Grassroots Physician
Perspective of ACO Transition
Building & Executing
New Delivery Models
Philip Gaziano, MD
CEO and Chair of ACA
November 17th, 2013
ACA & QHI Introduction
• Accountable Care Associates, LLC (ACA):
•
Founded in 2010, it is physician owned and operated, and a provider MCO to support and partner with
physicians and hospitals in managed healthcare delivery.
•
Philip Gaziano, M.D. is Chairman and CEO, and he helped develop some of ACA’s services from 1998 to
2010 in Hampden County Physicians Associates, a Massachusetts based multi-specialty physician
practice now served by ACA .
•
ACA Provides: Contracting, Consulting, Care Coordination, Reinsurance, Coding, Clinical Rounding,
Provider Educational, Chart Auditing, Risk Adjustment, Compliance, Quality Measures Management,
Custom Work Flow Design, and Other Provider MSO Services for Managed Healthcare Delivery.
• Quality Health Ideas, LLC (QHI):
•
Founded in 2003, it is an IT and Data Management Company, that is physician owned and operated by
Philip Gaziano, M.D. and Felicitas Thurmayr, M.D. Ph.D.
•
QHI Builds and Provides: Data Management, Quality Registry, Decision Support, EMR/EHR Integration,
HIE Integration, and Web Integration Tools and Services.
Healthcare Delivery & Payment
Improvements Require:
Care Coordination, Clinical Support,
Admin & Medical Director Support,
& New Data Services & Tools
The Good News Is That:
Costly, Slow, Data or Corporate Integrations
Are Not Necessary
© 2013 All Rights Reserved
About, Our Network, Integration,
& Provider Diversity
In 7 States (soon to be 10 to 11) We are Now Serving:
1,500 PCPs & over 50,000 Network Specialists
Connected to 37 Hospitals (17 Hospitals = Partners)
50% of PCPs are in practice groups of 1, 2, or 3
20% of PCPs are still use paper charts
29 different PCP EMRs – that do not share data
Hospitals have different EHRs, not connected to PCPs
Integrated – Only By Our Web Tools
© 2013 All Rights Reserved
Our ACA & QHI Growth
HCPA
ACA
January
Late in
1996
2010
2012
2013
Total PCPs Served:
7
140
250
1,500
Total Network Docs:
250
2,000
5,000
>50,000
Managed Members:
300
18,000
34,000
150,000
1
18
50
>150
Counties / States:
1/1
3/1
4/1
30 / 10
Care Managed ($Million/yr.):
0.2
125
290
$1.5 Billion
Our Employees:
We Are Adding Medicare ACO Members in up to 11 States for 2013
© 2013 All Rights Reserved
Global Delivery Systems
We Have or are Developing Services For:
• Medicare Advantage (Including SNP)
• Medicare ACOs (Pioneer & Shared Savings)
• Managed Medicaid
• Dual Eligible (Medicare + Medicaid: SCO, PACE…)
• Commercial Plans (HMO & PPO)(Like BCBS-AQC)
• State ACOs, Exchanges, Coops, and Pilots
• Captives & Self Insured
© 2013 All Rights Reserved
Old HMOs vs. New ACOs:
© 2013 All Rights Reserved
Physician Perspectives

Change is hard (usually only done if no other option)

Choices: Independence vs. Practice Aggregation
“One size doesn’t fit all” & “Timing is Everything”*

Satisfaction from: quality, control, & compensation

Risks (financial & legal) must be low

Changes require new data, but (too much data –
or confusing & wrong data is worse)

Improved providers’ work flows are needed
(wrong tools can: reduce efficiency & increase risk)

Needed guidance, & support…
…whom to call & with whom to partner?
© 2013 All Rights Reserved
Where is Healthcare Waste ?
1. Repeated Testing
2. Unmanaged Pharmacy
3. Reduced Prevention
4. Unmanaged Chronic Diseases
5. Some Post Acute Discharge Expenses
6. Member Psychosocial Needs
© 2013 All Rights Reserved
Some Global Budget Examples
Healthcare
%
%
%
Spending Possible Physician Hospital
%
%
%
SNF
Rx.
Other
%
Management
Infrastructure
($/Year)
Waste
Costs
Costs
Costs
Costs
Costs
Commercial $6,000
15+%
20%
22%
5%
23%
22%
8%
Medicaid $8,000
20+%
15%
30%
8%
15%
23%
10%
Medicare $11,000
30+%
11%
30%
11%
12%
24%
15%
© 2013 All Rights Reserved
Costs (Old)
Our Budgetary Goals
Healthcare
%
%
%
Spending Possible Physician Hospital
%
%
%
SNF
Rx.
Other
Management
Infrastructure
($/Year)
Waste
Costs
Costs
Costs
Commercial
$6,000
15+%
20%
22%
5%
23%
22%
8%
Medicaid
$8,000
20+%
15%
30%
8%
15%
23%
10%
Medicare
$11,000
30+%
11%
30%
11%
12%
24%
15%
© 2013 All Rights Reserved
Costs Costs
%
Costs (Old)
Management Budgets
Old Style Managed Care (HMO Type):
%
Physician
Care Costs
Commercial
Medicare
20%
11%
% Physician
Management
Costs
0%
0%
% Plan
Management
Costs
8%
15%
% ACA
Management
Costs
0%
0%
% Total
Managemnt
Costs
8%
15%
%
Savings
?
?
Newer Delegated Style (as by ACA) (HMO, PPO, ACO…) Managed Care:
%
Physician
Care Costs
Commercial
Medicare
22%
14%
% Physician
Management
Costs
1-3%
1-6%
New
Private &/Or
Hospital Based
© 2013 All Rights Reserved
% Plan
Management
Costs
3-4%
0-4%
% ACA
Management
Costs
1-2%
1-6%
% Total
Managemnt
Costs
5-9%
2-14%
%
Savings
12%
22%
Medicare Budget Outcomes:
Medicare Members
% of Total Care
$ Million Used
Ranked by
Budget Used
For 6,000 Members
% of & Total
Not
ACA
Not
ACA
Annual Expenses
Managed
Managed
Managed
Managed
Top 3%
50%
42%
30.0
20.2
Next 17%
30%
43%
18.0
16.3
Next 30%
10%
12%
6.0
5.8
Lower 50%
10%
12%
6.0
5.8
Total:
100%
100%
60.0
48.0
© 2013 All Rights Reserved
BCBS-AQC Efficiency Outcomes
© 2013 All Rights Reserved
AQC Quality Measure Outcomes:
2012 BCBS-AQC PCP Scores for Quality/P4P -vs.CareScreenTM Office (Not Necessarily the PCP) Use
/100 Members /Year
2012 All
Reserved
© 2013
AllRights
Rights
Reserved
Our 4 Year AQC Outcomes
7.9%
5.5%
4 yr. Ave. = below 2% /yr.
2011 & 2012 = 0%
= Real Savings
& Both Quality and Satisfaction Improved
© 2013 All Rights Reserved
Unique Aspects of ACCS
Our National Medicare SSP-ACO
1. Does Not Require Practice Integration
2. ACA Centralized Data and Compliance
3. Local Clinical Control & Branding
4. Proven Care & Quality Coordination
5. Proven Provider Education, Audits, & Feedback
6. No Initial Costs For Local Group
7. Free Data Tools + Clinical Support
8. New QVU Payment system available
© 2013 All Rights Reserved
Our QVU Based
CMS Innovation Center Grant
1. Based on our new QVU Payment Data
2. Medicare, Medicaid, Dual Eligible, & Chip
3. Commercial Too – We Have 6 Partners
4. Added Information Sharing
5. A Model for the Future
© 2013 All Rights Reserved
Global Delivery Risk Reduction
• Best practice activities increased
• Test tracking = better than EMR alone
• Malpractice cases are reduced
• Malpractice premiums decreased
• Satisfaction improved for all
• Practitioner work flow redesigns help
Global Delivery Systems Should Reduce Risk
© 2013 All Rights Reserved
Overall Quality Measures:
(Medicare, Medicaid, & Commercial)
• All measures improved
• All practitioners improved
• Practice & provider cultures are changing
• Members noticed and satisfaction is up
• The health plans and employers noticed
• Our MA Plans Ranked #2 & #4 in US
A Multi-Specialty Group Breakdown
Total
Revenue
($/Year)
/wk.
380
262
282
166
314
444
486
475
197
440
226
270
593
297
216
291
5,340
356
16%
$442,793
$391,947
$291,894
$193,629
$229,893
$520,919
$773,490
$716,213
$294,394
$612,747
$195,405
$196,497
$472,491
$344,372
$146,556
$215,332
$6,038,573
$402,572
50%
8.2
6.2
6.6
3.4
6.3
10.4
12.2
12.5
5.3
9.9
4.5
5.6
11.3
6.3
4.5
5.8
####
7.9
19%
PCP
(hrs)
Memb.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Total:
Ave:
%:
Memb.
PCP
No.:
1,824
1,654
1,985
1,497
1,562
1,926
1,784
1,891
1,300
2,229
1,578
1,731
1,456
1,720
1,895
1,562
27,594
1,840
84%
Total
Revenue
($/Year)
Total
PCP
(hrs)
/wk.
$394,975 33
$358,163 30
$429,839 36
$324,166 27
$338,241 28
$417,063 35
$386,314 32
$409,484 34
$281,507 24
$482,675 40
$341,706 29
$374,837 31
$315,287 26
$372,455 31
$410,350 34
$338,241 28
$5,975,301 499
$398,353 33
50%
81%
Memb.
FFS-Other
All Managed
Total
Revenue
($/Year)
$837,768
$750,110
2,267
$721,733
1,663
$517,795
1,876
$568,134
2,370
$937,982
2,270
$1,159,804
2,366
$1,125,696
1,497
$575,901
2,669
$1,095,423
1,804
$537,111
2,001
$571,334
2,049
$787,778
2,017
$716,827
2,111
$556,905
1,853
$553,573
32,934 $12,013,874
2,196
$800,925
2,204
1,916
PCP
(hrs)
/wk.
43
38
45
32
36
47
45
48
30
52
35
39
40
39
41
36
646
41
100%
16% of Members are in global managed care contracts,
And they require 19% of the PCPs’ time (about 5 to 10 extra min. /visit)
 Contributes 50% of practice revenues (for RVUs, QVUs, & management)
© 2013 All Rights Reserved
Payment
Considerations
© 2013 All Rights Reserved
Fee For Service
(RVU Based) Payments
= Volume Payments
• Do not account for quality differences
• Do not reward prevention
• Do nor reward efficiency (savings)
• Do not reward Care Coordination
• May Reward adverse effects and bad outcomes
© 2013 All Rights Reserved
Capitation Payment
Considerations
• May account for quality differences
• Rewards prevention better
• May reward efficiency (savings)
• May reward Care Coordination
• May change who sees the beneficiary
• May be interoperated as an entitlement
© 2013 All Rights Reserved
Global Payment
Considerations
• Accounts for and rewards quality
• Rewards prevention best
(and promotes wellness)
• Rewards efficiency (and gives savings)
• Rewards Care Coordination
• Produces the greatest innovation
• The way of the future
© 2013 All Rights Reserved
QVUs
(Better than RVUs for Global Systems)
QVUs = Quality Value Units
• Designed by ACA & QHI for Payments
• Tracked and Reported Real Time
• Attributed QVUs Have Predictive Value
• Provide Quality Tracking
• Provide Budget Tracking
© 2013 All Rights Reserved
Discussion