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Establishing Collaborative Accountable Care (ACO’s – Shared Savings)

Establishing Collaborative Accountable Care (ACO’s – Shared Savings). Jeffrey Kang, MD, MPH Chief Medical Officer, CIGNA Scottsdale Institute April 27, 2011 Scottsdale, AZ. Outline.

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Establishing Collaborative Accountable Care (ACO’s – Shared Savings)

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  1. Establishing Collaborative Accountable Care (ACO’s – Shared Savings) Jeffrey Kang, MD, MPHChief Medical Officer, CIGNA Scottsdale Institute April 27, 2011 Scottsdale, AZ

  2. Outline • Difference between Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACO’s) and pilots underway • Overview of CIGNA’s approach to ACO’s • Early results • Collaboration with hospitals and professionals – What support do they want/need from health plans? • Other payment models

  3. Collaborative Accountable Care CIGNA Collaborative Initiatives PATIENT CENTERED MEDICAL HOME COLLABORATIVES: Pay for certification Pennsylvania Governor’s Chronic Care/ PCMH Coalition (5/08) CIGNA COLLABORATIVE – ACCOUNTABLE CARE: Pay for outcomes Vermont Blueprint for Health (7/08) Colorado Multi Payor Collaborative (6/09) CIGNA Medical Group, AZ (7/08) New Hampshire Citizen’s Health Initiative (6/09) Eastern Maine Healthcare Systems, ME (1/10) Dartmouth-Hitchcock Clinic, NH (6/08) Piedmont Physician’s Group, GA (6/10) Washington Medical Home Reimbursement Pilot (Q 2 11) Medical Clinics of North Texas, TX (8/09) Mercy Medical Group. MO (7/10) Maryland Medical Home Reimbursement Pilot (Q 3 11) ProHealth, CT (10/09) Holston Medical Group, TN (8/’10) Methodist HealthCare, TN (6/11) 3

  4. Collaborative Accountable Reward (in addition to standard fee for service payments) Risk-adjusted Expected Trend Gain-share TOTAL MEDICAL COST (pmpy) Initial Care Coordination fee Actual Trend Pmpm Improvement Yr. 1 Yr. 2 Yr. 3 • Must pass elements compared to market. • Quality: EBM and patient satisfaction improved or maintained at better than market average in order to be eligible for gain-share • Affordability: per capital medical cost - trend better than market average

  5. Collaborative Accountable Care – Early Financial and Quality Results (July 09 to June 2010)

  6. What do Providers Want/Need from Health Plans to be Successful?(descending order of importance) CMS provided in PGP – Physician Group Practice Demos • Insurers protect them from insurance risk (willing to be penalized for poor performance) • Covering care out of the ACO’s coverage area • Managing care out of the ACO’s coverage area • Value-based benefit design to encourage consumer compliance • Medical cost and quality reports to identify opportunities for improving • Physician and hospital cost and quality profiles • Gaps in care reports • Predictive models • Health and Wellness services • Uncommon disease (e.g. transplant) case management services • Disease management (chronic care) services • Case management (acute care) services CIGNA and other health plans are providing to ACO’s

  7. Other Payment Models

  8. Questions and Discussion

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