9. Market Trends, PPACA and Health Reform PPACA is mostly about health insurance reform; it significantly impacts health care delivery reform For doctors and hospitals, the clearest aspects of PPACA spell out payment reduction schedules Health Reform’s government payment schedules are not keeping pace with inflation Providers must retain current commercial insurance base to ensure economic sustainability Kaiser May 12, 2011 3
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11. Goal: Increase the scope of insurance coverage and access to a greater number of Americans and reduce costMay 12, 2011 4
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13. Start with Value & Triple Aim VALUE = Quality/Cost … as compared to peers TRIPLE AIM = Improved Outcomes, Lower Costs & Higher Patient Satisfaction May 12, 2011 6
15. Payment Reform = New Ways to Deliver Care If PPACA covers more lives, and payment reform is in place, what mechanisms do we have to ensure quality care? PPACA contemplates an Accountable Care Organization
36. Definition of Care Coordination “Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.” May 12, 2011 14 Source: AHRQ
58. Typical payor data sets won’t be enough – incomplete and far too old to help manage care and COST of careMay 12, 2011 18
59. NCIPA Profile Physician owned and operated Colorado corporation Consists of 667 providers 168 Primary Care Physicians 328 Specialist Physicians 171 Other Contracted Providers Holds multiple contracts Health Plan Direct ERISA May 12, 2011 19
64. Current Situation May 12, 2011 24 Services: - Provider Network - Claims Adjudication and Payment Customers: - PVHS - Poudre School District - Columbine (400 lives) 50 % ownership 50 % ownership
65. PVHS Proposal “We (PVHS) would purchase NCIPA’s fifty-percent (50%) interest (in UMA), becoming the sole owners of UMA.” May 12, 2011 25
66. How Can We Help PVHS Do This? May 12, 2011 26 By collaborating with PVHS to become the physician driven vehicle through which UMA can quickly develop a Clinically Integrated accountable care organization
68. Administrative Driven Infrastructure Components Third Party Administration Financial Management Healthcare Operations Management Utilization Management Quality Assurance CVO Case Management Business Operations Management IT Systems and Analysis Payor Contracting & Contract Management Legal May 12, 2011 28
69. Physician Driven Infrastructure Components &/or Committees Clinical Integration Care Coordination Health Information Technology & IT Management Credentialing Network Development Contracting and Finance May 12, 2011 29
70. Role & Functions to Consider To be the physician driven vehicle through which UMA can: Provide clinically integrated services Perform Utilization Management Develop, approve and implement EBM practice guidelines for all specialties (HealthTeam Works) Monitor physician compliance to practice guidelines and report compliance to participating providers (Verisk Health – Sightlines Medical Intelligence) Counsel non-compliant providers and discipline them if non-compliance continues Implement and assist Systems of Care supporting patient centered medical homes and medical neighborhoods (CO Medical Society initiative) May 12, 2011 30
71. Role & Functions to Consider (continued) To be the physician driven vehicle through which UMA can: Prove that value to those who are paying for healthcare is critical to receiving fair reimbursement for services rendered in that receiving fair reimbursement is essential to achieving the professional satisfaction of NCIPA providers Ensure only high quality providers satisfying established criteria participate in the network (Credentialing) Promote clinical HIE interconnectivity in collaboration with CORHIO Establish compensation options such as P4P, bundled payments and shared savings arrangements (starting with PVHS as the Beta site) May 12, 2011 31
110. May 12, 2011 47 DISCUSSION A Walter Hankwitz, MBA, FACHE, CMPE Highlands Health Management, Inc. awhankwitz@highlandshealth.com B: 423/863-1363 C: 423/534-0212
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