Early Lessons from an Accountable Care
Organization
Scott D. Barlow
Chief Executive Officer
September 30, 2014
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Central Utah Clinic
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Founded in 1969, largest independent medical group in
Utah.
Operate 101 offices - Utah, Mesquite NV and Paige, AZ.
Currently employ over 1,400 professionals and staff.
Medical staff of 170+ physicians, 100+ midlevel
providers.
Completely paperless in all care locations since 2002.
Certified Medicare quality reporting registry.
Participating in the Medicare Accountable Care MSSP
program and five other commercial value based pilots.
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Operational Flows
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Improving the reliability, safety and value of care is about
designing consistent operational flows - logistics.
An EHR is a tool to help create consistent designs, but is
not itself an answer.
Data sets mineable, relevant and actionable.
“HPN” – provider/system competency, manageable.
Sustained improvement does not rely on “I’ll remember
to do it the next time”, or hard work.
Design operational flows so the care we should provide
happens every time.
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Primary Care Report Card
Cardiology Report Card
MSSP Program Projections as of June 30, 2014
N = 14,000
Meeting all 32 Quality Metrics.
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Payer 2 – NCQA Quality Scores
Clinical Service
Gen. Pop. Percentile
Target Pop. Percentile
Medicare Patients: n=347
Breast Cancer Screening
COL Screening
CMC – LDL Screening
CDC – LDL Screening
CDC – Eye Exam
CDC – Kidney Disease Monitor
CDC A1C Test
50th
25th
<10th
10th
25th
10th
50th
90th
50th
90th
10th
25th
50th
75th
Commercial Patients: n=3,041
Breast Cancer Screening
COL Screening
CMC – LDL Screening
CDC – LDL Screening
CDC – Eye Exam
CDC – Kidney Disease Monitor
CDC A1C Test
75th
50th
<10th
<10th
25th
<10th
25th
90th
90th
<10th
10th
50th
25th
<10th
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Payer 3 - Quality Measures
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Population = 2,300
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Overall measures remained unchanged 2012 to 2013.
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Satisfaction survey scores improved:
3Q = 87%
4Q = 94%
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Population = 89%
Readmission rate (50% GI Diagnosis):
Regular pop. = 14%
Participating pop. = 8%
Savings generated above expected $986,724
Savings $429 per member
Bonus Earned
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CY 2013 vs. CY 2012 Clinic Utilization Improvement over Benchmark
Change in Utilization/1000 Members
Util/1000
INPATIENT FACILITY
Surgical
Medical, Non-Maternity
Maternity
Total IP Facility
OUTPATIENT FACILITY
Surgical
Emergency Room
Rad/Pathology
Other OP Facilty
Total OP Facility
% Total Spend
20.0%
-42.1%
4.3%
-12.9%
days
3.6%
days 17.1%
days
2.6%
days 23.3%
-9.2%
-4.8%
-3.9%
-8.0%
-6.4%
cases 9.6%
cases 4.8%
cases 4.2%
cases 9.2%
cases 27.9%
Util/1000
% Total Spend
PROFESSIONAL
IP Professional
OP Surgical Professional
PCP/Preventive
Rad/Pathology
All Other Professional
Total Professional
-12.6%
-3.1%
-5.5%
-1.8%
3.4%
-1.4%
RX/OTHER
Prescription Drugs
Other Medical Benefits
Ancillary Benefits
-4.0% scripts
-6.6% units
-30.5% units
TOTAL MEDICAL
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Payer 3 - Impact
-3.1%
proc.
proc.
visits
proc.
visits
3.0%
4.3%
7.0%
4.3%
12.3%
30.9%
14.8%
2.8%
0.3%
100.0%
Data shows change in CY2013 vs .CY2012. Paid claims run-out through March 2014.
Utilization is on a risk-adjusted basis.
Observed trends can reflect many variables other than Program Impacts, random fluctuation and
utilization changes due to other programs
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Payer 4
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N = 1,900 + 3,050 commercial
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No bi-directional data feed.
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Savings 7.8% of expected.
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Shared savings earned
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Missed quality targets so no payment.
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Payer 5
N = 1,100
Measurement:
PPO
HMO
Admits per 1,000
TARGET
213.4
189
166.8
189
ER per 1,000
TARGET
345.1
305
272.1
305
Readmit Rate
TARGET
8.41%
11.3%
16.13%
11.3%
Bonus Earned = 2.3% of total claims costs saved!
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Payer 6
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N = 11,300
Quality Measures:
Total Cost of Care – MET
BP Control of those with Hypertension – MET
Cholesterol management, Cardiac patients – NOT MET
Bonus Earned
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Challenges
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Patient attribution – who is accountable for whom?
Medicare claims review 1.79M beneficiaries:
Beneficiaries saw a median of 2 PCP & 5 Specialists.
Median level of 4 different entities or practices.
Median of 35% of PCP visits with their attributed PCP.
(“Care Patterns in Medicare and Their Implications for Pay for Performance”, NEJM, March 15, 2007)
(JAMA Internal Medicine, April 2014 – 145 ACO’s attribution, one-third switched 2010 to 2011)
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Past care challenges: Review period, SNF or Consulting
Care, Validate and refresh process.
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Challenges
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Patient attribution – who is accountable for whom?
Start with key partners (willing, capable, critical mass) –
system of care – LOGISTICS!
Data value – complete costs, mineable to the provider and
patient.
Data exchange to be bi-directional – 60%+ data missing.
Relevant data – complete, variation amongst peers, timely.
Golden Few – Care Management, Care Transitions.
Risk Stratification – Coding intelligence.
Patient & Family involvement/engagement?
Set and manage to targets – quality, budgets “VALUE”.
Maintaining the model? Improvements become new target?16
Lessons Learned
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Aligning the interests of the payers, patients and
providers can improve Quality & Costs.
Models of success require a Holistic patient focus.
Providing enhanced information enables better care.
Need to start with a limited cohort of Providers.
Need critical mass to be a “system of care”.
Programs will be different, but need to be consistent and
relevant to the care model.
We can improve the system of care!
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Questions?
sbarlow@centralutahclinic.com
801-429-8034
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