Contracting with ACOs and Other
Multiprovider Arrangements
John J. Durso
2014 PEAK Leadership Summit
March 19, 2014
Senior Partner
Ungaretti & Harris LLP
Three First National Plaza
70 W. Madison Street - Suite 3500
Chicago, Illinois 60602
312.977.4440
312.977.4405 fax
jdurso@uhlaw.com
Jill M. Krueger
President and CEO
Symbria
1520 Kensington Road - Suite 110
Oak Brook, IL 60523
630.413.5810
630.413.5811 fax
jkrueger@symbria.com
1
JOHN J. DURSO
Senior Partner
Chicago
312.977.4440 (office)
312.802.5632 (cell)
jdurso@uhlaw.com
John Durso is a partner and senior member of the Healthcare Practice Group. John has dedicated his 36-year legal career to
serving long term care and other providers, religious organizations, churches and other not-for-profit organizations in virtually
every area of legal practice including: mergers; acquisitions; affiliations; joint ventures; corporate restructuring; tax; corporate
workouts; bankruptcy; tax exemption; health care finance; public finance; labor and employment; complex litigation;
administrative and regulatory; reimbursement; fraud and abuse; HIPAA; survey and certification; alternative insurance and
risk mechanisms (including captive insurance companies); risk management. His clients include post acute long-term care
facilities; CCRCs; assisted living facilities; senior housing community based services and other providers of every type and
size serving seniors; post acute care alliances; national and state trade associations; hospitals and health systems;
integrated delivery networks; ACO’s; physician and physician groups; religious institutes; churches; educational institutions;
social services agencies; other not-for-profit institutions; investment bankers, insurance companies, pension funds REITs,
private and other sources of capital to providers. John also serves as a volunteer director of many not-for-profit health care
providers and educational institutions’ Board of Directors.
John is a frequent lecturer on legal issues and he also writes a legal update column for McKnights Long Term Care News and
he has appeared in and produced the ABA/ACHE’s annual television show entitled, “Health Law Progress and Legislative
Update.” He has also appeared on a number of other television shows and has testified before congressional committees on
legal issues related to health care.
Distinctions
+ Chambers USA: America's Leading Lawyers for Business (2009-2013)
+ Illinois Super Lawyers – Healthcare (2005-2010)
+ Best Lawyers in America directory (2005-2010)
+ A/V Rated, Martindale-Hubbell
Admissions
+ Illinois; U.S. Supreme Court; U.S. District Court for the Northern District of Illinois
Education
+ Loyola University of Chicago School of Law (J.D., cum laude, 1977)
+ Northern Illinois University (B.A., magna cum laude, 1974)
2
JILL M. KRUEGER
President and CEO
Symbria
Oak Brook
630.413.5810
jkrueger@symbria.com
Jill M. Krueger is the President and Chief Executive Officer of Symbria, Inc. (formerly Health Resources Alliance,
Inc.) and its affiliates. Symbria, located in Oak Brook, Illinois was founded by 11 Chicago-based senior care
providers. Symbria’s primary purpose is to combine the resources of its members to create new business which
generate financial returns, enhance the quality of their services and improve the overall market position of
each individual organization. Ms. Krueger is responsible for the continued growth and strategic direction of two
main business lines, rehabilitative and wellness services, and institutional pharmacy services.
Ms. Krueger is
currently launching a third business line which consists of physician alignment strategies; data collection and
outcome measurement tools; and benchmarking reports all designed to effectively position Symbria’s skilled
nursing providers as the “partner of choice” within the markets they serve. She is responsible for the oversight of
seven joint venture rehabilitative and fitness companies serving seniors in twelve states and an institutional
pharmacy which serves over 5,000 nursing beds in the Chicagoland area. Symbria was started in 1996 by Ms.
Krueger and has grown from $300,000 in revenue to over $105 million
Prior to her joining Symbria, Ms. Krueger was a Partner at KPMG responsible for overseeing the firm’s National
Long-term Care and Retirement Housing Practice. In that role, she worked with senior care providers and major
health systems to develop and implement elder care strategies. She was responsible for overseeing the
preparation of feasibility studies, financial planning, and market studies for long-term care and retirement housing
clients throughout the United States. In addition, Ms. Krueger served as an audit partner on several local
retirement community and nursing home engagements.
Ms. Krueger is a Certified Public Accountant and a Certified Management Accountant. She has served as a Public
Commissioner for the Continuing Care Accreditation Commission (CCAC) and as a member of the CCAC Financial
Advisory Panel. Ms. Krueger also served on the Board of Directors and as the Chairperson of the Audit Committee
for publicly - traded assisted living company. She currently serves on the Board of Directors for Franciscan Sisters
Communities of Chicago, Fifth Third Bank – Illinois Affiliate, Capital Senior Living, and Wisconsin Illinois Senior
3
Housing (WISH).
What is an “ACO Participant?”
 “‘ACO Participant’ means an individual or group
of ACO provider(s)/supplier(s)…that alone or
together with…other ACO participants
comprise(s) an ACO…” §425.20.
 ACO Participants are the primary entities that
makeup the ACO, typically hospitals and
physicians
4
What’s next?
 The role of ‘other entities’ is yet to be fully
defined by CMS.
 However, ACO Participants need ‘other entities’
in order to provide for their beneficiaries.
 ‘Other entities’ can become desirable for ACOs
to partner with, and eventually become full
Participants, if they focus on the quality metrics
that determine shared savings.
5
What is an Other Entity?
 Some provisions of the Final Rule refer to “ACOs, ACO
Participants, ACO Providers/Suppliers, and other
individuals or entities performing functions or services
related to ACO activities.”
 ‘Other entities’ would include a long-term care facility that
provides services to an ACO’s beneficiaries
 These so-called ‘other entities’ do not have to be
involved in governance, share savings, or comply with
some of the other provisions of the Final Rule
 ‘Other entities’ DO have to comply with quality metric
reporting and submitting data for quality measurement
6
Written Agreements
 ACOs may be reliant on ‘other entities’ to meet
their quality and performance metrics (and thus
achieve their shared savings)
 To that end, some ACOs will choose to have
written agreements with ‘other entities,’ while
some may choose to have more informal
arrangements
7
Are ACO’s likely to have closed
panels or “other entities”. Any idea
how many nursing homes would
likely be needed per ACO? What
about the metrics upon which they
are likely to decide who gets
included and who does not?
8
What role will the insurance
companies have in ACO construction
or operations? Will they become a
driver in some way? Or will they just
hope to still have a different role in
healthcare?
9
What a Senior Care Provider Brings to ACO
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Cost effective and efficient (reduced unit cost)
Lower cost workbench and lower unit cost services
Eye on readmission protocols
Well managed care (CCRC) senior settings (covered lives for ACO)
Home care
Rehab care
Sub acute Medicare services
Care and case management services
ProviNET and IT knowledge
Shared Savings (risk and reward)
Board seats on ACO regarding governance and planning
We want their continued and expected Medicare referrals
Our tie in and coordination of doctors, nurses, etc. servicing its seniors
covered lives
10
Chicagoland ACOs
 Independent Physicians’
ACO of Chicago
 15,000 covered lives
 Physician-only ACO
based in near-north
Chicago
 Website
 Contact: Dr. John
Venetos 847-975-1114
samv5161@aol.com
11
Chicagoland ACOs
 Alexian Brothers ACO,
LLC
 16,000 Covered Lives
 Mainly in northwest
Chicagoland
 Website
 Contact: Don Franke 847590-2444
don.franke@alexian.net
12
Chicagoland ACOs
 Medicare Value Partners
(Presence Health)
 16,000 covered lives
 Mainly in the northwest suburbs,
Elgin
 Website
 Contact: Dr. Richard Ferrans 773792-7974
richard.ferrans@presencehealth.
org
13
Chicagoland ACOs
 Advocate Physician Partners Accountable Care, Inc.
 Over 100,000 covered lives
 Largest area ACO, with a presence throughout
Chicago
 Website
 Contact: Matt Hendrick 847-375-2226
matthew.hendrick@advocatehealth.com
14
Chicagoland ACOs
 Chicago Health Systems,
ACO, LLC (Vanguard)
 9,700 covered lives
 Located mainly in the near
western suburbs, also
includes Weiss Memorial
in the North
 Website
 Contact: Dr. Gary Wainer
708-783-3000
gwainer@chicagohealthsy
stem.com
15
Chicagoland ACOs
 OSF HealthCare and BCBS of IL announced in May that
they will be forming a Pioneer ACO
 Starts on January 1, 2014
 40,000 covered lives
 Located primarily in the southwest suburbs
 Website
 Contact: James G. Farrell 309-677-0767
16
We Are Quality
Standards of Practice for Skilled Nursing
Practitioners
Introduction
 With the advent of significant changes in healthcare reimbursement,
physician practice in skilled nursing care must change as well. We
must adopt higher quality and maintain a greater measure of control
over quality through closed medical staffs.
 The goal is to achieve the proper mix of coverage and care by
physicians and physician extenders, such as physician assistants and
nurse practitioners, who agree to practice according to the high
standards established by skilled nursing providers. We also aim to
enable and expect collaboration among practitioners working in the
facility and in the community.
17
Definitions
 Tier 1 physician. Attending/Primary Care Physician.
The office-based attending/primary care physician
whom the patient would typically see when not in
the skilled nursing center. The attending/primary
care physician may also see the patient in the skilled
nursing center if he or she agrees to comply with the
Standards of Practice.
 Tier 2 physician. Physician practicing primarily in a
skilled nursing setting who agrees to the Standards
of Practice adopted by the members of Symbria.
The Tier 2 Physicians will also sign the Symbria
Compact.
18
Definitions Continued
 Physician extender. Physician assistant or nurse
practitioner with a collaborative agreement with
the attending or primary care physician or
SNFist.
 Practitioners. Anyone with a license to treat
patients, including nurse practitioners, physician
extenders, and consulting physicians.
19
Tier 2 physician profile
 Tier 2 physicians will commit to the Standards of
Practice and consistently achieve all quality
measures. They will meet all credentialing
requirements established by the Symbria skilled
nursing provider.
20
Ethical Standards
Each Tier 2 physician will agree to:
 respect the existing patient-doctor relationship when
asked to collaborate on a case;
 timely and open communication with other
physicians to provide services based on medical
necessity and quality that result in the best
outcomes for the patient; and
 adhere to these standards unless, by mutual
agreement between the Tier 1 physician and Tier 2
physician the patient relationship can evolve in a
different direction.
21
Practice Standards
 All Tier 2 physicians and physician extenders will commit to a
common goal of working together and collaborating with other staff
members to develop or adopt and implement strategies, processes,
and tools to effectively target acute care readmission rates of 14%
or less.
 All Tier 2 physicians and physician extenders will use current best
evidence in making decisions about the care of individual residents.
Clinical performance measures may be developed from evidencedbased clinical guidelines and used in quality improvement initiatives.
 Tier 2 physicians will adhere to the hospital standard that each
patient’s history and physical is complete within 24 hours of
admission to the facility.
 The Tier 1 physician and the Tier 2 physician will consult by
telephone or in person about the patient prior to, or at the time of,
the patient’s history and physical.
22
Practice Standards Continued




(1)
Tier 2 physician or physician extender will see patients within 24 hours of a
medically necessary medication change.
Tier 2 physicians will deal immediately with acute changes of condition(1),
either by telephone or in person. The Tier 2 physician will follow up with the
patient within 24 hours, unless a life-threatening condition exists or a more
urgent need results in other more immediate follow-up, such as a
hospitalization.
All Tier 2 physician or provider visits will be medically necessary. Using the
general understanding that the LTC care plan is generated from the physician,
a minimum visit requirement of once weekly is required for any patient that
remains qualified under Medicare guidelines to remain in the facility.
All Tier 2 physicians or providers will provide additional visits based on the
stability of the patient and medical necessity. Medical judgment will be the
deciding factor of the medical necessity of the visit. However, requests by
family or nursing staff to see a patient will be honored as sufficient
requirement for medical necessity.
“Acute Change of Condition in the Long-Term Care Setting, Clinical Practice Guideline.” American Medical Directors Association. 2003.
23
Practice Standards Continued
 The Tier 1 physician and the Tier 2 physician will consult by
telephone or in person about the patient at or around the time of
discharge.
 The Tier 2 physician will provide a face-to-face encounter prior to
discharging the patient back to the Tier 1 physician. The encounter
will occur within 72 hours of the discharge.
 Formulary compliance by the Tier 2 physician in authorizing
admitting orders and all other medication changes or additions.
 All provider encounters will be dated and time will be noted.
 All Tier 1 and Tier 2 physicians and providers will allow access to
their performance data for quality control.
24
Overall Impact to Skilled Nursing
 Significant pressures on “cost” effectiveness
 Attention on outcomes
 Loss of census due to:
 Shorter length of stay
 Patients bypassing skilled nursing to home health
 Lack of alignment with payer (ACO, Convener,
Insurance company)
25
Repositioning Strategies

Operations
 Physician Alignment
 Competent nurses – Interact Tool
 Effective admission/discharge planning
 Know costs/streamline costs
 Hospital Relations
 5 star rating
 QAPI
 Technology
 Outcomes and benchmarking

Effective post acute partners
2626
Current Activity
 ACO shifting short stay patients to/from selected
communities
 Many times based on proximity to hospital
 Some hospitals still operating under the
traditional setting
 Keeping patients in ACO system is a MAJOR
focus
 Some CCRCs have eliminated short stay
Medicare A services due to shrinking volume
27
2627
Current Activity
 Bundled Payment initiatives also gaining traction
 National conveners such as Remedy and Signature
focusing on orthopedic DRGs
 Narrow networks versus open networks
 Risk sharing arrangements becoming more prevalent
 Illinois Bone & Joint has significant impact in Chicago
market
 Focus on decreased length of stay
 More effective doctors will actually start with lower rates –
will be tougher to realize upside
2828
Baptist Health System ACO/CI Post Acute Care
29
Clinical Integration/ACO-Current Status
 BHS Integrated Physician Partners, LLC-(CIO)
344 Physicians
 FTC compliant physician network based on a measured
quality and efficiency narrative. Legal and financial awards
based on improvement of care of the population served.
 Sophisticated health information technology (Crimson)
serves as the foundation of the network across all parts of
the patient care continuum-inpatient and ambulatory CI
modules successfully implemented
 BHS Physician Partners, LLC established as a Tier 1 offering
for our BHS self-insured employee population effective
10.1.12 ( 8000 lives including dependents)
30
Clinical Integration/ACO-Current Status
 BHS Accountable Care, LLC
377 Physicians and 14,314 Medicare Beneficiaries
 Only San Antonio Healthcare system awarded an
ACO by CMS, on 7.1.12
 2013 CMS GPRO quality data submission
successfully completed
 Development of Post-Discharge Program has
established relationships with SNFs, LTACs, Home
Health and Rehab.
31
Goals
 The goal of the Post-Acute Care (PAC) program is to
coordinate patient care thus improving patient health,
reducing hospital admissions and increasing health
literacy.
 Identify and establish a working relationship between
post acute care facilities and our post discharge
physician and support staffs.
 Leverage innovative technologies, processes/clinical
pathways and improved communication to enhance the
patient experience and quality of care.
32
Patient Follow-Up
 Telephonic care provided by the Access Baptist call center
uses standardized scripts for HF, MI and PN patients
along with patients that fall into an “other” category.
 Patients who answer appropriately to “high risk” questions
will be flagged and marked for follow-up.
 Patient follow-up identifies gaps in care such as a lack of
medications, no follow-up PCP appointment,
unrecognized symptomology and general health literacy.
33
Community Relationships
 The BHS ACO is also working to develop relationships
with local providers of alternative levels of patient care.
 These post-acute providers include care provided in the
home and in an alternative setting.
 Providers will share the goals of the BHS ACO PostAcute Care program and will share an open dialog with
the BHS ACO/CI to ensure quality patient care.
34
Alternative Levels of Care
Long Term
Acute Care
Hospitals
Skilled
Nursing
Facilities
InfusionSe
rvices
BHS
ACO
Acute
Rehab
Hospitals
Home
Health
Care
Agencies
Medical
Equipment
Hospices
35
Skilled Nursing Facilities
SNF
Facilities have been identified based on BHS
Hospital location, volume of patients presently
referred, Medicare ratings and ACO Advisory
Physician recommendations.
The goal of these relationships is to have all
ACO patients cared for providers within the
BHS ACO network with evidenced based
chronic care guidelines to ensure the same
level of quality patient care regardless of facility.
36
Possible Short-Stay Metrics
SNF
Reports of moderate to severe pain
New or worsening pressure ulcers
Administration of seasonal “flu” vaccine
Administration of pneumococcal vaccine
Administration of antipsychotic medications
Return to acute care within 30 days
Staff trained on INTERACT
37
Metric Sources
SNF
Using the Medicare “Nursing Home Compare”
tool that is available online and shows the
previous metrics from the yearly nursing home
evaluation. Using this tool would mean
comparing the SNF to the state and national
average.
Having the nursing home staff complete a
manual check list on ACO patients on a monthly
basis. Using this method we could specify what
numbers we are looking for.
38
Primary Care Follow-Up
 An ACO Discharge Form has been developed to ensure that
primary care providers have the medical information needed to
appropriately follow-up with ACO patients three days post
discharge.

We are currently in the process of working with Medi-Mobile to
automate this process when a physician uses the “PCP Direct
Discharge” function.
 Physicians not using the Medi-Mobile application will have to
manually complete the form and hand off to nursing or case
management for submission to the PCP’s office.
39
Community Relationships
The BHS ACO is also working to develop relationships with local
providers of alternative levels of patient care.
Providers will share the goals of the BHS ACO Post-Acute Care
program and will share an open dialog with the BHS ACO/CI to
ensure quality patient care.
Skilled Nursing Facilities
Home Health Care
Acute Rehab Units
Hospice & Palliative Care
Long Term Acute Care
Infusion Services
Durable Medical Equipment
40
Preferred Providers - Locations
Preferred Provider Locations
BHS Hospitals
Skilled Nursing Facilities
Acute Rehab Units
Long Term Acute Care
41
Skilled Nursing Facilities
 Facilities have been identified based on BHS Hospital location,
volume of patients presently referred, Medicare ratings and ACO
Advisory Physician recommendations.
 The goal of these relationships is to have all ACO patients cared
for providers within the BHS ACO network with evidenced based
chronic care guidelines to ensure the same level of quality
patient care regardless of facility.
 Patients who go to these facilities need the benefit of physical
therapy, occupational therapy, and nursing. The LOS can vary
from a few days to a few weeks depending on the medical
complexity of the patient.
42
Acute Rehab
 The BHS ARU will be the acute rehab provider of choice for the
BHS ACO. This will allow BHS ARU the right of first refusal for
all ACO patients who have a rehab evaluation ordered.
 ARU appropriate patients must be in need of up to three hours
per day of therapy and meet appropriate admissions criteria as
per Medicare guidelines
 By following BHS ACO ARU Referral Process we are able:
 To use Medicare funds properly by appropriately placing the
patient
 To allow BHS rehab staff the opportunity to connect with
physicians to provide education on patient appropriateness
43
Long Term Acute Care
 Long term acute care hospitals have been selected based on the
number of ACO physicians that have privileges at area LTACs
and based on the relationships that BHS has with local facilities.
 Patients who are appropriate for this level of care are too
medically complex to discharge to a lower level of care but are
no longer in need of acute interventions.
 This includes patients with acute and chronic pulmonary
concerns, patients with highly complex wound care, those who
require multiple long term IV antibiotic therapy and other
disorders that require 24 hour nursing care and daily physician
rounding.
44
Home Health, Palliative and Hospice Care
Process for home health preferred provider selection for the
BHS Shared Savings ACO:
Took most recent quality data from Medicare (calendar year 2012)
and highlighted HHCs that reported being able to manage patients
with heart failure.
Took referral report from case management for HHC referrals made
in 2012 and highlighted HHCs that had 20 or more referrals during
that time period.
Of that, 15 agencies were left, including Reliant HHC and
CHRISTUS Homecare. Reliant and CHRISTUS were taken out at
this point as Reliant will be included in the list due to being a part of
BHS and because CHRISTUS is direct competition.
45
Home Health, Palliative and Hospice Care
Process for home health preferred provider selection for the
BHS Shared Savings ACO:
The remaining 13 agencies were chosen based on their ability to
care for heart failure patients and/or the amount of referrals they
received over the past year from the case management
department.
HCC Compare Spreadsheet
HHC Questionnaire
BHS HHC Scoring
46
CMS Health Innovation Challenge Grant
 3 Year $7.3 million Grant - Awarded July 1, 2012 to University of North
Texas Health Science Center in partnership with Brookdale
 Goal is to revise and implement INTERACT III Program in SN, IL , AL,
and home health to reduce readmissions
 Implementing electronic medical record to share data between
healthcare providers
 Initially targeting 27 Communities in Florida and Texas with intent to
expand to all Brookdale locations during and after grant period
 Expected savings of more than $9 million
47
INTERACT: A Quality Improvement Program
Quality Improvement Tools
Communication Tools
Decision Support Tools
Advance Care Planning Tools
48
Outcomes
 Clinical
 Reduction in overall hospitalization rates
(unplanned admissions)
 Reduction in 30 Day readmissions
 Quality metrics (e.g., falls, pressure ulcers,
dehydration, weight loss)
 Financial
 Decrease costs to Medicare
49
Closing the Loop in Health Care
50
Questions & Comments
Contacts:
John J. Durso, Senior Partner
Ungaretti & Harris LLP
312.977.4440
jdurso@uhlaw.com
Jill M. Krueger, President and CEO
Symbria
630.413.5810
jkrueger@symbria.com
51
Appendix
52
Overview of the INTERACT Quality Improvement
Program
•
•
•
The INTERACT Version 3.0
Tools are meant to be used
together in everyday care in the
nursing home
Adaptation of program to multiple
settings (AL, IL, HH)
Data sources (Brookdale,
hospitals, CMS claims data)
53
Overview of the INTERACT Quality Improvement
Program
 Can help safely reduce hospital transfers by:
1. Preventing conditions from becoming severe enough to require
2.
3.
hospitalization through early identification and assessment of
changes in resident condition
Managing some conditions in the NH without transfer when this
is feasible and safe
Improving advance care planning and the use of palliative care
plans when appropriate as an alternative to hospitalization for
some residents
54
Using the INTERACT Early Warning Tool:
Stop and Watch
55
Interacting with Hospitals
The NH to Hospital
Transfer Form has two
pages.
 The first page has
information that ED
physicians and nurses
identified as essential
to make decisions
about the resident
 Consistent and clear
clinical terms are used
56
Interacting with Hospitals
The NH to Hospital
Transfer Form has two
pages.
 The second page has
additional information
that will be helpful to
inpatient teams, and
can be sent within 24
hours if the resident is
admitted to the
hospital
57
Interacting with Hospitals
The NH to Hospital Transfer
Data List has recommended
contents for transfer forms for
incorporation into standard forms
and electronic sharing of data
58
Interacting with Hospitals
This Transfer Checklist
can be printed or taped
onto an envelope, and is
meant to compliment the
Transfer Form by
indicating which
documents are included
with the Form
59
Interacting with Hospitals
Information Transfer From the
Hospital
INTERACT has a sample
Hospital to Post-Acute Care
Transfer Form that puts the data
into a format that is easy to read
and flows logically for a receiving
clinician.
60
Interacting with Hospitals
Information Transfer From the Hospital
 The Hospital to PostAcute Care Transfer
Form highlights Critical
Time Sensitive
Information
 But, there is no
substitute for a warm
handoff.
61
Questions?
62