Overview Advocate Physician Partners & Clinical Integration Program. September 13 & 14, 2010

Transcription

1 Overview Advocate Physician Partners & Clinical Integration Program September 13 & 14, 2010

2 Agenda Overview of Advocate Health Care & Advocate Physician Partners Formation of Advocate BroMenn Physician Partners What Is Clinical Integration? PHO Membership Process Questions & Answers 2

3 Overview of Advocate Health Care & Advocate Physician Partners Marty Manning President, APP 3

4 About Advocate Health Care 10 Hospital Campuses 6,000 Medical Staff 200 Sites of Care 27,000 Associates $4.1 Billion Annual Revenue AA Bond Rating 2.5 Million Visits Annually Pluralistic Physician Integration Approach 4

5 Advocate Mission and Vision Mission The mission of Advocate Health Care is to serve the health needs of individuals, families and communities through a wholistic philosophy rooted in our fundamental understanding of human beings as created in the image of God. Vision A faith-based system providing the best health outcomes and building lifelong relationships with those we serve. 5

6 Advocate 2020 Strategic Framework Mission, Values, Philosophy Faith-Based System Best Health Outcomes / Lifelong Relationships Operational Excellence Health Outcomes Advocate Experience Funding our Future Innovative Care Models Growth Partnerships Same-Site Growth Service Lines Brand Medical Home Seamless Access Relationship Management Health Navigation Technology Integration Built on a Strong Physician Platform 6

7 Advocate s Physician Platform 5,500 Physicians on Hospital Medical Staffs; 3,600 Members of APP Independent Non-APP 1,900 Independent APP 2,800 Employed & Affiliated APP 800 As of September

8 APP Fact Sheet Joint Venture Between Advocate & Physicians Formed in 1995 As a Super PHO Currently, 9 Physician Hospital Organizations Over 3,600 Participating Physicians 8 Clinically Integrated Fee-for-Service Contracts Covering Over 700,000 PPO Lives 2 Capitated HMO Contracts Covering Over 230,000 Capitated HMO Lives 8

9 APP Vision Statement The Vision of Advocate Physician Partners is to be the leading care management and managed care contracting organization in Chicagoland... Illinois and the nation! 9

10 Physician Representation Throughout APP Governance APP Board of Directors 9 PHO Boards Contract & Finance Utilization Management Pharmacy & Therapeutics Quality Improvement & Clinical Integration Credentialing & Peer Review Clinical Integration Measures 10

11 Participating Health Plans All Major Plans in the Market Includes HMO Risk and Fee-for-Service Payment is Composed of Base Rates Incentive Compensation Same Measures Across All Payers Common Processes at Practice Level 11

12 Formation of Advocate BroMenn Physician Partners Dana Gilbert VP Clinical Innovation, APP 12

13 New Local PHO for Clinically Integrated Contracts BPN Has Messenger Model Contracts APP Cannot Contract Using Messenger Model Form New PHO for BroMenn & Eureka Advocate BroMenn Physician Partners No Membership Fee or Annual Fee 13

14 Advocate BroMenn Physician Partners PHO Formally Incorporated This Year PHO Board Elected Once Membership Approved Board Composition 5 Physicians Elected by Physician Membership 5 Hospital Representatives Appointed by Advocate Health Care Board Dr. Marlito Favila Hired As Medical Director Recruiting APP Vice President 56 Applications Initiated for Advocate Medical Group 14

15 BroMenn PHO Physicians Will Be Part of APP Governance PHO President Member of APP Board PHO Physician on APP Committees Consolidated Finance Credentialing Quality Improvement & Clinical Integration Utilization Management Committee Members Compensated Not Required to Be PHO Board Member 15

16 Clinically Integrated BroMenn Contracts Health Link PPO Humana (PPO, POS) In Process: BCBS PPO (CI Contract only) Aetna (EPO, HMO, PPO, POS) Advocate Associate PPO BeechStreet (PPO) Cigna (PPO, POS, EPO) Health Alliance PPO HFN (PPO & EPO) United Health Care (HMO, PPO, POS) 16

17 Funds Flow for Clinically Integrated Contracts APP Physicians Paid Fee-For-Service at Contracted Rates (No Withhold) Health Plan Funds Separate Incentive Paid to APP Incentive Earned by APP Physicians Based on APP Clinical Integration Program Structure 17

18 What Is Clinical Integration? Dr. Mark Shields Vice President Senior Medical Director 18

19 Clinically Integrated A Group without Walls Working Together With Other Providers And Hospitals To Improve Quality, Safety And Cost- Effectiveness Of Care Rendered to All Patients This Improvement In Care Allows Doctors To Jointly Negotiate With Insurance Companies 19 19

20 Clinical Integration Definition A Structured Collaboration Among APP Physicians And Advocate Hospitals Active And Ongoing Program Designed To Improve Quality And Efficiency Joint Contracting With Managed Care Organizations Necessary To Accelerate Improvements In Health Care Delivery 20

21 Clinically Integrated FFS Contracts Payers Reimburse APP Physicians Directly At Negotiated Rates Annual Contributions To CI Or Quality Incentive Fund FTC Consent Decree Allows CI Program Pay-For-Performance Is The Catalyst Quality Incentive Amounts Determined By: Individual Performance PHO-Level Performance 21

22 Clinical Integration Components 5 Categories of Measures Clinical Effectiveness Efficiency Patient Safety Patient Experience Medical & Technological Infrastructure Moving Toward Population Management Tracking Via Disease Registries 22

23 How the CI Program Works Identify Initiatives with High Impact for Employers Chronic Disease Conditions Pharmaceuticals Benefits Costs, Absenteeism, Presenteeism Utilize Best Practices of Evidence-Based Medicine Establish Performance Targets Annually Obtain Payer Contracts to Reward Improvement Supply Physicians with Tools, Training & Feedback Provide Physician s a Progress Reporting System Reward Performance At End of Year 23

24 Guidance in Selecting Initiatives IOM Priority Areas The Leapfrog Group Healthy People 2020 USPHTF DHHS HEDIS of NCQA CMS QIO s AMA Physician Consortium s Managed Care Organizations Advocate Efficiency and Cost Information 24

25 Measures Create Focus 36 Initiatives (e.g., Diabetes, Asthma, etc.) Over 100 Specific Measures 28 Specialty-Specific Physician Report Cards Multiple Areas of Focus Clinical Effectiveness Medical & Technological Infrastructure Efficiency Patient Safety Patient Experience 25

26 NCQA Data on Diabetes Measures: Significant Difference in HMO & PPO Outcomes Measure Big HMO PPO Difference HbA1C Testing Between 89.0% 79.5% Poor Control (>9) Measuring 28.4% 74.4% Good Control (<7) & Managing 43.3% 13.5% Annual Eye Exam 56.5% 35.8% LDL-C Screening 84.8% 74.7% Over 3 LDL-C Control (<100) Times 45.5% 14.8% Monitoring Nephropathy Better! 82.4% 65.9% Blood Pressure Control (<130/80) 33.4% N/A 13.5% Blood Pressure Control (<140/90) 65.6% Better N/A 26 26

27 NCQA Data on Diabetes Measures: How 2009 APP Performance Stacks Up Managing Results! Measure HMO PPO Expected Actual HbA1C Testing 89.0% 79.5% 86.0% 87.0% Poor Control (>9) 28.4% 74.4% 43.0% 28.0% Good Control (<7) 43.3% 13.5% 34.0% 47.0% Annual Eye Exam 56.5% 35.8% 50.0% 52.0% LDL-C Screening 84.8% 74.7% 82.0% 84.0% LDL-C Control (<100) 45.5% 14.8% 36.0% 56.0% Monitoring Nephropathy 82.4% 65.9% 77.0% 84.0% Blood Pressure Control (<130/80) 33.4% N/A N/A 45.0% Blood Pressure Control (<140/90) 65.6% N/A N/A 74.0% 27 27

28 APP Infrastructure & Support Services Carrots and Sticks Alone Are Not Enough Disease Registries with Robust Data Feeds Online & Quarterly Physician Report Cards Online Patient Education Tools & Clinical Protocols Patient Reminders and Coaching Orientation for New Physicians Medical Director Coaching Physician Collaboratives Hospitalist Program e-prescribing Program Generic Voucher Program Diabetes Clinics 28

29 Highlights of 2009 CI Results Moving the Dial on Quality Generic Prescribing: 4.6% > Local Plans LDL Good Control : 7% > National Rate Childhood Immunizations: 24% > NCQA Benchmark Depression Screening: 2x > National Median Diabetic Care: Exceeded NCQA Highest Performance Levels on 9 Measures Asthma Action Plans: 45% > National Benchmark 29

30 Value for Physicians Access to Managed Care Contracts Turnkey P4P Program Positioned for Healthcare Reforms Clinical Innovation Centralized Credentialing Patient Reminders & Education Medical Management Services Clinical IS (Disease Registries, EMR) Value Added Services 30

31 Value for Hospitals Creates Business Partnership with Key Physicians to Drive Quality & Safety, Lower Cost Helps Focus Physicians on Hospital Goals Strengthens Loyalty/Increases Engagement Physicians Drive Clinical Outcomes 31

32 Value for the Marketplace Focus on Clinical Outcomes Demonstration of Efficiencies Ongoing Improvement Stable/Cohesive Network Measure and Display Results Led by Physicians 32

33 Membership Requirements & Application Process Judi Miller Vice President Medical Services & Clinical Integration 33

34 Physician Membership Requirements High Speed Internet Access Advocate Intranet Portal Account Active Participation in CI Program Physician Medical Staff Member at Partner Hospital 34

35 Physician Membership Requirements Cooperation with Providing PPO Claims Information to APP Actively Used Addresses for Physician and Office Manager Complete Core Advocate Patient Safety CME Attend New Physician Orientation Meet Board Certification Criteria Sign APP Participation Agreement 35

36 Physician Link With APP Physician Physician Participation Agreement PHO APP Corporate Membership Agreement 36

37 Application Information Web Site APP Maintains Delegated Credentialing Credentials Physicians For All Of The Clinical Integration Contracts One Process One Time For All Contracted Payers Streamlined with Medical Staff Office Remains A Separate Process 37

38 Application Process 1. To Receive a Full Application Obtain a Pre-Application which Initiates Process Submit the Completed Pre-Application to APP CVO If Minimum Membership Requirements Are Met, APP Application Forwarded to Physician Via to The Address on Pre-Application Includes Link to Advocate Physician-Specific Confidential Website» Electronic Application Awaits Completion Application Includes Both Credentialing and Business Related Materials 38

39 Application Process 2. Application Packet Completion Pre-Populated Electronic Application Provided if Possible Physician Reviews and Updates Information Information Also Used to Communicate to Payers Electronically Complete Application SIGN Application with the Mouse Submit Documents Online if Possible (i.e., scanned DEA, ILCS, etc.) Fax or Mail Remaining Paper Documents to APP 39

40 Application Process 3. Advocate CVO Verifies All Required Documents Received 4. Advocate CVO Verifies Information 5. APP Credentialing Committee Reviews Application And Approves Membership 40

41 41 Questions & Answers