Renaissance Medical Management: Aligning Incentives for Effective Care

1. Renaissance Medical Management CompanyOverview A Pioneer Accountable Care Organization

2. Agenda • Brief History of Renaissance • Overview of RMMC programs • Provider Collaboration Model • Question

3. Renaissance exists to support the practice of medicine in an economically sustainable way • Renaissance works in conjunction with physicians and payers to build new compensation models designed to properly align incentives for delivering efficacious care

4. Founded in 1999 Created to align goals and objectives of providers and payers Originally a specialist-owned organization Recapitalized into a primary care – owned company Chairman of the Board – Dr. Barry Green Practicing Physician Chief Medical Officer – Dr. Kenneth Goldblum Practicing Physician Remains privately held by doctors History of Renaissance

5. Compensation should be driven by Quality • Less event-driven care means lower costs and higher quality • HEDIS and CAHPS becoming ever more important in purchasing decision • Improved outcomes drive lower costs for • the Patient • the Payer • the Employer/Purchaser • Lower costs can fund incentives

6. Essential Components for Effective P4P • Clinical Staff to manage the process • Coordinate with the practices • Outreach to the patients • Establish treatment goals • Effective web based connectivity with the practices • Registry of patients needing preventive care • A meaningful incentive program • Clear • Specific • Measurable

7. People, Processes and Technology In the right combination…produces • Improved HEDIS Scores • RMMC managed program has consistently produced HEDIS scores in 90th percentile nationally • Demonstrated cost reductions for payer • Validated by third party actuarial firm • Lower Readmissions • Less Event Driven Care • Better Outcomes • Slowing the progression of risk scores

8. Patient Centric Quality Incentive Model • Physician Coordination • Quality Improvement Committee • Regional Medical Directors • Health Services teams • Web-based tools • Quality Program • Developed by physicians and Plan • Updated annually • Clinical Nurse Outreach • Follows physician’s plan of treatment • Coordinates with patient and caregivers • Web-based tools to manage plan • Chronic Care Management • Care modules to improve outcomes • Reduce event-drive episodes • Reduce readmissions • Educate patients for self-management • Incentive Program • Clear • Transparent • Actionable • Effective Pay for Performance Physicians Patient Payers Lower Costs, Higher Quality

9. Role of the Organization • Education • Physician Leadership • Technology development • Patient Services: nursing support team • Physician office support • Program development and administration • Data management • Contracting

10. Education • Pay for Participation • 2-3 Learning Sessions per year • 3 Regional Physician Group meetings each year • Result sharing and feedback from peers • Chronic Care Model: teamwork and tools • QI processes • Leadership development

11. Physician Leadership • CMO and four regional Medical Directors • Physician Quality Improvement Committee • Developmental process • Physician led board • Quality Improvement doctor in each office

12. Patient Services • Telephonic nursing support for high risk patients and patients with chronic illnesses • Home visit program in past • Transitional Care program to decrease readmissions • Tied closely to enhancement program • “Inside” operation

13. RMMC Enhancement Program • Continues to evolve over time • Physician designed and administered • Goals are quality improvement, cost reduction, and physician income enhancement • Incents both processes and outcomes • Uses single and composite measures

14. RMMC Enhancement Program • Includes HMO members that are formally associated with a PCP office • Also includes PPO members that are identified by a validated algorithm we developed • Penetration of over 20% in most of our offices • Earnings represent about a 10% increase in overall compensation

15. Diabetes Measures • Began with just an enhancement for measuring glycohemoglobin • Now includes a composite measure of glycohemoglobin under 7, LDL under 100, and urinary micro albumin measured and treated if abnormal • Separate measure for blood pressure under 130/80

16. Other Measures • CAD: LDL <100, on BB and ACEI/ARB’s where appropriate • CHF: BP <130/80, on BB and ACEI/ARB’s • Colorectal Cancer Screening • Breast Cancer Screening

17. Program Supports • Patient Services nurses working with a Diabetes specific module • Regular physician meetings with Patient Services with patient identification • Active use of reports available through the PMT to identify patients missing data and patients not at goal • Learning Sessions on starting insulin and on treating statin intolerant patients

18. Program Supports • Learning Sessions on talking to patients about changing their health behaviors • Referral to community resources including hospital based CDE programs • Regular regional doctor meetings with result sharing • Review of specific patient’s treatment with regional medical directors • Team meetings in offices to discuss progress amongst doctors and staff

19. Renaissance Operations

20. Our Clinical Staff • RMMC RNs collaborate with PCPs on chronic population • Care Modules: • Transitional Care • Diabetes • CHF • CAD • Respiratory • Falls Risk Assessment • Hypertension • Telephonic and home visit care models • Patient Discharge Partners Program for transitional care post hospitalization • Coordination of community resources

21. Our Proprietary Technology Tools • Population Management Tool (PMT) • Web-based, secure and compliant • Used by 100% of network practices to identify patients not at goal • Interfaces with QuestTM & LabCorpTM • Interfaces with EMR • Coordinated Care Tool • Provides clinical care management capabilities • Risk Assessment • Goal setting • Patient monitoring • Nursing documentation • Outcomes reporting

22. Impact on Compensation • PCP’s earn incentives for quality metrics • Via incentive payment, enhancement to fee schedule or capitation payments • Paid regularly • Gain share • Upside arrangement where payer and provider share in total cost savings • Paid annually based on total costs saved and allocated based on quality performance and membership

23. Dr. Ken Goldblum CMO and Practicing Physician Clinical quality performance

24. Results from Diabetes Program RMMC is an IPA in SE PA, using the tools and processes and pay for results model, the IPA has consistently delivered superior HEDIS results

25. …and Lower Disease Burden Progression-Diabetic Patients Well managed patients can lower the disease burden over time. In this case the population of the IPA had a higher disease burden in 2005 than the cohort group, while the progression of the risk scores would be expected with increasing age, the rate can be slowed by effective management reducing the event driven care, complications and intensity of the disease.

26. HMO Commercial Diabetes 120% 97% 96% 94% 93% 100% 90% 90% 89% 74% 80% 68% 54% 54% 51% 51% 60% 42% 40% 19% 13% 20% 0% HbA1c Testing Annual 9.0% 7.0% HbA1c < HbA1c > Testing Annual Cholesterol BP< 140/90 BP< 130/80 Monitoring Annual 100 LDL Nephropathy Cholesterol < RMMC National 90th HEDIS HMO DM Commercial

27. HMO Medicare Diabetes 120% 99% 99% 95% 100% 92% 90% 90% 88% 77% 80% 65% 63% 58% 60% 53% 52% 35% 40% 18% 20% 5% 0% Testing Annual HbA1c 7.0% 9.0% HbA1c < HbA1c > Cholesterol Cholesterol Testing < 100 LDL Annual BP< 140/90 BP< 130/80 Monitoring Nephropathy Annual RMMC National 90th HEDIS HMO DM Medicare

28. Disease PopulationCommercial Total PMPM Normalized to RMMC for 2005

29. Disease PopulationMedicare Total PMPM Normalized to RMMC for 2005

30. Disease PopulationCommercial Acute Re-admission Rate Normalized to Plan for 2005

31. Disease PopulationMedicare Acute Re-admission Rate Normalized to RMMC for 2005

32. Diabetes: Disease Population Commercial PMPM Normalized to RMMC for 2005

33. Diabetes: Disease Population Medicare PMPM Normalized to RMMC for 2005

34. Diabetes: Disease Population Commercial Acute Re-admission Rate Normalized to RMMC for 2005

35. Diabetes: Disease Population Medicare Acute Re-admission Rate Normalized to RMMC for 2005

36. Current Risk Scores: Medicare 5 years Continuously Diabetic & Under 80

37. Source of SavingsMedicare

38. Source of SavingsCommercial

39. What Doctors Learn Population Management QI processes Working in teams and using tools Result sharing Helping patients change their health behaviors

40. RMMC Conclusions It is possible to change PCP behavior but it takes about a 10% reimbursement bump Multiple avenues of support improve results The greater the degree of practice penetration the better Improved care of patients with chronic illness lowers costs

41. Questions?