An ACO Success Story: The Path to Market Leadership

Transcription

1 An ACO Success Story: The Path to Market Leadership

2 the decisions made in the primary care setting have important implications for downstream medical care...primary care physicians can be seen as a chief executive officer (CEO) in charge of approximately $10 million of annual revenue. - Jama. Health Reform and Physician-Led Accountable Care: The Paradox of Primary Care Physician Leadership Introduction Defining a strategy for transitioning from fee-for-service (FFS) to fee-for-value (FFV) represents a significant challenge for healthcare organizations. Assuming accountability for both the cost and quality of care for patient populations across the care continuum necessitates the ability to coordinate, collaborate, communicate, and cooperate at a level rarely seen in healthcare. This paradigm shift requires the development of stronger relationships between a community of providers, and the right mix of technology enablers to facilitate the efficacy of those relationships. ACO Technology Enablers According to the Brookings Institute Adopting Accountable Care: An Important Guide for Physician Practices, there are four critical areas that must be addressed in the successful development of an ACO: 1. Identifying and managing high-risk patients 2. Developing high-value referral networks 3. Using event notifications 4. Engaging patients While there are a plethora of technology solutions on the market today asserting to be ACO enablers, it s interesting to note that the solutions most ACO s seem to focus on are in the area of identifying and managing high-risk patients through the use of EHRs and analytics. Some have attempted to share information via HIEs including notification of selected events, and some have begun some form of patient engagement. However, there has been less attention paid on point number two, the development of high-value referral networks and their potential to materially affect health and cost outcomes. In this whitepaper, we will profile an innovative IPA that stepped outside of the box by emphasizing the development of high-value referral networks in their transition to an ACO, and the profound results they achieved as a result. The Tipping Point Key Physicians, a Medical Home Network and Independent Physician Association (IPA), is comprised of more than 300 providers in the Triangle region of North Carolina. Each of the network s 61 practice locations is recognized by the National Committee for Quality Assurance as a Patient-Centered Medical Home. Like most IPA s at the time, Key Physicians recognized in 2011 the need to evolve the organization and build the capabilities necessary to take on value based contracts. In the early stages of developing a strategy, they learned that a national health plan was looking for a partner in the Raleigh market to participate in their population health management program. At that point, the insurer had focused on 2

3 partnering with organizations with a single EHR and a single tax id, and as a result all of the partnerships formed to date had been with Health Systems. Key Physicians believed that a physician-lead ACO could offer the best value and highest quality of care. With the partnership decision eminent, the time was right for Key Physicians to make the leap into accountable care. Finding a Competitive Edge The executive team at Key Physicians recognized that in order to be awarded a population health contract, they would need to prove an IPA could deliver the level of care coordination and collaboration across the community that the insurer was looking for, without a common EHR. In addition, the uncertainty and associated risk of taking on a value based contract with no guarantee of ROI meant that a large investment in technology wasn t feasible. They needed to empower their providers with something simple that would add value almost immediately, and at an affordable price point. Within these guardrails, Key Physicians began to formulate their strategy. They quickly concluded that the providers could easily identify the highest risk patients, and by combining that information with the rich data the insurer would provide for the attributed population, they would be able to identify and manage their highest risk patients without an expensive and lengthy implementation of analytics. Being able to deploy (ICC) rapidly over a diverse group of practices, as large as hospitals clinics with hundreds of providers or small clinics with sole practitioners, with or without EMRs, is a critical factor in our success and a major benefit of the system, Ray Coppedge, Executive Director, Key Physicians Key Physicians also knew that improving care coordination meant that providers needed an easy way to bi-directionally share contextually relevant information prior to a patient visit, including what the provider needs to know and what they need to do. HIE s are one source of patient information, but are limited to those providers who can and will connect, the relevant patient information is often buried in fifteen pages of other information, and they lack the ability to coordinate care delivery. It quickly became clear that the quickest and most effective course of action to efficiently coordinate care as well as minimize the cost of high quality care was by having the ability to create, manage, and measure high value referral networks. With a community-based referral coordination system, Key Physicians would have the ability to coordinate care between PCP s and specialists, and at the same time minimize leakage. In conjunction with co-management agreements, a referral coordination solution would give Key Physicians exactly what they needed to secure their first value based contract. Community Adoption With no solutions on the market that met their requirements, Key Physicians partnered with Infina Connect to adopt and refine Intelligent Care Coordinator (ICC), an EHR agnostic SaaS referral coordination solution. Key Physicians began using ICC in January 2012, and quickly experienced viral adoption across the entire Raleigh area. With ICC, Key Physicians became the first organization in the nation to successfully deploy a referral coordination solution adopted by a majority of 3

4 In their first year of using ICC, a national insurer reported that the Key Physician practices had an 83% success rate for referring patients to the highest value providers, compared to less than 40% success rate for their peers. providers across a metropolitan area, including over 1700 physicians at 400+ offices and clinics, as well as 3 local hospital systems. Even though the practices all use disparate Practice Management systems and EMRs, they were easily able to adopt ICC. Being able to deploy (ICC) rapidly over a diverse group of practices, as large as hospitals clinics with hundreds of providers or small clinics with sole practitioners, with or without EMRs, is a critical factor in our success and a major benefit of the system, says Ray Coppedge, Executive Director, Key Physicians. Proving Value With referral coordination and co-management agreements in place, Key Physicians pursued and was awarded the population health contract, becoming the first IPA in the nation invited to participate in a population health program with this insurer. Their success was largely due to their ability to coordinate care, collaborate, and communicate across the entire community of providers, regardless of EHR or ownership. Providers in the Key Physicians network are able to ensure patients are referred appropriately within a high value network and mitigate gaps in care throughout their patient populations. By minimizing referral leakage, providers are also able to decrease healthcare costs and save the patient money, while ensuring they receive high quality care. By enabling their provider network, Key Physicians has holistically been able to: Improve the coordination of care and ensure a high level of communication and patient information transfer occurs between providers across the continuum of care. Establish high value networks and ensure patients are referred to high value services. Have visibility into the ongoing status of referrals (i.e. submitted, opened, accepted, declined, cancelled, scheduled, visited) and receive electronic patient summaries from other providers. Path to Market Leadership In their first year of using ICC, the national insurer reported that the Key Physician practices had an 83% success rate for referring patients to the highest value providers, compared to less than 40% success rate for their peers. In a typical example, they are able to refer patients to high quality providers committed to coordinating care via comanagement agreements, resulting in lower overall costs and improved patient care. These care coordination activities, made possible by ICC, have helped Key Physicians maintain a 6% better-than-market total medical cost for its attributed population. The technology strategy that Key Physicians adopted has continued to pay off. They successfully won additional population health contracts, which led to a partnership with a local health system and further expansion to collectively include over 75,000 patients under ACO value based reimbursement relationships. Key Physicians providers now manage patient populations comprised of multiple commercial and government 4

5 contracts. Based on their current trajectory, Key Physicians and their partners expect to double their attributed populations to exceed 150,000 lives in Key Physician s has established a strong market presence over the last several years in the Triangle area, known for both quality and value, by virtue of the ACO move. By empowering their providers with ICC, Key Physicians was able to achieve a market presence that had eluded them previously. Broadly speaking, the leadership position that Key Physicians has established for delivering high value care has afforded them a competitive advantage and negotiating power across the healthcare community in their region. We believe that the adoption and use of critical technologies that assist in the management, optimization, and coordination of patient information can drive true collaborative care and provide immense value to our practices, patients, and the community overall, said Ray Coppedge, Executive Director at Key Physicians. Being able to streamline the referral process and ensure closed-loop communication and coordination between primary care and specialists enables Key Physician practices to deliver even higher-quality care and help create a healthier North Carolina. Key Takeaways According to a recent study conducted by Oliver Wyman, more than two-thirds of the U.S. population now live in localities served by ACO s and more than forty percent live in areas served by two or more. Additionally, by 2017, John Moore at Chilmark projects (based on conversations with multiple insurers) that approximately fifty percent of reimbursements will be value-based. The U.S. heathcare system is evolving rapidly toward value based care, and it will soon be almost impossible for providers to exclusively deliver fee for service care. With no guarantee of upside ROI for risk based contracts, healthcare organizations must be cautious when developing their technology strategy. Expensive solutions with long implementation and payback cycles will only serve to increase risk. As some organizations have already learned the hard way, large technology investments in solutions such as population health analytics and HIE s before they have sufficient contract opportunity increases up front costs and delays their return on investment. A more cost effective way to ensure high value care and near term return on investment is to focus on coordinating care within high value referral networks. By understanding referral patterns, reducing unnecessary referrals, identifying and working with high value providers, and improving coordination and communication between primary care and specialists, an ACO can ensure patients receive higher quality of care at a lower cost than many thought possible. 5

6 References Engelberg Center for Health Care Reform at Brookings. (November 2014). Adopting Accountable Care: An Implementation Guide. Executive Summary. McClellan, Mark, MD, PhD, Mostashari, Farzad, MD, MPH, Sanghavi, Darshak, MD. Jama. Health Reform and Physician-Led Accountable Care: The Paradox of Primary Care Physician Leadership. The Brookings Institution, Washington DC CentreGreen Way Suite 250 Cary, NC USA Phone: (919) Fax: (877)