ACO, PCMH, PCSP
The Ingredients for a Medical Neighborhood
Presented by:
Cindy Friend, RN, BSN, MSN, MBA/HCA
Executive Consultant
November 8, 2013
Agenda – Ariel 40
Heading
• Healthcare Reform
• Future of Healthcare
• PCMH
• PCSP
• ACO
• Payment Reform
• Healthcare Organization Fundamentals
• Organize, Prioritize & Strategize
2
Healthcare
Reform
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– Ariel
40
ACO
PCMH
ARRA/MU
PQRS/eRx
HIPAA
3
The Future
of Healthcare
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– Ariel
40
Medical
Neighborhoods
ACO
PCMH
Meaningful
Use
HIPAA,
PQRS &
eRx
4
The Medical
Neighborhood
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– Ariel
40
Hospital
Pharm
acy
Lab/
Rad
Home
Health
Patients
Payer
s
LTC/R
ehab
Employer
s
Governm
ent
Physicians/
Clinics
5
The Name
Means
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– Ariel
40the Same
•
•
•
•
•
•
ACO
PHO
CIN
IDN
ICO
CCO
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Medical Neighborhood
Foundation
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– Ariel 40
• PCMH – Patient
Centered Medical Home
ACO
• PCSP – Patient Centered
Specialty Practice
• ACO – Accountable Care
Organization
Medical
Neighborhood
PCMH
PCSP
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Today vs.– Tomorrow
Heading
Ariel 40
Today
vs.
Tomorrow
My patients are those who make
appointments to see me
Our patients are everyone in our patient
population
A patient’s chief complaint or reason for the
visit determines care
We systematically assess all our patient’s health
needs to plan care
Care is determined by today’s problem and
available time
Care is determined by a proactive plan to meet
patient needs
Patients are responsible for coordinating
their own care
Care is standardized according to evidencebased guidelines
I know I deliver high quality care because I
am well trained
A prepared team of professionals coordinates all
of the patient’s care
Acute care needs met through next available
visit and walk-ins
We continuously measure our quality and make
rapid changes to improve our performance
It’s up to the patient to tell us what
happened to them
We track test results and referrals, and followup, including ED visits and hospitalizations
Operations center on meeting the doctor’s
needs
A multidisciplinary team works together and has
defined roles and responsibilities
Source: The University of Oklahoma-Tulsa (revised)
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PCMH – Ariel 40
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• Primary Care Providers
• Recognition programs
• NCQA 2011Standards
• Includes Stage 1 Meaningful Use
Requirements
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PCMH Numbers
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– Ariel 40
• Started with 38 in
2008
• Over 6,000 medical
practices
• Almost 30K clinicians
• 49 States
Source: The Commonwealth Fund
• ~15% of all primary
care practices
Source: Market Watch, Business Wire, 2013
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PCMH Standards
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– Ariel 40
Source: NCQA
11
PCSP – Ariel 40
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• Specialty practices
• NCQA recognition program
• Launched end of 3/2013
• Includes Stage 1 and Stage 2 Meaningful
Use Requirements
12
PCSP Standards
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– Ariel 40
Source: NCQA
13
ACO
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– Ariel 40
• Community collaborations
• Almost 500 ACOs among private and
public payers
• Accreditation available
14
Number of
ACOs
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– Ariel
40
600
464
500
400
341
484
493
363
300
215
200
100
144
42
67
84
154
100
0
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
2010 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 2013
Source: Levitt Partners, 2013
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Medicare–Reimbursement
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Ariel 40
%
20%
20%
18%
20%
22%
Source: Dartmouth Atlas, 2010
16
Medicare–ACOs
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Ariel 40
Source: RUPRI Center for Rural Health Policy Analysis, 2013
17
ACO by State
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– Ariel 40
Source: Levitt Partners, 2013
18
ACO Standards
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– Ariel 40
Source: NCQA
19
The Effort
Continues
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– Ariel
40
• Aetna and WellSpan form ACO (10/11/13)
• River Health applies for MSSP (8/30/13)
• Memorial Hermann Physician Network and
BCBS of Tx (9/18/13)
• Rutgers and Robert Wood Johnson
Medical School form ACO (10/16/13)
• More than 300 Physicians Join Brown &
Toland’s ACO with Cigna (10/15/13)
20
Payment–Reform
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Ariel 40
Source: United Healthcare
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Fundamental
Heading ArielComponents
40
Business
Healthcare
Organization
Clinical
Technical
22
Business– Ariel 40
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• Shared Governance
• Legal, Policy & Compliance
• Operations
• Finance
• Population Management
• Risk Management
• Performance Reporting
23
Technical– Ariel 40
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• IT Infrastructure
• Clinical Systems & Tools
• Regulations
• Data Analytics
• Reporting Requirements
• ACO Connectivity
• Patient Connectivity
• Health Information Exchange
24
Clinical – Ariel 40
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• Staff Assessment, Engagement &
Education
• Population Management
• Evidenced-Based Care Management
• Care Coordination
• Care Transitions
• Care Planning
25
Clinical – Ariel 40
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•
•
•
•
•
•
Clinical Workflow
Patient Engagement
Quality Measures
Performance Analysis
Quality Improvement
PCMH Practice/ Recognition
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The Subcomponents
Heading
– Ariel 40
Shared
Governance
Performance
Reporting
Risk
Management
Legal, Policy &
Compliance
Business
Business
Operations
Population
Management
PCMH Practice/
Recognition
Staff
Assessment,
Engagement &
Education
Population
Management
Performance
Analysis
Healthcare
Organization
EvidencedBased Care
Management
Quality
Improvement
Clinical
Clinical
Quality
Measures
Finance
Care
Coordination
IT
Infrastructure
Health
Information
Exchange
Patient
Connectivity
Clinical
Systems &
Tools
Technical
Technical
Regulations
Care
Transitions
ACO
Connectivity
Patient
Engagement
Data Analytics
Care Planning
Clinical
Workflow
Reporting
Requirements
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Organize,– Prioritize
Heading
Ariel 40 & Strategize
• Initiate stakeholder outreach and education
• Establish a separate entity with authority and
accountability
• Conduct organizational assessments,
improve deficiencies, and obtain recognition
• Improve medical management
• Identify technology requirements and
implement systems
• Establish performance evaluation, reporting,
and improvement process
• Develop a strategic plan and execute!
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Thank You
For more information, please contact:
Cindy Friend, RN, BSN, MSN, MBA/HCA
cfriend@beaconpartners.com
443.413.6901
1.800.4BEACON │ BeaconPartners.com
BOSTON · CLEVELAND
· SAN FRANCISCO · TORONTO
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