Key Physicians Value Driven Health Care Conrad L. Flick MD John Meier MD, MBA.

Key PhysiciansValue Driven Health Care

Conrad L. Flick MDJohn 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.

The Relationship of Organization Type and Payment Methods

Conti

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of P

aym

ent B

undl

ing

Integrated system capitation

Global DRG fee: hospital and physician inpatient

Global DRG fee: hospital only

Global ambulatory care fees

Global primary care fees

Blended FFS and medical home fees

FFS and DRGs Small practices;

unrelated hospitals

Source: Shih et al, The Commonwealth Fund, August 2008

Independent Practice Associations; Physician Hospital

Organizations

Fully integrated delivery system

Continuum of Organization

Outcome measures; large % of

total payment

Care coordination and intermediate outcome measures; moderate %

of total payment

Simple process and structure measures;

small % of total payment

Conti

nuum

of P

4P D

esig

n

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

• 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

Key Physicians TodayPrimary Care Medical Homes

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 HomePrinciples

• 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

• 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.

• 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.

• 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.

Defining the ACO

Key’s ACO Network

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

Accountable Care Contracting

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 ElementsProviding Value Based Care in a more complex market

Pro

vide

r N

etw

ork

Narrow

Moderate

Broad

Insurance Price Sensitivity

High Moderate Low

Population Mgmt – Case Specific

Population Mgmt –- Case Specific- Disease Based

Population Mgmt –- Case Specific- Disease Themes- Organize around Medical Condition

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