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Collaborative Healthcare Models
Objectives/Challenges Require Collaboration 
2 
Common Objectives 
• 
Need to demonstrate success and build awareness around quality, service and efficiency results 
• 
Make it easy for members / patients to navigate the system 
• 
Engage and motivate members through proactive on-boarding, outreach, and navigation resources 
• 
Reduce network leakage 
Common Challenge 
• 
Consumers are skeptical 
• 
By definition, new models are generally unproven and limited 
• 
Fragmented clinical decision making is still the norm 
Countering Skepticism 
• 
Collaboration model, resources, reputation, and data must support capabilities 
• 
Care teams must engage patients through physician- driven population health programs and proactive member/beneficiary support services 
• 
Early identification of at-risk patients by sharing data and delivering impactful disease management resources is key
Trends Supporting Collaborative Models 
• 
Current trends are placing pressure on physicians to 
- 
Use health information technology 
- 
Develop resource intensive care management processes 
- 
Seek help in groups 
- 
Retire 
• 
Physicians are seeking help to alleviate administrative and financial challenges. 
• 
Without infrastructure and support, physicians become the most qualified but the least equipped to lead. 
• 
Volume, revenue, and physician relationships are at risk 
• 
Hospitals must have engaged physician partners to drive sustainable clinical process improvement 
• 
To date, some ACOs have achieved savings in part by excluding hospitals 
• 
“Hospitals want to do robotic surgeries, heart catheterizations, PET scans, MRIs—all the expensive items. We actually felt that hospitals were part of the problem.” William Biggs, MD CEO Amarillo Legacy Medical ACO 3 
• 
Cigna, Aetna, Blues and others are increasingly looking to ACO physicians and aligned resources to manage chronic conditions, coordinate care and reduce costs 
• 
Physicians are engaged in care management. We didn’t ask them in the past, and we didn’t pay for it either, Jill Hummel, WellPoint. 
• 
When a patient hears from a physician versus an insurance company, you know there is a much better chance of changing the behavior, M. Murphy, CEO Iowa Health System ACO. 
PHYSICIANS 
HOSPITALS 
PAYORS
Clinical Alignment 
Mission and Cultural Alignment 
Economic Alignment 
Less Integration 
More Integration 
Employment - Fixed Comp 
Co - Management 
Gain - Sharing 
Joint Ventures 
Recruitment Assistance 
Medical Directorships 
Employment - Variable Comp 
Call Coverage Agreements 
Integration Framework 
Population Mgmt / CIN / ACO 
Active Communication, Information Sharing, and Educational Connection Points Confidential Working Draft 4
Overlapping PCMH / CIN / ACO Framework 
Requirements 
Medical Home 
Clinical Integration 
Accountable Care 
Care Coordination 
X 
X 
X 
Patient Centeredness 
X 
X 
X 
Evidence-Based Guidelines 
X 
X 
X 
Meaningful Use Requirements 
X 
X 
X 
Coordinating Transitions of Care 
X 
X 
X 
Financial Integration 
X 
X 
Communication & Collaboration among Providers 
X 
X 
Performance Metrics Selection & Reporting 
X 
X 
Demonstration of Improved Quality & Cost Reduction 
X 
X 
Population Health Management 
X 
Greater Clinical Integration Across Care Continuum 
X 
Population-Based Risk Management 
X 5
Population Health Priorities and Challenges 
Priority Programs 
Primary Care 
• 
Medical Home 
• 
High risk stratification 
• 
Mental health 
Specialty Care 
• 
Clinical protocols 
• 
Referral management 
• 
Virtual visits 
• 
Bundles 
Care Continuum 
• 
Post acute networks 
• 
Mobile observation units 
• 
Urgent care 
Patient Engagement 
• 
Shared decision making 
• 
Virtual patient communities 
• 
Customized educational materials 
Infrastructure 
• 
HIT, data sharing and analytics 
• 
Infrastructure/program management 
Implementation Challenges 
Clinical Management 
• 
Building comprehensive clinically integrated network 
• 
Reaching population health critical mass (lives) 
• 
Risk adjustment and predictive modeling accuracy 
• 
Developing, implementing and monitoring clinical protocols 
Operational 
• 
Start-up costs 
• 
Easy access/use by patients 
• 
Clarity on where/who provides clinical and admin support services 
• 
Consistent messaging from beneficiary enrollment to the physician’s office 
• 
Provider incentives 
• 
Reporting to demonstrate services and value 
Legal 
• 
Anti-trust, Stark, civil monetary penalty restrictions 6
• 
PCMH Operations Staff: Training and technical assistance to help physicians achieve Medical Home principles. 
• 
Care Management and Coordination Staff: Support the PCMH/APCP practices and are operationally integrated with the Facility Based Case Management program. 
• 
Other potential internal or contract resources include: 
- 
Disease management 
- 
Coding optimization 
- 
Patient education and self-management 
• 
Medical Informatics Staff: Primary analytic resource supporting care management team, CPC physician leaders, PCMH Steering Committee, and PCMH PODs. 
• 
Point Of Care Tool Set: Complete and timely information about patients at the point of care. 
• 
Population Management Tool Set: Technology and skills for population management and coordination of care 
Resource Considerations 
7
Standardized CDR 
HIT - Data Extraction, Standardization and Reporting 
Confidential Working Draft 8 
HOSPITAL SYSTEMS - Clinical, Demographic and Financial Data 
PHYSICIAN SYSTEMS - Electronic Medical Record 
(EMR)/PMS 
ANCILLARY SYSTEMS - Additional Data Sources (payer, Medication fulfillment, Ref Lab, Registry, etc) 
PAYOR SYSTEMS - Claims Data – Budgets, Utilization, and Financial 
External Entity Reporting (MSSP-GPRO, Commercial Payor - BTE, IPIP, QIO, etc.) 
CCR/CCD (Standardized Clinical Coordination Data Sharing) 
Evidence-based Clinical Guidelines PQRI Measures 
Interface Engine 
Clinical Protocol Engine 
Point of Care / Gaps in Care Reports (patient specific, CDS) 
Internal Reporting/Data Analyses (population registry) 
Reporting Engine
Coordinated Message around and through PCP 
• 
A sustained competitive advantage will require achieving and maintaining engaged and motivated members through: 
• 
Consistent messaging from enrollment to the primary physician (Medical Home/APCP) 
• 
Coordinated plan/provider member service resources 
• 
Easy access and use by members 
• 
Agreement / clarity on services included 
• 
Reporting results 9 
Connecting the dots between results and resources 
Consistent message around care programs, service content, source, how to access, and value
Collaborative Network Navigation Aids 
Onboarding Enrollment Resources 
• 
Find a Physician 
• 
BioScreening / Health Risk Assessment 
• 
Web Based Scheduling 
• 
Patient Portal 
• 
Data Sharing / HIE 
• 
Population Health Programs 
- 
Wellness 
- 
Care Coordination 
- 
Chronic Disease Management 
- 
24 Hour Nurse Line 
• 
Pharmacy Benefits Educate Members & Activate Navigation Aids 
Payor Based Member Services 
Member Onboarding and Navigation Aids 
Population Health Programs 
Provider Based Members Services and Network Referral Coordination / Scheduling 
Ancillary 
Specialist 
Post Acute 
Acute 
Web Based Member Services 
Engage Medical Home Relationship 
• 
Informed PCP Visit 
• 
Discuss BioScreen Results 
• 
Activate Indicated Population Health Programs 
New Member 10
DISCUSSION / NEXT STEPS 
How do we work together? 
9/3/2014
Sample WayPoint Case Study 1 
• 
Advanced Primary Care Initiative (Patient Centered Medical Home) 
• 
Innovative population management payer contracting relationships 
• 
Patient quality and safety incentive programs 
• 
ACO Start-up 
• 
Medicare Shared Savings Program application and implementation 
• 
Strengthening health information technology and population management infrastructure 
• 
Assessed existing clinical integration resources, evaluated existing incentive structures, and refined objectives to reflect market-specific priorities 
• 
Developed enterprise scope, structure, governance and leadership 
• 
Developed provider network composition 
• 
Created reporting tools and processes 
• 
Created Physician and care team incentives tied to quality initiatives 
• 
Created health information technology resource plans 
• 
Created staffing plans and operating budget estimates 
• 
PCMH implementation in 12 months with more than 100 physicians in various independent and employed practices certified to date 
• 
CMS Medicare Shared Savings Program ACO approved 
• 
Multiple commercial payer ACO contracts 
• 
Among the largest ACOs nationally and named one of Becker’s “100 ACOs to Know” 
• 
Included in the 29 ACOs that experienced significant shared savings through the first quarter of 2013 Confidential Working Draft 12 
Client Need 
WayPoint Work 
Results
Sample WayPoint Case Study 2 
• 
Approval by Medicare to participate in the Medicare Shared Savings Program 
• 
ACO organizational structure and start up activities 
• 
Population health management technology implementation 
– 
Analytics to identify, stratify and assess the patient’s risk 
– 
Analytics to improve provider performance and measure quality 
– 
Health Information Exchange 
• 
Clinical process improvement and care management people, process and technology resources 
• 
Drafted and submitted the ACO application for CMS approval 
• 
Facilitated the technology architecture of data sharing based on their selected technology vendors 
• 
Review and negotiation of selected technology contracts 
• 
Data submission for beneficiary data sharing claims feed 
• 
Project oversight for implementation of HIE, risk modeling application and physician performance application 
• 
Begun restructuring of clinical process improvement workflow and associated governance 
• 
Facilitated care management model discussion 
• 
CMS Medicare Shared Savings Program ACO approved 
• 
Multiple commercial payer ACO contracts 
• 
Among the largest ACOs nationally and named one of Becker’s “100 ACOs to Know” 
• 
Included in the 29 ACOs that experienced significant shared savings through the first quarter of 2013 Confidential Working Draft 13 
Client Need 
WayPoint Work 
Results

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Collaborative Healthcare Models

  • 2. Objectives/Challenges Require Collaboration 2 Common Objectives • Need to demonstrate success and build awareness around quality, service and efficiency results • Make it easy for members / patients to navigate the system • Engage and motivate members through proactive on-boarding, outreach, and navigation resources • Reduce network leakage Common Challenge • Consumers are skeptical • By definition, new models are generally unproven and limited • Fragmented clinical decision making is still the norm Countering Skepticism • Collaboration model, resources, reputation, and data must support capabilities • Care teams must engage patients through physician- driven population health programs and proactive member/beneficiary support services • Early identification of at-risk patients by sharing data and delivering impactful disease management resources is key
  • 3. Trends Supporting Collaborative Models • Current trends are placing pressure on physicians to - Use health information technology - Develop resource intensive care management processes - Seek help in groups - Retire • Physicians are seeking help to alleviate administrative and financial challenges. • Without infrastructure and support, physicians become the most qualified but the least equipped to lead. • Volume, revenue, and physician relationships are at risk • Hospitals must have engaged physician partners to drive sustainable clinical process improvement • To date, some ACOs have achieved savings in part by excluding hospitals • “Hospitals want to do robotic surgeries, heart catheterizations, PET scans, MRIs—all the expensive items. We actually felt that hospitals were part of the problem.” William Biggs, MD CEO Amarillo Legacy Medical ACO 3 • Cigna, Aetna, Blues and others are increasingly looking to ACO physicians and aligned resources to manage chronic conditions, coordinate care and reduce costs • Physicians are engaged in care management. We didn’t ask them in the past, and we didn’t pay for it either, Jill Hummel, WellPoint. • When a patient hears from a physician versus an insurance company, you know there is a much better chance of changing the behavior, M. Murphy, CEO Iowa Health System ACO. PHYSICIANS HOSPITALS PAYORS
  • 4. Clinical Alignment Mission and Cultural Alignment Economic Alignment Less Integration More Integration Employment - Fixed Comp Co - Management Gain - Sharing Joint Ventures Recruitment Assistance Medical Directorships Employment - Variable Comp Call Coverage Agreements Integration Framework Population Mgmt / CIN / ACO Active Communication, Information Sharing, and Educational Connection Points Confidential Working Draft 4
  • 5. Overlapping PCMH / CIN / ACO Framework Requirements Medical Home Clinical Integration Accountable Care Care Coordination X X X Patient Centeredness X X X Evidence-Based Guidelines X X X Meaningful Use Requirements X X X Coordinating Transitions of Care X X X Financial Integration X X Communication & Collaboration among Providers X X Performance Metrics Selection & Reporting X X Demonstration of Improved Quality & Cost Reduction X X Population Health Management X Greater Clinical Integration Across Care Continuum X Population-Based Risk Management X 5
  • 6. Population Health Priorities and Challenges Priority Programs Primary Care • Medical Home • High risk stratification • Mental health Specialty Care • Clinical protocols • Referral management • Virtual visits • Bundles Care Continuum • Post acute networks • Mobile observation units • Urgent care Patient Engagement • Shared decision making • Virtual patient communities • Customized educational materials Infrastructure • HIT, data sharing and analytics • Infrastructure/program management Implementation Challenges Clinical Management • Building comprehensive clinically integrated network • Reaching population health critical mass (lives) • Risk adjustment and predictive modeling accuracy • Developing, implementing and monitoring clinical protocols Operational • Start-up costs • Easy access/use by patients • Clarity on where/who provides clinical and admin support services • Consistent messaging from beneficiary enrollment to the physician’s office • Provider incentives • Reporting to demonstrate services and value Legal • Anti-trust, Stark, civil monetary penalty restrictions 6
  • 7. • PCMH Operations Staff: Training and technical assistance to help physicians achieve Medical Home principles. • Care Management and Coordination Staff: Support the PCMH/APCP practices and are operationally integrated with the Facility Based Case Management program. • Other potential internal or contract resources include: - Disease management - Coding optimization - Patient education and self-management • Medical Informatics Staff: Primary analytic resource supporting care management team, CPC physician leaders, PCMH Steering Committee, and PCMH PODs. • Point Of Care Tool Set: Complete and timely information about patients at the point of care. • Population Management Tool Set: Technology and skills for population management and coordination of care Resource Considerations 7
  • 8. Standardized CDR HIT - Data Extraction, Standardization and Reporting Confidential Working Draft 8 HOSPITAL SYSTEMS - Clinical, Demographic and Financial Data PHYSICIAN SYSTEMS - Electronic Medical Record (EMR)/PMS ANCILLARY SYSTEMS - Additional Data Sources (payer, Medication fulfillment, Ref Lab, Registry, etc) PAYOR SYSTEMS - Claims Data – Budgets, Utilization, and Financial External Entity Reporting (MSSP-GPRO, Commercial Payor - BTE, IPIP, QIO, etc.) CCR/CCD (Standardized Clinical Coordination Data Sharing) Evidence-based Clinical Guidelines PQRI Measures Interface Engine Clinical Protocol Engine Point of Care / Gaps in Care Reports (patient specific, CDS) Internal Reporting/Data Analyses (population registry) Reporting Engine
  • 9. Coordinated Message around and through PCP • A sustained competitive advantage will require achieving and maintaining engaged and motivated members through: • Consistent messaging from enrollment to the primary physician (Medical Home/APCP) • Coordinated plan/provider member service resources • Easy access and use by members • Agreement / clarity on services included • Reporting results 9 Connecting the dots between results and resources Consistent message around care programs, service content, source, how to access, and value
  • 10. Collaborative Network Navigation Aids Onboarding Enrollment Resources • Find a Physician • BioScreening / Health Risk Assessment • Web Based Scheduling • Patient Portal • Data Sharing / HIE • Population Health Programs - Wellness - Care Coordination - Chronic Disease Management - 24 Hour Nurse Line • Pharmacy Benefits Educate Members & Activate Navigation Aids Payor Based Member Services Member Onboarding and Navigation Aids Population Health Programs Provider Based Members Services and Network Referral Coordination / Scheduling Ancillary Specialist Post Acute Acute Web Based Member Services Engage Medical Home Relationship • Informed PCP Visit • Discuss BioScreen Results • Activate Indicated Population Health Programs New Member 10
  • 11. DISCUSSION / NEXT STEPS How do we work together? 9/3/2014
  • 12. Sample WayPoint Case Study 1 • Advanced Primary Care Initiative (Patient Centered Medical Home) • Innovative population management payer contracting relationships • Patient quality and safety incentive programs • ACO Start-up • Medicare Shared Savings Program application and implementation • Strengthening health information technology and population management infrastructure • Assessed existing clinical integration resources, evaluated existing incentive structures, and refined objectives to reflect market-specific priorities • Developed enterprise scope, structure, governance and leadership • Developed provider network composition • Created reporting tools and processes • Created Physician and care team incentives tied to quality initiatives • Created health information technology resource plans • Created staffing plans and operating budget estimates • PCMH implementation in 12 months with more than 100 physicians in various independent and employed practices certified to date • CMS Medicare Shared Savings Program ACO approved • Multiple commercial payer ACO contracts • Among the largest ACOs nationally and named one of Becker’s “100 ACOs to Know” • Included in the 29 ACOs that experienced significant shared savings through the first quarter of 2013 Confidential Working Draft 12 Client Need WayPoint Work Results
  • 13. Sample WayPoint Case Study 2 • Approval by Medicare to participate in the Medicare Shared Savings Program • ACO organizational structure and start up activities • Population health management technology implementation – Analytics to identify, stratify and assess the patient’s risk – Analytics to improve provider performance and measure quality – Health Information Exchange • Clinical process improvement and care management people, process and technology resources • Drafted and submitted the ACO application for CMS approval • Facilitated the technology architecture of data sharing based on their selected technology vendors • Review and negotiation of selected technology contracts • Data submission for beneficiary data sharing claims feed • Project oversight for implementation of HIE, risk modeling application and physician performance application • Begun restructuring of clinical process improvement workflow and associated governance • Facilitated care management model discussion • CMS Medicare Shared Savings Program ACO approved • Multiple commercial payer ACO contracts • Among the largest ACOs nationally and named one of Becker’s “100 ACOs to Know” • Included in the 29 ACOs that experienced significant shared savings through the first quarter of 2013 Confidential Working Draft 13 Client Need WayPoint Work Results