Clinical Integration Update Michele Madison [email protected] 404-504-7621 Clinical Integration • The integration of clinical information and healthcare delivery services from distinct entities. • Continuum of care, including preventative, outpatient, inpatient acute hospital and postacute 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, LLC Accountable Care Coalition of Georgia, LLC Accountable Care Coalition of Greater Athens Georgia II, LLC Accountable Care Coalition of Greater Augusta & Statesboro, LLC Accountable Care Coalition of Southern Georgia, LLC Accountable Care Coalition of Western Georgia, LLC Morehouse Choice ACO-ES The Premier Health Care Network, LLC Meridian Holdings, Inc. WellStar Health Network, LLC Accountable Care Coalition of Coastal Georgia Accountable Care Coalition of Greater Athens Georgia Breakdown of ACOs Networks of Individual Practices Group Practices Hospital/Professional Partnerships Hospital employing ACO professionals Federally Qualified Health Center Rural Health Clinic Critical Access Hospital 121 90 66 44 55% 41% 30% 20% 15 11 4 7% 5% 2% Bundled Payment 1. 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 ACO Changes in the payer marketplace United Purchases Physician Practices Humana Purchases Concentra Cigna 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.