a conversation about mgo and physician driven clinical integration who/what is mgo? what is clinical...

A Conversation About MGOand

Physician Driven Clinical Integration

Who/What is MGO? What is Clinical Integration? Why is MGO Clinically Integrating? When/How is MGO Clinically Integrating?

What’s it to you?John Schmeling, MDVP Physician [email protected]

1

mailto:[email protected]

Who? MGO is…

• 640 practices/groups in 32 Ohio counties– 501 (78%) of groups comprised of 1-3 physicians

• 2,001 physicians– 659 (33%) primary care physicians– 1342 (67%) specialists – all specialties

• > 150 Physicians engaged in leadership roles• MGO Physicians responsible for > 90% of

OhioHealth’s revenue

2

What ? MGO’s Mission

The Medical Group of Ohio (MGO) is an organization of health care professionals

working together, as a business, to improve the process of delivering health care and to enhance

the professional satisfaction of its members.

A physician business for –Quality–Enhancing Satisfaction

Obtain Fair Reimbursement Increase EfficiencyReduce Hassles Reduce Overhead

A physician business for –Quality–Enhancing Satisfaction

Obtain Fair Reimbursement Increase EfficiencyReduce Hassles Reduce Overhead

3

What ? Business Services

• MGO Practice Resources (MGO PR) – Billing/claims processing, coding, collections, group

purchasing, PMS and EMR, and more• Communications

– Written: MGO Update, Quality Matters, Business Matters, Burgundy Book

– Electronic: www.theMGO.com, MGO E-news • Professional Liability by Physicians for Physicians

(PLPP)– Physician owned and controlled professional liability program – Long term stability with rates based on MGO physician’s

experience

4

What ? Contracting – via OHG

50/50Ownership

andGovernance

A Physician-Hospital Organization

OhioHealth Group

Aetna, Cigna, Great West, and others

and

to the Market

OhioHealth Group

PhysiciansFacilities

5

What ? Clinical Integration A Definition

and

a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs.

6

Clinical Integration is characterized by an active and ongoing program to evaluate and modify practice patterns

Why ? Clinical Integration

To meet your needs in fulfillment of MGO’s Mission

• Purchaser’s/Market’s Expectations

• Legal considerations

• Prove, Improve and be Fairly Reimbursed for the Quality Care you deliver

7

Why ? Purchaser’s Expectations

What do you consider when you purchase something important?

• Quality• Cost

Quality/Cost = Value

• Service

As a purchaser, You want value!

8


The purchasers of health care want value too!

9

The Purchasers of healthcare

are increasing their

expectation / pressure for providers to: • Prove and improve quality• Decrease cost (or reduce the rate of rise) • Improve service / access

(government,

employers, patients, and plans)

10


• Evidence based care processes• Support for prevention and wellness• Effective management of chronic diseases• Measure/prove, communicate and improve

our performance

11

Why ? Purchaser’s Expectations- Quality -

• Reduce waste and needless repetition–Right service, right time, every time

• Support prevention and wellness –Primary and secondary–Coordinated with employer driven programs

• Increase efficiency

12

Why ? Purchaser’s Expectations- Cost -

• Utilize Information Systems – Enhance communication– Provide better, more timely information

• Provide Patient Centered Care– Comprehensive, Coordinated, Convenient and

Compassionate– Across many conditions, services and settings

13

Why ? Purchaser’s Expectations- Service -

Conclusion 1:

The best way for Physicians to meet the

purchasers’/market’s expectations is by

collaborative clinical efforts


14


To meet your needs in fulfillment of

MGO’s Mission



• Prove, Improve and be Fairly Reimbursed for the quality care you deliver

15

Why ? Legal Considerations- Anti-Trust -

• For the FTC to allow “competitors” to jointly negotiate as one, there must be a compelling Benefit– i.e. new product/service that meets market needs

16

• Two legal standards – at least one must be met– Clinical Integration– Financial Integration

• 2002 - sold the HMO– no longer financially integrated– not clinically integrated

17

Why ? Legal Considerations

• 1995 – 2001 MGO was financially integrated via 50% ownership of HealthPledge HMO – MGO negotiated contracts utilizing a single

signature contracting model

Financial Integration (financial risk)

• MGO delivers the payers, terms/rates, the message, to the physicians and then delivers the physicians’ individual responses back to the payer

18


• Negotiation (even commenting on the terms of the offer) is NOT allowed

Messenger Model

While the FTC doesn’t provide a precise definition or checklist for Clinical

Integration, there are a growing number of organizations the FTC has recognized as

clinically integrated.

19


MGO has been learning from them!

• New systems and programs to improve quality and efficiency

20

Why ? Legal ConsiderationsCharacteristics of FTC Recognized Programs

• Physician Standards of Care - develop, measure, provide feedback and assure compliance

• Commitment by physicians to participate in the systems and programs

• Investment of human and monetary capital

Every organization the FTC has

recognized as Clinically Integrated has

found collective negotiations to be

necessary in order to achieve these

characteristics.

21


Conclusion 2:

Physicians’ ability to attain fair reimbursement is related to their ability to negotiate

22


Conclusion 3:

To achieve Clinical Integration it may be necessary to negotiate on behalf of physicians


To meet your needs in fulfillment of

MGO’s Mission



• Prove, Improve, and be Fairly Reimbursed for the quality care you deliver

23


and


24


Programs to Evaluate and Modify Practice Patterns

How ? Prove, Improve, Reward

25

Pay for Quality (P4Q) Pilot Program

An employer, OhioHealth, wanted to work with MGO physicians to assure that a high

percentage of their associates / insureds received prevention and wellness services.

26


27

Quality of Care Measures for theOhioHealth Insured Patients (OHIPs)

P4Q PilotBreast Cancer

0%

50%

100%

2006 2007 Nat'l

67% 68% 67%

The proportion of female OHIPs age 40-64 having received a mammogram in the last 2 years.

Reference: U.S. Preventive Services Task Force Recommendation 2002

Cervical Cancer

The proportion of female OHIPs age 18-64 having received a Pap test during the last 3 years..


0%

50%

100%

2006 2007 Nat'l

68% 70% 80%

Colo-rectal Cancer

Reference: U.S. Preventive Services Task Force Recommendation (modified) 2002

0%

50%

100%

2006 2007 Nat'l

29% 35%43%

Preventive Health Visits

2008 Baseline for Rewards

The proportion of OHIPs having received at least one coded preventive health service visit last year.

0%

50%

100%

2006 2007

40%

Asthma

The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma last year.

Reference: HEDIS – modified 2007

0%

50%

100%

2006 2007 Nat'l

63%78% 90%

0%

50%

100%

2006 2007 Nat'l

A1C in Diabetics

For every 1% reduction in blood sugar level, the risk of developing eye , nerve or kidney disease is reduced by 40%

44%53%

88%

44%

28


P4Q Pilot

Cervical Cancer


0%

50%

100%

2006 2007 Nat'l

68% 70%80%

28

29


P4Q PilotBreast Cancer

0%

50%

100%

2006 2007 Nat'l

67% 68% 67%

The proportion of female OHIPs age 40-64 having received a mammogram in the last 2 years.


Cervical Cancer



0%

50%

100%

2006 2007 Nat'l

68% 70% 80%

Colo-rectal Cancer

Reference: U.S. Preventive Services Task Force Recommendation (modified) 2002

0%

50%

100%

2006 2007 Nat'l

29% 35%43%

Preventive Health Visits

2008 Baseline for Rewards

The proportion of OHIPs having received at least one coded preventive health service visit last year.

0%

50%

100%

2006 2007

40%

Asthma

The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma last year.


0%

50%

100%

2006 2007 Nat'l

63%78% 90%

0%

50%

100%

2006 2007 Nat'l

A1C in Diabetics

For every 1% reduction in blood sugar level, the risk of developing eye , nerve or kidney disease is reduced by 40%

44%53%

88%

44%

Patient Name Age

AKERS, BOB 50.3

BENDER III, TIM 44.9

BENDER, LORETTA 43.0

CLARK, KATHY 56.4

MCNAMARA, TONY 52.4

PORGE, SANDY 57.8

TAYLOR, MINDY 47.1

WILLIS, BETTY 48.9

Patient Counts 8 3 of 3 0 of 1 0 of 1 1 of 1 0 of 1 3 of 4 0 of 1 2 of 7

2 of 2 0 of 1 0 of 1 1 of 1 0 of 1 2 of 3 0 of 1 1 of 5

1 of 1 0 of 0 0 of 0 0 of 0 0 of 0 1 of 1 0 of 0 1 of 2

Target Performance for Bonus 38%0%

*

No

0% 0%

67%

69%

*

CECE

CECENo

YesNoNoCENoYesNoNo

YesCE

YesYes

YesNo

Yes

YesYes

20%

41%

68% 70% 44%

100% 0% 50%

No No

35% *

Preventive

Elig/Met Elig/Met Elig/Met Elig/Met Elig/Met Elig/Met Elig/Met Elig/Met

ColorectalOHG DIABETIC

COMBINEDHBa1C* LDL* Nephropathy* Mammogram

OH

CA

ETN

A

Your Performance

Your Performance

Your Performance (%) 100%

Pap

100%

*

0%

*

*Your Performance (%)

Target Performance for Bonus

100%

41%

0%

32%0% 0%

0%

68%

2009 Actionable Report on OhioHealth Insured Patients for Dr. SMITH DO, BILL FAMILY PRACTICE 5111111

Based on Claims Received and Paid as of 12/31/2008)

You are a MGO Physician

Instructions: Please review this report

For cells with a "Yes" - Congratulations as the service has been rendered and we have claims history on it.

For cells with a "No" - Consider a review of your records to confirm (to the best of your knowledge) a need for the service and then assist your patients in realizing same. If a service has recently (e.g. approximately the last three months) been performed, it may not show up on this report but will in future reports.

Note: Some patients will be listed on multiple physician reports - all receive "credit" when the patient receives the service.

* When diabetes is present, all 3 measures must be met (HBa1C, LDL, Nephropathy).

0

Aetna Patients

Not Eligible For Measure

Report Example: MGO physician report w/ Aetna patients. Shaded Performance % (Green = met/exceeded target, Red=Did not meet). Includes key for grey non-fields.

Actionable

Baseline Measures Forming the Standards of Eligibility for Rewards for

MGO Physicians Caring for OhioHealth Insured Patients (OHIPs)

The proportion of OHIPs having received at least one coded preventive health service visit in 2007. (99381 thru 99396)

The proportion of adult diabetic OHIPs having received all 3 of the following last year: 1) HBA1c test at least 2/year 2) annual LDL level and 3) annual urine microalbumin or prescribed an ACE/ARB

The proportion of female OHIPs age 18-64 having received a Pap test during 2005-2007.

Cervical Cancer Colo-rectal Cancer

The proportion of OHIPs age 50-64 having received either a fecal occult blood test in the last year, or barium enema, flexible sigmoidoscopy or colonoscopy since 2004

Preventive Health Visits Diabetes

The proportion of female OHIPs age 40-64 having received a mammogram in 2006 or 2007.

68 %68 %

Breast Cancer


Reference: U.S. Preventive Services Task Force Recommendation 2003 Reference: U.S. Preventive Services

Task Force Recommendation (modified) 2002

Asthma

70 %70 % 35 %35 %

38 %38 %78 %78 %44 %44 %

The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma in the previous year.


$11.80 $8.43 $22.62

$9.82 $20.57 $21.37

P4Q Pilot

31




Cervical Cancer


70 %70 % $8.43

P4Q Pilot

32



The proportion of OHIPs having received at least one coded preventive health service visit in 2007. (99381 thru 99396)

The proportion of adult diabetic OHIPs having received all 3 of the following last year: 1) HBA1c test at least 2/year 2) annual LDL level and 3) annual urine microalbumin or prescribed an ACE/ARB


Cervical Cancer Colo-rectal Cancer

The proportion of OHIPs age 50-64 having received either a fecal occult blood test in the last year, or barium enema, flexible sigmoidoscopy or colonoscopy since 2004

Preventive Health Visits Diabetes

The proportion of female OHIPs age 40-64 having received a mammogram in 2006 or 2007.

68 %68 %

Breast Cancer


Reference: U.S. Preventive Services Task Force Recommendation 2003 Reference: U.S. Preventive Services

Task Force Recommendation (modified) 2002

Asthma

70 %70 % 35 %35 %

38 %38 %78 %78 %44 %44 %

The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma in the previous year.


$11.80 $8.43 $22.62

$9.82 $20.57 $21.37

P4Q Pilot

33

Breas

t Can

cer S

cree

ning

Cervi

cal C

ance

r Scr

eeni

ng

Color

ectal

Can

cer S

cree

ning

0%

20%

40%

60%

80%

46%

70%

34%

68% 70%

35%

75% 76%

49%

2008 Baseline (claims through 12/31/07)2008 Target Performance (claims through 12/31/08)

MGO Physician Performance Preventive and Wellness Measures

(based on claims paid through 10/31/08)P4Q PilotMulti-Year Measures

34

Comparison of Compliance Rates for Preventive and Wellness Measures Based on claims paid through 12/31/2008

Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening

0%

10%

20%

30%

40%

50%

60%

70%

80%

46%

70%

34%

68% 70%

35%

75% 76%

49%

Multi-Year Measures

2008 Baseline (claims through 12/31/2007)2008 Target Claims through 12/31/2008

Com

plia

nce

Rate

Preventive Visits Asthma Management Diabetes Management

0%

20%

40%

60%

80%

100%

120%

0% 0% 0%

44%

78%

38.%

51%

100%

28%

One-Year Measures

2008 Baseline (claims through 12/31/2007)2008 Target Claims through 12/31/2008

Com

plia

nce

Rate

35

Conclusion 4:The pilot program is demonstrating marketable quality improvement results

How ? Clinical Integration Prove, Improve, Reward

36

Conclusion 5: Clinical Integration program can work well for physicians – both in quality and fair reimbursement


and


37


Programs to Evaluate and Modify Practice Patterns


38

Clinical Guidelines

• Evidence based

How ? Clinical Guidelines

39

• Developed/modified by MGO physicians

• Accountable, via measurement


40

Many more to follow• Broad clinical array

– Specialty and Primary Care– Inpatient, Ambulatory and Office related

• Market and data driven

First 5 have been established• Asthma and Diabetes Management• Cancer Screening – Breast, Cervical and Colo-rectal

• Add other Data Sources, potentials include– Physician Office 100% of your patients– Hospital, ……….


41

It’s ALL about DATA

Data Warehouse• Start with Claims Data

– Employer (OhioHealth) 20,000 patients– Payer (Aetna) 60,000+ patients

Conclusion 6:Clinical guidelines and their supporting data are a framework around which MGO physicians can Prove, Improve, and be Fairly Reimbursed for the Quality care we deliver

42

Conclusion 7:Clinical Integration provides MGO physicians the opportunity to distinguish themselves in the market based on quality and value



and


43

Clinical Integration is characterized by an active and ongoing programs to evaluate and modify practice patterns

Interdependence and Cooperation

Among Physicians


44

Non-clinical Metrics and Rewards

• Develop interdependence and cooperation

How ? Non-Clinical Metrics

45

• Build infrastructure - to support quality/cost initiatives

• Metrics/rewards for physicians in specialities where clinical metrics are not yet developed

• Data capture

MGO’s Clinical Integration is available to ALL MGO physicians

Examples being considered


46

• High speed internet; ORB use• Secure messaging through a common web

portal, etc.• Use of E-prescribing or Disease Registries• Intra-MGO referrals

And get rewarded for meeting non-clinical metrics

Conclusion 8:

Non-Clinical metrics can build infrastructure that supports the ongoing development and implementation of Clinical Integration

47


Conclusion 9:

Non-Clinical metrics allow all MGO physicians to participate in and be rewarded by our Clinical Integration program from the outset

What ? Your Role?

Participate now by: • Remain attentive to communications • Engage in developing/utilizing MGO practice

guidelines • Reinforce the importance of and your commitment

to Clinical Integration • Refer to other MGO physicians

More steps in the future

48

When ? Timeline

• Steps in Progress• Spring - Summer 2009

– Finalize initial criteria for participation– Communicate our pilot results to the market

• Summer - Fall 2009– Be prepared to deliver our new Clinically

Integrated product to the market

49

Conclusion 10:

Clinical Integration is attainable for me and my practice

50

When ? Timeline

Conclusion 11:

Clinical Integration is a realistic goal and has an achievable timeline for initial implementation

Edward T. Bope, MD Chair Family Practice Dale A Michalak, MD Vice Chair Family Practice Carl A. Krantz, MD Treasurer Obstetrics/GynecologyMaurice C. Mast, MD Secretary Internal Medicine Kevin J. Anderson, MD Internal Medicine David T. Applegate, II, MD Family Practice Gregory A. Barrett, MD Pediatrics Nicholas J. Davakis, MD Cardiovascular Disease Steven B. Duff, MD Thoracic Surgery Dennis Flynn, MD Family Practice Daniel C. Hiestand, MD Anesthesiology Jeffrey T. Innes, MD General Surgery Howard B. Levin, DO Cardiovascular DiseaseLarry J. Lilly, MD General Surgery James J. Powers, MD Physical Medicine/Rehabilitation Barbara B. Rayo, MD Pediatrics Steven A. Santanello, DO General Surgery Terry S. Slayman, MD Family Medicine Michael Sprague, MD Obstetrics/Gynecology Kendall L. Stewart, MD PsychiatryCassandra Suggs, MD Family Practice

2008 MGO Board of Managers

51

Thoughts ! Comments !Questions ?

52

a conversation about mgo and physician driven clinical integration who/what is mgo? what is clinical...

Documents