Accountable Care Organizations: Perspectives from the Billings Clinic Experience

1. Accountable Care Organizations: Perspectives from the Billings Clinic Experience Montana HealthCare Forum November 28, 2012 Helena F. Douglas Carr, MD, MMM Medical Director, Education & System Initiatives

2. Physician Group Practice Demonstration 2005-2010The Alpha Medicare ACO

3. 10 Organizations Physician Group Practices Everett, WA – Everett Clinic Marshfield, WI – Marshfield Clinic Integrated Delivery Systems Academic Medical Center Springfield, MO – St Johns Danville, PA-Geisinger Billings, MT-Billings Clinic St. Louis Park, MN – Park Nicollet Winston-Salem, NC-Novant-Forsyth Ann Arbor, MI - University of Michigan Bedford, NH-Dartmouth Hitchcock Physician-Hospital Organization Middletown, CT – Integrated Resources for Middlesex Area (IRMA)

4. Common Basis for Strategies among the PGP Groups 1. Focus: High Cost Areas Components of Medicare Expenditures For Billings Clinic (base year 2004) Inpatient 40% Hospital OP 24% Part B 22% SNF 7% Home Health 3% DME 4% Reduce avoidable admissions, ER visits, etc. 2. Focus: Chronic Care & Prevention High prevalence and high cost conditions Provider based chronic care management Care transitions Palliative care Financial Savings are INPATIENT driven. Quality Measures are OUTPATIENT driven.

5. Heart Failure Diabetes Billings Clinic PGP Year 5 Coronary Artery Disease HTN, Screening, Prevention

6. “A detailed analysis of the demonstration is currently available only for the first two years. That analysis showed that, for patients in the 10 group practices during the 2nd year, average Medicare spending excluding the bonuses paid to physician groups was about 1 percent below projections…similar estimates are not yet available for other years…”

7. Summary Results

10. How The PGP (2005-2010) Influenced the Development of ACOs

11. Comparison of Shared Savings Models

12. Growth and Dispersion of Accountable Care Organizations November 2011 ACOs BY SPONSORING ENTITY “The range of entities that have sponsored ACOs, from small IPAs to national insurance companies indicates the wide range of business models that will ultimately provide accountable care.” “It appears, for now, that defining oneself as an ACO represents an acceptance of the direction the industry has been headed rather than an adoption of a truly new form of care delivery.” • Medicare SSP has lead to commercial adoption of ACOs • Market specific clustering of activity • Basic tenets of accountable care previously existed; title is new

13. Growth and Dispersion of ACOs November 2012 30 SS-2 sided FFS Capitation Episode/DRG 34% 36% 30%

14. Many ACOs are reimbursed on a Shared Savings model based on Spending Targets ACO Launched Projected Spending Target Spending Shared Savings Actual Spending

16. Movement Towards ACO Raises Key Questions What is the COST impact of delivering accountable care? What is the REVENUE impact of delivering accountable care? What is the COST impact of building an ACO? How do you manage the hospital and physician relationship through transition to an ACO? How do you manage two parallel entities through the transition? How do you manage the pace of that transition? Current FFS System Accountable Care Organization 16

17. The Bridge from FFS to Accountable Care What are the underpinning building blocks? Current FFS System Accountable Care Foundational Philosophy: Triple Aim™ Measurement 17

18. The ACO Model A group of providers willing and capable of accepting accountability for the total cost and quality of care for a defined population. • Core Components: • People Centered Foundation • Health Home • High-Value Network • Population Health Data Mgmt • ACO Leadership • Payor Partnerships • Payer Partners • Insurers • Employers • States • CMS 18

19. Why PCMH within ACO? • Emphasizes prevention • Encourages cognition/relationship over technology • Less variation in utilization • Allows for most efficient delivery methods: allied professionals, phone, e-mail, web-enabled • Proven concept in other modern nations, staff-model HMOs • Access closest to patients • Promotes shared decision making • Leverage point for post-hospital care

20. Montana Patient Centered Medical Home Initiative www.csi.mt.gov/medicalhomes

21. BCBSMT PCMH Program • Begun in 2009 with Western Montana Clinic (St. Patrick Hospital) and Billings Clinic. • Added St. Patrick’s, CMC, Kalispell, Bozeman, and St. Vincent’s 2010-2011. Added Northern Montana Hospital and South Hills Medical Group in 2012. • Planning to add St. Peters, Benefis, Holy Rosary. • Limited to PCP providers with access to EMR. • 2009/2010: Chronic disease only. • 2011 and beyond: Chronic disease and preventative care.

22. PCMH-Physician Groups(*=active)

23. 2012 BCBSMT PCMH Program Chronic Diseases Preventative Care

24. BCBSMT-PCMH Early Trends PCMH All other PCPs

26. PCMH Perspectives Provider Payer Patients

28. Questions?