Transcript Key Physicians Triangle Orthopedics

Key Physicians
Value Driven Health Care
Conrad L. Flick MD
John Meier MD, MBA
Value Driven Health Care
• Key Physicians
– Primary Care based
– HEDIS based quality metrics
– Shared cost savings based contracting
– Viable independent primary care physicians and
specialists within an interdependent network
– Integrating patient data systems without a single
EMR
– Population management across the network
Value Driven Health Care
• Value: Patient health outcomes per dollar spent
– Coverage
• Moving toward ‘universal’ coverage
– Delivery system
• Coordinating across the full cycle of care
• Primary care coordinating the medical
condition
– Reimbursement
• Moving toward bundled payments
“A Strategy for Health Care Reform – Toward a Value Based System,” Michael Porter,
NEJM July 9, 2009, 361: 109-112.
Integrated system
capitation
Outcome measures;
large % of
total payment
Global DRG fee:
hospital and
physician
inpatient
Care coordination and
intermediate outcome
measures; moderate %
of total payment
Global DRG fee:
hospital only
Global ambulatory
care fees
Global primary
care fees
Continuum of P4P Design
Continuum of Payment Bundling
The Relationship of Organization Type and Payment
Methods
Simple process and
structure measures;
small % of total payment
Blended FFS and
medical home
fees
FFS and DRGs
Small practices;
unrelated hospitals
Independent Practice
Fully integrated delivery system
Associations; Physician Hospital
Organizations
Continuum of Organization
Source: Shih et al, The Commonwealth Fund, August 2008
Wake County/Raleigh Market
Key Physicians’ History
• 1994: Organization Formed as an IPA
• 1995-1996: Capitated / Risk Contract
– HealthSource
• 1997-2009: Fee-for-Service Contracting
– Pay-for-Performance where possible
• 2009/2010: NCQA Patient-Centered Medical Home Recognition
– Catalyst for Key’s “Accountable Transformation”
• 2011: Blue Quality Physician Recognition
• 2012/2013: Accountable Care Shared Savings Contracting
– Cigna
– BCBSNC
Key Physicians Today
Primary Care Medical Homes
• 51 Independent Primary Care Practice Locations in the
Triangle
• 184 Physicians and 51 Mid-Level Providers
• 11 PCP Practices with 35 Physicians and 13 Mid-Levels in
process of joining
New Models of Care Delivery
• Patient Centered Medical Home: The Triple Aim
– Improve the health and safety of the population served
– Improve the experience of each individual
– Improve affordability as measured by the total cost of care
• Accountable Care Organizations (ACOs)
– “Medical Home on Steroids”
– Exclusive or Preferred Networks
• Clinical Integration
– Interdependence & Cooperation across an exclusive provider
network
– Care Coordination and Care Management
– Capability to measure and report quality and value
Patient Centered Medical Home
Principles
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Personal physician
Physician directed medical practice
Team approach
Whole person orientation
Coordination of care
Quality & safety
Enhanced access
Payment for added value
Key Physicians Goals
• Support Member Practices with PCMH and BQPP
• Position Key for Success in Accountable Care (ACO) Contracting
– IT System Requirements
– Care Management Resources
• Accountable Transformation of Network
– 2010: Patient Centered Medical Home Recognition
– 2012: Virtual Integration across Medical Neighborhood
Infina Intelligent Care Coordinator
– 2012: Accountable Care Contracting as a Network
– 2013/2014: Clinical Integration
Defining the ACO
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CMS: Accountable Care Organization is “an organization of health care providers
that agree to be accountable for the quality, cost, and overall care of Medicare
beneficiaries who are enrolled in the traditional fee-for-service program who are
assigned to it.” The ACO will promote evidence based medicine, be able to report
quality and cost measures, and coordinate care including the use of technological
systems.
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HIMSS: ACOs are provider organizations that accept responsibility and financial
risk for the cost and quality of care delivered to a specific population of patients
cared for by the organizations and clinicians. The collaborative effort of the ACO
model centers on the patient by coordinating and managing care to deliver
wellness, economic and clinical value rather than treating episodes of disease
and sickness.
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Key Physicians’ Definition: A provider-led organization whose mission is to
manage the full continuum of care and be accountable for the overall costs and
quality of care for a defined population.
Key’s ACO Network
Ancillary
Services
Partners
Specialist
Partners
Key Physicians
Medical
Homes
Accountable Care Contracting
 Integration: Connect Medical Homes to Medical
Neighborhood
◦ Co-Management Agreements for patient care and
adherence to evidenced based guidelines
◦ Electronic communication , referral tracking and care
coordination
◦ Population Management
◦ Care Coordinators (Patient Care Advocates)
◦ Actionable Data shared by Health Plan to ACO
◦ Physician Identifies and Refers High Risk Patients
◦ Discharge Planning and Gaps in Care
◦ Valued member of the care team
Current Tactical Focus
• Patient Steerage to High Quality / Value Providers
– Key’s ACO Network
• Urgent Care
• Cigna Care Designated / BCBS Tier 1 Practice Specialists
• Co-Management Agreements
• “Choosing Wisely” Awareness and Mind-Set
• Address Preventable Events
– Duplicate Services, Un-needed Services, Avoidable ED visits,
Readmissions, Reducing Complications
• Delivery System Redesign – Patient/Population Management
– Care coordination, Care transition, Post-discharge management
– Patient engagement and education (Employers, Insurers/Payers,
Practice, Community)
Medium Term Priorities
• Improve Quality and Reduce Costs
• Quality – HEDIS
• Costs – Avoidance, Reducing Price Variation
• Expand the ACO Network
– Counties outside of Wake County
• Network Identification/Marketing
• Ensuring patients are steered (via benefit design) to our practices,
never away from them
• Employers, Insurance Companies, Third Party Providers
• Information Technology
• Integrating EMRs
• Sharing Information
• Within the network
• From health systems/data systems outside the network
• Patient engagement and education
Future Strategic Elements
Providing Value Based Care in a more complex market
Population Mgmt –
- Case Specific
- Disease Themes
- Organize around Medical Condition
Provider Network
Broad
Moderate
Narrow
Population Mgmt –
- Case Specific
- Disease Based
Population Mgmt
– Case Specific
High
Moderate
Low
Insurance Price Sensitivity
Value Driven Health Care
• Key Physicians
– Primary Care based
– HEDIS based quality metrics
– Shared cost savings based contracting
– Viable independent primary care physicians and
specialists within an interdependent network
– Integrating patient data systems without a single
EMR
– Population management across the network