Northwest Medical Group Alliance Clinical
Download
Report
Transcript Northwest Medical Group Alliance Clinical
New Risk and Collaboration Models
for Providers
Clinically Integrated Network
January 2014
Agenda
Objectives for Today
Provide a brief history and context
Share the vision, objectives, and strategies
Review the model of care
Review Physician Care Network’s clinical and administrative services
Provide a status of recent activities and upcoming milestones
Share the requirements and benefits of physicians joining the CIN
2
Background
Market & Competitive Pressures
Hospitals
Consolidating; increasing negotiation strength
Employing primary care and specialty physicians
Health Plans
Creating narrow networks and increasing price pressure
Implementing bundled episodic payments
Pushing risk based payment and shared savings models
Tying quality metrics to reimbursement levels
Requiring changes to protocols and treatment to improve outcomes
Demanding significant data compilation required to track and monitor
Result: A serious threat to the long-term viability of physician owned practices
3
Addressing the Threat
Plan of Action
In 2013, the Northwest Medical Group Alliance initiated a study to determine the
feasibility of creating a physician-led, Clinically Integrated Network (CIN)
Their network of over a dozen independent physician practices with more than 700
physicians is sufficient for limited network products
The proposed CIN delivery model is marketable and the timing is optimal
Hospital affiliation is not a priority
Member participation criteria can be met by most, if not all, medical groups in the
Alliance and beyond
The right vehicle for the CIN is the Physicians Care Network (PCN)
4
Physicians Care Network
Overview
Formed in 1997, serves as a mechanism for sharing financial risk through clinical
integration across multiple medical group practices
Contracts with various health plans on behalf of its Members and administers quality
and care management programs in accordance with payer terms and conditions
Integration across care settings of standardized clinical protocols
‒ Steerage of patient care to lower cost settings
‒ Utilization management of high risk populations
‒ Formularies that promote generic drug use
Develops the provider network for health plans
‒ Billing, credentialing, administration of risk pools and other risk sharing arrangements
‒ Management information services related to administration of those contracts
5
Physicians Care Network
Overview (continued)
Engaged with four Medicare Advantage (MA) health plans
‒ PCN participates with three of the four MA health plans under full risk, fully delegated (care
management, claims, credentialing) arrangements
‒ Participates in the Medicare ACO Shared Savings Program with the Centers for Medicare and
Medicaid Services (CMS)
‒ Contracts with four health plans that focus on shared savings and reduction in the total cost of
care delivered to plan beneficiaries
6
Vision & Business Aims
Vision
Enable independent physician practices in the Pacific Northwest to
remain independent and thrive in the new healthcare environment
Business Aim
Develop and operate a clinically integrated network of independent physician practices
that secures and supports performance of value-based contracts that reward practices
for delivering high quality patient care in an efficient manner
7
Strategies
Achieving the Business Aim
Create a robust and engaged clinically integrated network of independent physician practices
Identify, secure, and deploy an essential infrastructure to support CIN operations in a costeffective manner
Engage physicians as leaders and full participants in the CIN's development and operations
Support participants’ practice transformation efforts
Identify, evaluate, and pursue network value-based payor contracting opportunities
Develop the capacity to accurately report the health status of defined patient population(s)
Ensure participants’ adherence to CIN-approved evidenced-based standards of care
Deliver "high-touch" care coordination for high-risk and patients who may become high risk
Deploy proven patient engagement tools to manage network patients
Develop metrics and measure outcomes for continuous quality improvement
8
Desired Outcomes
Outcomes
Engage a critical mass of independent physician practices as CIN participants
Create a sustainable business model to support essential CIN infrastructure and
services to its participating practices
Transform participants’ practices to engage in population health management
Secure favorable value-based payor contracts for CIN participants
Demonstrate quality through participants’ achievement of specified standards
Reduce the total cost of care for defined population(s) by specified targeted amounts
(percentage reductions)
Improve the overall patient experience of care
9
Model of Care
Scalable Services to Meet Patient Needs
High risk – high cost,
complex needs
Cost Containment, support and
coordination
Rising risk – at least
one chronic condition
Motivational Interviewing,
closing care gaps, strengthening
relationship to PCP
Low risk
Engage, set the stage
10
Model of Care
Enhanced Care Model
Care coordination service delivery model with a focus on keeping patients healthy over
time through screening and prevention, early intervention, health education, and
meaningful management of chronic conditions
High risk / high cost patients actively managed and transitioned from high cost hospital
based services to lower cost community based and home based care
Primary care providers rewarded based on the outcomes they achieve rather than by
the number of exams they provide or tests they order
Evidence based clinical protocols, vetted by extensive research, and determined by
experts to be most effective compared to other treatment options
Information sharing occurs across care settings to reduce duplication of unnecessary
diagnostic and treatment orders and eliminate waste
Formularies that include step-therapy and increased use of generic drugs
11
PCN Services
Care Management Services
Train and coach providers on the Enhanced Care Model
Establish and disseminate CIN guidelines and protocols (in collaboration with Member
groups)
Promote practice improvement, quality, and cost management goals
Collaborate with Member groups to establish quality and cost measures and clinical
benchmarks that drive health system change
Extend risk identification and care management tools and processes to Members
Provide risk adjusted coding training and services
12
PCN Services
Administrative Services
Create the CIN, secure investors, and implement
Prepare legal documents for the joint venture: Bylaws, Articles of Incorporation, etc.
Develop Member participation agreements and negotiate contracts
Engage health plans and negotiate innovative payment models
Administer payment models
Develop prospective budgets and resource planning
Develop initial performance measures and baseline statistics
Brand, manage, and expand the network across the state
Manage CIN staff and liaison with in-kind services provided by Member groups
Credential Member physicians
Provide decision support and analytics tools and processes
13
PCN Systems
Primary Systems
Phytel/Verisk – Concurrent and retrospective review
Stratify, validate, and manage risk
Identify care gaps
Assist with quality indicators; track and trend quality measures
Track population health around complex and chronic conditions
Aggregate disparate data sources into consistent data sets for analysis and comparison of quality
and cost metrics
Assist staff in its patient outreach activities through a set of protocols that support preventive and
chronic care follow-up
EZ-Cap – Administration
Referral and Authorization Management
Customer Service
Encounter Submissions
Reporting
14
CIN Status
Recent Developments
Negotiated a term sheet with investors and gained agreement to move forward and
engage provider groups
Developed milestones to ensure progress, safeguard ongoing capital investment, and
provide investors with some assurance for their investments
Updated the Participation Agreement and created supporting materials for engaging
prospective provider groups
Prioritized the list of potential provider groups
15
CIN Governance Model
Clinically Integrated Network
Board of Managers
Executive Director
Medical Director
(also supports MA business)
Population Health
Management
Performance
Improvement
Physician lead/controlled committees
Contracts
Technology
Business lead/controlled committees with physician participation
16
Revenue Model
Care management fee (e.g.PMPM)
This approach…
Ensures there is immediate revenue to help offset operating costs
Provides an alternative to health plan contracts that only provide the potential for
limited savings at the end of a contract period
Avoids the diminishing returns associated with continuously squeezing costs out of the
system
The CIN plans to charge a flat per member per month (PMPM) fee
A flat fee across the entire population is much simpler than charging a much higher fee
for only the high-risk patients; it also provides a more predictable revenue stream
This approach is not unique; it is consistent with other PCN and standard industry
arrangements
The up-front fee may have to work in conjunction with a shared savings arrangement
17
Next Steps
Upcoming Activities
Formally create the CIN enterprise
‒ Execute the Term Sheet
‒ Form the CIN legal entity (Operating Agreement, Articles of Incorporation, Bylaws, etc.)
‒ Elect the Board of Directors; form and charge committees
Immediately kick off the next phase of provider group engagement
Execute contracts with health plan(s)
Complete the recruiting process and hire a Medical Director as soon as possible
Engage a CIN consulting firm to support implementation
Create a formal budget for 2015
18
Important Dates
2015 Milestones
1/1/2015
Form and
Capitalize Entity
2/1/2015
Operationalize
Committees
4/30/2015
Health Plans
File 2016 Products
9/1/2015
Population Health Systems
Available to Members
1/1/2015
1/1/2016
Members Enroll in
New Product(s)
1/1/2016
3/31/2015
Health Care Authority
Selects 2016 ACO Partners
4/1/2015 - 9/30/2015
Implement
Model of Care
19
Joining the CIN
Membership Participation Criteria
Use a certified electronic medical record system
Meet or be in the process of meeting Meaningful Use standards
Identify and track at least one patient population or chronic condition
Have experience tracking some patient costs
Have process in place for managing transitions of care
Use ePrescribing, CPOE or electronic results reporting
Agree to cost management and performance risk management protocols
Agree to share data transparently
Agree to adopt the new model of care
20
Joining the CIN
Member Benefits
The ability to remain independent as an alternative to large health system employment
‒ With a number of quality focused provider groups, anchored by The Polyclinic and supported
by Physicians Care Network, the CIN will enable independent physicians to participate in riskbased, total cost of care contracts that they would otherwise not have access to
‒ This is critical to practice survival as health plan products are increasingly steering patients to
narrow networks
Enhanced provider leadership over clinical decisions through selection and
implementation of evidence based clinical protocols
Decision making seats on committees and influence to Board decisions
Innovative care delivery alternatives that enhance patient experience that, in turn,
leads to growth in market share and revenue sharing opportunities
Access to population health management tools
21
Joining the CIN
Member Benefits (continued)
Training and administrative services that streamlines data compilation and extraction
for health plan quality metrics management
Financial analysis capabilities
An environment where independent providers can support one another through
referrals, team based care, and care coordination while reducing the total cost of care
Risk adjusted coding training and resources
22