Clinical Integration UpdateMichele Madisonmmadison@mmmlaw.com404-504-7621

Clinical Integration

• The integration of clinical information and healthcare delivery services from distinct entities.• Continuum of care, including preventative,

outpatient, inpatient acute hospital and post-acute care to improve the value of care provided• Ultimately designed to achieve Triple Aim• Improving Population Health• Reducing Costs• Improving the Experience of Care

Clinical Integration Models

Accountable Care Organizations

Hospitals and Physicians

Physicians

Healthcare Systems and Health Plans

ACO• Recognized under State Law as Legal Entity with a TIN.• Governing Body must have 75% representation from ACO

members.• Financial and clinical integration.• A leadership and management structure that includes

clinical and administrative systems.

“Better health care for individuals” defined as health care that is safe, effective, patient-centered, timely, efficient, and equitable

Georgia ACOs• Accountable Care Coalition of Central Georgia, LLC

Accountable Care Coalition of DeKalb, LLCAccountable Care Coalition of Georgia, LLCAccountable Care Coalition of Greater Athens Georgia II, LLCAccountable Care Coalition of Greater Augusta & Statesboro, LLCAccountable Care Coalition of Southern Georgia, LLCAccountable Care Coalition of Western Georgia, LLCMorehouse Choice ACO-ESThe Premier Health Care Network, LLCMeridian Holdings, Inc.WellStar Health Network, LLCAccountable Care Coalition of Coastal GeorgiaAccountable Care Coalition of Greater Athens Georgia

Breakdown of ACOs

Networks of Individual Practices 121 55% Group Practices 90 41% Hospital/Professional Partnerships 66 30% Hospital employing ACO 44 20% professionalsFederally Qualified Health Center 15 7% Rural Health Clinic 11 5% Critical Access Hospital 4 2%

Bundled Payment1. Episode of care as the acute care hospital stay

only (Model 1), 2. The acute care hospital stay plus post-acute care

associated with the stay (Model 2), 3. Just the post-acute care, beginning with the

initiation of post-acute care services after discharge from an acute inpatient stay (Model 3).

4. A single, prospective bundled payment that would encompass all services furnished during an inpatient stay by the hospital, physicians and other practitioners.

Norman Oklahoma PHO• 280 participating physicians and the hospitals in the

Norman Regional Health System

• Horizontal Agreements to Provide Services among Competing entities

• Collaborative clinical activities, • clinical practice guidelines;• physician performance measures; • conducting peer review and corrective action

processes, and • designing and implementing quality improvement

initiatives

St. Lukes –Saltzer Medical Group• St. Luke’s . . . “are to be complimented on their

foresight and vision.”• Acquired Physician practices and . . .• went one too far . . .

• Provided 80% of Primary Care Providers in Service Area• Could have negative impact on managed care

negotiations notwithstanding the improvement in patient outcomes• Courts Ordered Divestiture

Lessons Learned

• Interdependence of Physicians is important• Must include Quality Reporting/Metrics• Independent Negotiation of Rates• Reduction of Costs• Joint Contracting is Subordinate • Patient Satisfaction Improvement

Beyond Medicare/Medicaid

Third Party Payers are also supporting Clinical Integration

BCBS partnership with Emory for ACOChanges in the payer marketplace

United Purchases Physician PracticesHumana Purchases ConcentraCigna Opens Alternative Physician Practices

Disclaimer• The materials and information presented and contained

within this document are provided by MMM as general information only, and do not, and are not intended to constitute legal advice.

• Any opinions expressed within this document are solely the opinion of the individual author(s) and may not reflect the opinions of MMM, individual attorneys, or personnel, or the opinions of MMM clients.

• The materials and information are for the sole use of their recipient and should not be distributed or repurposed without the approval of the individual author(s) and Morris, Manning & Martin LLP.

• This document is Copyright ©2011 Morris, Manning & Martin, LLP. All Rights Reserved worldwide.