Lessons Learned from Multiple Structural ACO Models. Brown & Toland Physicians Overview

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Lessons Learned from Multiple Structural

ACO Models

A Conversation with Brown & Toland

Physicians

2014 CAPG Annual Healthcare Conference June 5, 2014

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Stephanie Mamane, Director, PPO & ACO

Claire Shoen, Vice President , Network Management and Product Development Andrew Snyder, MD, Chief Medical Officer (moderator)

Marcus Zachary, DO, Medical Director, ACO

Brown & Toland Physicians Overview

• Multi-specialty, clinically integrated, 100% Physician-owned IPA formed in 1992 • Provides comprehensive administrative, group contracting, practice

management and clinical management services

• Represents over 525 primary care physicians and over 1200 specialists across p p y p y p the San Francisco Bay Area

• Headquartered in San Francisco, network coverage in five counties, 250 employees

• Multiple hospital partners • Patient Volume

300,000 for various products

1992 Leader of Care Coordination Led to HMO

Contracting

1999 Leader in Clinical Integration Led to PPO

Contracting

• Commercial HMO • Medicare Advantage • PPO

• Medi-Cal Managed Care • ACO

2014 Brown & Toland Physicians

Contracting

2010 Leading in ACO

Development

Led to ACO contracting

2013 Accountable Care 2.0 Knox‐Keene

Future Leader in Population Health Total Cost of

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• Elite Status-- CAPG standards of excellence program 2008-2013 • Selected as 1 of 32 Pioneer ACOs by CMS, 3rd_{top performer after year 1}

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Awards & Accolades

• Named “Top Performing Physician Group” in 2012 by the Integrated

Healthcare Association (IHA) in its annual California Pay for Performance (P4P) initiative

• Various quality based health plan awards (Blue Shield of California, Anthem Blue Cross, Health Net)

• PBHG Blue Ribbon Award winner for three years for quality, cost, data and partnering

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partnering

• Employer awards, including Bay Area Best Places to Work (2010, 2011- SF Business Times)

• Multiple marketing and advertising awards, including BTP’s member newsletter

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The Pace of Change

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Brown & Toland’s Current Total Cost of Care Landscape

ACO Description Patients 2014 Growth

City and County of San Francisco

CCSF employees and retirees enrolled in Blue

Shield HMO 18,759

Pioneer Medicare ACO Traditional Medicare FFS patients who were _{aligned by CMS to a B&T Pioneer physician} 17,000

PPO ACO (currently 2 commercial plans) PPO patients aligned to B&T physicians. TCC Model. Data by reports and raw data provided. 18,500 32,500 (2 additional Plans)

Restricted Knox Keene License as BTHS to

Knox‐Keene (Full Risk) Restricted Knox‐Keene License as BTHS to _{assume Full clinical financial risk} 925 10,000

Hospital Shared‐Risk HMO patients with which the Hospital entered

into Capitation with a BTP Management QIP 7,000

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• Engagement

Topics for Today’s Conversation

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• Interventions and Outcomes

• Lessons Learned

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IPA & Physicians

Engagement at many levels

Hospital Hospital Member Member Health Pl Health Pl Employer Employer

_IPA

Coordination

Care Coordination Care Coordination Patient EngagementPatient Engagement Physician EngagementPhysician Engagement

Population

Health

9 Member Member Plan Plan

Quality Improvement Quality Improvement Data & Analytics Data & Analytics Practice Management/ MSO Services Practice Management/ MSO Services

Health

Critical Engagement - Where to Start

Strengths, experience and capabilities of each partner must be recognized to foster integration, accountability and success

Governance and Employer, Member & Ph i i Population Health Care D li Measurement & T ki Data E h

•How do we partner to better achieve integration?

•What gaps and redundancies currently exist and how do we address these?

•How are our stakeholders impacted (employer,

CRITICAL QUESTIONS THAT NEED TO BE ADDRESSED TO BUILD INTEGRATION

Leadership Physician

Engagement Management

Delivery & Tracking Exchange

•How do we collectively engage to drive desired outcomes?

•How do we communicate – internally and externally?

patients, members, physicians, care providers, project resources)?

•How do we redesign the care delivery and care transition processes to be proactive and efficient both horizontally (coordination of activities at the same stage of delivery) and vertically (coordination of care at different stages)?

•What are each organization’s capability strengths and how do we collectively leverage?

•What are the challenges of implementing clinical change?

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• Relationship realignment from necessary competitors to meaningful collaborators

• Use process of data refinement as vehicle for transparency shared

Health Plan Engagement

Use process of data refinement as vehicle for transparency, shared truths, aligned expectations, and partnership accountability

̶ This group activity requires feeding, watering and time to grow. ̶ Plan early tactics, resource allocation and performance metrics

accordingly. Waves of activities (vs. tsunami) highly recommended

• Health Plans have excellent Project Management Resources to

l t i t l t k d t f th

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supplement your internal resources – take advantage of them • Quality improvement initiatives can decrease costs in one area and

increase cost in another, be mindful of that result at the onset

• Meet early and often

• Define, Measure, Scope, Execute, Measure, Tweak, Measure, Repeat….

Health Plan Engagement – Lessons Learned

• Identify goals based on agreed upon data and establish measurable interventions

• This work will identify silos inside all partnership organizations

• In holding partners accountable, be kind and constructive in your criticism as you will be receiving your own fair share

• Keep track of anecdotal stories of how interventions improved quality ofKeep track of anecdotal stories of how interventions improved quality of care for individual patients –this helps all participants when the going gets tough

• Celebrate successes – it will help for the next wave of work • Each party with skin in the game needs a financial win

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• Keep expectations low and requests to providers focused

• Be very specific regarding patients criteria/measurement – agree on what you’re going to measure and how to get physician to buy in

Provider Engagement

what you re going to measure and how to get physician to buy in • MUST get clinical information

• Ask for their help

• Face to face meetings to educate the provider about all the services available and who you are looking for

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• Give them easy way to contact you

• Train the whole team to always loop back with the provider • Its not about the short term but the long term

• Providers identify patients for us and “task” care

management via the enterprise platform

(self sustaining referrals)

Provider Engagement – Future State

(self sustaining referrals)

• Quarterly “rounds” with engaged providers to both report

out and reload

• Integrated pods/teams will include referral nurse, clinical

nurse, physician service reps, social worker

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• Some organizations cold calling works but not ours

• Attribution isn’t precise so verifying provider-patient can

Patient Engagement

Attribution isn t precise so verifying provider patient can

be challenge

• Senior and commercial tactics are different for

communication

• Tool kit needs to be broad (low tech still works great)

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• No data is accurate and perfectly real-time – learn to

apologize gracefully to providers and patients

• Tactics are dependent on

̶ Population – Captive or attributed ̶ Risk – Population acuity mix

Hospital Partner Engagement

̶ Incentives - Upside, Downside, Realistic Targets ̶ Financial alignment understood by all parties

̶ Unaligned objectives and unsupported financial incentives quickly surface

• Different levels of engagement for different ACO models

̶ Inpatient requires hospital partner buy-inInpatient requires hospital partner buy in

• FFS, Capitated Risk, or DRG – incentives and management differs

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• Employers can add tremendous value to program dynamics • Identify employer objectives and health conditions

Employer Engagement

̶ Bus Drivers with low back pain/return to work ̶ After Hours Access

̶ Transitions of Care Improvement Opportunities ̶ Employer resources to reinforce messages ̶ Educated employer is an empowered employer

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̶ Wellness initiatives ̶ Benefit plan development ̶ Market purchasing power

Internal Engagement

Exec ACO Leadership Committee Committee (Strategic) ACO Subcommittees (Tactical) Operations ACO Committee

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Interventions and Outcomes

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Interventions Across the Continuum of Care:

Build with Caution - Different populations will have different needs

Awareness creating early engagement Access increasing access to care Chronic Mgmt regaining optimal health ED Mgmt directing patients to appropriate care Inpatient coordination of patient Outpatient continuation of care Wellness making prevention easy • “Orientation to PCP” member letter • Member communication/ postcards on access alternatives • B&T Dedicated Nurse Advice Line • PCP outgoing messages updated with after hours information • Assistance with post‐ discharge appointments • Expansion of after‐ hours availability to • Generic vs Brand Utilization Management and targeted outreach • Stratification of highest risk members via Predictive Modeling Tools • Management of high risk medications within senior population • ED discharge instructions & PCP follow up for non‐ emergent care • Personalized Care Plan, including discharge instructions, shared with PCP • Transition of Care Calls; Transitional Clinic • POLST, Palliative, and Compassionate Care programs • Scope of Practice for PCPs to standardize best  Coordinated discharge planning/ transition of care, & IDT rounding • Dedicated Hospitalist Program • Advanced Illness and End‐of‐Life Programs • Manage elective inductions • SNF model of care • Cross‐organizational access to traditionally proprietary medical record systems (MIDAS & Ibex, Epic, and AllScripts) • B&T screening programs • Dedicated member engagement team • Leverage Plan Wellness program • Gaps in Care

quality program hours availability to create the “After Hours Network” • Leveraging B&T’s Patient‐Centered‐ Medical Home population • High‐touch, integrated complex case management program • Referrals from Care Transitions Manager into complex case management program PCPs to standardize best practices across all B&T practices • Home Visits Program • Behavioral Health Integration • Dedicated Pharmacist & Medication Management Strategy • Post discharge appts. for high risk patients • Reengineering hospital discharge process • ED Care Managers to prevent avoidable admissions • Quarterly distribution of Access & ED utilization data for all PCPs; Transparency • Urgent Care access and education quality program

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Coordinated Care across the Continuum

1% Catastrophic Illness 4% 5+ Conditions 20% 2‐4 Chronics 25% 1 Chronic Condition 15% At‐Risk 35% 21

2014 Brown & Toland Physicians Physicians

No Ongoing Physical Health Needs

Social Risk Clinical Risk Behavioral Risk

• Non-HMO population: you’re not going to find these patients on a capitation list or with an ID card that is stamped “ACO” anywhere on it

Interventions – Patient Identification is Key

• Program identifier loaded in Physician EHR • Flag added to Hospital admitting software

• IPA Case Manager embedded in Emergency Department • Bi-lateral view-only access into partners clinical documentation

systems systems

• Physician Signature “On-File” with IPA for Orders • New provider resource tool development

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CCSF ACO Results Show Positive Impact on Key

Metrics

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Brown & Toland CCSF Commercial ACO Utilization Dashboard

Note: Reporting Dates based on admission dates, not discharge or paid dates

Last date of service month Oct-12 Last paid month Dec-12

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Brown & Toland CCSF ACO Inpatient Utilization, Rolling 12 Months of Data

Brown & Toland CCSF ACO Admits/K Target Admits/K Brown & Toland CCSF ACO Days/K Target Days/K

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Brown & Toland CCSF ACO ER Visits/K Rolling 12 Months of Data

Brown & Toland CCSF ACO ER Visits/K, Total Target ER/K

180 190 200 210 220 230 40 45 50 Da ys /K Ad mi ts /K

Brown & Toland CCSF ACO Membership&Mean DxCG Concurrent Risk Score

Membership Mean DxCG Concurrent Risk Score

130 136 142 148 154 160 166 172 ER V is its /K

Brown & Toland CCSF ACO Generic Rx Rates Rolling 12 Months of Data

Brown & Toland CCSF ACO Generic Rx Rate Target Generic %

23 1.25 1.30 1.35 1.40 1.45 1.50 1.55 1.60 1.65 1.70 1.75 19,000 20,000 21,000 Ris k Sc ore Me m b er sh ip 68.0% 70.4% 72.8% 75.2% 77.6% 80.0% G e ne ric P re scr ib in g Ra te

Pioneer ACO & Knox-Keene Admits/1000

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• Program measures our cost trend over performance time compared to market cost trend

Commercial PPO – Early Results

• Early indicators showed our OP Facility costs much higher than market

• Through various interventions focused on OP Ancillary and ED avoidance, increased use of After-Hours practices, our costs went down -7.7% over course of performance year.

• Market trend for OP Facility was -0 5%

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• Market trend for OP Facility was -0.5%

• By contrast, IP Facility costs skyrocketed - our trend increased by over 15%. Due to unexpected increase in maternity on small population.

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Lessons Across the Spectrum

• Attribution and Analysis of population

must be understood before the

contract is signed •Quality programs, targets, and relative value vary considerably across Plans • Commercial Payers each have their own unique model • Less or different PPO data • HMO Attribution and data acquisition easier, • Often lack accountable PCP •Commercial Populations are different than Senior • Different disease burden (ex. IP drivers) • Different high‐cost utilization patterns 27

(PPO), ‘previously unmanaged’ • “Open” network (PPO)

• Different cost drivers

Lessons Across the Spectrum

HMO PPO

UM Management ‐ Prior Authorization Pharmacy & Radiology Steerage

Referral Management OON repatriation

Evidence‐based concurrent reviews Lack of concurrent review opportunity

Utilization, Care and Pharmacy Management

Steerage as main driver

Upfront cap augments infrastructure More difficult to resource

Sicker, 5% = 50%, better data, better analytics

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• Health Plan Engagement

Must share data, resources, and work collaboratively. I’ll show you mine if you show me yours

• Provider Engagement

Engagement Lessons

Analytics will never substitute for the physician’s perspective (you cannot bypass the physician)

• Patient Engagement

Not one size fits all. Seniors will fill out surveys. Commercial patients receptive to phone calls. But warm outreach better than cold • Hospital Partnerships

Things had to get bad before they got good. Must have trust to succeed

d th t t k ti d ff t

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and that takes time and effort • Employer Relations

For the best results, employer must be engaged. Help us help you • Internal Stakeholders

You cannot communicate too much or too often

• Multidisciplinary coordination may be underestimated • Engage hospitalists early and often

Clinical and Analytical Lessons

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• Have a SNFist strategy for Seniors

• Creativity counts: build from managed care experience, look for new solutions to old problems

• Do assessment in planning phase

• Understand your population and levers you have access to before jumping in

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• You’ve seen one ACO, you’ve seen one ACO

• Time and resource commitments (many meetings x many health

Operational Lessons

plans = calendar madness)

• Internal Governance – Oversight of program differences, relative value, and programmatic approaches

• Focus, focus, focus – need to have, not nice to have

• Reality is that these populations are not all alike so identify market

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• Reality is that these populations are not all alike so identify market leverage and environmental leakage

• Each ACO has very different potential ROIs - multivariate

• Prioritize the early financial wins to fund future program

Financial Lessons

development

• Value of Quality improvement measures are the trigger of

success

• Upfront costs and ROI – be realistic!

• Payout upfront necessary because of delay / timing of

shared savings – must fund start up costs

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• Investment required long before return horizon.

• External upfront funding from plan often is recovered

Financial Lessons

before shared savings thresholds are met.

• Identify your home runs early on (i.e. Admits, ED,

ancillary steerage)

• Invest for the future, not single project

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• ACO - Marathon, not a sprint

• Data must be customizable and integratable at the same time

Final Thoughts, please remember….

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• Complementary to provider and managed care workflows and processes

• Plan, measure, find programmatic overlap

• Long term sustainability beyond low hanging fruit?

• Physician groups can lead this change – it is individual patient management that becomes the sustainable advantage

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Lessons Learned from Multiple Structural ACO Models. Brown & Toland Physicians Overview