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In support of our partnership with the National Rural Health Association, PYA participated in the Rural Health Clinic and Critical Access Hospital Conference, September 30 to October 3, 2014, in Kansas City, MO. One session featured PYA Principals Jeff Ellis and Martie Ross, who shared their experiences and insights in developing and operating rural network alliances as a way for providers to maintain their independence through interdependence.
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The Third WayMaintaining Independence Through Interdependence
National Rural Health AssociationCritical Access Hospital ConferenceOctober 2, 2014 – Kansas City, MO
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Residents are older, sicker, poorer, more likely to be
uninsured, have higher
healthcare costs
Fiercely independent
Access to healthcare key
to survival
Rural Communities
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Pursue strategy of local service delivery
High fixed costs/low volume
Current payment systems unravelling
No defined strategy for payment and delivery system reform
Rural Healthcare
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Consolidate or Close or . . .?C
apit
al I
nve
stm
ent
Loss of Control
MinorityInvestment
Joint Venture
ManagementAgreement
Joint Operating Agreement
AssetPurchase/Acquisition
Lease
Merger/MembershipSubstitution
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SSOCShared
Services Operating Company
CSOCClinical System
Operations Company
The Third Way
Page 6
• Governance structure to support decision-making process
Independent providers form new company
• Group purchasing arrangements• Combine administrative functions• Coordinated IT solutions• Share best practices
Leverage resources and
pursue economies of scale
Shared Services Operating Company
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SSOC Examples
Stratus Healthcare (Georgia)
Value Care Alliance (Connecticut)
Trivergent Health Alliance (Maryland)
Illinois Rural Community Care Organization
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Population health
management
Clinical integration
Joint contracting
Planned Evolution
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Still focused on local delivery of care
Not addressing continuum
of care
Still operating
in silos
But What’s Missing?
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Triple AimThree Dimensions of Value
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Sick Care Population Health
Bringing Value to Healthcare
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Sick Care
Population Health
Provider- Centered
Patient- Centered
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Sick Care
Population Health
Diagnose and treat
presenting illness or
injury
Address preventive and
chronic care needs of specific
population
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Sick Care
Population Health
Fee-for-Service Reimbursement
Value-Based Payment Models
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Sick Care
Population Health
Risk Resides With Payer
Risk Resides With Provider
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Sick Care
Population Health
Provider Silos
Systems of Care
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Silo
System
Single provider
treats one patient at a
time
Providers in collaboration
support health of defined population
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Network •Extended group with similar interests or concerns who interact and remain in informal contact for mutual assistance or support
System •Regularly interacting or interdependent group of items forming a unified whole
Care System Operations Company
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• Vehicle for independent providers to form system of care• Collaborative decision-making through new governance
structure– Define population served– Establish continuum of care – Define each participant’s role in that continuum– Identify and secure necessary resources– Align incentives– Require accountability
CSOC Characteristics
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CSOC Survey
Vanderbilt Health Affiliated Network
University of Iowa Health Alliance
Health Network of Missouri
Kansas Heart and Stroke Collaborative
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Vanderbilt Health Alliance Network
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Vanderbilt Health Affiliated Network• Formed in September 2012 as Vanderbilt employee
health plan
• Expanded provider network to meet employees’ needs
• Now expanding offering to other employers (Aetna and BCBS-TN)
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VHAN - Mountain States Health Alliance
• Share evidence-based care models• Collaborate in medical research and
clinical trials• Develop consultative relationships
among specialists and subspecialists• Support physician recruitment• Develop continuum of care in
cardiovascular and oncology service lines
• Develop narrow network for joint contracting
Affiliation agreement
announced in May 2013
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VHAN – West Tennessee Healthcare
•Educational program support•Enhance delivery of oncology support programs for physicians and patients•Consultative services to build upon clinical programs•Joint clinical research trials
Cancer program affiliation
agreement announced in
May 2013
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University of Iowa Health Alliance
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University of Iowa Health Alliance
• Transition primary care practices to PCMH model
• Establish evidence-based medicine standards of care
• Pursue programs to determine/address health status of communities
• Develop provider educational programs • Pursue patient engagement strategies • Share IT and data analytics costs• Collaborate in research initiatives • Position organizations to participate in new
payment models
Formed in 2012 among 4 health
systems (50 hospitals); provider
network for Iowa/NE CO-OP
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Academic medical center + 4 community
hospitals
2+ years as learning collaborative
Formed new entity in June 2014 to develop clinically integrated
network
Health Network of Missouri
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Network Compacts
Covenants among all Members
Developed and operationalized by task forces comprised of Member representatives
Specific charges to task forces developed through Steering Committee planning process
Interactive and mutually supportive
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Member Contracts
Vehicle for arrangements between less than all Members
Allows Alliance to move expeditiously on matters of interest to individual Member groupings
Network Compact development takes priority, but can pursue Member Contracts at same time
Transparency between Members about work being done under Member Contracts
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• Franchise reputation– Control vs. collaboration
• Disease specific (cancer, heart)• Continuum of care?• Reach out to rural?
MD Anderson, Mayo, Cleveland Clinic
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Univ
ersity
of
Ka
nsas
Hos
pital r
ec
eiv
ed
$12.
5
milli
on
Healt
h
Car
e I
nnovati
on
Awar
d
Foc
us
on r
egi
onal syst
ems
of car
e f
or
pati
ents at risk
of
or
who
hav
e s
uff
er
ed
heart attack
or str
ok
e
Kansas Heart and Stroke Collaborative
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The Kansas Heart and Stroke Collaborative is a care delivery and payment model to improve rural Kansans’ heart health and stroke outcomes and reduce total cost of
care for that population.
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Overarching Strategies
Integration(Teamwork)
Incentives(Rewards for Teamwork +
Fieldwork)
Interventions(Fieldwork)
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University of Colorado Health• Defensive move against national systems
– Centura, Health One, Sisters of Charity Leavenworth
• Focus on efficiencies
• Prestige of AMC association (research and education)
• Looking for like-minded partners
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IncentivesRewards for Teamwork & Field Work
•Direct payment for care management services•Upward payment adjustments for participating rural physicians and mid-level providers•Disease-specific shared savings program
Transitional payment model
• Build shared analytic infrastructure to identify and evaluate alternatives to cost-based reimbursement to preserve local access to care
Transformational payment model
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• Shared vision
• Balance interests (common vs. individual)
• Committed resources– Time and energy
– Financial
• Accountability
• Trusting environment
Commit to Action
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SSOC/CSOC Phases
Strategy Development
•Engage in level-setting education•Define rationale and objectives•Determine scope•Examine feasibility
Partner Assessment•Develop selection criteria•Perform SWOT analysis•Enter into letters of intent
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SSOC/CSOC Phases
Establish Terms of Relationship • Prioritize
objectives
• Document rights and responsibilities
Commence/ Maintain Relationship• Strategic
and operational planning
• Secure IT infrastructure
• Develop timelines and link resources
• Identify performance measures
Exit Strategy• Specify
triggers• Determin
e procedures to wind down alliance
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Provides structured environment for discussion and
decision
Promotes trust and transparency
Balances power among diverse
participants
Protects individual rights
and concerns
Facilitates joint decision-making
in a safe environment
How Structure Facilitates Organization’s Function
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Balanced time/energy/economic investments by participants
Balanced voting rights/reserved powers for participants
Shared vision and goals while recognizing “sacred cows” to be protected
Formal but flexible and adaptable rules of operation
Provides fair opportunity for participants to engage and be heard
Allows for organizational change/growth to address evolution of function
Key Elements of an Effective Structure
Page 43November 15, 2013
Prepared for University of Missouri Health System
Pershing Yoakley & Associates, PC9900 W. 109th Street, Suite 130
Overland Park, KS 66210913.232.5145
Martie [email protected]
Jeff [email protected]
