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“The Integrator”Accountable Care Across the Continuum

BRENDA BRUNS, MDEXECUTIVE MEDICAL DIRECTOR, HEALTH PLAN

ACHP Medical Directors, March 2, 2011

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Who We Are Founded 1947

– Financing & Delivery System– Consumer Governed, Not for Profit

Washington and North Idaho

675,000 Members/patients– Group Practice GH Physicians – 2/3– Contracted Network - 1/3

1,281 Providers (27 Different Specialties) in Group Practice

– 26 Primary Care sites/4 Multispecialty sites

Contracts with 6,000 physicians & 44 hospitals

$23.4M Research Grants (2008)

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The Integrator’s RoleResponsible for the Triple Aim

Partnership with Individuals and Families

Redesign of Primary Care

Population Health Management

Financial Management

Macro System Integration

Proprietary - do not duplicate

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Group Health Goals & Tactics

A major component of Group Health’s 2007-2012 strategic plan is to achieve a significant (~10%) cost advantage over leading competitors

Tactics to “bend trend” include:

System wide primary care medical home deployment

Emergency department/hospital inpatient utilization (EDHI)

Shared decision making/preference sensitive conditions

Content of care/clinical variation

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•Clinical Integration Model

Our current strategies are a necessary foundation

• Benefit design

• Contracting

• EDHI

• Content of Care

• Medical Home

• Clinical Integration (CI) takes a ‘value stream’ approach for the development and management of a competitive, cost effective network

• CI model includes strategies to evaluate and modify network physicians’ practice patterns and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.

• The program would result in a competitive network that relies on strong contracted relationships as well as unique features of the Group Practice to create a distinctive experience for GH members

Evolving to a “Macro” Clinical Integration Model

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Information systems

Entire care team has real-time transparency about patients, with effective coordination

Patients supported to manage their own care, driven by proactive outbound treatment

Patient centered

Collaborative organizations that are under clinical leadership with aligned management systems and cultures

Practice structure

A single, coordinated, transparent, and evidence-based approach to patient care that supports continuous improvement

Common care approach

Community partners

A broad set of community stakeholders that are fully aligned on a common care model

Payment structures

The right payment structures in place to drive alignment on a common care approach

Care Model for Clinical Integration

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…each of which have specific enabling sub-components

Practice structure

– Leadership roles– Management systems– Practice locations– Care team culture

Payment structures

– Salary components– Incentive structures for

patients and providers– Benefit design

Patient centered

– Self-management tools and motivation

– Patient education, knowledge, and skills

Common care approach

– Clinical vision– Care team structure– Common care processes– Performance management– Population management

Information systems

– Tools and functionality– Physical location and

accessibility of tools

Community partners

– Coordinated efforts for wellness

– Care extension

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Group Health ACO Strategy

Form key provider partnerships in major markets to control EDS trend and expand Group Health medicine more broadly into the communities we serve

Deploy and build in our best clinical practices; primary and specialty care; information technology; care management; premium, contracts, membership and claims administration; marketing and sales capability as infrastructure to support the partnership network

Build a financial model which yields profitable growth in every market through best medicine at the lowest per capita cost

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Strategy and Goals

• Grow the Group Practice by expanding our footprint in markets and through clinical integration with strategic partners

• Engage in markets through a continuum of clinical integration models that control financing and delivery of care

• Growth in market share through a coherent network that is attractive and affordable to our members

• Improve per capita cost through selective and enhanced strategic partnerships

• Improve quality of care through reduction of clinical variation throughout the delivery system

• Increase Group Health’s influence on the member experience and how care is delivered

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GH Delivery System

ACO Structure &Management

Medical Management/Clinical Integration

Functions

Delivery of Care/Integration of Delivery System Functions

Key hospital partners

Key Medical Group

PartnersHospital

Multi-Specialty

Other

Products

Rep

ortin

g

Ph

ysician

Perfo

rman

ce (P

rofilin

g)

IT: EMR connectivity,

Meaningful Use

Netw

ork D

esign

Group Health ACO Structure

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Group Health as IntegratorFinancial stability Contracting support Business expertise Clinical initiatives and pay-for-performance

Patient services and programs Consulting Nurse Service Case management and outreach services Health and wellness programs Hospitalist programs Community health care programs/initiatives

Urgent care access Take Care Stores (on-line ordering) Physician continuing medical education

Access to medical practice support services

Health insurance Purchasing network – medical/surgical

supplies Vaccine programs

Access to clinical quality programs, tools and expertise

Disease predictive modeling, registries and management protocols

Evidence-based tools and clinical practice guidelines

Patient population research Patient safety monitoring and reporting Collaboration on clinical quality initiatives Shared best practices

Access to technological leadership and support Electronic health record E-prescribing On-line patient tools: email physicians, prescription

refill, request appointments, online records

Access to patient partnership programs Healthy living and wellness resources Shared decision-making materials Preference-sensitive care Patient health education courses

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Necessary Internal Competencies

Knowledge about fee-for-service medical practices

Knowledge about new contracting models

Portability of business model

Data capability to provide transparency

Revised infrastructure to support a CI model

Grouper approaches in reimbursement

Marketing capabilities of care effectiveness

Risk tolerance

Expertise on legal models for integration

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MAKING IT WORK

Aligned financial incentives that promote collaboration across the

continuum of care

Payment reform from pay for volume to pay for value

Common medical management

Shared values

Cultural change

Community partnerships

Administrative simplicity

Consistent patient experience

Management of patient flow and transitions

Electronic medical records for coordinated care

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Essential Characteristics of Strategic Partners

Same philosophy of care

Level of IT commitment

Using common standards and practice guidelines

Commitment to an integrated patient care revenue model (vs. acute care / FFS revenue model)

Sharing performance data

Providing preferred access to GH enrollees

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Going Forward

Developing standard process to assess markets in which we operate.

Includes evaluation of market demographics & trends; current delivery systems in those markets, our performance in those markets; forecast of goals for that market

A set of criteria that can be used to evaluate "potential fit" of potential partners with GHC's care philosophy

Business model that can forecast number and type of primary care and specialty providers to serve projected volumes

New Payment Models

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Adjust Strategy to Provider Environment

Single hospital, current state includes challenging contracting relationship

Single hospital unsure/uninterested regarding ACO’s

Community wherein single hospital is purchasing key medical groups to form ACO

Multiple hospital communities without ACO development

Multiple hospital communities with developing ACO’s by one or more players

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ACO Approach

High Performing Tiered Network Program (Build)

Goal: Development of a state-wide tiered network based on Group Practice as the first tier

Includes market analysis, build out of network, product design, and branding and marketing

ACO Integrator Program (Manage)

Goal: Provide centralized services and performance management for local market ACOs to ensure a consistent patient experience and improve quality and cost across the network

Includes business structure, support systems and infrastructure, partner on-boarding and development, clinical protocols and pathways

Local Market ACOs Program (Operate)

Goal: To develop an integrated delivery system within a local market through expansion of the Group Practice footprint and/or strategic alliances with key business partners that delivers care within Group Health’s organizing principles Includes local ACOs processes and support structures, local clinical integration of delivery system

Management Guidance Team Executive Leadership

Core TeamImplementation