Employed and Independent Physician Alignment Models

1. Employed and Independent Physician Alignment Models Presenters: Erick J. Laine, M.D. Executive Vice President/Chief Operating Officer, Iowa Health Physicians and Clinics Aric R. Sharp Vice President of Network Development, Iowa Health System; Chief Executive Officer, Quincy Medical Group Gary L. Knepp, D.O., FACOFP Chief Medical Officer, Methodist Medical Center; President, Methodist Medical Group

2. “NewGroup” and“Physician Alignment”

3. NewGroup and Physician Alignment Iowa Health System: “NewGroup”

4. NewGroup and Physician Alignment Iowa Health System IDS…OSC…ACO… Other Senior Affiliates IDS…OSC…ACO… Waterloo IDS…OSC…ACO… Cedar Rapids IDS…OSC…ACO… Peoria IDS…OSC…ACO… Central Iowa Board Exec Team Support systems (IDS) Med Groups Hosp Other operating entities 8 Regional Senior Affiliates Aligned Medical Staff Practices and Independents

5. NewGroup and Physician Alignment “NewGroup” as System-Wide Medical Group IDS…OSC…ACO… Other Senior Affiliates IDS…OSC…ACO… 9th Senior Affiliate Waterloo IDS…OSC…ACO… Cedar Rapids IDS…OSC…ACO… Peoria IDS…OSC…ACO… IDS… Central Iowa “New Group” Board Exec Team Hosp Support systems (IDS) Med Groups Hosp Other operating entities 8 Regional Senior Affiliates Group Aligned Medical Staff Practices and Independents

6. NewGroup and Physician Alignment What NewGroup is… A distinct legal entity A distinct operating entity A distinct clinical model (multi-specialty group) A senior affiliate “Owns” responsibility and accountability for Clinical, professional performance/outcomes Operational performance/outcomes Financial performance/outcomes Legal, regulatory performance/outcomes Has commensurate decision-making authority for these domains.

7. NewGroup and Physician Alignment Larger Collaboration / Partnership “NewGroup” Physician Recruiting Professional Service Agreements Practice Acquisitions Other Operating Entities • Performance Outcomes: • Clinical performance • Operational performance • Business/Financial performance • Legal/Regulatory performance • Performance Outcomes: • Clinical performance • Operational performance • Business/Financial performance • Legal/Regulatory performance

8. NewGroup and Physician Alignment What NewGroup is not… An MSO to individual private practices An operating extension of the hospital A potpourri of “service line” entities A mélange of clinical models a collection of single specialty groups a collection of “centers of excellence” Merely a professional staffing resource for Hospitals, Nursing Homes etc.

9. NewGroup and Physician Alignment What’s New about “NewGroup”… “Best Outcome For Every Patient Every Time” “Doing it right the first time!”

10. NewGroup and Physician Alignment “Disruptive Change” Necessity of Change “Value” “Volume” Integrated Healthcare Systems Fractionated Healthcare “Sustainability” 1-D “Simple” Systems 3-D “Complex” Systems Axis Of Change

11. NewGroup and Physician Alignment Disruptive Change Crisis “OLD World”:1-Dimensional “NEW World”:3-Dimensional 1. Individual Patients 2. Individual Providers 3. Individual Organizations 4. Performance = A or B or C or D 5. “Autonomy” Pt Populations / Care Coordination 2. Integrated Team-based Care IDS / OSC / ACO Performance = A + B + C + D 4. “Accountability” Consolidation… Complexity… Transformation

12. NewGroup and Physician Alignment Beyond “Physician Alignment”

13. NewGroup and Physician Alignment Failed “Alignment”… Providers: Society: “Growth”….. “Performance”… “Coordination”… “Sustainability”… “Quality, Safety”….. “Access”… “Cost”, “Affordability”… “Sustainability”…

14. NewGroup and Physician Alignment “Alignment” “Physician Alignment”

15. NewGroup and Physician Alignment “Alignment” “Patient” “Physician” “Physician-Driven” … “Patient-Centered”

16. NewGroup and Physician Alignment “Alignment” ) ( ( ) (“Patient”) “Physician” • a) Individual Patients… • b) Populations of Patients • 1st order populations • 2nd order populations • 3rd order populations • c) Entire population

17. NewGroup and Physician Alignment “Alignment” ) ( ( ) ( “Providers” ) “Physician” • Physicians… • Primary Care • Medical Specialties • Surgical Specialties • b) Mid-Level Providers • C) Provider Teams

18. Dimension 1: System “Alignment” ( ) ) ( ( ) ) ( (“Physician”) ( “Organizations” ) • Hospitals… • Medical Groups… • Other providers… • Regional IDS/OSC/ACO… • System of Care…

19. NewGroup and Physician Alignment “Magnitudes of Alignment”

20. NewGroup and Physician Alignment “High-Value” “High-Performing” “Highly-Functional” “Highly Integrated” Value to -Hospitals -IDS/OSC -System Management Consequences Expectations Planning Capacity Needs Communication Culture People Super-Structure Infra-Structure Structure Value-based Performance Information Time

21. NewGroup and Physician Alignment Beyond “Alignment” “Sustainability” Performance “High-Value Network” “Closed Economy” FFS: “Volume” “NewGroup” Performance Platform Highly Integrated Highly Functional High Performing High-Value VBC: “Value” Volume 2012 2013 2014 2015 2016

22. NewGroup and Physician Alignment Beyond “Alignment” Highly Integrated... Highly Functional…High-Performing… High-Value Providers: a) Physicians… b) Mid-Level Providers c) Staff d) Care Teams Patients: a) Individual Patients… b) Populations of Patients “It Works!” Stakeholders: a) Payers… b) Employers… c) Local community… d) Regions… e) State level… f) National level… Organizations: a) Hospitals b) Medical Groups… c) Home Health… d) Regional IDS/OSC/ACO… e) System…

23. NewGroup and Physician Alignment Being Different… Solving healthcare problems will require a different kind of thinking… Solving healthcare problems will require a different kind of being…

24. NewGroup and Physician Alignment 6 Aspects of Trust (Social Capital) 1. BeingHonest 2. BeingOpen 3. BeingCompetent 4. Being Committed 5. BeingReliable 6. Caring

25. Methodist Medical Group Aligning with the Future

26. Methodist Medical Group Aligning with the Future Trademark Adoption MMG Options Continue as Methodist Medical Group Adopt the New Group name After Review by Physician Governance Committee, MMG Leadership Committee and MHSC Board, decision was to adopt the Trademark agreement and change the name of the Methodist Medical Group

27. Methodist Medical Group Aligning with the Future Trademark Adoption Physicians using the IHS name, logo or trademark must: Be employees of an IHS Affiliate. Actively pursue Iowa Physician Clinic Medical Foundation quality improvement, care coordination and service improvement standards. Participate in Iowa Physicians Clinic Medical Foundation approved surveys related to patient, employee and provider satisfaction. Participate in standardized of EHR build and workflow.

28. Methodist Medical Group Aligning with the Future MMG Decision Path We evaluated the decision by looking at the trademark standards and comparing them to our current alignment and strategic plan. As we worked through each standard, we found we had no difficulty aligning with each of the standards. To help explain each standard’s impact on MMG, we will review each standard separately.

29. Methodist Medical Group Aligning with the Future Be employees of an IHS Affiliate. MMG is an operating department of Methodist Health Service Corporation, sharing a common board structure. All MMG physicians and advanced practice providers are employees of Methodist. President of MMG (Gary Knepp, DO) reports to the CEO (Debbie Simon, RN) of the corporation. Currently MMG employs 98 physicians, 41 advanced practice providers and 39 residents. Deliver care in 35 clinics.

30. Methodist Medical Group Aligning with the Future MMG Specialties • Family Practice • Pediatrics • Sports Medicine • Express Care • Internal Medicine • Cardiology • Cardio-Vascular Surgery • Pulmonology/Critical Care/Sleep • Rheumatology • Neurology • ENT • Podiatry • Psychiatry • Adult Hospitalist • Pediatric Hospitalist • Pediatric GI • Perinatology • Physical Med and Rehab • Senior Health • Palliative Care • In-school Health Clinics

31. Methodist Medical Group Aligning with the Future Actively pursue Iowa Physician Clinic Medical Foundation quality improvement, care coordination and service improvement standards. MMG is an active member of the New Group Operating Committee. Participating in IHS ACO quality metrics. MMG has a well developed quality, process improvement and patient safety culture. Have set service standards at the 95th per-centile on Press Ganey patient satisfaction surveys. Already participating in HCAHPS and CGCAHPS surveys.

32. Methodist Medical Group Aligning with the Future MMG Structure Deeply integrated into overall Methodist Structure. MMG President serves as CMO of organization. Many committees integrate MMG clinic activities and hospital inpatient activities with a focus on the patient. Care Coordination is becoming an integral part of the culture. Many MMG physician serve dyad role with inpatient departments and committees. Many support departments are shared with staff dedicated to MMG areas such as Finance, Human Resources and IT.

33. Methodist Medical Group Aligning with the Future MMG Medical Pod Structure Admin Director Medical Director Site Supervisor Physician Site Lead Site Supervisor Physician Site Lead

34. Methodist Medical Group Aligning with the Future Achieving Physician Alignment Pod Medical Directors Site Leads Operational Committee Participation Governance Committee Participation Hospital Medical Staff Roles Hospital Department Medical Directors Ongoing Leadership Development and Training Residency Training Programs Board Membership

35. Methodist Medical Group Aligning with the Future Participate in Iowa Physicians Clinic Medical Foundation approved surveys related to patient, employee and provider satisfaction. MMG currently participates in Press Ganey and CG CAPHS surveys. MMG participates in Methodist annual Great Place to Work employee and annual Press Ganey provider surveys. Adopting IHS survey formats will require losing Press Ganey comparisons to previous year’s data but will allow us to begin comparing to IHS peers and should not hinder our current process improvement activities.

36. Methodist Medical Group Aligning with the Future Participate in standardized of EHR build and workflow. MMG and Methodist Medical Center currently utilize McKesson EHR systems. MMG had voice and vote in selection of the EPIC Ambulatory platform. Decision already made to move to EPIC platform in both the inpatient and clinic environment in 2014. MMG has direct participation in the clinical IQ4 planning and implementation committees.

37. Methodist Medical Group Aligning with the Future Adopting Trademark Agreement and new IHS name. Hardest decision was giving up MMG name! Our goals and strategic plan are already aligned. Adopting common processes, procedures, policies should improve our ability to achieve the triple aim goals. Care coordination within a multistate system is an even higher goal than just in the Peoria Region. We look forward to a shared future.

38. Alignmentin the Quincy Region

39. Alignment in the Quincy Region Quincy Medical Group Quincy Population, 40,630 Service Area 112,000 Founded in 1937 135 providers 100/35 (Physician/Midlevel) 28 Specialties 50% Primary Care, 50% Specialty Care All primary care under CRHC Broad Ancillary Scope McKesson EHR

40. Alignment in the Quincy Region Quincy Medical Group Location Outreach

41. Alignment in the Quincy Region Patient Centered Medical Home • Level 3 Recognition for all QMG Primary Care providers • Over half of the Level 3 recognition providers in the state of Illinois are a part of Quincy Medical Group Value Foundation

42. Alignment in the Quincy Region Recent Past Value Initiatives Automated Outreach Calling via Phytel 35,000 outreach calls per year Asthma, COPD, Diabetes, Hypertension, High Cholesterol, Wellness Behavioral Health imbedded in Primary Care practices 6 LCSWs and Child Psychologist NuFit for You – Fitness Centers 5 locations, 120 classes per week, corporate on-site Corporate Wellness HRS, Biometrics, Point System tied to Activity, EE Reviews

44. Alignment in the Quincy Region “Traditional healthcare leaders try to buy time, fend off change, and maximize revenue under the existing payment system while they can.” “The new leaders focus on outcomes and use performance measurement as a motivating tool to organize colleagues and drive improvement. Harvard Business Review May 2011 Healthcare Leadership

45. Alignment in the Quincy Region Position to prepare for a new payment model by taking incremental steps toward an integration platform. Position with size and scope in advance of significant change. Scale will be necessary in population management. Position to optimize learning and synergy of infrastructure across a larger organization. Preserve a physician led model in the local market for the future. Position by taking steps at a time when the clinic is exceptionally strong to provide time to transform the model. 2011How should we position QMG?

46. Alignment in the Quincy Region Iowa Health System owns 45% interest in QMG • Physician Shares. QMG remains physician owned and governed. • 8 physicians on Board of Directors including Iowa Health CMO QMG participating in IHAC – ACO • Participating in MSSP 9,500 attributes lives Physician Committees • Customer Service, Quality, Finance, Information Tech Physician Leadership Institute • Focused around the Triple Aim Affiliation Structure

47. Alignment in the Quincy Region Physician Leadership Institute Project Teams Customer Service Quality Measurement & Improvement Cost of Care Reduction

48. Alignment in the Quincy Region Customer Service • Physician Project Team • 5 Physicians • COO • Professional Project Manager • Retooled QMG Mission, Vision, Values • Best Outcome for Every Patient Every Time • Developed Formal Program • Service Measurement • Service Training • Service Recovery • Physician Led

49. Alignment in the Quincy Region Quality & Measurement Improvement • Physician Project Team • 5 Physicians • CMO • Professional Project Manager • Developed Quality Measurement Process • Diabetes as Pilot • Physician Dashboard • Adding COPD, CHF, Hypertension, Osteoporosis • Aligned with New Group Initiatives • Explorys tool will replace reporting

50. Alignment in the Quincy Region Scoping the Cost Project Reducing Cost Imaging Admissions Generic Rx Readmissions Emergency Room Nursing Home Direct Various Strategies HP3 Project Current 9.6% NP Care Project