Advocate Good Shepherd
Physician Partners
April 23, 2012
ANNUAL MEETING
Agenda
6:00 PM
6:05 PM
6:10 PM
6:15 PM
6:45 PM
PHO President Remarks
Hospital President Remarks
Election
AdvocateCare Update
Check Distribution
PHO Highlights
Dick McDonough, MD
President, AGSPP
3
APP Organizational Chart with
AGSPP Representatives
APP Board of Directors
Lee Sacks, MD, Chief Executive
Officer
Robert Zimmanck, MD, Chairman
Jane Dillon, MD, Vice Chairman
Mark Gross, MD, Member At
Large
Consolidated Finance
Committee
J. Dean Feldman, MD
4
Utilization
Management
Committee
Debra O’Connor, MD
Quality Improvement &
Patient Safety
Committee
Dick McDonough, MD
Pharmacy &
Therapeutics
Committee
Clinical Integration
Measures Committee
Credentialing &
Peer Review
Committee
Michael Fell, DO
PHO Board Composition
Physician
Directors
Hospital
Directors
Dick McDonough, MD, President
J. Dean Feldman, MD, Secretary
Fred Locher, MD
Michelle Roig, MD
Don Calcagno
Karen Lambert
Barry Rosen, MD
George Teufel, Treasurer
Non-Voting Representatives
Debra O’Connor, MD, Medical Director
Annual Election
• 2 year Term expiring 2014
– J. Dean Feldman, MD
– Michelle Roig, MD
• 1 year Term expiring 2013
– Mark Gross, MD
6
Good Shepherd
Hospital Update
Karen Lambert, President
Becoming a Population
Health Management
Enterprise
Scott Kent
VP, Field Operations, APP
Accountable Care
Is Here to Stay
Costs By Age Categories
Heathcare Costs by Age
U.S. is spending much
more for older population
$45,000
$40,000
Annual per capita healthcare costs
UK
$35,000
Germany
Sweden
$30,000
US
Spain
$25,000
$20,000
$15,000
$10,000
$5,000
$0
10
20
30
40
50
60
70
Age
Source: Fischbeck, Paul. “US-Eruope Comparisons of Health Risk for Specific Gender-Age Groups” Carnegie Mellon University; September, 2009.
10
80
90
Two Years Ago …
• Blue Cross & Advocate/APP Faced 2 Choices:
– Lower Unit Cost Now
– Partner Together/Reduce Waste
• Employers Demanding Change Even If Reform
Overturned
– “Unstoppable Market Force Unleashed”
• Prepares Us for ACOs in 2012
• First Mover Advantage
• Better Patient Care  Fulfills 2020 Vision
11
What Results Have We Seen?
• 4.2 % HMO Membership Growth in Last Year
– Added Blue Advantage HMO in 2011
• APP Physician Membership Growth
– 208 Total; 37 PCPs
• Blue Cross PPO Shared Savings Trends Are
4.6% Positive Thru Q3 2011
• $13 M Shared Savings in 2011 Payout
• $6.4 M HMO Full Risk Earned Funds in 2011
Payout
12
APP’s New
Approaches to
Medicare
Planned Participation in 2 Models
• Medicare Shared Savings Program (MSSP)
– Program for Accountable Care Organizations
(ACOs) Established in Health Reform Act
– Start Date: July 1, 2012
• Medicare Advantage HMO
– New Opportunity with Blue Cross
– Targeting “Age In” Population
– Start Date: January 1, 2013
14
What Is the
Medicare Shared
Savings Program?
What MSSP Isn’t . . .
• MSSP Is Not a Bundled Payment Program
• MSSP Is Not a Capitated Payment Program
• All Physicians and Hospitals Continue To
Submit Fee-for-Service Bills To Medicare
• All Physicians and Hospitals Continue To Be
Paid by Medicare Using the Medicare Fee
Schedule
– None of the FFS Payments Are Sent To APP
16
APP’s MSSP Details
• 3½ Year Contract Starting July 1, 2012
• No Downside (Repayment) Risk
• Up to 50% Share of Savings Based on
Quality Score
– 33 Quality Measures in 4 Domains
– Pay-for-Performance Phased in Over 3 Years
• 125,000 Medicare Beneficiaries
• $1.5 Billion Annual Medical Expenses
• Estimated 50% of Spend “In Network”
17
Why Participate in MSSP?
• Better Overall Care for Patients
• Aligns with Advocate 2020 Strategy and
Vision to Develop Lifelong Relationships
with Patients
• Extension of Clinical Integration Program
• Helps Transition to One Model of Care
– Gets Us to Critical Mass
– Prepares Us for Emerging Opportunities
18
What’s In It For Physicians?
• Improved Coordination of Care Benefits Your
Patients
• A Percentage Point Improvement In Total
Cost Will Increase APP Incentive Pool by
About $6 Million
– 1% of $1.5 Billion Annual Spend on 125,000
Medicare Beneficiaries Is $15 Million
– APP Receives 50% of Savings Multiplied by
Quality Score
– $6 Million If Quality Score Averages 80%
19
Blue Cross
Medicare Advantage
Contract
Medicare Advantage Opportunity
• Blue Cross Planning Medicare Advantage
• BC Has Large Share of Medicare Supplement
Market
• Targeting Younger Medicare Population (~66)
– Interest In Capturing “Age In” Market
• BC Application Submitted to CMS In February
• Required Binding Commitment of Provider
Network
• APP Would Be Central to Network, But Others
Necessary to Satisfy CMS’ Geo Access
Requirements
21
APP Board Approved Blue Cross
Medicare Advantage
• Start Date of January 1, 2013
• Global Risk Arrangement
• Responsibilities Delegated to APP
– Utilization Management
– Credentialing
– Part B Claims Payment
• Counties Included: Cook, DuPage, Kane &
Will
• Counties Excluded: Lake, Kendall, McHenry,
McLean
22
In-Network Care
Coordination
Why Is “In-Network Care” Important?
Keeping Care in APP
Network Is Good for
Patients, Good For Doctors
& Good for Advocate
24
Good for Patients…
Care Managers Assist Patients
• Outpatient CM for Complex Patients
• Inpatient CM for All Hospitalized Patients
• Transition Coaches After Discharge to
Assure Follow Up with Physicians & Avoid
Readmissions
25
Good for Quality Improvement
• Internal Transparency of APP Allows Doctors
to Share Performance with Colleagues
• Which Can Lead to:
– Mutual Efforts to Improve Performance
– Opportunities to Change Referral Patterns Based
on Data, Not Hunch
• Clinical & Patient Experience Data Is Not
Available from “Out-of-Network” Providers
26
Good for Financial Performance
• Contracts Represent Over 60% of All Physician
Billings BCBS PPO, BCBS HMO, MSSP & MA
• Admissions and ER Visits Outside of Advocate
Lead to Uncontrolled Care & Expenditures
• Physician Care Outside of APP Leads to
Uncontrolled and, Often, Undocumented Care,
Testing & Expenditures
• Out-of-Network Care Compromises Patient Care
& Reduces Shared Savings
27
In-Network Care Incentives
• Counseling Patients About In Network Care
Takes Physician Time
• 2 New Incentives and 1 Established Incentive
Encourage In Network Care
1. % of Hospital Days In-Network
2. SCIP Performance and Increase of In-Network
Inpatient Surgical Cases
• Current: Inpatient Performance Incentive
28
Improvement from Baseline in the
Percentage of In-Network Acute Care
• Includes All Non-Hospital Based Physicians
• Attributed APP PPO Patients Measured
• Weighted at 5% of the Total CI Score
• Tiered Points Allotted:
6% Improvement Over Baseline (Top Tier)
4% Improvement Over Baseline (Mid Tier)
2% Improvement Over Baseline (Lower Tier)
Increase in In-Network Inpatient
Surgical Care If SCIP Achieved
• SCIP Performance Targets Must Be Achieved
• Measures % Improvement Over Baseline in Inpatient
Surgical Cases
• Eligible Specialties: Cardiovascular, Thoracic, Vascular,
Colorectal, General Surgery, Orthopedics, and OB/Gyn
• Weighted at 5% of the Total CI Score
• Tiered Point Allocation:
– 6% Improvement Over Baseline (Top Tier)
– 4% Improvement Over Baseline (Mid-Tier)
– 2% Improvement Over Baseline (Lower Tier)
Inpatient Performance
Incentive Fund
• Applies to All Doctors with Admissions
• Performance Based on LOS and
Readmissions
• Payment Based on Performance Level for
Practice Group and Volume of Admissions for
Individual Physician
• Earnings Up to $120 per Admission
• 3 Earnings Tiers for 2012
31
What Do You
Need to Do?
What Should Physicians Do?
• Sign New Physician Participation Agreement
• Sign New Business Associate Agreement
• Work with APP to Collect Names &
Addresses of Medicare Beneficiaries
• Work with APP To Facilitate Medicare Claims
Data Sharing:
– APP Required To Send Patient Letter Allowing
Them Not To Share Medicare Claims Data
– APP Would Like Patients To Allow Data Sharing
To Assist in Improving Patient Care
33
Focus on AdvocateCare
AdvocateCare Index
• ED Visits/1000
• Admits/1000
• Length of Stay
• 30-Day Readmissions
• % Days In-Network
34
SynAPPs Update
PCPs Live on SynAPPs by PHO as of 3/31/12
n = 161
45
42
40
40
35
30
23
22
25
20
15
13
15
10
4
2
5
0
Christ
Condell
Good
Samaritan
Good
Shepherd
Illinois
Masonic
Lutheran
General
South
Suburban
Trinity
Specialists Live on SynAPPs as of 3/31/12
(Excluding PCPs and Pediatricians)
n=188
Physician Count
44
24
24
17
15
10
9
10
9
7
5
3
1
2
2
2
Specialty
3
1
Benefits of SynAPPs
• Selected by APP Physician Task Force
• SynAPPs Program Benefits Based on 4 Criteria:
– InterOperability:
• Fully Integrated System (PM, EMR, Patient Portal, P2P, MAQ
Dashboard, Lab, CIRRIS, and CareConnection Interfaces)
– Cost:
• Lowest Cost of Full Spectrum EMR’s
– Pace of Roll-Out:
• Scalable Database to 3,000 Physicians
– Functionality:
• Ease of Interfacing and Inclusion in CareNet Plus
• Ongoing Support from SynAPPs Team
• Robust Physician and Non-Physician User Groups Across APP
• Proven Track Recording Helping APP Physicians Achieve MU
Meaningful Use
– 94 APP SynAPPs Physicians Have Achieved
Medicare Meaningful Use
• Anticipated Medicare MU Incentive Dollars
$1,692,000
– 7 APP SynAPPs Physicians Have Achieved
Medicaid Meaningful Use
• Anticipated Medicaid MU Incentive Dollars
$99,000
– Total Anticipated Meaningful Use Incentive
Dollars to APP SynAPPs Physicians $1,791,000
39
Lake Cook Orthopedic
Associates
•
“The organization and support from the
dedicated APP teams has made the
transition to SynAPPs much more
manageable than we had feared.
People like Renee Witthoff have been
invaluable in organizing our training,
looking out for our best interests in
dealing with any problems as they
occurred. From initial introductions to
the software, hardware upgrading,
training and implementation, and now
meaningful use, the experience and
help of the various SynAPPs teams has
been of great help during this process.”
~ Dr. Frederick Locher
40
New APP Membership Criteria
• SynAPPs Required for PCPs Not Currently on an
EMR by January 1, 2014
• New Physicians Joining APP on an EMR NOT
Meeting Highest Current Stage of Meaningful Use
Criteria Must Adopt SynAPPs within 12 Months
• Once Stage 2 Meaningful Use Criteria Finalized, Any
Physician NOT on EMR Certified for Stage 2 Will
Need to Convert to SynAPPs within 12 Months
Incentive Distribution
Model
New PCP Reimbursement
• PCP Cap Changing to FFS on July 1st, 2012
• Paid at 110% of Medicare
• Services Rendered to HMOI, Blue Advantage
and Humana HMO Patients
• Final Monthly Capitation Payments for Paid
by July 15th, 2012
43
2011 CI Year-End Results
100
95
90
85
80
75
70
65
60
55
50
44
88.97 89.11
84.74
75.84
79.22
Final Results: Post Reconsideration Process
84.67 84.47
79.93
79.5
Single Fund, Single Distribution
• “One Program, One Set of Measures, One
Set of Incentives”
• Integration of HMO Surpluses, CI Funds &
Shared Savings Dollars Into One Fund
• Creation of Value Pool Concept
• Increased Weighting On, and Eligibility for,
Work Pool
• Must Achieve Minimum Score of 65% for
Payout
45
Single Incentive Fund Payout
Professional
HMO
Surplus
$28.4 M
Facility
HMO
Surplus
$6.4 M
CI Funding
$65.2 M
Minus Infrastructure Costs, Deficits and 120%
Fee Schedule
$19.5 M
Physician
46
AdvocateCare
Shared
Savings
$13.0 M
Advocate Physician Partners
Combined Incentive Fund Distribution History
2007-2011
($ in millions)
$120.0
$5.2
$100.0
$5.0
$80.0
$60.0
$4.8
$101.4
$80.0
$56.0
Unearned
Earned
$4.0
$40.0
$20.0
$12.9
$91.6
$63.9
$0.0
2007
47
2008
2009
2010
2011
Advocate Good Shepherd Physician Partners
Physician Incentive Fund Distribution History
2007-2011
($ in millions)
$14.0
$12.0
$1.0
$10.0
$1.5
$0.8
$8.0
$6.0
$0.9
$0.7
$8.8
$4.0
$2.0
Unearned
Earned
$5.3
$10.4
$10.5
2010
2011
$6.3
$0.0
2007
48
2008
2009
Questions &
Answers
Check Distribution
Birdie Chow, PHO Director
50
Amount Paid
to 120% of MC
CI Earned &
Unearned
Registry Work
Incentive
Value Pool - PCPs
Inpatient
Incentive Earned
& Unearned
TOTAL Earned
& Unearned
51
Logistics for Check Distribution
• PHO Member by July 1, 2011 to be Eligible for Clinical
Integration Distribution
• Meadow Room
• Checks Distributed by Name:
– Last Name if You Are a Solo Practitioner
– Group Name if You Are in a Group Practice
• Please Designate 1 Person per Group to Obtain Checks
52