Co-Management: Successfully Improving Care Along the Surgical Continuum Gerald Biala, SCA Senior Vice President of Perioperative Services Matt Kossman, SCA Vice President of Perioperative Services Hillary Rosenfeld, SCA Director of Perioperative Services

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The Partner of Choice for Leading Health Systems

45+ Health System Partners | 750K+ Surgical Procedures | $1.3+ Billion NPR 2

Learning Objectives

• Define the basics of co-management agreements • Identify critical success factors in working with co-management arrangements • Demonstrate how co-management agreements are utilized in partnering with physicians to achieve surgical integration 3

Shared Decision Making and Management

Many publications/bond rating agencies citing the need for physician engagement

• Sg2, Innovation Snapshot: Integrating Physicians, Hospitals and Innovation, Nov 2011 – “Clinical culture can be a roadblock to health care innovation, so it is imperative to include physician leaders in innovation activities. These clinical leaders are instrumental in promoting more rapid positive change in organizational culture. Creating culture change among physicians generally plays to the characteristics physicians value in their life and work, including capitalizing on their variety of skills, their role as an expert and having responsibility for significant tasks.” • Becker’s Hospital Review, Top 10 Strategic Initiatives for Hospitals in 2013 – 7. Explore new physician alignment strategies. Again, this initiative ties in with the move to population health management. Trying out new physician relationship strategies, such as physician-hospital organizations, clinical co-management, ACOs, employment or joint ventures can join hospitals and physicians together on the same platform and can be used to support the population health strategy as well as capture market share. "There are multiple vehicles for alignment. All of them are important and many play a role in the same marketplace.” • Fitch 2014 Outlook: Operational strategies to achieve the lowest possible cost per unit of service can help hospital credit ratings • Moody’s 7/2013: Concerns regarding physician alignment, supply costs, readiness for emphasis on value 4

Brief Background and History of Physician Engagement

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Physician Engagement in Management Clinical

Quality/Safety Outcomes Enforcement of P&Ps Disease Specific Outcomes Staff Competency

Operational

Utilization Management Efficiency Measures Cost Management Satisfaction Outcomes

Strategic

Program Development Physician Preferences Capital Investment Profitable Growth Effective physician alignment strategies can generate clinical, operational, and strategic improvements to perioperative programs to achieve positive margins on Medicare and increasingly fixed commercial reimbursement.

Medical Chair / Directorships Medical Staff OR Committees Governance Councils Co-Management Agreements 6

Traditional Surgery Physician Alignment Models

Medical Chair/ Directorships • • Fee for service arrangement with hospital Single point of engagement with physicians Traditional OR Committees • • Oversight for quality of care often extended to management of resources Appointed members with limited involvement in final decision making and implementation Governance Councils • Executive Committee with select members blending senior admin and physician leadership • Decision making in a voluntary role Co Management Agreements • • A physician group contracted and paid to jointly manage resources Decision making authority with responsibility for implementation 7

The Unique Role of a Governance Council

Senior Administration • Hospital strategic planning • Surgical services strategic planning • Overall hospital performance • Hospital budget Governance Council • Operational planning and management • Performance improvement and monitoring • Rapid response for decision making • Department budget OR Committee • Focus on quality of patient care • Identification of needs for performance improvement • Input to governance council

YOUR SURGERY STRATEGY

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IMPLEMENTED

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Co-Management Arrangements

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Common Clinical Co-Management Themes

• Align with physicians and grow market share • Seek alternatives to traditional employment models • Build a high-quality, lower-cost delivery model • Implement alternative payment methodologies • Optimize service line performance • Disengaged physicians; non-inclusive decision making process • Decreased focus and loss of interest after agreement signed 10

Physician Co-Management Evolution

First Generation Co-Management – Individual Hospital

service line leader Single or Multiple Specialties

A “First Generation” co-management agreement is specific to one hospital and the participating physicians Results are contained to the individual hospital and physicians practicing therein First generation co-management is focused on a single specialty or subspecialty goals and often lacks true physician integration extending into overall strategic planning 11

Co-Management Roles and Expectations

• • • Hospital Physicians Shared involvement of management and operations for individual or multiple service lines to achieve surgical integration

Management & Accountability

• Purpose is to provide leadership to improve quality and efficiency of care Administrative team partnered with physicians in improving quality and operational indicators

Surgical continuum Compensation

• Administrative services, medical director services, and quality improvement initiatives Necessary clinical services are covered • Quality improvement initiative targets established and compensation at risk based on performance A hospital/physician alignment strategy to delivery greater quality and financial value along the surgical continuum of care

Example Co-Management Structure

Executive Council Physician LLC Co Management Agreement Hospital Medical Director Quality Efficiency Operations Strategy Finance

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Economics of Co-Management

• Limited physician start-up, ~$3K per participant • Physician ROI ~40% • Hospital ROI 25% to 50% • Hospital ROI achieved through benefits of physician alignment: – Population health management – Accountable care organization – – Strategic planning/growth Efficiency improvements – Expense management 14

Factors for Successful Co-Management

• Transparency and cooperation between all parties • Balance needs of hospital and physician leaders with industry dynamics, evolving business models • Collaborative development of strategic plans • Common language, objectives, and attainable goals • Recognition and acceptance of baseline data • Effective leadership structure and commitment to delivery • Be intuitive 15

Implementation Expectations

Program Maturity Pre-Signing First and Second Year

Focus Outcomes

Succeeding Years

Defining co management focus and goals while establishing trust Organization and clarity around goals; building successful partnerships between different physician practices and hospital leaders Heavy investment in establishing structure, data analysis, and setting base line measures Early results achieved through collaboration and alignment of financial and clinical objectives Program evolution into strategic areas across multiple sites and specialties Achievement of quantifiable results; positive ROI 16

Co-Management to Achieve Surgical Integration

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Achieving Surgical Integration through Co-Management

• Multispecialty Physician collaboration • Disease management • Leverage community resources • Return to functionality • Evidence-based protocols and robust scoreboards Primary Care Physician Surgeon Transition Planning Pre, Peri, Post Operative Planning • Stewardship of clinical and financial resources 18

Surgical Integration: Strategic Benefits

Value Delivery • Physicians more inclined to implement operational & quality improvements for other patients • Simplifies surgical coordination for physicians • Decrease in total costs of care Patient Experience • Strengthens the link between hospital and post-acute care • Patients appreciate a more seamless care network Payer Essentiality • Hospitals become good partners for bundled payments, ACOs, narrow network arrangements, self-insured entities • Segue into commercial payer partnerships Source: Harris, Elizonda, & Isdaner. January 2013. “Medicare Bundled Payment: What is it worth to you?” Healthcare Financial Management Association.

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Surgical Integration: Interdependence Along the Surgical Continuum

Pre-Surgery

Disease Management

─ Develop evidence-based pre-peri post operative protocols

Care Management

─ Multidisciplinary physician planning and collaboration of pre- & post surgical care plan

Transition Planning

─ Optimize site of surgery, post-acute placement Day of Surgery

Transition Planning

─ Finalize post-operative rehab & pain management program

Utilization Management

─ Identify and steer to optimized network of rehab partners

Operational Optimization

─ Throughput efficiency, costs per case Post-Surgery

Transition Planning

─ Deliver progress notes to surgeon and PCP; coordinate post-acute destination

Operational Optimization

─ Quarterly clinical case review of exceptions

Care Management

─ 1:1 coaching of high-readmission risk patients

Utilization Management

─ Appropriate pre-op testing and surgical setting to maximize margins

Strategic Planning

─ Assemble and lead a multi-disciplinary team of stakeholder sponsors ─ Help replicate capitated episode model with top payers ─ Enhance ancillary network where value gaps exist 20

Physician Co-Management: A Strategy for Surgical Integration Improve efficiency

• Leverage physician engagement to eliminate waste and unnecessary cost across the surgical continuum • Implement model that allows providers to keep more of the savings, reinforcing alignment

Drive volume

• Increase patient satisfaction, reduce leakage to competitors through coordination of surgical care continuum • Capture health plan and employer market share through narrow networks and member incentives

Create value

• Partnership strengthens coordination between hospital, community, and post-acute stakeholders • Align surgical strategic plan with industry dynamics for better outcomes, patient satisfaction, and lower total costs of care 21

Physician Co-Management Evolution

Second Generation Co-Management – Multiple Hospitals/Health System

ASCs & HOPDs

A “Second Generation” co-management agreement adds to the core by integrating additional hospitals and physicians to expand the surgical care continuum Patient outcomes and operating efficiencies are optimized through implementation of comprehensive Utilization, Disease, Periop, and Transition management across the entire community as part of the health system surgical integration strategy Engaging physicians in a second-generation co-management agreement is an ideal tactic for surgical population management, ACOs, bundled payment strategies, and value-based purchasing 22

Expanding Co-Management Agreements Across Continuum

• Designing third iteration of co management service agreement • Embed standardized protocols to align resources, costs, and outcomes with contemporary reimbursement • Empower physicians to lead the way in increasing risk capacity to prepare for surgical population management • Proactively engage payers and employers to e

Health System Service Line Contract

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Case Studies

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Case Study: Florida Hospital – Carrollwood

Adventist Health System System Profile     9 OR hospital, heavily focused on orthopedics Large orthopedics group engaged in clinical co-management agreement Multiple in-efficiencies and disenfranchisement with perioperative leadership Hospital seeking to grow surgery volume and expand market share • • Co-Management Outcomes

Process

– Realignment of co-management with newly developed perioperative governance structure provided integration of initiatives and expanded authority – Educational programs on management process and roles/expectations of physicians, hospital leaders and staff – Committees and task forces established for action

Outcomes

– Improved case on time starts from 36% to 95% – Achieved consistent 100% SCIP measures and reduced surgical site infections rates from 2.73% to 0.8% – Improved patient satisfaction for four key physician measures from 36 th percentile to 90 th percentile – Hospital experienced a 10% increase in surgical case volume as a result of improved schedule management resulting in approval to add 3 additional OR suites 25

Case Study: Genesys Health System

Ascension Health System Profile  450 bed regional medical center  20,000 surgical cases across three operating room sites  Established 3 co-management companies with one overall Coordinating Council  Contracting economy with decreasing market share and surgery volumes • • Design and Manage Co-Management Relationships

Process

– Physicians engaged to manage perioperative resources – Integrated leading management and clinical practice – Developed clinician led supply/implant expense management

Outcomes

– Improved efficiency and quality measures – 85% OR utilization (from 65%) – 20 minute average turnover – 95% on-time starts – 90% or better SCIP scores – Reduced labor and implant expenses – Coordination of care across continuum for pre-surgical and postoperative care of the diabetic patient – Active engagement on Quarterly Strategic Planning with Primary Care Physicians linked to Operational tactics allowing for capturing of surgical cases leaving community 26

TriHealth: Integrated Health System

System Profile      Bethesda North: 17 OR hospital Good Samaritan: 22 OR hospital Bethesda Surgery Center: 4 OR HOPD Co-management agreement includes >30 physicians managing clinical, operational, business, and quality aspects of surgical hospital/HOPD in conjunction with TriHealth and SCA Development of health system wide perioperative council Co-Management Outcomes •

Process

– Leadership development for transition of new perioperative director – Formation of daily huddle and planning to add cases and consolidate to maximize utilization – Strategic planning related to right case/right location initiative, development of laparoscopic center of excellence •

Outcomes

– Improved efficiency and quality measures – SCIP measures 100% – Turnover times <15 minutes – 25% decrease in instrument repair expense – First case on-time starts 88% – Implementation of case profitability analytics, scheduling and optimization models, financial and operational benchmarking, and quality best practices 27

Q & A

Gerry Biala SVP, Perioperative Services Surgical Care Affiliates 772-713-3278 [email protected]

Matt Kossman VP, Perioperative Services Surgical Care Affiliates 404-617-5734 [email protected]

Hillary Rosenfeld Director, Perioperative Services Surgical Care Affiliates 276-759-3446 [email protected]

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