On March 3, 2016 at Highmark Blue Shield there were healthcare executives gathered for the Healthcare Executive Forum of Central PA's quarterly event. This American College of Healthcare Executive's event was worth 1.5 face to face credits. We focused on the issues and preparation for changing healthcare landscapes. Three speakers shared their experience, which was bountiful. These speakers are Moderator: Terry Madonna, Director of the Center for Politics and Public Affairs, Franklin and Marshall College; Speakers: Gerald Walsh, VP, Provider Contracting and Relations, Highmark; Thomas Northrop, NorHealth Management Group, CEO; Michael Consuelos, SVP, Clinical Integration at The Hospital & Healthsystem Association of Pennsylvania. Visit our website for full biographies and more at www.centralpa.ache.org.

1. Value
and
Accountability:
Preparing
for
the
Future
American
College
of
Healthcare
Execu=ves
March
3,
2016
Michael
J.
Consuelos,
MD
MBA
Senior
Vice
President,
Clinical
Integra4on
The
Hospital
&
Healthsystem
Associa4on
of
Pennsylvania

2. • PA
trends
• How
is
PA
measuring
up?
• Alterna4ve
Payment
Models
2
Value and Accountability

3. Less Need for Inpa8ent Hospital Care
Inpa4ent
Admissions
per
Million
Sources: Pennsylvania Department of Health
3
1.703
1.718
1.685
1.708
1.725
1.686
1.653
1.617
1.578
1.545
1.494
1.350
1.400
1.450
1.500
1.550
1.600
1.650
1.700
1.750
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014

4. 4
Freestanding
Ambulatory
Surgery
Centers
Source:
HAP
analysis
of
PHC4
data
1,159
1,190
1,144
1,066
1,059
1,043
1,037
1,042
1,055
1,082
1,111
530
620
766
843
895
962
993
986
1,008
1,006
996
0
200
400
600
800
1,000
1,200
1,400
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Hospitals
Freestanding
ASCs
Outpa4ent
Surgeries
(000s)

5. 5
5
Hospital Consolida8on in Pennsylvania
68
75
79
77
84
86
83
90
93
99
97
103
110
117
117
122
114
107
104
94
89
85
78
72
64
62
57
48
41
39
-­‐
20
40
60
80
100
120
140
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
#
Hospitals
in
Health
Systems
#
Independent
Hospitals
1General Acute Care hospitals include community and children’s hospitals.
Source: PA Department of Health, data compiled by The Hospital & Healthsystem Associa8on of PA (HAP)

6. Total
Dollar
Impact
Total
Impact
Rank*
Total
Dollar
Impact
Total
Impact
Rank*
Total
Dollar
Impact
Total
Impact
Rank*
U.S.
Impact -­‐ -­‐ -­‐
Pennsylvania $2,200,200 4 ($858,700) 39 ($2,070,200) 46
*
One
is
best.
Value
Based
Purchasing
Program
FFY
2014 FFY
2016FFY
2015
The Penalty Box(es)
Total
Dollar
Impact
Total
Impact
Rank*
Total
Dollar
Impact
Total
Impact
Rank*
Total
Dollar
Impact
Total
Impact
Rank*
U.S.
Impact ($213,500,200) ($412,132,400) ($419,536,300)
Pennsylvania ($8,626,100) 43 ($20,376,100) 45 ($21,572,200) 46
*
One
is
best.
FFY
2016
Readmission
Reduction
Program
FFY
2014 FFY
2015
Total
Impacted
Hospitals
Total
Dollar
Impact
Total
Impact
Rank*
Total
Impacted
Hospitals
Total
Dollar
Impact
Total
Impact
Rank*
U.S.
Impact 720 ($338,343,600) 755 ($336,940,400)
Pennsylvania 39 ($19,403,600) 49 39 ($18,088,900) 48
*
One
is
best.
FFY
2016
HAC
Reduction
Program
FFY
2015
Source:
CMS
Medicare
Quality-­‐Based
Payment
Reform
(QBPR)
programs
for
federal
fiscal
years
(FFY)
2014–2016

7. Exhibit 3. State Scorecard Summary of Health System Performance Across Dimensions
2014 Scorecard Ranking Revised 2009 Scorecard
Ranking*
A
ccess
&
A
ff
ordability
Prevention
&
Treatm
ent
A
voidable
H
ospitalU
se
&
Cost
H
ealthy
Lives
Equity
A
ccess
&
A
ff
ordability
Prevention
&
Treatm
ent
A
voidable
H
ospitalU
se
&
Cost
H
ealthy
Lives
Equity
1 Minnesota 1 1 1 1 1 Minnesota 1 1 1 1 1
2 Massachusetts 1 1 3 1 1 2 Hawaii 2 2 1 1 1
2 New Hampshire 1 1 1 1 1 2 Massachusetts 1 1 3 1 1
2 Vermont 1 1 1 1 1 2 Vermont 1 1 1 1 1
5 Hawaii 2 2 1 1 1 5 Connecticut 1 1 2 1 1
6 Connecticut 1 1 3 1 1 5 New Hampshire 1 1 2 2 1
7 Maine 1 1 2 2 1 5 Rhode Island 1 1 2 1 1
7 Wisconsin 1 1 2 2 1 8 Iowa 1 1 2 1 1
9 Rhode Island 1 1 2 1 1 9 Maine 1 1 2 2 1
10 Delaware 1 1 2 3 1 9 North Dakota 1 2 1 2 1
10 Iowa 1 1 2 2 2 9 Wisconsin 1 1 2 1 1
12 Colorado 3 1 1 1 2 12 South Dakota 2 2 1 3 2
12 South Dakota 2 2 1 2 2 13 Delaware 1 1 2 3 2
14 North Dakota 1 2 2 3 2 14 Pennsylvania 1 1 3 3 1
15 New Jersey 2 2 3 1 2 15 Colorado 3 1 1 1 4
15 Washington 2 3 1 1 2 15 Michigan 2 1 4 3 1
17 Maryland 2 2 3 2 1 17 Nebraska 2 3 2 2 3
17 Nebraska 2 1 2 1 3 18 New York 2 2 3 2 1
19 New York 2 3 3 1 1 18 Washington 2 3 1 1 3
19 Utah 4 3 1 1 2 20 Kansas 2 2 3 2 2
21 District of Columbia 1 2 4 3 1 20 Montana 4 3 1 2 2
22 Pennsylvania 2 1 3 3 1 20 Utah 3 3 1 1 4
23 Kansas 2 2 3 2 3 23 New Jersey 2 2 3 2 2
24 Oregon 3 3 1 2 3 24 District of Columbia 1 2 4 3 2
24 Virginia 2 3 3 2 3 24 Maryland 2 2 4 3 3
26 California 3 4 2 1 3 24 Oregon 3 3 1 2 3
26 Illinois 2 2 4 3 2 27 Alaska 4 2 1 3 3
26 Michigan 2 1 4 3 2 27 Virginia 2 3 2 2 4
29 Montana 4 3 1 2 4 29 California 3 4 1 1 3
29 Wyoming 3 2 2 3 3 30 Wyoming 3 3 2 2 3
31 Alaska 3 4 1 3 3 31 Indiana 2 3 3 3 2
31 Idaho 4 3 1 2 4 31 Ohio 2 2 4 4 3
Performance Quartile
Top Quartile
Second Quartile
Third Quartile
Bottom Quartile
Source:
Commonwealth
Fund
May
2014

9. HHS Makes Historic Announcement
January 26, 2015
9
Category 1: Fee for Service – No Link to Quality
Category 2: Fee for Service – Link to Quality
Category 3: Alternative Payment Models with FFS Infrastructure
Category 4: Population Based Payment
HHS
sets
clear
goals
and
4meline
for
shi[ing
Medicare
reimbursements
from
volume
to
value

10. Source:
HCPLAN
1/12/2016
h`ps://hcp-­‐lan.org/workproducts/apm-­‐whitepaper.pdf

11. 2015
HAP
Payment
Reform
Summit
“Forging
our
Path
from
Volume
to
Value”
11
6%
50%
44%
0%
0%
25%
56%
19%
Fee-­‐for-­‐service
with
no
link
of
payment
to
quality
Fee-­‐for-­‐service
with
a
link
of
payment
to
quality
Alterna=ve
payment
models
built
on
fee-­‐for-­‐service
architecture
Popula=on-­‐based
payment
HHS
payment
framework:
Where
are
HAP
members?
Today
2018
50%
31%
6%
13%
How
will
a
shiZ
to
value-­‐based
reimbursement
affect
your
organiza=on?
Benefit
somewhat
Benefit
substan=ally
Lose
a
li_le
Lose
a
lot
Not
be
affected
one…
None
Survey:70 clinical, administrative, and financial leaders from hospitals and health systems

12. Top 3 challenges in preparing for
value-based payment:
12
0%
10%
20%
30%
40%
50%
60%
70%
80%
Nurse
engagement
Administrator
engagement
Lack
of
capital
Other
(please
specify)
IT
infrastructure
Health
policy
uncertainty
Physician
engagement
63%
63%
50%
38%
13%
6%
69%

13. The Other Challenges
13
• Lack
of
reimbursement
to
support
required
pa4ent
care
• Pa4ent
engagement
• Movement
to
value
before
payment
mechanisms
catch
up
and
adap4ng
to
a
risk
model
• Lack
of
control
of
the
full
con4nuum
of
care
necessary
to
make
value-­‐based
reimbursement
work
appropriately
• Lack
of
ac4onable
data
from
payers;
living
in
both
FFS
and
value
worlds
simultaneously
• Some4mes
the
quality
measures
do
not
really
add
value
or
pa4ent
quality
• Redesign
of
the
health
system
for
popula4on
health
• Have
all
the
providers
working
in
synch
• Ongoing
modifica4on
of
core
measures

14. Michael J. Consuelos, MD MBA
Senior Vice President, Clinical Integration
The Hospital & Healthsystem Association of Pennsylvania
mconsuelos@haponline.org

15. FROM ANALYTICS TO ACTION –
SPEED, COST & RATIONAL BEHAVIOR
REALLY MATTERS NOW
HEALTHCARE EXECUTIVE FORUM - CENTRAL PA
Listening to Employers: How Health Systems Can Support Population Health
Management and Accountability for Care We Provide
Thomas Northrop, FACHE - CEO
NorHealth Management Group, LLC
March 3, 2016

16. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
The Landscape
— US Healthcare falls significantly short of potential for: Quality, Consistency, Cost and Access.
— Determinants of how ‘well’ we live: 40% lifestyle; 30% genetics; 20% - public health & environment; 10% -
health delivery.
— High medical costs, yet Providers have little impact on 90% of life factors.
— ‘More of the same’ behavior in Health sector increases costs, not our results.
— 95% of dollars spent go to medical care, only 5% to population-wide health
improvement efforts.
— Healthcare cost growth far outstrips growth in US disposable income.
— More health spending reduces money available for rest of Economy (education, defense, infrastructure,
social security, etc.)
— Rate of ‘waste’ in current health spending – 30-50% of dollars spent.

17. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
The Landscape (cont.)
— Integrated delivery Systems (Intermountain, Kaiser) have addressed Quality of care and Cost of
care for decades: Not called ‘PHM’ then, simply trying to deliver care/cost balance for patients
and community.
— ‘Accountable Care’ boils down to: (1) Manage fixed-price contracts for the treatment/
management of individual patient health; (2) Apply patient-specific concepts of balancing cost-
of-care with quality-of-care to large populations of patients.
— Data-driven, clinician-led performance improvement combined with market pressures will
produce change. How Long Will It Take?
— For the rest of us, PHM is in Early Development: inconsistent definitions; limited operational
understanding; and hype from vendors combine with misaligned incentives in provider space,
payment space and employer space. Result is a far too slow-moving, costly mess. We can do
better.

18. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
The Landscape (and how to move beyond it)
— Just 18.2 million U.S. lives now managed under an ACO – very small sample.
— Current economic models insufficient to drive change. Example from PA data: 6% FFS w/ no link of payment
to quality; 50% FFS w/ some link between payment and quality; 44% with alternative payment models based
on FFS architecture; 0% with population-based payments in place.
— New attempts: a) HTA Alliance b) Bree Initiative- Wash State; c) Intel-Portland Collaborative. Good attempts
to redefine the game. Basic measures used: 1) Evidence-based care? 2) Patients satisfied? 3) Same-day access?
4) Rapid return to function? 5) Care affordable & savings produced?
— Value-based payment push will accelerate Winners & Losers – Which will yourorganization be?
— Speed, Cost effectiveness, Rational behavior essential.

19. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
My View
— Living thru FFS while straddling toward Value-based Pay – Very challenging.
— Speed of change, Cost effectiveness, Rational behavior are essential.
— Identify your Biggest Problem Areas (‘vital few’)- Readmits? HAIs? Others?
— Go after problems NOW - generate Financial Savings & Quality Gains NOW.
— Use national analytics - Don’t lose time building internal data warehouse first.
— After Analytics - Determine Action/Process changes required then DO THEM!
— Build real incentives to change for key players/decision-makers.
— Seek ‘open architecture’ collaborative access learning … Learn, Learn, Learn.
— Adjust as needed based on results.
— Use achieved savings to build internal data warehouse for future gains.

20. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
Cost-effective Innovation –
— Healthy Partners - 400+ San Diego physician group (Key Benefits Group). Direct Employer
contracting thru self-funded Ins. Establish proven Care Regimens based on evidence-based
medicine – Operates on gain-sharing that rewards Providers for reducing each Employer’s net
health spend.
— MDwise, Inc - 330,000 Pt Indiana-based Medicaid/vulnerable patient group. (ZeOmega’s Jiva
pop hlth mgmt app). Disease/case mgmt reduces SNF Readmits & ER visits: 66% less
readmits, 61% drop in Pt LOS.
— U Miss Med Ctr - “Analysis of initial Pt group with (Jvion RevEgis app). Acute Myocardial
Infarction case prediction nearly two times better than with Stress tests, 20% better
than CT coronary angiograms in predicting AMI events in low risk pop. w/in 12 months of
discharge.” Dr. John Showalter, UMMC Chief Hlth Information Officer. Video:
www.jvion.com/client.html

21. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
Sequential PHM Criteria (Typical)
Use criteria to build roadmap & evaluate progress. Get started NOW. Reasonable yet aggressive typical
roadmaps & timeline include:
Year 1 - Pt Registries, Patient Attribution.
Year 2 - Precise Numerators, Clinical & Cost Metrics.
Year 3 - Clinical Practice Guidelines, Risk Management Outreach.
Year 4 - Acquiring External Data, Patient Communication System, Patient
Education/Engagement System.
Year 5 - Complex Clinical Production Guidelines, Care Team
Coordination System, Pt Specific Clinical Outcomes System.
[*PHM ‘Criteria’ used with permission approval of Health Catalyst, Inc.]

22. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
Recommended Time/Cost Sequence
— Five years is far too slow to generate savings and results.
— Identify your biggest presumed problems impacting Revenue/Quality.
— Access ‘external national data’ now as temporary ‘data warehouse surrogate’.
— Evaluate external data against your ‘vital few’ clinical/financial indicators.
— Confirm accuracy of ‘vital few’ indicators in your organization then act on them.
— Build multiple ‘Change Teams’ to address process changes needed.
— Develop/implement/assess Incentives needed to support changed behaviors.
— Monitor, Adjust, Improve further … based on results achieved thus far.
— Pursue addtl key clinical/financial challenges from your organization.
— Use achieved savings to invest in future internal Data Warehouse.

23. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
— Questions & Discussion

24. ANALYTICS TO ACTION – Speed, Cost & Rational Behavior
— Thank You!
Thomas Northrop, FACHE – CEO
NorHealth Management Group, LLC
tnorthrop.nmg@gmail.com
804-405-4983
March 3, 2016

25. Accountability for the Care We Provide
Health Care Executive Forum of Central PA
March 3, 2016
Gerald Walsh
Vice President, Provider Contracting & Relations
Highmark Inc.
HIGHMARK.COM

26. “Accountable Care”
Beyond CMS’ Rules and Regulations
An Insurers Perspective

27. ACO Defined
The
ACO
concept
is
one
that
is
s4ll
evolving,…
a
group
of
health
care
providers...who
voluntarily
come
together
to
provide
coordinated
high-­‐
quality
care
to
popula4ons
of
pa4ents.
The
goal
of
coordinated
care
provided
by
an
ACO
is
to
ensure
that
pa4ents
and
popula4ons
—
especially
the
chronically
ill
—
get
the
right
care,
at
the
right
4me
and
without
harm,
while
avoiding
care
that
has
no
proven
benefit
or
represents
an
unnecessary
duplica4on
of
services.
27
Source:
Health
Catalyst
(What
is
an
accountable
care
organiza4on),
Dr.
John
Haugom
and
Dr.
David
Burton

28. The Institute for Healthcare Improvement
28

29. My Point of View
• Clinical/Care Management of a Population
• Total Cost of Care - Measured
• Quality – Measured
• Patient Satisfaction
• Shared and Aligned Reward
29
Change the Conversation

30. Why spend your valuable and limited time on developing a provider –
payer relationship around an accountable care model?

31. The 10 Things CEOs Need to Know in 2015
(The Advisory Board Company, Research Briefing, 2015)
31

32. 32
The 10 Things CEOs Need to Know in 2015
(The Advisory Board Company, Research Briefing)

33. Payment Continuum
33
Fee
for Service
P4V
Incentives
Bundles Gain Share Risk Share
% of
Premium

34. 34
The Advisory Board Company, Care Transformation Center Population Health Survey Results, 2014
Medicare is pushing you in this
direction
Your making investments in people
and tools
Maximize your investments and
create efficiencies

35. Consumerism (B2C)
35
Price
Network

36. Key Components and Key Challenges
of a
Payer – Provider Accountable Care Relationship

37. 37
Key Components of a Commercial Payer ~ Provider
Accountable Care Relationship
Attributed Population
Physician Leadership – Champions
Clinically Integrated Network
Primary Care Driven
Care Coordinators
Post Acute Care Collaboration
Information Sharing – Bi-directional
Quality Metrics
Financial Alignment
Governance Committee
Measureable Goals

38. Key Challenges
38
Population
Health
Management
Trust
Data
Share
and Use

39. Key Challenges: Data Share and Use
(beyond reports from health plans)
• Will/Can the health plan share claims data : raw or filtered?
• Will/Can the provider share clinical data?
• Who houses the data (health plan, provider, third party)?
• What tools and technology will be used and who pays for it?
• Can the tool match clinical and claims data?
• Is the reporting real time and robust enough?
• How do you make it actionable?
39
“Almost 12% of providers who responded to our survey even said that there would be a positive impact on
their organizations if their health plans stopped sending data.”
The Advisory Board Company, 2015 HIPAC Data-Sharing Survey
Data Use Agreement

40. Key Challenges: Population Health Management
40
www.urgentcareadvisors.com
Define It
ID a
population
Who will
do what?
How will it
be
funded?

41. Key Challenges: Trust
41