Using Technology to Drive CIN Performancenchica.org/wp-content/uploads/2016/08/hamburger.pdf · •Payer wants $ reduction. Why a CIN? •Increase quality/efficiency •Decreased

August 29, 2016

Using Technology to Drive CIN Performance

Sheldon Hamburger

CINs/ACOs Driving VB Care

By 2015, an estimated 715 CIN/ACOs, 424 of whom are in the MSSP, will manage ~25-30Mcovered lives across the country.

• Source: Leavitt Partners Center for Accountable Care Intelligence; Becker’s Hospital Review

Agenda

• What is a CIN?• Gauging preparedness • Strategy and implementation considerations• Lessons learned

What is a CIN?

What is a CIN?

• Clinically Integrated Network• More concept, less specific• Integrating disparate organizations• Clinically versus financially integrated• But financially inspired & driven• Payer wants $ reduction

Why a CIN?

•Increase quality/efficiency•Decreased costs, errors, variations•Improved outcomes, safety, satisfaction•Basis for negotiation with payers•New opportunity: self-insured employers

Possible value propositions

• Increased market share • Reduced “cost” (internal) in a VB model• Bonus payments for savings (e.g.,

MSSP)• Management fees (e.g., PMPM for

care management)• Avoid/eliminate FFS penalties (e.g.,

readmission)

ACO 1

Health System

Group Practice

Health System

Group Practice

ClinicMedicalPractice

Without a CIN

Payer

ACO 1

Health System

Group Practice

Health System

Group Practice

ClinicMedicalPractice

ACO 2Payer/ Employer

With a CIN

Key Responsibilities• Program oversight• Strategy and planning• Direction, committees• Ultimate problem resolution• Leadership – physician champions• Compliance• Ultimate program responsibility

Governance

Organization• Board of Directors/Managers

–Chair, Vice, Secy, Treas, CMO, CTO

• Committees–Finance, Quality, Compliance, Contracting–Membership, Technology, Care Cord.

Governance

Governance

Committee ResponsiblitiesFinance

• Budgeting and financial planning• Compensation incentives strategies• Contracting oversight

Membership • Determine membership strategy, qualifications • Direct processTechnology

• Develop and implement technology strategy to support business needs• Determine and select required technology solutions• Develop and manage implementations to budget/timeline

Legal • Design/implement corporoate/organization structure • Manage contracting process at all levels

Sheet2

Sheet1

Salaries4.02

Op Ex0.59

IT Infr.3.11

Other0.66

LoHi

Pop Health7085

Bundles910

Quality1525

Perf. Impr.13

SalariesOp ExIT Infr.Other4.01999999999999960.593.110.66

Pop Health

LoHi7085Bundles

LoHi910Quality

LoHi1525Perf. Impr.

LoHi13

Sheet3

Participant 1Participant 2Participant 3

RoleFounderFounderAssociate

Equity60%40%0%

Board StatusTBDTBDTBD

ContributionCapexCapexOngoing fees

Sheet4

CommitteeResponsiblities

Finance• Budgeting and financial planning• Compensation incentives strategies• Contracting oversight

Membership• Determine membership strategy, qualifications • Direct process

Technology• Develop and implement technology strategy to support business needs• Determine and select required technology solutions• Develop and manage implementations to budget/timeline

Legal• Design/implement corporoate/organization structure • Manage contracting process at all levels

Participant 1 Participant 2 Participant 3Role Founder Founder Associate

Equity 60% 40% 0%Board Status TBD TBD TBDContribution Capex Capex Ongoing fees

Governance

Participation Criteria

• Maintaining appropriate IT infrastructure• Comply with care protocols and pathways• Participation in all network contracts• Measure/report performance at physician/ network levels

• Example: eRx using single medication list

Governance

Contracting

• Payers, employers, government• VB Structure:

– Premium rates (PMPM)– Bonuses and incentives – Shared savings model– Increased FFS rates based on performance– Incentive payments for performance metrics

Governance

CMS Spend (Claims Paid) Target Price Result

$18,000 $20,000 CMS pays you $2,000

$21,000 $20,000 You pay CMS $1,000

Shared Savings Model

Shared savings

•Physician committees develop guidelines and monitor compliance

•Care management teams working with physicians & patients

•Portal as a tool to deliver relevant clinical data in “real time”

•HIE as a tool to store/deliver/analyze/report•Other tools to support workflow, patient engagement, etc.

Common “attributes” of a CIN

IT as the backbone of the CIN

• Interoperability !!• Disparate organizations, systems, techs• You’ve likely addressed somewhere else• Similar tech issues• Vastly different integration issues

– Each connection has exponential effect

Actionable alerts• Deliver at point of care• Outlier situations: overdue tests, missed appts• Updated in RT as transactional data arrives• Updated in RT as users provide feedback

Examples of CIN IT capabilities

Reporting• Consolidated views of outlier patients• Drill-down capabilities to full detail• Workflow handovers • Case management directing the process

Examples of CIN IT capabilities

“An active and ongoing program to evaluate and modify the clinical practice patterns of the physician participants so as to create a high degree of interdependence and collaboration among the physicians to control costs and ensure quality.”

FTC/DOJ Statements of Antitrust Enforcement Policy in Health Care, #8.B.1(1996) http://www.ftc.gov/bc/healthcare/industryguide/policy/statement8.htm

Wait !!

What the FTC looks for:

• Mechanisms to monitor/control utilization designed to control costs and ensure quality of care

• Network physicians who further these efficiency objectives

• Investment of significant capital in infrastructure

FTC/DOJ, Improving Health Care: A Dose of Competition Ch. 2, p.37 (July 2004).

Wait !!

Challenges

• Disparate organizations• Confusion with other models• Financial investment requirements• IT:

• Connecting different technologies• Various policies: data, standards• Integration• Privacy and security

Challenges

• Lack of physician leadership/champion– Only physicians can drive necessary change

• Lack of customer revenue– No sales/value proposition or model

• Heavy focus on MSSP– No vision beyond the initial program

• Physicians incented to refer internally

Agenda

• What is a CIN?• Gauging preparedness • Creating a strategy and implementation plan• Lessons learned

•100% accurate•100% complete•100% consistent•Real time•Single source of truth

CIN technology nirvana

Portal

HIE

Data Repository

A conceptual view

Portal

HIE

Data Repository

Use case – lab order

RHIO/HIE

Discharge Summary

Chart Summaries

ADT/Demographics

Record Locator

Pharmacy Radiology Lab

Radiology Report

Consent Provider Directory, Portal,

Scheduling

A conceptual view

Gap analysis

Governance

Gaps RecommendationsCommittee Formation

Committee Status: Still in formation and meeting resistance in some quarters.

More education of key stakeholder could be helpful -C-suite support is needed.

Policy Development: This remains open as it relates to data oversight.

Leadership intervention is needed to resolve open questions.

Organizational StructureParticipant Alignment: The final list of

partners and roles is still open.IT requires finalization in order to complete the final

architecture.

IT StrategyParticipant Readiness: Technology inventory

is unknown.

An authoritative inventory needs to be compiled to develop final architecture, standards, and data

access policies, costs, timelines, etc.

Technology assessment

• Requirements and priorities• Timing: short, medium, long term• Key attributes/drivers for tech• Access to CIN participants• Team structure/approach• Assessment reporting tools


• Provider/participant inventory• Internal systems inventory• Post-acute inventory• Community resources• Gap analysis


• Issues– How to gather info (survey, interview, etc.)– Having some capabilities CIN– Current initiatives won’t stop– These are roadblocks or pre-requisites– Non-cooperative participants

Pushback

• We’re different‒ Our region moves slower & unhealthier than

other parts of the country• Physicians see no value in participation‒ Monetary and strategic

• Independent providers uninterested‒ Focused on FFS business with no intent to

move to value-based contracting

Success factors

1. Well defined/articulated vison, goals, and expectations2. Physician-driven/led model3. Cross-functional participation4. Effective use of analytics5. Smart investment/use of new/existing infrastructure 6. Efficient and effective integration plan7. Culture of continuous improvement8. Continual enhancement of care pathways/protocols9. Transparency, communication, win-win partnerships

10. Ability to scale

More than just healthcare

Heat map – summary view

EMR Case Management TeleHealthPatient

Engagement AnalyticsData

ExchangeGeneral

TechnologyParticipant 1Participant 2Participant 3Participant 4Participant 5Participant 6

High Risk Significant holes, defectsMedium Risk Limited capabilities and/or in progressLow Risk Capability in place/operational

EMR Electronic Medical Record SystemCase Management Dedicated process/staffing/toolsTeleHealth Remote connectivity/monitoringPatient Engagement Direct technology interactionAnalytics Technology and toolsData Exchange HIE, DIRECT, otherGeneral Technology Privacy, security, telecom, etc.

Heat map – detail viewIssue Component

Par.

1

Par.

2

Par.

3

Par.

4

Par.

5

Par.

6

Par.

7

Par.

8

Par.

9

Par.

10

1. EMRa. Implementation/use of EMR and integration with non-conventional partners such as Rx, food banks, various social servicesb. Secure and interoperable data exchange among all partiesc. Interim/long term transition plan for non-connected partners such as portal, HIE, other.d. Behavioral/social health support and infrastructure

2. Case Managementa. Use of standard, evidenced-based transition planning protocols in EMRb. Use of standard, risk-stratified discharge plans, CCDs, med-rec to next-site-of-care across care continuum c. Distribution/notification of care, quality, safety and follow-up alerts

3. Telehealth

a. Use of telemedicine and home monitoring post-dischargeb. Availability of base infrastructure such as high—speed connectivity in rural areasc. Availability of devices for patients such as a loan program

4. Patient Engagement

a. Secure messaging for patient-provider communication

b. Use of patient portals

c. Patient education technology

High Risk Significant holes, defectsMedium Risk Limited capabilities and/or in progressLow Risk Capability in placeNot Applicable Not Applicable

Heat map – HIE capabilitiesHIE 1 HIE 2 HIE 3 HIE 4 HIE 5 HIE 6 HIE 7 HIE 8 HIE 9

ADT

Lab

Rads

Rx Issued

Rx Filled

Discharge Summary NoticeContinuity of Care Document(CCD)Consolidated Clinical Doc. Arch. (C-CDA)

Currently receiving the corresponding EHR data feed.Receiving a variety of EHR data feeds that can be leveraged for new connections.The Local HIE has no capability in this area.

Heat map – score to color

Attribute Max ScorePart. Score

Part. Perc. Risk Level

Single sign-on 12 2 17% High RiskEMPI 20 10 50% Medium RiskDW 12 8 67% Medium RiskAnalytics 12 5 42% Medium RiskDR 8 7 88% Low RiskeRx 12 11 92% Low RiskFHIR support 6 0 0% High Risk

Heat map - summary

Attribute Hospital Clinic Outp. LabInpatient care Low Risk Medium Risk High RiskCare transitions Low Risk Medium Risk Medium RiskOutpatient care Medium Risk High Risk High RiskPost-acute care Low Risk Medium Risk Medium RiskPatient/Family Medium Risk Low Risk Low RiskCommunity Based Resources High Risk Medium Risk Low Risk

Heat map – detail view (again)Issue Component

Par.

1

Par.

2

Par.

3

Par.

4

Par.

5

Par.

6

Par.

7

Par.

8

Par.

9

Par.

10

1. EMRa. Implementation/use of EMR and integration with non-conventional partners such as Rx, food banks, various social servicesb. Secure and interoperable data exchange among all partiesc. Interim/long term transition plan for non-connected partners such as portal, HIE, other.d. Behavioral/social health support and infrastructure

2. Case Managementa. Use of standard, evidenced-based transition planning protocols in EMRb. Use of standard, risk-stratified discharge plans, CCDs, med-rec to next-site-of-care across care continuum c. Distribution/notification of care, quality, safety and follow-up alerts

3. Telehealth

a. Use of telemedicine and home monitoring post-dischargeb. Availability of base infrastructure such as high—speed connectivity in rural areasc. Availability of devices for patients such as a loan program

4. Patient Engagement

a. Secure messaging for patient-provider communication

b. Use of patient portals

c. Patient education technology

High Risk Significant holes, defectsMedium Risk Limited capabilities and/or in progressLow Risk Capability in placeNot Applicable Not Applicable

Participant 1 observations

Many solid solutions but no corporate-wide

strategy

• Core technologies are solid, reliable infrastructure• Redundant applications create needless overhead and inefficiencies • “We have more confidence in our IT team than the technology."

Team skeptical about readiness for CIN

• Clinical technologies lack basic CIN-related needs such as risk strat., referrals, care cord.• Inconsistent data/info often mentioned by users• Almost no analytics capabilities/reporting • "We can't report basic results - how are we ready for a CIN?"

Current bundled payment experience has soured

many

• Risk-bearing bundled payment program has not been successful• Lack of effective care coordination cited as problematic• Current technologies don't yet support care coord.• “We can't keep our patients on track to lower cost venues.”

Participant 2 observations

Technology on path to support risk-based programs

• Solutions are integrated internally and provide basic pop. health analytics• External/ambulatory sites are moving to core EMR or will integrate• “We're continuously looking to the future."

Centralized EMR-based solution has unproven outside

connectivity

• Single EMR idea is logical• Still lacks proven integration with ambulatory, post-acute, etc.• “Will our integration strategy really work?"

Users married to internal tech

solutions

• Internally developed technology provides excellent functionality• Consistent adoption and ongoing enhancements confirm acceptance• Unclear that users would adopt another solution• “Why can't other products work like this?"

Participant 1 recommendationsRecommendations Timing

Recruit analytics expertise NowIdentify risk-based analytics that would be applicable to all future programs Now

Identify technology solutions for risk stratification, post-acute referral, and case management

1-3 months

Determine capabilities of core EMR technology vs. those that need to acquired 3-6 months

Develop integration strategy for users of non-core EMR technology 3-6 months

Determine how to aggregate and deploy realtime analytics 3-6 months


Complete integration strategy between disparate systems - focusing on data sharing Now

Identify population health analytics that would be applicable to all programs Now

Develop workflows, care pathways for all settings 3-6 months

Determine optimal referral networks and performance criteria 3-6 months

Develop network out-of-network strategy 3-6 months


Identify population health analytics that would be applicable to all programs Now

Determine capabilities of core EMR technology vs. those that need to acquired Now

Develop connectivity solution, both short and long term 3-6 months

Develop network out-of-network strategy 6-12 months

General recommendations

Recommendations Timing

Corporate-wide eduction on risk-based programs Now

Memorialize vision and strategy for risk-based care Now

Develop strategy for business development in ACO, BP, CIN, etc. 1-3 months

Engage other CINs to learn about success and failure 3+ months ongoing

Agenda


Business strategy timeline

Year 1 Year 2-3 Year 4-5

Program MSSP Large employer, internal full risk External full risk

Goals

Timely deployment of patient record

Initial care coordination

Population health contracts (PMPM)

Develop clinical analytics

Analytics management Full care coordination

Measure/reduce internal unit costs

Integrate wellness programs

Advanced analytics and care management

Thinking

• Can we lead transformation initiatives?• Does our IT align with our CIN model?• What investments would be needed?• Do we have HIE/connectivity?• Where does our architecture fit?• Do we have the necessary partnerships?• Can we create them?

Thinking

• Connectivity between same vendor, different instances

• Vendor or 3rd party connectivity?• “Throw-away” solution first?• Building a centralized IT organization• Privacy/security/access

Business drivers that move IT

Business Drivers IT Issues

Retain/increase patientsDeliver timely information

at point of care & analytics





Identifying the patients who drive spend (20% drive 80%)

Deliver analytics, risk stratification tools







Manage high-risk patients Deliver care pathways thru IT systems







Manage high-risk patients Deliver care pathways thru IT systems

Improve clinical metrics Deliver KPIs that drive improved care

What to do now?

• Map assessment results to business drivers

• Example:– Only 5-10 systems meet our CIN needs – Only 2 are scalable– Participant 2’s EMR project consuming IT capacity– So….focus on near term requirements for MSSP– “Throw-away” solutions offer best approach

What to do now?

• Use 3rd party connectivity solution– Until founding participants are on same EMR – Interim: provide portal access to everyone

• Expand capabilities with new programs– More patients = more revenue– Ultimately replace “throw-away” solutions

What to do now?

• Establish central IT group – CIN owned and operated– Driven by CIN budget/priorities– Provides centralized reporting/analytics

• Open issues– Single EMR for all participating providers– Post-acute connectivity for care coordination/

transitions– Common analytics engine

Draft timeline

Budget2017 2018 2019

Fixed CostsSG&A $1,000,000 $1,200,000 $1,000,000IT - General $0 $0 $0IT - Risk Programs $0 $0 $0Case Mgt Programs $0 $0 $0Other $120,000 $100,000 $25,000

Total Fixed Costs $1,120,000 $1,300,000 $1,025,000

Variable CostsSG&A $0 $0 $0IT - General $2,000,000 $2,000,000 $2,200,000IT - Risk Programs $500,000 $1,000,000 $1,300,000Case Mgt Programs $0 $0 $0Other $200,000 $250,000 $250,000

Total Variable Costs $2,700,000 $3,250,000 $3,750,000

Total Costs $3,820,000 $4,550,000 $4,775,000

Allocations2017 2018 2019

# Active LivesParticipant 1 20,000 30,000 50,000 Participant 2 30,000 40,000 60,000 Participant 3 40,000 55,000 80,000 Participant 4 50,000 62,000 85,000

140,000 187,000 275,000

% AllocationParticipant 1 14% 16% 18%Participant 2 21% 21% 22%Participant 3 29% 29% 29%Participant 4 36% 33% 31%

100% 100% 100%

No preference to payer/program

2017 2018 2019Connected PCPs(?)

Participant 1 100 105 110 Participant 2 120 125 130 Participant 3 140 145 150 Participant 4 150 155 160

510 530 550

% AllocationParticipant 1 20% 20% 20%Participant 2 24% 24% 24%Participant 3 27% 27% 27%Participant 4 29% 29% 29%

100% 100% 100%

Agenda


Lessons learned

• Navigating competing corporate entities– CIN of CINs– Key drivers– Find the consensus builders– Work thru them– Stay out of the arguments

Lessons learned

• Working with and across payer programs– ID the programs first– Leverage success– Sign up as many as possible now– Prices aren’t getting better

Lessons learned

• Learning to settle with less to gain more– No matter the ROI, budget is limited– Pick best chance of quick success– A quick win builds momentum…..

• …..and frees up cash for the next phase– A loss costs you big time

Fee-based

Value-based

It’s your choice

Questions/comments

Sheldon Hamburger

[email protected](248) 613-7166

mailto:[email protected]

Slide Number 1Slide Number 2AgendaAgendaWhat is a CIN?What is a CIN?Why a CIN?Possible value propositionsSlide Number 9Slide Number 10Slide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Shared savingsSlide Number 18IT as the backbone of the CINSlide Number 20Slide Number 21Slide Number 22Slide Number 23ChallengesChallengesAgendaAgendaSlide Number 28Slide Number 29Slide Number 30Slide Number 31Gap analysisTechnology assessmentTechnology assessmentTechnology assessmentPushbackSuccess factorsSlide Number 38Slide Number 39Heat map – summary viewHeat map – detail viewHeat map – HIE capabilitiesSlide Number 43Heat map - summaryHeat map – detail view (again)Participant 1 observationsSlide Number 47Participant 1 recommendationsParticipant 2 recommendationsParticipant 3 recommendationsGeneral recommendationsAgendaAgendaSlide Number 54ThinkingThinkingSlide Number 57Slide Number 58Slide Number 59Slide Number 60What to do now?What to do now?What to do now?Slide Number 64Slide Number 65Slide Number 66AgendaAgendaLessons learnedLessons learnedLessons learnedSlide Number 72Slide Number 73Slide Number 74

Documents

Using Technology to Drive CIN Performancenchica.org/wp-content/uploads/2016/08/hamburger.pdf · •Payer wants $ reduction. Why a CIN? •Increase quality/efficiency •Decreased