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Integrated Systems and Payment Models
PEAK Symposium
Connie MarchPresident & CEO, Presence Life ConnectionsMarch 16, 2014Washington, D.C.
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HonestyThe 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.
OnenessThe 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.
PeopleThe 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.
ExcellenceThe Value of Excellence empowers us to always strive for exceptional performance as we work individually and collectively to best serve those in need.
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.
Mission
Va
lue
s
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.
Vision
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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.
PortfolioOperating
ModelFinance
Innovative Care Model
Growth & Integration
Culture Transformation
Presence Health Strategic Plan
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.
Status Quo
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Presence Health is moving toward an integrated operating model
Operating CompanyHolding Company
Holding company
Strategic guidance
Strategic control
Integrated operating company
Fully integrated operating company
• Stand alone functions
• Decisions at ministry level
• Decentralized• Not integrated
• Integrated common functions
• Major decisions made at the System level
• All key capabilities standardized
• Highly integrated • Unified/consistent
brand & experience
• System guidance to ministries
• System input into some operating decisions
• Some standardization
• Little integration
• System directives with some ministry autonomy
• System participates in all major decisions
• Many key processes standardized
• Some integration
• System directed operations
• System makes all operating decisions
• All processes standardized
• Wholly integrated
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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
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Presence Health PartnersInnovative Care Models
Goal: Create integrated network (Presence Health Partners) capable of supporting Presence Health in managing 50% of top-line 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.
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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
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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.
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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 ACOMedicare 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 2PLC 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
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PH Network – Provider Network
Selection Criteria•Historical volumes•Physician preference•Geographic distribution•Engagement in the project•Value added to the network
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Gainsharing OverviewBundled 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
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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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Business model is transitioning from pre-reform…
Pre-Reform Business Model
Hospitals
ddDoctors
ddPatients
Source: Kaufman, Hall & Associates, Inc.
26Source: Kaufman, Hall & Associates, Inc.
The Post Post-Reform Business Model
… to a post-reform business model
Patients
Healthcare Company
Hospital Outpatient ServicesDoctors Continuum
of Care
Content of Care
• Commodity • Make vs. buy • Low-cost provider• Contract to
specifications
Select Contract(?)
Who Is This?
Employers Medicare and Medicaid
Fee-for-Value Model
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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
Commercial ACO/Insurance
Bundled Payment, Model 2
Peri-acute Constellation
Medicaid Managed Care
Medicare Shared Savings Program
Medicaid Assisted Living
Veterans CareHome Bound Elderly-
Targeted At Risk Population Segment
Medical Home
Bundled Payment, Model 3
Narrow Network
Dual Eligible Managed Care
Multiple Opportunities