PEAK Symposium
Integrated Systems and Payment
Models
Connie March
President & CEO, Presence Life Connections
March 16, 2014
Washington, D.C.
Vision
Inspired by the healing ministry of Jesus
Christ, we, Presence Health, a Catholic
health system, provide compassionate,
holistic care with a spirit of healing and
hope in the communities we serve.
We will be a leader in transforming
health care by delivering clinical
excellence, outstanding value and
exceptional experience to achieve better
health for our communities.
Values
Mission
Honesty
Oneness
People
Excellence
The Value of
Honesty instills in
us the courage to
always speak the
truth, to act in
ways consistent
with our Mission
and Values, and
to choose to the
right thing.
The Value of
Oneness inspires
us to recognize
that we are
interdependent,
interrelated and
interconnected
with each other
and all those we
are called to serve.
The Value of People
encourages us to
honor the diversity
and dignity of each
individual as a
person created and
loved by God,
bestowed with
unique and personal
gifts and blessings,
and an inherently
sacred and valuable
member of the
community.
The Value of
Excellence
empowers us to
always strive for
exceptional
performance as we
work individually
and collectively to
best serve those in
need.
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Presence Health: At a glance
Midwest Regional Catholic-sponsored Healthcare System
Acute care hospitals
Long-term acute care
hospital
Nursing & rehab centers
Senior housing communities
Adult day centers
Primary & specialty care
clinics
Home care agencies
Comprehensive behavioral
health network
Occupational health
Immediate care centers
Outpatient surgery centers
Employed physician network
Hospice agencies
Medical residency programs
Clinical pastoral education
program
School of radiology
University (nursing/nurse
practitioners/health
informatics)
3
Presence Life Connections: At a glance
. A division of Presence Health that provides a peri-acute constellation of
care, support and services that enhances lives by connecting the right person
to the right service at the right time.
Primarily serve older adults
Provide services/support to
6,000 people daily
172,000 annual home health
visits last year
1.9 million residents days in
our nursing & rehab centers
and housing communities last
year
1,800 Lifeline customers
3,600+ employees
Provide management services
50 sites in Illinois and Indiana,
including:
20 nursing and rehabilitation
centers
14 senior housing communities
6 home care agencies
3 hospice agencies
2 adult day centers
1 child day center (part of
intergenerational center)
Misc. HCBS
2 centralized LTC pharmacies
4
Peri-acute Constellation
Vision:
We will be a leader in transforming health care by delivering clinical excellence, outstanding
value and exceptional experience to achieve better health for our communities.
Growth &
Integration
Finance
Portfolio
Innovative
Care Model
Culture
Transformation
Presence Health
Strategic Plan
Status
Quo
Presence Health is moving toward an integrated operating
model
Holding
company
• Stand alone
functions
• Decisions at
ministry level
• Decentralized
• Not integrated
Holding Company
Strategic
guidance
• System guidance
to ministries
• System input into
some operating
decisions
• Some
standardization
• Little integration
Strategic
control
• System directives
with some ministry
autonomy
• System
participates in all
major decisions
• Many key
processes
standardized
• Some integration
Integrated
operating
company
Fully
integrated
operating
company
• Integrated
• System directed
common
operations
functions
• System makes all
• Major decisions
operating
made at the
decisions
System level
• All processes
• All key
standardized
capabilities
standardized
• Wholly integrated
• Highly integrated
• Unified/consistent
brand &
experience
Operating Company
7
Culture Transformation: Core Competencies
that Support Population Health Management
 A culture that can embrace change
 A clinical delivery system that has care coordination at
its center
 A very sophisticated information technology platform
 A cost structure that can cope with an unpredictable
revenue platform
 Capability to take risk all the way to full capitation
 A physician alignment strategy that supports all of the
above
A Very Demanding Going-Forward Agenda
Reference: Kaufman Hall
8
9
Presence Health Partners
Innovative Care Models
Goal: Create integrated network (Presence Health Partners)
capable of supporting Presence Health in managing 50% of topline revenue from value-based contracts in 2017
Requires Presence Health to enroll 520,000 covered lives by
2017
Assumes 50% of Presence Health’s current Medicare, Medicaid
and commercially insured patients will be seen through some
form of value-based payment
– ACO, ACE, capitation, % of premium, etc.
10
Presence Health CMS Innovative Care Model Pilots
• Medicare Shared Savings Program
• Bundled Payment for Care Improvement, Models 2 & 3
Presence Health has two internal shared risk care models and one
external risk care models
– Medicare Shared Savings Program (MSSP)
– Bundled Payment for Care Improvement (BPCI), Model 2
– Bundled Payment for Care Improvement (BPCI), Model 3
Presence is participating in these projects to develop the capabilities to
manage the health of populations and assume risk for the outcomes:
– Quality, Cost and Patient Experience
Presence believes that developing expertise in this arena is a critical
strategy and will position the organization and our partners for success
in the evolving healthcare environment
11
Recent National Reports Indicate Some Medicare Shared
Savings Program (MSSP) ACOs will be Successful
There are 400 CMS MSSP and Pioneer ACOs in operation today
50% have generated savings
15% have generated sufficient savings to distribute shared savings to
network participants.
12
Presence Health’s Accountable Care Organization (ACO)
Medicare Shared Savings Program (MSSP)
Presence is:
– Serving as an accountable care organization
– Taking risk on overall health cost and outcomes for Medicare
population
Medicare Value Partners (PH) ACO began operations January
1, 2013
Medicare Shared Savings Program
20,000 beneficiaries attributed to ACO
94% of beneficiaries in Cook County (Chicago)
400 providers in two Presence Health acute care Chicago
regions
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Presence Health’s ACO
Medicare Value Partners: PLC Participation
ACO Board Membership
Participation in service development
Participating PLC providers within ACO Geographic Area
– Nursing Facilities
– Home Care
– Exploring HCBS participation
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Bundled Payment for Care Improvement, Model 2
Presence Health is:
Serving as awardee convener
Taking risk on outcomes and cost for Medicare total hip and
knee replacement episodes of care 3 days pre-op through 90
days post acute
Three year pilot; start date January 1, 2014
Rewards performance – Fee for Value vs Fee for Service
Providers may assume risk
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Bundled Payment, Model 2
PLC Participation
Care design teams
PLC providers within BPCI Geographic Area
– Nursing and Rehab Centers
– Home Care
Assuming risk for quality and cost outcomes for hip and knee
replacement for PLC post-acute care for 90 days
Gainsharing participant
16
BPCI Overview
Care Model Redesign and Support
17
PH Network – Provider Network
Selection Criteria
• Historical volumes
• Physician preference
• Geographic distribution
• Engagement in the project
• Value added to the network
18
Gainsharing Overview
Bundled Payment for Care Improvement, Model 2
To encourage innovation, CMS and the Office of the Inspector
General (OIG) are waiving rules that prohibit gainsharing
Providers have flexibility in determining how savings will be
distributed among participating providers
CMS will reconcile Presence performance against a Target
Price, which is the historical payments per episode trended
forward to 2013 and then discounted by pre-determined
percentage
CMS savings (CMS payment reductions) may be shared among
the participating providers
Presence has a Gainsharing Committee that oversees the
gainsharing accounting and fund distributions
19
Bundled Payment for Care Improvement, Model 3
Awardee convener is Illinois Bone and Joint Institute (IBJI)
Taking risk on outcomes and cost for Medicare total hip and
knee replacement post-acute care for 90 days
Northern Chicago area market
Three year pilot
Start date: January 1, 2014
Providers may assume risk
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Bundled Payment for Care Improvement, Model 3
Presence Life Connections is:
Post-acute provider
Assuming risk for outcomes and cost for Medicare hip and knee
replacement for PLC site post-acute care within 90 days
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PLC Participation in Non-Presence Medicare ACOs
Service Providers
– Selected Nursing and Rehab Centers within Geographic market
– Selection Criteria Varies
•
•
•
•
•
Typically 4 or 5 star CMS overall rating, may specify quality star rating
Low hospital readmission rate
Short post acute length of stay
Preferred referral services within ACO system services
Physician and/or patient preferences
Program designed by ACO, typically with little or no post acute
provider input
Requires quality data submission to ACO
Participation at discretion of ACO
Fee for service
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Presence Innovative Care Model Outcomes
Medicare Shared Savings Program-Presence Health ACO
– Quality data submission end of March
• Must attain quality metric targets to access shared savings
– Initial cost data promising but too early for final determination
– Reviewing placement criteria based on early data analysis
– Learning importance of physician & provider collaborations
BPCI, Model 2 and Model 3
– Initiated January 1, 2014
– Too early for meaningful outcomes data
– Learning importance of clear communication as model is refined
Medicare Shared Savings Program-Non-Presence ACO
– Insight into ACO metrics prior to PH ACO started
– Hospital readmissions, Emergency Dept. visits reduced
– Progressive shortening of post acute patient lengths of stay
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Challenges with Innovative Models
Communication
– Identification of participating
patients
– Hand offs from provider to
provider
– Key software, hardware,
interface installation and
implementation
Multiple pilots at same
provider locations
concurrently
– Patient/pilot identification and
differentiation
– Patient, staff, physician,
community education &
awareness for each pilot
Data
– Access to pilot and site specific
data
– Timely receipt and submission
of data
Risk assumption
– Financial uncertainty—budget
vs actual—retrospective review
– Quality metrics
– Requires new skills, software,
processes
Culture change: New models
concurrent with old models of
care
Change management
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Business model is transitioning from pre-reform…
Pre-Reform Business
Model
Hospitals
d
Doctors
d
Patients
Source: Kaufman, Hall & Associates, Inc.
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… to a post-reform business model
The Post Post-Reform Business Model
Employers
Medicare and
Medicaid
Patients
Fee-for-Value
Model
Select
Contract(?)
Who Is
This?
Healthcare Company
Content of Care
Hospital
Doctors
Outpatient
Services
Continuum
of Care
•
•
•
•
Commodity
Make vs. buy
Low-cost provider
Contract to specifications
Source: Kaufman, Hall & Associates, Inc.
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Opportunities—Value-based Care
Peri-acute Providers
Determine your path
Make the tough decisions and start now
Drive down per unit costs
Use evidence to demonstrate value to partners
Ability to assume care for higher acuity and/or specialty
population care
Care management
Good quality outcomes
High participant satisfaction
Market your value
Fill the care/service gaps
Be open to new opportunities
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Medicare Shared
Savings Program
Multiple Opportunities
Medicaid Managed
Care
Bundled Payment, Model 3
Commercial
ACO/Insurance
Home Bound ElderlyTargeted At Risk
Population Segment
Veterans Care
Medicaid Assisted Living
Peri-acute
Constellation
Bundled
Payment, Model 2
Medical Home
Narrow Network
Dual Eligible
Managed Care