ACO’s – Getting from Here to There
Benefits / Risks / Opportunities
Robert Margolis, M.D.
Chairman & CEO
HealthCare Partners
National Delivery System
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California
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Florida
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HealthCare Partners
LLC
HealthCare Partners
Medical Group
HealthCare Partners
IPA
JSA
Nevada
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Pinnacle Health Care
Systems
Summit Medical Group
Fremont Medical Group
Rainbow Medical Group
In Patient Physician
Network (IPN)
HealthCare Partners
•HealthCare Partners and its physician
networks nationally serve over 1,000,000
patients including over 168,000
Medicare Advantage and over 500,000
commercially insured members primarily
through global capitation.
•
•The pre-eminent physician-owned,
professionally managed, patient-centered
coordinated care system in the nation
and an important delivery system in the
many communities we serve.
Proactive Population
Management
The continuous ‘Virtuous
Cycle’ of Improved care
and outcomes is at the
heart of HCP’s proactive
population management.
Continuous improvement to drive:
•Better Care
•Better Quality
•Better Efficiency
•Better Patient Experience
Target Patient Population
80%
RiskStrat PMPM
Risk Stratification PMPM Costs
81%
82%
83%
$4,500
84%
$4,000
85%
$3,500
86%
87%
$3,000
88%
$2,500
89%
90%
$2,000
91%
$1,500
92%
93%
$1,000
94%
95%
$0
96%
Predicted Cost Percentile
99
%
98
%
97
%
96
%
95
%
94
%
93
%
92
%
91
%
90
%
89
%
88
%
87
%
86
%
85
%
84
%
83
%
82
%
97%
81
%
80
%
$500
98%
99%
Stratifying Patients into the
Appropriate Program
$250 - $260
High
PMPM
Hospice/Palliative Care
Home Care Management
Provides in-home medical and palliative care management by
Specialized Physicians, Nurse Care Managers and Social Workers for
chronically frail seniors that have physical, mental, social and financial
limitations that limits access to outpatient care, forcing unnecessary
utilization of hospitals
Level 4
Home Care
Management
$220 - $200
High Risk Clinics and Care Management
intensive one-on-one physician /nurse patient care and case
management for the highest risk, most complex of the population.
As the risk for hospitalization is reduced, patient is transferred to
Level 2. Physicians and Care Managers are highly trained and
closely Integrated into community resources and Physician
offices or clinics.
Complex Care and Disease Management
Provides long-term whole person care enhancement for the
population using a multidisciplinary team approach.
Diabetes, COPD, CHF, CKD, Depression, Dementia
Self Management, PCP
Provides self-management for people with
chronic disease.
Level 3
High Risk
Clinics
Level 2
Complex Care and Disease
Management
Level 1
Self-Management & Health Education
$ 50 - $100
Programs
Low
PMPM
The HCP Care Team Approach
Interactive and collaborative
teams of clinicians support HCP
clinical programs.
High Risk Programs:
•Home Care
•ESRD
•Comprehensive Care Center
•Post-Acute Comprehensive Care
Disease Management Programs:
•Diabetes
•CAD
•CHF
•COPD
•Dementia
Clinical Data, Clinical Tools
Disease Registries for every HCP physician to better understand the
make up of his or her patient panel
Web-based, Self-Serve, Disease Registries:
• Diabetes
• COPD
• CHF
• CKD
• Dementia
• CAD
• Asthma
• Depression
Outreach / Compliance Opportunities
Custom Registries Based on Specific Interventions
9
Results – Medicare Patients
• Acute Bed Days ~ 1/3 national average
@ 800 days 1K
• Readmission – all cause 30 days ~ ½
national average @ 12% (including
elective readmissions)
• Terminal in hospital care ~ ½
national average @ < 20%
• Quality / HEDIS metrics ≥ national
statistics
• Patient Satisfaction (“very” and
“completely satisfied”) > 90%
CMMI Opportunity
• Embrace Medicare FFS ACO’s
• The Quality Improvement and
Savings Opportunities are
Enormous
• Population Based Payment
Incentives Work!
Clinica Family Health Services
Pete Leibig, CEO
WWW.CLINICA.ORG
Patient Centered Population Health Management
Underserved
population
Continuity
If one thing…
TEAM Based
Way to be
evidenced
based
Care Space
Design
Patient Centered Population Health Management
Group Care
Space
Design
Alternative
Visits
• Lower A1c
• Lower LBW
• Higher
Satisfaction
Advanced
Access
Information Systems
Partnering
Community
Health
Record
EHR
Templates
Evidence
based
Registries
Outcome
Reports
Self Management - Patient Activation
Pregnancy Outcomes
40.0%
USA
Colorado
30.0%
Clinica
Centering
20.0%
10.0%
0.0%
C Section Rates
Low Birth Weight
Preterm
CMMI Help!
www.clinica.org
• Colorado cutting Clinica’s FQHC
payments as a way to reduce Medicaid
expenses. DRAT!!!
– Quality up – outcomes improving
– Compensation down $3 million (23%)
– HRSA wants more users at same cost to
them – 22% of total
• Need demonstration of FQHC QI
Investment payoff to 3rd parties
• Share FQHC savings impact with
Governors and Medicaid Directors in a
meaningful way –they are trying to
save money by cutting what we’re paid.