Transcript Cornerstone’s Journey from Fee-for-Service to Pay-for-Value Michael Ogden, MD, MMM, CPE Chief Clinical Integration Officer Cornerstone Health Care, PA Cornerstone Health Enablement Strategic Solutions (CHESS) An Unsustainable Future $8.0 $7.1T (24%

Cornerstone’s Journey from
Fee-for-Service to
Pay-for-Value
Michael Ogden, MD, MMM, CPE
Chief Clinical Integration Officer
Cornerstone Health Care, PA
Cornerstone Health Enablement Strategic Solutions
(CHESS)
An Unsustainable Future
$8.0
$7.1T
(24% of GDP)
Expected future trend (6.5% growth)
Sustainable trend (affordability followed by 4.5% growth)
$7.0
Industry spend ($T)
$6.0
3.1T
$4.3T
(21% of GDP)
$5.0
$4.0
1.5T
$4.0T
(14% of GDP)
$2.6T
(18% of GDP)
$3.0
Trend reduction
Waste reduction
$2.0
A period of growth below GDP growth will be
necessary to reach affordability (30%
reduction in costs as a percent of GDP)
$2.8T
(14% of GDP)
After affordability is achieved, long-term
growth must be at the same level of GDP
growth to ensure sustainability
$1.0
2010
2012
2014
2016
2018
2020
2022
2024
Time
The funding gap is widening, creating a need for rapid transformation in the
market
Sources: National Health Expenditure data, Bureau of Economic Analysis, Oliver Wyman analysis
2026
The Value Proposition
•
Health care cost and
utilization trends are
unsustainable
•
Waste and variation in
practice lead to 30% of costs
that can be taken out of the
system
•
Lowering payments is not a
good answer
• Incentivizing patients,
providers, and payers around
value and appropriate
utilization should be a key
strategy for improvement
The Healthcare Delivery System Model is Changing
Value Based
Volume Based
Reimbursement
Organizational
model
Value drivers
Profit pools
Investments
•
•
•
FFS/DRGs
No payment for
readmits, never events,
etc.
Departmental
•
•
Volume
Efficiency (on a
procedure level)
•
•
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Visits
Surgery / Procedures
Outpatient ancillary
•
•
Capacity
Revenue-producing
assets
Patient referrals
•
•
•
Outcomes & Quality
based
Global payments
•
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•
Populations
Conditions
Focused factories
•
Quality and low
variability
Efficiency (on a
population level)
•
•
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•
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•
•
Wellness and prevention
Population
management
Chronic condition
management
Health IT
Clinical integration
Commercialization
Sources of Revenue in
Fee-for-Value
Fee for
Service
Quality
Shared
Savings
Management
Patient
Satisfaction
Risk
Problem Statement
Value-Based Models
are a Solution to the
US Healthcare Crisis
• The US healthcare
system is in a spiral
• Reform has created
new models
• Aim to improve health,
reduce cost, and
enhance patient
satisfaction
These Models Require
Providers to Undergo
Transformative
Change
• Every facet of their
operations
• Clinical care must focus
on quality and results
• Reimbursement must
incent new behaviors
• New technology must
be adopted and utilized
to its fullest potential
Willing Providers Need
Substantial Capital to
Achieve This Change
• Requires millions in
investment
• Hospitals have the
funds, but cannot
move quickly due to
their volume-based
model and bureaucracy
• Physician groups can
move faster but lack
the capital base,
settling for incremental
change and suboptimal
results
New Capabilities Needed to Become Population
Health Managers
1
2
3
4
5
6
Leadership and
Organizational
Alignment
Leadership, organizational, and governance structure and culture that is conducive to the
transformation to a value-based care delivery model
Care Delivery
Continuum Assets
Network management with, alignment with, ownership of, or employment of facilities and
providers that deliver and coordinate care across the continuum
Core Clinical
Technology
Infrastructure
Healthcare information technology infrastructure for the data storage, usage, and transfer
need to enable coordinated, evidence-based care
Population Analytics
and Performance
Management
Analytic capabilities, platforms, and tools to enable population management and
performance management
Integrated Clinical
Models
Care delivery roles, processes, activities, and behavior change, centered around value-based
care across the delivery system and care continuum
Financial and
Risk Management
Financial tools and capabilities needed to negotiate, execute, and manage riskbased contracts
Many of these areas are outside of providers’ typical core competency areas,
increasing the likelihood that many ACOs will need outside support
Mission:
To be your medical home
Vision:
To be the model for physician-led
Health care in America
Values:
As a physician owned and directed company,
We are committed to ensuring that patient care
is patient centered, efficient, effective,
equitable,
safe, and timely.
Cornerstone Health Care 2013
• 1,800 employees
• 89 locations
230 physicians
• 185 shareholder physicians
111 advanced practice providers
34 specialties and ancillary services
• 21 Practices with extended hours
29 Primary Care practices recognized by
NCQA as PCMH Level 3
• Physicians on staff at 15 different hospitals and 6
health systems
Cornerstone Specialties
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•
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•
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•
Allergy and Immunology
Bariatric Surgery
Breast Surgery (8/2013)
Cardiology
Endocrinology
Family Practice
Gastroenterology
General Surgery
Hematology
Hospitalists
Infectious Diseases
Internal Medicine
Nephrology
Neurology
•
•
•
•
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Oncology
Ophthalmology
Otolaryngology
Orthopedics
Pediatrics
Psychiatry
Plastic Surgery
(7/2013)
Podiatry
Pulmonology
Rheumatology
Urology
Vascular Surgery
Cornerstone Ancillary Services
Audiometry
Ambulatory Endoscopy Center
Behavioral Medicine
Clinical Pharmacy
Imaging
Infusion Services
Laboratory Services
Pain Management
Physical Therapy
Sleep Lab
ACO
Medicare Shared Savings Program
(MSSP) – 2012
Cornerstone developed a five-pronged strategy for
developing the population health management
capabilities required to become an ACO.
Cornerstone Population Health Management Strategy
1
3
2
Medical
Home
Clinical
Integration
Information
Integration
4
Organizational Realignment
5
Reimbursement Model Transformation
=
Accountable
Care
Organization
Infrastructure Needs for
Accountable Care
Network
Development
and Support
Structure and
Governance
Patient
Engagement
Quality
Management
Innovation
Care
Transformation
Support
Information
Continuity and
Management
Operational
Support
Financial
Analysis and
Reporting
Cornerstone’s Timeline
July 2012
Dec 2010:
CHC goes live
on Humedica
MinedShare
July 2011
Service Line Monthly
Meetings
March 2011
PCA Program
Conceived
Jan 2012
CHC & Oliver
Wyman Redesign
October 2011
Shareholder
Vote to move to
PFV
Weekly Care
Pathway
Redesign
meetings
PFV: Negotiating
Contracts
Optum &
Teradata
Tech
partners
April 2012
Personalized
Cancer Care
w/embedded
Primary Care
March 2012
Personalized
Cardiac Care
Program
MSSP ACO
Personalized
Primary Care
Program
February 2013
Care Outreach
April 2013
All lives under
Shared Savings
Contracts
(except Medicaid)
Informatics Investment
Population Costs
Foundation for Care
Management Redesign
•
•
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•
•
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Reduce fragmentation
Reduce unexplained variation in care
Optimize patient engagement
Utilize best available evidence as basis for care
Apply resources to the most appropriate level
Concierge medicine without the concierge price
The Triple Aim of Population Health
Management
• Optimize care for the entire
population, not only the sick
• Improve patient satisfaction in
physician interactions
• Use predictive modeling to
anticipate key health needs of
the population
• Provide tailored support services
to help patients navigate the
system
• Increase prevention efforts to
reduce number of at-risk
patients
• Devote practice resources and
support to improving quality
Improve
population
health
Improve
patient
experience
Reduce cost
of healthcare
• Implement initiatives to reduce
inequitable variation in outcomes
• Provide consistent access to care,
reducing acute health crises and
visits to the emergency
department
• Eliminate redundancy of services
• Reduce preventable utilization
• Drive care to lower cost settings and specialties
Physician and Patient experience will also improve as a result of this
transformation due to more meaningful patient interactions and
improved health outcomes
PCAs
Purpose: To provide an exceptional level of care to each Cornerstone
patient, and facilitate those who are looking for a doctor and a place to
call their medical home.
•
Provide immediate and ongoing personal contact to
enhance our patients’ experiences with Cornerstone
•
Answer questions or concerns
•
Help make appointments with Cornerstone physicians
for new and established patients
•
Help manage our patients’ diabetes, hypertension, or
other conditions, and any other factors that may put
patients at risk for serious complications
•
Provide crucial outreach by identifying and contacting
those patients who are overdue for important
appointments
By providing personal phone reminders and making appointments
with the appropriate doctor(s), the Advocates help our patients better
manage serious diseases and improve their overall health.
PCA Program Results
• Identified population with opportunity:
Diabetes
• Outreach to improve HgBA1C testing
• Achieved 30% improvement within 1
year
PCA Program Future
• Referral management
Navigation
Purpose: To provide an exceptional level of care to each Cornerstone
patient by extending the physician’s reach by enabling health navigators
to educate and assist patients to better manage their chronic conditions
and to improve overall patient health.
•
Provide patients with educational materials
relating to their chronic condition
•
Coordinate follow up care
•
Motivate patients to take control of their
healthcare
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Offer support to the patient
•
Help patients identify and overcome barriers
By assisting and educating patients with chronic conditions, health
navigators have helped patients lose weight, quit smoking, increase
physical activity, and regain their independence.
Cornerstone followed a disciplined process to
identify areas of opportunity and quantify
savings for each care model
Identify Opportunity
1
•
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Stratification of population into similar categories
High cost areas reveal several market specific opportunities
to reduce waste and curb increasing cost trends
Develop Care Model
2
•
•
Opportunities bundled into a unified program called a ‘care
model’ aimed at transforming care
Market specific recommendation developed on staging of
care models
Quantify Impact
3
•
•
Savings estimates developed by site of service and
population segment for each care model
Savings assumptions applied to clinical spend matrix to
identify the magnitude of savings per market
July 2012:
Personalized Cardiac Care Program
– Dedicated team of 3
physicians: Care transitioned
from existing providers to a
member of the team
– Embedded behavior health
psychologist (PhD)
– Embedded pharmacy services
– 2 Health Navigators
– Nurse Practitioner
– Nutritionist
– Telemetric weight monitoring
(planned)
A Year in the Life of
Patient #1
Red indicated CHF related incidents
Blue indicates non-CHF related incidents
A Year+ in the Life of HFC
Patient #1
Inpatient Admissions
CHF Related
90
80
70
60
50
40
30
20
10
0
85
-69%
26
Pre HFC Post HFC
Percent Reduction
90
80
70
60
50
40
30
20
10
0
-29%
17
12
Pre HFC
Post HFC
Percent Reduction
Inpatient Admissions
Non CHF Related
80
70
60
50
40
30
20
10
0
76
-50%
38
Pre HFC Post HFC
Percent Reduction
80
70
60
50
40
30
20
10
0
+11%
27
Pre HFC
30
Post HFC
Emergency Department Visits
CHF Related
(not resulting in hospitalization)
30
30
25
25
20
-75%
20
15
15
10
10
5
0
12
-38%
26
16
5
3
Pre HFC Post HFC
0
Pre HFC
Post HFC
Emergency Department Visits
Non CHF Related
40
35
30
25
20
15
10
5
0
-67%
24
8
Pre HFC Post HFC
40
35
30
25
20
15
10
5
0
-24%
34
Pre HFC
26
Post HFC
Limitations of the Data
• Manually extracted
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Inconsistent follow-up period
Lack of capture of all events in EMR
May overestimate positive results
Short follow-up period
• Claims Based
– Limited data with small sample size; results
annualized from 6 months of data
– Pre-enrolled utilization may be included
– Accuracy of coding may have significant effect on
event categorization
– May underestimate positive results
– Short follow-up period
Patient Care Redesign
November 2012: Development of
Personalized Primary Care Program
– Design team consists of a
group of 7 physicians,
(internists and family
physicians) plus CHESS
support team
– Launched November 19th,
2012
– Navigated patient services
mirror Personalized
Cardiac Care
Selection: Charlson Score
Personalized Primary Care
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Psychology
Nutrition services
Social Work
Navigation
Team-based care
Goals for PPCP
•
Quality of Care
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Blood Pressure Controlled to <140/90 mmHg;
Glycemic Control among Diabetics (defined as HbA1c <
8%);
Cholesterol Control: LDL-C < 100 mm/dL;
BMI: Reduce mean population BMI from baseline for
Personalized Primary Care Program by xx% within one
year of program launch.
Increase depression/distress screening among the
target population (Behavioral Health subcommittee to
decide upon screening tool at January meeting: PHQ-9
vs Mood Scale), and improve screening result scores
over time.
•
Cost of Care/Utilization
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–
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–
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30% Reduction in ED Visits within one year of program
launch;
40% Reduction in Hospital Admissions within one year
of program launch;
Reduction/Avoidance of 30-day Readmissions;
Risk Score reduction for target population. Through
predictive modeling, assesses patient’s relative risk for
future cost based on predicted probabilities of
hospitalizations/high utilization/high medical and/or
pharmacy spend.
Patient Experience of Care
–
Press Ganey provider-specific scores: physician in
comparison to other physicians in same office setting,
as well as to CHC overall.
April 2012:
Cornerstone Personalized Cancer Care
• Group of 5 hematologist/oncologists
breaking down responsibilities for
different tumor lines: breast, lung, GU, GI
and TBD
• Director of Psychosocial Oncology (PhD
psychologist with specialty training in
oncology)
• Tumor line specific Health Navigators
• Nutritionist & Pharmacist & Chaplain
• Embedded Internist to handle primary
care needs
• Development of Palliative Care Program
• Concierge
Standardized Pathways for
Biopsy and Surgery
Early Cornerstone Results
•
2012 Press Ganey Award for Patient Satisfaction
•
$7.3 million in Quality and other P4P incentive
payments since 2010
•
ACO contracts with Aetna, BCBS, Cigna, Coventry, and
UHC
•
Clinical Co-management Agreements in cardiology
and oncology (~ $1 Million saved)
•
July 2012 Medicare Shared Savings Program ACO
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All Primary Care Practices are NCQA recognized Level
3 PCMHs
•
Top 5 Cigna Collaborative Care Collaborative national
performer
•
NC Business Journal top employer
Newer models:
Extensivist
Life Care
Unsustainable Healthcare Delivery System
$8.0
$7.1T
(24% of GDP)
Expected future trend (6.5% growth)
Sustainable trend (affordability followed by 4.5% growth)
$7.0
Industry spend ($T)
$6.0
$4.3T
(21% of GDP)
$5.0
$4.0
$4.0T
(14% of GDP)
$2.6T
(18% of GDP)
$3.0
Trend reduction
Waste reduction
$2.0
A period of growth below GDP growth will be
necessary to reach affordability (30%
reduction in costs as a percent of GDP)
$2.8T
(14% of GDP)
After affordability is achieved, long-term
growth must be at the same level of GDP
growth to ensure sustainability
$1.0
2010
2012
2014
2016
2018
2020
2022
2024
Time
The funding gap is widening, creating a need for rapid transformation in the
market
Sources: National Health Expenditure data, Bureau of Economic Analysis, Oliver Wyman analysis
2026
Care model savings estimates – savings
across the continuum of care
Condition Based
Population Based
Care Model
Target Population
Services
Est. Savings on Target
Population Spend*
Extensivist Model
Late Stage & Poly
Chronic (Top 3-5% of
spenders)
• High touch care coordination with specialists, case
managers and ancillary providers
• Savings realized through reduced utilization (ER visits,
imaging/testing, inpatient visits etc.)
~17%-24%
CHC Chronic and
Complex Care Clinic
Model
Complex Conditions
(and residual Late
Stage & Poly Chronic)
• High touch care coordination (lighter staff to patient
ratios than Extensivist model)
• Savings realized through reduced utilization (ER visits,
imaging/testing, inpatient visits etc.)
~11%-18%
Patient Centered
Medical Home
Model
Healthy, At-risk, and
Early Stage Chronic
• Emphasis on wellness and prevention
• Medical savings realized by having a more engaged
patient population, steerage towards lower cost
settings, and avoided admissions
~1%-3%
Cardiology Model
Sickest 20% of CHF
patients
• High touch care coordination with significant lifestyle
management, medication management, and adherence
to well accepted evidence-based medicine protocols
~31%-39%
Oncology patients
• High touch care coordination with significant lifestyle
management, medication management, and adherence
to well accepted evidence-based medicine protocols
~7%-13%
Oncology Model
* Represents savings on clinical spend for the target population (e.g., 20% clinical spend reduction for the top 3-5% of spenders for Extensivist care model)
44
Healthcare organizations have an
opportunity to change our delivery
system– ACO’s are one
opportunity
For Physician Organizations, Several
Indicators Will Likely Predict
Future Success
Value-Based Care Delivery
Scale
With scale comes operational
efficiencies and capability
advancements – increased scale
additional drives market
influence and power
Risk Adoption
In order to fund the
investment required and to
gain the economic upside
opportunities, providers will
need to continue to adopt
increasing levels of financial
and clinical risk on their
patients
Patient Engagement
Intense focus on created
patient-centric solutions that
drive quality of care while
removing excess cost –
organizations must achieve
both standardization and
innovation
Strategic Partnerships
Extending patient care
beyond the walls of the
provider office means
forging key partnerships
with organizations that
provide services critical to
an integrated patient care
experience (e.g., home
health, Rx, etc.)
New models of outreach,
engagement and experience
means surrounding patients
with complete suite of product,
services, clinical care and health
management
Technology & Infrastructure Advancements
Significant buildout of
analytic intelligence,
information sharing, health
management infrastructure,
etc. remains critical to win
in a FFV environment
Focusing on the Triple Aim, Three
Forward-Looking Strategic Goals
1
Create a potential for long-term return on investment
in a successful contemporary business model.
2
Create an environment that permits a more enjoyable
practice of medicine while enhancing the ability to
deliver high quality, patient-centered care.
3
Provide financial stability for your providers in the
changing health care economic climate.
Not just more care-the Right Care, at
the Right Time, in the Right Setting,
with the Right Resources
Thank You!
Michael Ogden, MD, MMM, CPE
[email protected]