Creating high performance systems of care

1. California Regional Meeting April 23, 2010 Donald W. Fisher, PhD President and CEO American Medical Group Association dfisher@amga.org

3. December 2008 Meeting PGP Members/Newt Gingrich/Congressional Staff Best Practice Description AMGA Intent � create momentum/case for separate medical group funding mechanism, i.e., ACOs Results in Request by Congressional Staff for Legislative Proposal/Language ACO Legislative History

4. Draft Proposal Based on PGP Demonstration With Improvements Provider Comparison Cohort Efficiency Comparison Cohort Savings Threshold One Year �Look back� Leverage�Everyone wants this to be Successful ACO Legislative History

5. Tactics� Hill Visits/Fly Ins/Conference Calls Included as Section 3022 of the PPACA Legislative History

6. Considered by Senator Max Baucus to be the Signature Delivery System Reform Piece Others Agree� �For Medicare to become sustainable, the delivery system has to change. ACOs could prove to be an important catalyst for delivery system reform by creating incentives for increased organization and joint decision making.� MedPAC Report to the Congress, June, 2009 Legislative History

7. To Be Determined�But Some Say� What is an ACO?

8. �An ACO is a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population.� Diane R. Rittenhouse, M.D., M.P.H., Stephen M. Shortell, Ph.D, Elliott S. Fisher, M.D., Ph.D, Primary Care and Accountable Care � Two Essential Elements of Delivery �System Reform, December 10, 2009, NEJM What is an ACO?

9. �The defining characteristic of an ACO is that a set of physicians and hospitals accept joint responsibility for the quality of care and the cost of care received by the ACO�s panel of patients� MedPAC Report to the Congress, June, 2009 What is an ACO?

10. Statute Says� Entities that Promote Accountability for a Patient Population and Coordinate Services under Parts A and B. Entities may be� Medical Groups IPAs Hospitals joint venture with Physicians Hospitals employing Physicians Anyone Else� Catch all What is an ACO?

11. Formal Legal Structure that allows for receiving and distributing Payments Sufficient Primary care capacity to manage 5,000 Medicare Beneficiaries Leadership and Management Structure that includes Clinical and Administrative Systems What is an ACO?

12. Promotes Evidence-Based Medicine Reports Quality and Cost Measures Coordinates Care Promotes Patient Centeredness What is an ACO?

13. Payment Shared Savings If ACO Meets Quality Metrics If ACO Meets Cost Benchmark/Threshold Quality Metrics AMGA-Focus on High Cost/High Volume Disease States AMGA-Staggered Reporting What is an ACO?

14. Benchmark ACO FFS Beneficiary Expenditures vs. ACO Benchmark (National) Threshold Will Depend on number of Beneficiaries Can Range from 2% (PGP figure) to� What is an ACO?

15. Payment, continued�.Partial Capitation ACO at Risk for Some, but not all of Part A & B Services No Additional Expenditures� HHS Shall not Spend More on Partial Capitation than fee for service What is an ACO

16. ACO Mania � similar to �Everyone is a Primary Care Physician� in 1990s Intense Interest because there may be Winners/Losers Shift in Reimbursement Focus What is an ACO

17. AMGA Principals as we move forward Multispecialty medical groups and organized systems of care are the Foundation for ACOs ACOs must be Physician-Led/Directed ACOs Agree to be Accountable by Providing Team-based Coordinated Care ACOs must have a Primary Care Core Shared Learning/Collaboration among ACOs What is an ACO

18. Rule Making Regulatory Perspective� Stark took over a Decade Unresolved Issues � Just a Sample Patient Attribution Which Quality Measures Savings Percentage Partial Capitation Issues Many Others� Next Steps

19. Legislative Initiatives Having created the Model, AMGA will Advocate for� Separate SGR �Bucket� Medical Malpractice Protection Next Steps

20. Create Educational Tools to help Develop/Form/Maintain ACOs Hold Regional Meetings/National Summit Taught by Experts Publish Book/Manual AMGA/ACO Collaboratives Consultants Other? Next Steps

21. For Members� Executive Level Strategic Thinking Fit ACO Definition? ACO Competition? Educate/Cooperate with Community Providers? Cultural Change? EMR/IT fine tuning? Next Steps Considered During Expanded Discussion Next Steps

22. Thank you� Questions and Comments