Building & Executing New Delivery Models Building & Executing New Delivery Models Grassroots Physician Perspective of ACO Transition Philip Gaziano, MD

Building & ExecutingBuilding & Executing

New Delivery ModelsNew Delivery Models

Building & ExecutingBuilding & Executing

New Delivery ModelsNew Delivery Models

Grassroots Physician Perspective of ACO

Transition

Philip Gaziano, MDCEO and Chair of ACA

November 17th, 2013

ACA & QHI IntroductionACA & 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 Healthcare Delivery & Payment Improvements Require: Improvements Require: Care Coordination, Clinical Support,

Admin & Medical Director Support,

& New Data Services & Tools

The Good News Is That: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


Our ACA & QHI GrowthHCPAHCPA

19961996

Total PCPs Served: 7

Total Network Docs: 250

Managed Members: 300

Our Employees: 1

Counties / States: 1 / 1

Care Managed ($Million/yr.): 0.2

ACAACA

20102010

140

2,000

18,000

18

3 / 1

125

JanuaryJanuary

20122012

250

5,000

34,000

50

4 / 1

290

Late inLate in20132013

1,500

>50,000

150,000

>150

30 / 10

$1.5 Billion

We Are Adding Medicare ACO Members in up to 11 States for 2013© 2013 All Rights Reserved

Global Delivery SystemsGlobal Delivery SystemsWe 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


Old HMOs vs. New ACOsOld HMOs vs. New ACOs:


Physician PerspectivesPhysician 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?


Where is Healthcare Waste ?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

Some Global Budget ExamplesSome Global Budget Examples


Healthcare

Spending

($/Year)

%

Possible

Waste

%

Physician

Costs

%

Hospital

Costs

%

SNF

Costs

%

Rx.

Costs

%

Other

Costs

%

Management

Infrastructur

e Costs (Old)

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%

Our Budgetary GoalsOur Budgetary Goals


Healthcare

Spending

($/Year)

%

Possible

Waste

%

Physician

Costs

%

Hospital

Costs

%

SNF

Costs

%

Rx.

Costs

%

Other

Costs

%

Management

Infrastructure

Costs (Old)

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%

Management BudgetsManagement Budgets


Old Style Managed Care (HMO Type):

Newer Delegated Style (as by ACA) (HMO, PPO, ACO…) Managed Care:%

Physician Care Costs

% Physician Management

Costs

% Plan Management

Costs

% ACA Management

Costs

% Total Managemnt

Costs

% Savings

Commercial 22% 1-3% 3-4% 1-2% 5-9% 12%Medicare 14% 1-6% 0-4% 1-6% 2-14% 22%

% Physician

Care Costs

% Physician Management

Costs

% Plan Management

Costs

% ACA Management

Costs

% Total Managemnt

Costs

% Savings

Commercial 20% 0% 8% 0% 8% ?Medicare 11% 0% 15% 0% 15% ?

NewNewPrivate &/OrPrivate &/Or

Hospital BasedHospital Based

Medicare Budget Outcomes:Medicare Budget Outcomes:Medicare Members

Ranked by

% of & Total

Annual Expenses

% of Total Care

Budget Used

$ Million Used

For 6,000 Members

Not

Managed

ACA

Managed

Not

Managed

ACA

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


BCBS-AQC Efficiency BCBS-AQC Efficiency OutcomesOutcomes


AQC AQC Quality Measure Outcomes:Quality Measure Outcomes:


2012 BCBS-AQC PCP Scores for Quality/P4P -vs.- CareScreenTM Office (Not Necessarily the PCP) Use

/100 Members /Year© 2013 All Rights Reserved

Our 4 Year AQC OutcomesOur 4 Year AQC Outcomes

7.9%

5.5%

4 yr. Ave. = below 2% /yr.

& Both Quality and Satisfaction Improved& Both Quality and Satisfaction Improved

= Real Savings2011 & 2012 = 0%


Unique Aspects of ACCSACCSOur National Medicare SSP-

ACO1. 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 BasedCMS 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


Global Delivery Risk ReductionGlobal 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 RiskGlobal Delivery Systems Should Reduce Risk


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 BreakdownA Multi-Specialty Group Breakdown


All Managed FFS-Other Total

PCP No.: M

em

b.

Total Revenue ($/Year)

PCP (hrs) /wk. M

em

b.


PCP (hrs) /wk. M

em

b.


PCP (hrs) /wk.

1 380 $442,793 8.2 1,824 $394,975 33 2,204 $837,768 432 262 $391,947 6.2 1,654 $358,163 30 1,916 $750,110 383 282 $291,894 6.6 1,985 $429,839 36 2,267 $721,733 454 166 $193,629 3.4 1,497 $324,166 27 1,663 $517,795 325 314 $229,893 6.3 1,562 $338,241 28 1,876 $568,134 366 444 $520,919 10.4 1,926 $417,063 35 2,370 $937,982 477 486 $773,490 12.2 1,784 $386,314 32 2,270 $1,159,804 458 475 $716,213 12.5 1,891 $409,484 34 2,366 $1,125,696 489 197 $294,394 5.3 1,300 $281,507 24 1,497 $575,901 3010 440 $612,747 9.9 2,229 $482,675 40 2,669 $1,095,423 5211 226 $195,405 4.5 1,578 $341,706 29 1,804 $537,111 3512 270 $196,497 5.6 1,731 $374,837 31 2,001 $571,334 3913 593 $472,491 11.3 1,456 $315,287 26 2,049 $787,778 4014 297 $344,372 6.3 1,720 $372,455 31 2,017 $716,827 3915 216 $146,556 4.5 1,895 $410,350 34 2,111 $556,905 4116 291 $215,332 5.8 1,562 $338,241 28 1,853 $553,573 36

Total: 5,340 $6,038,573 #### 27,594 $5,975,301 499 32,934 $12,013,874 646Ave: 356 $402,572 7.9 1,840 $398,353 33 2,196 $800,925 41%: 16% 50% 19% 84% 50% 81% 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)

PaymentPaymentConsiderationsConsiderations


Fee For ServiceFee For Service(RVU Based) Payments(RVU Based) Payments


= Volume 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

Capitation Payment Capitation Payment ConsiderationsConsiderations


• 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

Global Payment Global Payment ConsiderationsConsiderations


• 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

QVUsQVUs(Better than RVUs for Global Systems)(Better than RVUs for Global Systems)


QVUs = Quality Value UnitsQVUs = 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

Discussion

Documents

Building & Executing New Delivery Models Building & Executing New Delivery Models Grassroots Physician Perspective of ACO Transition Philip Gaziano, MD