Attaining Scale in a Changing Market
Update on the ACO and the Clinically
Integrated Network
Introducing…”Meridian Health Partners”
Richard J. Scott MD MBA FACS CPE
SVP Clinical Effectiveness and Medical Affairs
Executive Director, Meridian ACO LLC
Special thanks to the members of the Steering
Committee, ACO and Clinically Integrated Network
“Clinical Integration”
• “A means to facilitate the coordination of care across
conditions, providers, settings and time in order to
achieve care that is safe, timely, effective, efficient,
equitable and patient focused” – AMA
• CI is a continuous process of alignment between
hospitals and all providers across the continuum that
supports the triple aim of health care:
Better care for individuals, better health for
populations and lower per capita healthcare costs
Four Pillars of Integrated care
Collaborative Leadership
Governance body
Compliant legal structure
Payer strategy
Culture change
Aligned Incentives
Value based compensation
Program infrastructure
Physician leadership and support
Clinically
Integrated Care
Clinical Programs
Disease programs
Care protocols/PCMH
Clinical metrics
Population health management
Technology Infrastructure
Health Information Exchange
Disease registries
Patient longitudinal record
Patient portal to enable engagement
Collaboration: Current Options for
Hospitals and Physicians
Meridian Accountable Care Organization
Background and Strategy
•
A legal entity operated and governed by physicians and Meridian Health
System under a 50/50 consensus governance model
•
The ACO is a low-risk laboratory wherein Meridian and its physician
community can begin to learn population health and develop infrastructure to
potentially assume risk contracting with payers
•
It is also a vehicle to build market share, and the prototype for other “bend the
trend opportunities”
•
In each of the next 3 years, if MACO can decrease cost and document
quality, savings are eligible to be shared between CMS and MACO.
•
MACO has received historical beneficiary claims information from CMS. The
data show savings opportunities in:
– Hospital Admission
– Emergency Room Visits
– “High Cost” Imaging
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Bending the trend…
and sharing the savings
Under the MSSP, up to 50% of the savings can be
returned to the ACO for distribution to providers
Meridian ACO LLC
First Year Key Metrics
•
Effective Date: January 1, 2013
– Uniquely Attributed
Medicare Lives
(Original 39,705;
Current 59,446)
– Participating Physicians
874
– Participating PCP’s
250
– Medicare Spend
$454,000,000 (on 39,705)
– Average Age
74.3 years
– Gender
57% Female 43% Male
•
•
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Year 1 infrastructure app. $1.3M
Five Population health
managers hired
Annual ACO Quality Audit
• N = 4,244 beneficiaries identified for quality data
• 5 high-risk care managers collected data with support from 3
others in department
• 89 unique physician practice locations visited
– 60% of practices had all or part of record on paper
• 12 nursing homes/other facilities visited
– Only one non Meridian nursing home had required
information in electronic format (MHS locations had
Sigmacare)
• Numerous calls to non-ACO physicians to get required
information (e.g., ejection fraction, mammograms, lipid values)
3,898 miles driven by team
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Augmented Connectivity to Serve Clinical
Integration- Jersey Health Connect
•
•
•
•
•
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Atlantic Health System
Barnabas Health
Centrastate
Chilton Hospital
Deborah
Holy Name Medical
Center
• Englewood Medical
Center
• Trinitas
•
•
•
•
•
•
•
•
•
Robert Wood Johnson
St. Peters Univ. Hospital
Hunterdon Healthcare
Hackensack UMC
Children’s Specialized
Hospital
The Valley Hospital
St. Clare’s Health
System
Summit Medical Group
Optimus Healthcare
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Meridian ACO Yr 1 Quality Performance
vs 2012 ACOs (n=146)
Meridian Accountable Care
• ACE or ARB Tx
72%
• HTN Control(<140/90) 72%
• HbA1c Control(<8.0) 77%
• Tobacco Non-use
78%
________________________
Challenges
Depression Screening
Falls risk Screening
Medication reconciliation
Physician/ACO Compare
• ACE or ARB
69%
• HTN Control
67%
• HbA1c Control
65%
• Tobacco Non-use 72%
________________________
All fall below the 30%tileWill need improvement year
Two (PFP years two and
three)
30-Day All-Cause Readmissions/1,000 Discharges
200
150
100
50
0
2010
2011
2012
Meridian ACO
1Q2013
2Q2013
3Q2013
Total ACO
13
4Q2013
Total Expenditures/Assigned Medicare
Beneficiary
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Meridian RN Population Health Managers
• New role in 2013 to support the Medicare Shared Savings
Program (MSSP)
• Telephonic care management for high-risk patients and
patients with multiple chronic conditions
• Collaborate with provider offices designated as PCP
• Ensure services are deployed as needed across the
continuum through collaboration with existing providers
• Makes visits to hospitals, rehabilitation facilities, homes,
provider offices, and other locations as needed
• Experts in performance monitoring at multiple levels:
patient, provider, practice, and ACO
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Hypothetical Savings and Distributions
Year 1 for a 462M MSSP Program
If the ACO “bent the trend” and
collected/submitted data accurately
and on time:
- 2.0% = $9.24M Did not meet
threshold
- 2.3% = $10.6M (50% = $ 5.3M)
- 3.0% = $13.8M (50% = $ 6.9M)
- 5.0% = $23.2M (50% = $11.6M)
- 10.0% = $46.2M (50% = $23.1M)
(1)Based
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Distributable to ACO (1)
Total
$ 0 to ACO
$ 4.3M
$ 5.9M
$10.6M
$22.1M
on 2013 Projected ACO Expenses of over $1.0M to be repaid before distributions.
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MSSP 2012 “Winners” (114 Original, 44 had
savings, 29 qualify for bonus payments)
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Commercial ACO Activity Across New Jersey
• Horizon partnering with Central Jersey ACO, AtlantiCare
ACO and the Optimus ACO on shared savings programs that
include Medicare Advantage.
• CIGNA has announced a national goal to have 1,000,000
CIGNA insureds in PCMH Pilots by 2014. In NJ:
– CIGNA/Atlantic Health
15,000 covered lives
– CIGNA/Summit Medical Group 10,000 covered lives
• Aetna partnering with Optimus for 11,900 covered Medicare
Advantage lives in a shared savings model.
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Financial Success From Patient Management
Managing Three Distinct Patient Populations
HighRisk
Patients
Rising-Risk Patients
Low-Risk Patients
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5% of patients;
usually with complex
disease(s), comorbidities
15-35% of patients;
may have conditions
not under control
60-80% of patients;
any minor conditions
are easily managed
Trade high-cost
services for lowcost management
Avoid unnecessary
higher-acuity, highercost spending
Keep patient
healthy, engaged
with the system
Joint Venture: Advocate Physician Partners
•
Physician Membership
– 1,138 Primary Care
Physicians
– 2,984 Specialist Physicians
• Total Membership Includes 1,300
Advocate-Employed Physicians
•
•
•
Advocate Physician Partners delivers
services throughout Chicagoland and
Downstate Illinois.
•
•
12 hospitals, encompassing 11 acute
care hospitals and the state’s largest
integrated children’s network
Central Verification Office Certified by
NCQA
250,000 Capitated Lives/ 700,000
PPO Lives/ 100,000 MSSP Lives
320,000 “Attributable” Lives
One model for Governmental and
commercial ACO-like Contracts
AdvocateCare Model: changing the culture
toward population health management
Changing Paradigms…
FROM ...
TO ...
Silo Care Management
Enterprise care management
Episodes of Care
Coordination of care
Discharges
Transitions
Utilization Management
Right Care, Right Place, Right Time
Caring for the Sick
Keeping People Well
Production (Volume)
Performance (Value)
Physicians members
Physician partners
Clinical Integration at WellSpan..
“working as one”
• Like Advocate, have
organized a pluralistic 1200+
physician delivery system
• 660 employed and 600+
private practice physicians
•
•
•
•
Three hospitals
65% market share
1.5 B in revenue
Regional leader in Trauma,
Neurosciences,
Cardiovascular
• Coordinated continuum of
services:90 sites
• “Working as one” to create
healthy communities
through exceptional care
and lifelong wellness
Both WellSpan and Advocate Health…
• Have invested in Information technology that links all
elements of care (e.g. hospital, specialist, home health
agency, nursing home) and the patient’s community
(e.g. family)
• Have connected their medical staff to the system, and
each other
• Have organized their physicians into a unified delivery
system that includes facilities, services and
physicians
• Are positioned as population health managers to
provide value and accept risk
Clinical Integration
Steering Committee
Meridian Health
Partners, Inc.
(2014)
Clinically Integrated Network
Possible
Employee pilot:
Inner Circle
Network
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Meridian
(2013)
Accountable Care
Organization, LLC
Future Commercial
Performance-based
Opportunities
Medicare Shared
Savings Program
(ACO)
These
functions
have been
combined
Effective Q1
2014
Building “Meridian Health Partners”
Mission Statement
A fully integrated partnership between Meridian Health
and its physicians created to provide the highest quality,
most accessible and most efficient health services in
Monmouth, Ocean and our adjacent counties.
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Vision Statement
A fully integrated physician-health system enterprise, providing clinical
quality and efficiency that is demonstrably better than its competitors
A “pluralistic” model, providing efficient practice support, clinical
integration, connectivity and network services to physicians in a variety
of practice models
A vehicle to ensure the availability of primary and specialty medical
care services, ambulatory care, home care, long term care and
ancillary services
A platform to successfully integrate care and participate in pay
for performance, quality and other value based initiatives with
governmental and commercial payers
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Value for Hospitals
• Creates Business Partnership
with Key Physicians
• Focuses Physicians on
coordinated care
– Patient Safety
– Controlling costs
• Creates alignment
• Physicians Drive Clinical
Outcomes
• Positions for Health Care Reform
– ACOs
– Readmission Avoidance
– Migration to Risk acceptance?
Value for Physicians
• Access to and/or participation in
“shared savings” and other
contracts with payers- One interface
• Better alignment between primary care
and specialists- Network integrity
• Marketplace recognition for quality
care and excellent patient experience
• Support staff for chronic condition
registries and QI initiatives
• Management/HIT expertise from
system
Shared Savings Contracting:
Tenets for a workable Model
In order to have a successful shared savings contract model
1.The Network must consistently perform better than the market
2.Improve quality and access to care
3.Reduce cost/decrease complications and readmissions
4.Promote network integrity/minimize medically unnecessary
costly out migration
5.Increase volume to providers participating in Meridian Health
Partners
Enhance physician and patient satisfaction
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“Meridian Health Partners”

MHP will seek a higher level of clinical integration through
enhanced connectivity with the system, regional health
information exchange and eventually each other
 Over 600 “system based” and contractually aligned physicians
are already on board- including primary care, faculty practices
and hospital based physicians
 Actively seeking clinical pilots with health insurance companies
that evolve the “shared savings model” focused on quality and
efficiency
Substantial payer interest in Meridian’s CIN
“Meridian Health Partners”
 Shared Governance
 Consensus decision making
 Physicians comprise the majority of Board Members
 The ACO and MHP initiatives share one combined
board and committee structure
 No capital investment beyond time and expertise
“Meridian Health Partners”
Participation agreement provisions
 Commitment to move toward an EMR will facilitate quality
performance and point of care interventions. (Meridian’s IT
Subsidy program currently being revised to support clinical
integration and information exchange)
 Initial contract opportunities parallel the ACO- Upside only
“shared savings” or performance incentives for quality and
efficiency measures- all would participate
 Aligned Voluntary staff may “opt out” of any future fee schedule
or global risk contract arrangements
 Unlike the MSSP ACO- Participation is “non exclusive” for both
Primary Care and Specialist physicians
Meridian Health Partners: Poised for Population Health
Meridian’s Connected
Continuum
Next Steps….
• Our system based physicians and the
Meridian facilities are already committed
to the effort
• Hospital based groups now joining the
initiative bring enrollment to over 600
physicians
• Enrollment of aligned independent
physicians will begin in June, giving
them access to both shared savings/risk
program opportunities as they arise
•
Connectivity to Jersey Health Connect
will be supported to successfully
manage quality improvement and
network performance
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Thank You !
rscott@meridianhealth.com
Meridian’s Powerful Continuum
Key Health System Statistics
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Over 100 Convenient Locations
$1.7 Billion in Annual System Revenues
12,000 Team Members
2,100 Physicians on Staff
6 Hospitals: 1,700+ beds
 Jersey Shore University Medical Center
 K. Hovnanian Children’s Hospital
 Ocean Medical Center
 Riverview Medical Center
 Southern Ocean Medical Center
 Bayshore Community Hospital
Partner Companies
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Post Acute Care: 6 facilities, 906 beds
At Home Nursing, Hospice, & Rehab: Serving all of Central New Jersey
Ambulatory Care: 19 facilities, including hospital based
Primary Care: 102 physicians
Ambulance/Medical transport: 100+ vehicles
Occupational Health: 6 centers
Rehabilitation and Fitness: 9 outpatient, 2 inpatient facilities
Behavioral Health: 5 outpatient, 2 inpatient facilities
Meridian Geisinger Gold
 A 50/50 joint venture between Meridian and Geisinger
 Enabled Meridian to enter the insurance market
 Initially a 2-county Medicare Advantage offering
 724 participating physicians
 Superstorm Sandy disrupted
2012 open enrollment
 Live January 1, 2013 with 875
members last year
 Enrollment up nearly 5 fold
to over 4,300 lives for 2014
Meridian is uniquely
positioned for growth!
ACO Performance Domains
Application of Rules for 2014 (Using Meridian ACO 2013 Data)
Domain
Status/Issues of Ability to Share
in Savings
Patient/Caregiver Experience (7 measures) Unknown – survey conducted by
CMS this year
Care Coordination/Patient Safety
(6 measures)
Unknown - 4 of 6 measures
provided by CMS
2 of the 6 are <CMS 30th percentile
Corrective Action Plan (CAP)
Activation since 70% of all
measures in a domain do not score
above minimum attainment level. If
unknown 4 are >30th percentile, then
66.7%.
Preventive Health (8 measures)
None <CMS 30th percentile
At-Risk Populations (12 measures)
None <CMS 30th percentile
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