ESSENTIA HEALTH AS AN ACO (ACCOUNTABLE CARE ORGANIZATION)

ESSENTIA HEALTH AS AN ACO (ACCOUNTABLE CARE ORGANIZATION) Hello and welcome. Thank you for taking part in this presentation entitled "Essentia Health as an ACO or Accountable Care Organization -- What You Need to Know About Essentia's Evolving Model of Care." I am Patrick Twomey, Chief Medical Quality Officer for Essentia Health. Before we get going, I'd like to acknowledge Mary Thompson-Bode from the Public Relations Department. She was the creator of this PowerPoint presentation. She worked in collaboration with the Essentia NCQA advisory team. Let's begin with the question: What is an ACO? Accountable Care Organizations are providerbased organizations that take responsibility for meeting the health care needs of a defined population with the goal of simultaneously improving health, improving the patient care experience and reducing per capita costs. It's really all about meeting the Triple Aim. The Triple Aim calls for a better patient experience and by that we mean both clinical and service quality, as well as patient satisfaction. It also means better health across an entire group of patients otherwise known as population health, at the same time while lowering overall costs measured as an average of all patients in the group. The Triple Aim concept grew out of the Institute of Medicine report of 2001, which was entitled "Crossing the Quality Chasm: A New Health System for the 21st Century." This report has espoused six aims for healthcare reform in the United States. These six aims are: safe, timely, effective, efficient, equitable and patient-centered care. ACOs achieve the Triple Aim by focusing on wellness and disease prevention, effective chronic disease management, hospital care that achieves lasting positive outcomes, setting and achieving high standards for quality, safety and customer service, and leveraging all of the above to lower costs for the patient. So why is Essentia moving to an Accountable Care Organization-type model? Well, this model fits with Essentia Health's mission to make a healthy difference in people's lives. We believe focusing on wellness is the right thing to do. Public and private insurers and businesses see ACOs as the most promising way to organize health care and to improve care to patients while reducing the overall cost of health care. The current traditional fee-for-service payment model is unsustainable. Both public and private payers point to healthcare cost trajectories that will consume an ever greater share of GDP and the federal budget. At our current pace, healthcare costs in the United States will consume 34 percent of all federal expenditures by 2040. Essentia has been providing contracted ACO care to several smaller groups and our employee population for quite a few years now, including the Minnesota Senior Health Options or MSHO, U-Care for Seniors and Health Partners or our employee group. So we are now ready for a major transition. By January 2013, Essentia will be providing ACO care to greater than 100,000 patients through multiple state, federal and private payer contracts, including our first large ACO contract, the Medicare Shared Savings Program or MSSP. We will

also be obtaining ACO accreditation in early 2013 from the National Committee on Quality Assurance, or NCQA, which we will be talking about a little bit later in this presentation. First, let's take a look at the Medicare Shared Savings ACO contract. This contract will cover 33,000 Medicare patients who already have or will be assigned an Essentia primary care physician. This contract went into place on July 1, 2012, and will last 3 1/2 years. Essentia's baseline commitment to CMS is to reduce the total cost of care for this group of patients by 2 percent annually. If we reach this 2 percent cost reduction goal, Medicare will split the savings 50-50 with Essentia. However, those savings will only be realized by Essentia if we meet 33 care and patient experience quality measures. These quality measures fall into two categories: care for individual Medicare patients and care for Medicare patients as a whole or as a group. Taking a closer look at the quality measures, the first category deals with care for individual Medicare patients. This category is divided into seven patient/caregiver experience measures and six care coordination/patient safety measures. The patient/caregiver experience metrics will be measured by CMS using a combination of telephone and written surveys called CG-CAHPS. CG-CAHPS is an acronym, which stands for Clinician and Group Consumer Assessment of Healthcare Providers and Systems. It was developed by the AHRQ. This survey is similar to the inpatient HCAHPS tool, but is intended to assess the ambulatory care patient experience. This survey will measure patients' experiences and perceptions on a multitude of different categories: 1. Receiving timely care and clinic appointments as well as health information 2. How well our doctors communicated with the patients 3. How the patient rates the overall care received from his or her doctor? 4. Does the patient feel Essentia provided timely access to specialist care? 5. How well did Essentia focus on health promotion and education? 6. Did the patient feel that decisions about his or her health care were jointly shared with their doctor? 7. Did Essentia perform a thorough assessment of the patient's overall health and functional status? Let's highlight now measures in place to assess individual patient care coordination and patient safety: 1. These measures include all-condition readmission, which will be risk-adjusted. 2/3. They also measure what CMS terms ambulatory sensitive condition admissions. These will include COPD, adult asthma and CHF. All admission and readmission data will be derived from CMS claims data. 4. Percentage of primary care physicians qualifying for Meaningful Use Incentives. 5. Medication reconciliation after discharge from an inpatient facility. This measure is going to be looking at the patient's discharge medication list and whether or not the patient gets that reconciled at his or her first outpatient followup appointment. That reconciliation will need to be documented in the EMR.

6. Screening for fall risk. This measure requires Shared Savings Program patients to be screened yearly to make sure they are not at increased risk for falling. The medication reconciliation and fall screening are measured using GPRO data. GPRO stands for Group Practice Reporting Option. Some of you may be familiar with the previous program name of PQRS. This review identifies a random group of patients from the total Shared Savings patient population for manual chart review yearly. Let's now look at population Shared Savings quality measures. The population health metrics from the MSSP contract group include eight preventive health quality measures and 12 measures aimed at measuring Essentia's ability to identify patients who are at increased risk for certain key chronic diseases. The preventive healthcare measures include influenza and pneumococcal immunization rate, adult BMI screening and follow-up, tobacco use assessment and cessation intervention, depression screening, colorectal cancer and mammography screening and blood pressure screening. These measures will also be derived from GPRO reporting data. In regard to measuring at-risk patients, the Shared Savings metrics will include the D5 ambulatory care diabetic metrics with an additional measure of poor diabetes control, looking at patients with A1c levels greater than 9. Additional at-risk population measures like the diabetes metrics closely mimic ambulatory care measures already in place at Essentia, including hypertension control, lipid control and aspirin use in ischemic vascular disease, beta blocker use in congestive heart failure and lipid-lowering therapy and ACE/ARB use in coronary artery disease patients. In summary, the four quality domains of patient experience, care coordination and patient safety, preventive health and at-risk population management will each get equal 25 percent weighting in calculating the Shared Savings that Essentia will realize with the Shared Savings Program. As a Shared Savings recap, it is our first large ACO contract encompassing the care of over 33,000 patients. It focuses on clinical quality, patient satisfaction and cost reductions. We will be rewarded for reducing costs only if we meet Medicare quality measures and most measures are currently reported to Medicare so it won't require a lot of increased worker infrastructure on our part; most of them are already reported through GPRO data that we have been reporting for years. We are going to move on now to talk about accreditation, expressly NCQA accreditation, or the National Committee for Quality Assurance. Why is Essentia seeking this accreditation? Accreditation will establish Essentia as a national leader in terms of structuring an entire healthcare organization as an ACO. This is a statement to the healthcare industry that we are well-positioned to deliver on the Triple Aim. NCQA accreditation will act as a blueprint for quality that is understood by both patients and insurers. Accreditation will verify our status as an ACO with both governmental and private payers. It will serve as an ACO stamp of approval. Over and above that, maintenance of this accreditation will ensure that we are maintaining the highest standards, as ongoing reaccreditation activities will

help hardwire our standard care processes across Essentia. Accreditation is on two to three cycles that will keep us focused on delivering excellent integrated care to our patients. NCQA accreditation involves meeting seven organizational and structural standards as well as achieving 26 quality measures. Fortunately, most of these quality measures mirror our Shared Savings measures: The seven organizational and structural standards include: 1. Showing that Essentia has a well-established, accountable care structure and way of operating. 2. Providing access to a full range of services and specialty care to deliver what we consider comprehensive care. 3. Primary care that is patient-centered. 4. Care management to assure that we are closing gaps in care, and that's really about making sure we have tools to help us identify patients at high risk or with chronic conditions that need more attention and then, of course, addressing those needs. 5. Coordinated care with smooth transitions from one care environment to the next. 6. Patient rights and responsibilities that are clearly provided and communicated. 7. Clear, organized, and functional quality improvement process with frequent assessment of performance and action plans to improve. Moving on to the NCQA quality measures, you can see that most mirror our Shared Savings metrics. This slide depicts the CG-CAHPS survey questions, which as I mentioned previously is our ambulatory care patient satisfaction survey. You can see that it mostly matches our Shared Savings metrics in this regard. Next, we look at the patient safety prevention and population health metrics, which again very significantly overlap with our Shared Savings measures in this regard. Finally, you can see that with the identification and management of at-risk group metrics, we again have several metrics that look very much the same as our Shared Savings metrics. This slide depicts some additional NCQA quality measures that are not monitored by the Shared Savings Program. These include pediatric care measures and non-medicare-aged women's health metrics, including asthma control for patients ages 2 to 50, childhood and adolescent immunization status, well child checks, pediatric body mass index measurement, as well as cervical cancer screening and chlamydia screening. Can we meet NCQA standards and measures? We think the answer to that is yes. Are we ready for accreditation? As an integrated healthcare system, Essentia already has many of the pieces in place to meet the seven NCQA accreditation standards. We already track and report the 26 NCQA quality measures, so that portion of the accreditation will not require additional infrastructure or work to measure. The Encompass EHR greatly enhances our ability

to track measures and set alerts and enable proper patient care follow-up, and our clinicians at Essentia already have access to many management reports. These reports flag at-risk patients, as well as those who are off track from their care plans. We feel we have the pieces in place to achieve this accreditation. Who must be on board to make this work? We need the engagement of all of our physicians and non-physician practitioners, both primary care providers and specialists. We need our patients to take an active role in their care. We need to use the ACO model to empower them to engage in prevention, health maintenance and active management of their diseases. We also need full engagement of our nursing staff regardless of the setting, whether they be in an inpatient setting, ambulatory care, surgery, nurse online or other roles, and the same really goes for all members of the patient's care team -- in fact, full engagement of all Essentia employees is needed for Essentia to achieve its vision of becoming a nationally recognized leader in providing integrated highquality and cost-effective care, which is really what accountable care is all about. How do we get started? You can begin by tracking and improving performance as a team. Please review the Shared Savings quality metrics that measure work in your department and pinpoint areas that need improvement. Investigate what programs, initiatives or tools are already available to help address those measures. If measures are tracked currently, please review them frequently with your staff at section or staff meetings and hold accountable those who are responsible for delivering on the metrics. As a team, please review the Shared Savings quality measures to ensure that you understand them. Identify areas within your own department where you can help with our ACO strategy. Those areas might include improving your interactions with patients to enhance their overall experience with Essentia Health, finding ways to save money or improve efficiency to help reduce overall healthcare costs and ensuring that your service to other Essentia departments is prompt and courteous -- meeting the needs of our patients and supporting the work of our care teams. Thank you for your time and attention on this. Please call me or e-mail me with any questions you may have. You can reach me any time at (218) 786-4019 or by e-mail at Patrick.Twomey@essentiahealth.org.