the sccipa story 24 jan12

theSCCIPAstorywaynepanmdmbachief medical officer

SCCIPAA Pacific Partners Medical Group

Early ACO learnings from the “Left Coast”

Who is?

Individual Practice Association Medical Group of

Santa Clara County

SCCIPA

largest IPA in Santa Clara County

Santa Clara Countysize 1,304.01 sqmilespop 1,781,642 (2010)

medianincome $74,335

5 PCP80 Specialists

57 PCP104 Specialists



SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)Anthem Commercial ACO pilot (2011)

SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)Anthem Commercial ACO pilot (2011)

urban/suburban

rural

130,000patients

76,000 commercialACO

50,000 commercialHMO

5,000 MedicareHMO

nooriginal Medicare,

Medi-Cal,CHIP, uninsured

= managementservicesorganization

casemanagementmedicalmanagementnetworkmanagement

qualityimprovement

grievance&appeals

clinicaldataanalytics&reporting

compliance&auditing

claims&encounterprocessing

providercontracting

credentialingmemberservices

marketingoutreach

ITservicesfinance&riskmanagement

partialrisk

managingDOFR

ivisionfinancial esponsibility

DOFR

outpatientservices

inpatientservices

capitatepcps

specialistspaidffs

performancebonus

IHAP4P&HCC

IPAcitizenship

= softwareservicescompany

Access ExpressTMExUtilizationManagement

CaseManagement

QualityManagement


Access ExpressTM

ExcelicareTM


Coordinated Care Platform

ExcelicareTM ClinicalIntegrationEngine

QualityManagementAccess ExpressTM

CaseManagementAccess ExpressTM

UtilizationManagementAccess ExpressTM

130,000patients

“Living Laboratory”

130,000patients

peopleprocessesplatform

4groupsofpeople

physicians

physicianofficestaff

medicalmanagementstaff

healthplanstaff

teamsport

howdoteamsworkbest?

communicate

communicatecollaborate

communicatecollaboratecoordinate

skatetowherethepuckwillbe

Walter Gretzky(Wayne Gretzky’s father)

communicatecollaboratecoordinateanticipate

playbook

careplan

coach?

managedcare:PCP

unmanagedcare:?

hospitalistsSNFistsonsite case managerscomplex case managersutilization review staff

people:IPA/MSO

patientcenteredness

MIND THE GAP

carecoordinationandtransitions

hospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP

peopleprocesses

SNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP

peopleprocesses

onsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs

peopleprocesses

complex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks

peopleprocesses

utilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement

peopleprocesses

primary care physiciansspecialistsancillary providers

people:physicians/staff

primary care physiciansspecialistsancillary providersfront office staff

people:physicians/staff

case managersdisease managersmember outreachbenefit design

people:plan staff

communicatecollaboratecoordinateanticipate

peopleprocessesplatform

peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedback

peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own data

peopleprocessesplatformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback/enter their own data

more than an EHRmore than an HIE

clinicalintegrationengine

virtually integrated healthcare delivery system

designphilosophy

“put hot triggers in the path of motivated people”BJ Fogg, PhDDirector, Persuasive Technology LabStanford University

TRIGGERS: Are people being triggered at the most appropriate time and in their workflow (path)?

ABILITY: Have I made it easy for people to act? How can I make it even simpler?

MOTIVATION: Are incentives aligned properly? How can I increase their motivation?

patient

front desk staff

patient

front desk staffanalog to digitalconverter

analog to digitalconverter

eligibility check

MARY SMITH1234567890

1121/1/2011

$5.00$10.00$25.00

analog to digitalconverter

Click here to registerfor a password or

request more information

Powered by Access ExpressQ-v5.0.#.0.1 Build 2011.04.04.00

QualityManagementAccess ExpressTM

ACCESSEXPRESSQ New Message (3)New Eligibility Response


ANTHEM BLUE CROSS


IN THE PATH

ANTHEM BLUE CROSS

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890

MAMMOGRAPHY, CRC, CARDIO CARE,DIABETES CARE, HYPERTENSION,

GLAUCOMA, MED MONITOR, FLU VAC,PNEUMO VAC, DEXA, OSTEOPOROSIS,

RHEUM, COPD

POP-UP

digital to analog converter module

digital to analog converter module

x

xx

xxx

x

x

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD CLICK HERE

ANTHEM BLUE CROSS

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD

HOT TRIGGER

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD

ENABLINGFRONT OFFICE

STAFF

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD

SIMPLECARE PLAN

BLUE SHIELD OF CA


BLUE SHIELD OF CA

SMITH, MARY

8/15/1945

1234567890



RHEUM, COPD


MOTIVATIO

N

Description ofmeasure

Capability forphysician officeentry

Capability forphysician officeentry

ABILITY

weare

here

from: missclaudiawong.blogspot.com (January 30, 2011)

our healthcare journey

4x4 healthcare

4processes

4dimensionaldata

x

PCPs

Specialists

Patients

CaseManagers

anticipation collaboration

communication

coordination

behavioraladministrative

financial

clinical

reactivecare

$$$$$$

predictive

proactivecare

From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all

SCCIPAresults

53.6%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

Nov%2009%

Dec%2009%

Jan%2010%

Feb%2010%

Mar%2010%

Apr%2010%

May%2010%

Jun%2010%

Jul%2010%

Aug%2010%

Sep%2010%

Oct%2010%

Nov%2010%

Dec%2010%

Jan%2011%

Feb%2011%

Mar%2011%

Apr%2011%

May%2011%

Jun%2011%

Jul%2011%

Aug%2011%

Sep%2011%

Oct%2011%

Total%C%All%Health%Plans%

'11%C%Loosely%Managed%

'11%C%Moderately%Managed%

'11%C%Well%Managed%

Commercial*ADM*%

commercialadmits/1000

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11

Milliman ’11 Well-Managed

Milliman ’11 Moderately-Managed

Milliman ’11 Loosely-Managed

SCCIPA

175.5%

150.0%

175.0%

200.0%

225.0%

250.0%

275.0%

Nov%2009%

Dec%2009%

Jan%2010%

Feb%2010%

Mar%2010%

Apr%2010%

May%2010%

Jun%2010%

Jul%2010%

Aug%2010%

Sep%2010%

Oct%2010%

Nov%2010%

Dec%2010%

Jan%2011%

Feb%2011%

Mar%2011%

Apr%2011%

May%2011%

Jun%2011%

Jul%2011%

Aug%2011%

Sep%2011%

Oct%2011%

Total%@%All%Health%Plans%

'11%@%Loosely%Managed%

'11%@%Moderately%Managed%

'11%@%Well%Managed%

Commercial*BDAYS**commercialbeddays/1000

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

3.3#

2.5#

3.0#

3.5#

4.0#

4.5#

Nov#2009#

Dec#2009#

Jan#2010#

Feb#2010#

Mar#

Apr#2010#

May#

Jun#2010#

Jul#2010#

Aug#2010#

Sep#2010#

Oct#2010#

Nov#2010#

Dec#2010#

Jan#2011#

Feb#2011#

Mar#

Apr#2011#

May#

Jun#2011#

Jul#2011#

Aug#2011#

Sep#2011#

Oct#2011#

Total#A#All#Health#Plans#

'11#A#Loosely#Managed#

'11#A#Moderately#Managed#

'11#A#Well#Managed#

Commercial*ALOS*commercialalos

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

!274.6!!

!200.0!!

!250.0!!

!300.0!!

!350.0!!

Nov!2009!

Dec!2009!

Jan!2010!

Feb!2010!

Mar!2010!

Apr!2010!

May!2010!

Jun!2010!

Jul!2010!

Aug!2010!

Sep!2010!

Oct!2010!

Nov!2010!

Dec!2010!

Jan!2011!

Feb!2011!

Mar!2011!

Apr!2011!

May!2011!

Jun!2011!

Jul!2011!

Aug!2011!

Sep!2011!

Oct!2011!

Total!C!All!Health!Plans!

'11!C!Loosely!Managed!

'11!C!Moderately!Managed!

'11!C!Well!Managed!

Medicare(ADM(!

medicareadmits/1000

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

!1192!!

800!

1,000!

1,200!

1,400!

1,600!

1,800!

Nov!2009!

Dec!2009!

Jan!2010!

Feb!2010!

Mar!2010!

Apr!2010!

May!2010!

Jun!2010!

Jul!2010!

Aug!2010!

Sep!2010!

Oct!2010!

Nov!2010!

Dec!2010!

Jan!2011!

Feb!2011!

Mar!2011!

Apr!2011!

May!2011!

Jun!2011!

Jul!2011!

Aug!2011!

Sep!2011!

Oct!2011!

Total!A!All!Health!Plans!

'11!A!Loosely!Managed!

'11!A!Moderately!Managed!

'11!A!Well!Managed!

Medicare(BDAYS*(medicarebeddays/1000

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11




SCCIPA

!4.3!!

3.5!

4.0!

4.5!

5.0!

5.5!

6.0!

Nov!2009!

Dec!2009!

Jan!2010!

Feb!2010!

Mar!

Apr!2010!

May!

Jun!2010!

Jul!2010!

Aug!2010!

Sep!2010!

Oct!2010!

Nov!2010!

Dec!2010!

Jan!2011!

Feb!2011!

Mar!

Apr!2011!

May!

Jun!2011!

Jul!2011!

Aug!2011!

Sep!2011!

Oct!2011!

Total!B!All!Health!Plans!

'11!B!Loosely!Managed!

'11!B!Moderately!Managed!

'11!B!Well!Managed!

Medicare(ALOS(




medicarealos

JAN10

APR10JU

L10

OCT10

JAN11

APR11JU

L11

OCT11

SCCIPA

0.0%$

2.0%$

4.0%$

6.0%$

8.0%$

10.0%$

12.0%$

14.0%$

16.0%$

18.0%$

20.0%$

12$Mo$thru$2009Q4$

12$Mo$thru$2010Q1$

12$Mo$thru$2010Q2$

12$Mo$thru$2010Q3$

12$Mo$thru$2010Q4$

12$Mo$thru$2011Q1$

12$Mo$thru$2011Q2$

12$Mo$thru$2011Q3$

12#Mo#Rolling#Readmits#%#by#Quarter#

Commercial$Acute$ Medicare$Acute$

readmissions%byquarter

*

*

***

increase/same scores in 21 of 26 measures

When you improve a little bit each day, eventually big things occur. Don’t look for big, quick improvement. Instead, seek small improvement one day at a time. That’s the only way it happens - and when it happens, it lasts.

John Wooden

iteration

Virtually nothing comes out right the first time.Failures, repeated failures, are finger posts on the road to achievement. The only time you don’t want to fail is the last time you try something. One fails forward toward success.

Charles F. Kettering

don’t be afraid to FAIL....

failfast

what’snext?

shareddecision-making

unmanagedcare?

careplantoeverytouchpoint

incentivizecareteam

measurecompliance

includepatient

createdynamiccareplan

distributedpcmh

patientaspcp

patientself-coaching

carepch

CLINICALDATA

ADMINDATA

BEHAVIORDATA

PATIENTCOLLECTED

DATA

patientcaregivers

providerscare team

data integration/analysis

care plan

care planadapted from Mary Cain’s diagram (HT3.com)

Patient flow Technology

adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)

WhoLocation



WhoLocation

Assessment

MeasurementClinical Data

Care Plan Development

Care Plan Implementation

Re-assessment

PCP’s office

PCP’s office

PCP’s office

PCP’s office

patient

PCP

PCP

PCP

PCP

PCP & patient

paper/EHR

paper/EHR

paper/EHR

paper/EHR

paper/EHR



WhoLocation

Assessment




Re-assessment

PCP’s office

PCP’s office

PCP’s office

PCP’s office

patient

PCP

PCP

PCP

PCP

PCP & patient

paper/EHR

paper/EHR

paper/EHR

paper/EHR

paper/EHR

AE/EC

AE/EC



WhoLocation

Assessment




Re-assessment

PCP’s/careteampatient paper/EHR

paper/EHR

paper/EHR

paper/EHR

paper/EHR

AE/EC

AE/EC

PCP’s/careteampatient



patient








WhoLocation

Assessment

ContinuousMeasurement

Clinical/Personal Data

Care Plan Development w/SDM


ContinuousRe-assessment


paper/EHRAE/EC

paper/EHRAE/EC




patient






paper/EHRAE/EC

paper/EHRAE/EC

paper/EHRAE/EC

promotoras

CHF Patient Technology

PCPAE/EC

FUTURE PATIENT ENGAGEMENT STRATEGY

mobile app

data integra

tion&

analysis

track symptoms

track diet

track weight

track other behavior

mobileapp

wirelessscale

clinicaldata

patient

dynamiccareplan

medadherence

data

& CareTeam

caregiver

mobile app

mobile app

mobile app


DYNAMIC CARE PLAN STRATEGY

clinicalcombineclinical

&patient

data

AE/EC

patientID

match

patientcollected

evidence-based

algorithm

adjust care plan

clinical

patient

mobile app

mobile app

AE/EC

a patient-centered, evidence-based, high-quality,cost-effective, sustainable, healthcare delivery model

?From: Dan Roam, “American Healthcare: a 4-napkin explanation”www.slideshare.net/danroam/healthcare-napkins-all

get out of the rut

keep doing the same thing?

insanity: doing the

same thing over and over

and expecting different

results

think about...

transformedhealthcare

questions2

how will the patient benefit from this?

does this make it easier for the patient?

welcome tohealthcare2.0

[email protected]

Thank you!

WWW.SNOOPY.COM

the sccipa story 24 jan12

Health & Medicine