars of Clinical Integration Clinically Integrated Care Leadership Aligned Incentives Clinical Aligned Incentives Programs & Interventions Patient Longitudinal Record Aligned Incentives Governance, Organizational Structure Organization Alignment, Program Infrastructure Coordinated Care Management Technology Infrastructure

21 Program Changes Dynamics Over Time Primary Care Measures Specialty Care Measures Process Measures Outcome Measures Quality Measures Efficiency Measures Ambulatory Focus Inpatient Focus Full Continuum Clinical Measures Patient Satisfaction & Growth Commercial Population Medicare Population

22 Development Process Roadmap Formation/ Governance Physician Recruitment Payer Strategy Infrastructure Development

23 Program Design Considerations Balanced Scorecard Quality, Efficiency, Patient Experience Measures Short and Long-Term Value Creation Plan Market Relevance Emerging Governmental and Commercial Payer Areas of Focus Synergy with Hospital Quality Initiatives (e.g., Readmissions)

24 Program Design Considerations (cont.) Inclusion of All Relevant Physician Specialty Areas Antitrust Scrutiny (Ancillary Restraint Test) Physician what s in it for me (WIIFM) Qualification for PCMH, PQRS, Meaningful Use, MIPAA, etc.

25 Measure Selection Process Approach Which pay-for-performance programs does the organization currently participate? (i.e. MSSP, Bridges to Excellence, BCBS) What measures will serve the improvement priorities of the organization? Are the measures relevant to the stakeholders? What are the expectations among the different stakeholders? What data sources are currently available? Will the measure be able to be compared? Establish baseline results Build protocols and measures Identify current programs Identify measures to expand Consider employer and health plans Measures selected must be ones that can be measured and compared (consistent with national measures) and demonstrate VALUE. The FTC expects the same evidencebased protocols.

26 Domains and Measures Structure Process Outcomes Access Patient Experience Technology Standards Claims Data Clinical Data Patient Scheduling & Provider Availability Patient Surveys Source:

27 Domains and Measures: Definitions Structure: capacity to provide high-quality healthcare supported by other clinical quality measure domains Process: healthcare-related activity performed for, on behalf of, or by a patient supported by evidence that the clinical process has led to improved outcomes. Outcome: a health state of a patient resulting from healthcare detect the impact of one or more clinical interventions attributable to antecedent healthcare and should include provisions for risk-adjustment. Source:

28 Domains and Measures: Definitions (cont.) Access: attainment of timely and appropriate healthcare by patients supported by evidence that an association exists between the measure and the outcomes of (or satisfaction with) care. Patient Experience: patient's report of observations of (and participation in) healthcare, or assessment of any resulting change in their health supported by evidence that an association exists between the measure and patients values and preferences, or one of the other clinical quality domains Source:

29 Comprehensive Diabetic Care: Sample Measures by Domain Structure Process Outcomes Access Patient Experience Percentage of providers using CPOE (labs) Percentage of diabetics with HbA1c Testing Percentage of diabetics with HbA1c >9.0% Response time for clinical advice during office hours CAHPS Patient- Centered Medical Home (PCMH) survey results: Communication score

30 Comprehensive Diabetic Care: Measure Crosswalk Table Measure HEDIS NQF PQRS PCMH ACO MU HbA1c X X X X X X LDL C X X X X X X Medical attention for nephropathy X X X X Influenza Vaccination Pneumococcal Vaccination Eye exam X X X X Tobacco use X X Tobacco cessation X X X

31 Technology to Support Clinical Integration Standardize the clinical outcome elements within EMRs (ecw, Epic, Centricity, etc.) Become the basis of compliance Identify aggregation and performance criteria to help drive selection of a clinical disease registry Use a clinical disease registry, aggregate clinical performance data to support care coordination Disease state Care setting Provider activity/scorecards Program progress reports

32 Clinical Disease Registry is Key to Connection Clinical Disease Registry (CDR) supports Clinical Integration goals of connecting care, tracking clinical outcomes and comparing against evidence-based protocols Employed Physicians Hospital(s) Clinical Disease Registry Community Providers Ancillaries

33 Payer Contracting & Pay for Performance Strategy Engage payers in contract/program discussion Determine the economic and medical impact Engage purchasers early to determine cost drivers Self-insured large employers Health plans Build CI around these drivers Create a partnership with provider community Identify or determine other health plan incentives (i.e., IPRO, PCMH Level 1-3)

34 Summary Healthcare is going through a transformation Changes in healthcare delivery and bending of the cost curve will make all of us more accountable Adoption and integration of information technology is a big driver of change New financial models will align incentives and modify behaviors Continue to manage the cultural change Aligned objectives will prepare you for accountable care

35 Contact Timothy J. Quinn, MD MercyCare 1790 Blairs Ferry Rd. Hiawatha, IA Phone: Daniel J. Marino Health Directions, LLC Two Mid America Plaza, Suite 1050 Oakbrook Terrace, IL Phone:

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