We at Boehringer Ingelheim know that there are many issues affecting health care in the United States. In this presentation Dr. Lee Sacks of Advocate Health takes a look at accountable care organizations (ACOs) and their role in health care reform. Understanding the Implications of Accountable Care Organizations for Patients and Providers, was a web conference given on July 31, 2012 and which we hope will provide offer an understanding of best practices among ACOs and tips for helping constituents adopt and participate in ACOs.

1. Explaining Accountable Care
Organizations (ACOs): Key Strategies
for Educating Constituents
Boehringer Ingelheim Patient Advocacy Relations
Web Conference Agenda
July 31, 2012
Lee B. Sacks, MD

2. AGENDA
• Introductions and Goals
• Introduction to ACOs
• Communicating with Health Care Providers
Lessons Learned
Challenges
• Communicating with Patients
• Questions and Answers
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3. New Payment Models Incentivize
Value and Accountability
High
Insurance product
Prepaid/capitation
Degree of Complexity
Shared savings/global budgets
Condition-specific budget/medical home
Bundled payment for episodes of care
Bundled payment for acute care (inpatient only)
P4P/value-based purchasing
Inpatient case rates (eg, DRGs)
Fee for service
Low
Scope of Risk High
P4P = pay for performance; DRG = diagnosis-related group.
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4. Accountable Care Organizations*
• Strategy to “Bend the Cost Curve” and
Improve Coordination and Quality of Care
• Implementing a Learning System
– Strategic Focused Goals and Objectives
– Skills and Tools
– Measurement and Accountability
– Leadership
*Shortell, Stephen M., Lawrence P. Casalino, Elliott S. Fisher How the Center for Medicare
Innovation Should Test Accountable Care Organizations Health Affairs 29. No 7 pp. 1293 -
1298
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5. Accountable Care Organization
• Affordable Care Act required HHS to create
ACOs by January 2012
• Provider Groups accept responsibility for cost
and outcomes for a specific population
• Must provide data to be used to assess
performance
• Attribution / Alignment
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6. Federal ACO Requirements
• “Become Accountable for • Report Key Data to HHS:
Quality, Cost, Overall Care” of Assignment, Quality, Etc
FFS Beneficiaries • Leadership and
• At Least 3 Yr Contract Management Structure
• Formal Legal Structure to • Processes to Promote EBM,
Receive/Distribute Shared Patient Engagement, Quality,
Savings Cost, Care Coordination
• Enough Primary Care for • Meet Patient-Centered
Assigned Beneficiaries (At Criteria
Least 5000)
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7. CMS Description of MSSP
• New approach to health care delivery
• Provider organizations become accountable for quality,
cost and service to defined group of Medicare
beneficiaries (Medicare Parts A and B services)
• Encourages investment in infrastructure & redesigned
care processes
• Providers with attributed patients may only participate in
one ACO
• Medicare shares savings with ACO
• Patients continue Medicare FFS benefit and retain
their ability to choose any provider
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8. What MSSP Isn’t . . .
• MSSP is not a bundled payment program
• MSSP is not a capitated payment program
• Physicians and hospitals continue to submit fee-
for-service bills to Medicare
• Physicians and hospitals continue to be paid by
Medicare using the Medicare fee schedule
– No FFS payments are sent to ACO
• No assignment of Medicare patients to PCPs
– CMS attributed patients retrospectively based on
physician services provided during the year
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9. MSSP Contract Structure
• 3½ year contract starting July 1, 2012
• Retrospectively attributed beneficiaries with
prospective data sharing
• Shared savings with no downside (repayment)
risk
• Up to 50% share of savings based on quality
score
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10. Status Through July 2012
• 154 Organizations Participating in Shared
Savings Programs (2.4 M beneficiaries)
– 32 Pioneer
– 6 Physician Group Practice Transition
Demonstration
– 27 April 1 Medicare Shared Savings Program
(MSSP)
– 89 July 1 MSSP (1.2 M beneficiaries)
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11. Challenges for ACOs
• Large Multi-specialty Groups are the Exception
• 9 of 10 Americans Get Their Medical Care in a
Solo or Small Practice*
• Infrastructure is Required to Drive Quality
Outcomes Demonstrated by Multi-specialty
Groups
• Culture is not Created Over Night
• Patient Mistrust or Misunderstanding
*NEJM 360;7 Feb. 12, 2009
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12. MSSP Is Good for Patients &
Physicians
• Infrastructure to support coordinated care
management across the continuum
– Outpatient care managers follow complex
patients to support access to appropriate care
– Inpatient care managers coordinate care and
provide communication to the patient’s family
– Transition coaches assist patients in follow-up
with their physician following discharge
• Patients retain full FFS Medicare benefit
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13. Changing Paradigms
From TO
Silo Care Management Enterprise Care Management
Episodes of Care Coordination of Care
Discharges Transitions
Utilization Management Right care, at the right place,
at the right time
Caring for the sick Keeping people well
Production (volume) Performance (value)
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14. Clinical Integration is the
Foundation of an ACO
• Provides Infrastructure for Integration of Small
Practices
• Overcomes Problems Seen Within the Fee-
for-Service Model
– Incentives to Providers Drive Improvement
• Creates Business Case for Hospital and
Doctors to Work for Common Goals
• Allows One Approach for Commercial and
Governmental Payers
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15. What Clinical Integration Looks Like
Jane Smith, OB-GYN
Patient with
Diabetes
Mammography
Endocrinologist
Lab Test Results
Primary Pharmacy
Care
Physician
APP Data Warehouse and
Disease Registries
Primary Care Physician • OB-GYN • Endocrinologist
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16. Clinical Integration 4.0:
Increasing Physician/System Integration
Clinical
Integration
to
Increasing Accountable
Primary
Physician/ Care
Care/
System
Ambulatory
Increasing Integration
Measures
Specialist
Measures
Maturing Years: Health Reform:
Early Years: Middle Years:
2010 - 2011 2012 - ongoing
2004 - 2006 2007 - 2009
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17. Creating a Culture of Engaged
Physicians
• Physician Engagement in Governance
• Physician Leadership Development
• Shared Identity and Values → “Membership”
• Infrastructure Investment to Enable Success
• Appeals to Pride and Sense of Excellence
– Recognition for Quality and Efficiency
– Consistent Use of Evidence-based Medicine
– Power of the Outcomes of the Group
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18. ECM Infrastructure & Support
Physician Office
Communication
Performance
Strategies
Coaches
Outpatient Care
Management
• Dedicated Outpatient
PCP CMs for High-Risk
Access/Virtual patients Market Share
Visits Growth/Backfill
Emergency/Acute
Post Acute Care Management
• SNF CM Model • Inpatient CMs
• SNF, LTACH, • ED CMs
Inpatient Rehab • Hospitalists
Network • Physician-Partnered
• Transition Coaches CM Model
CM
Data & Analytics
Risk/Reporting
System
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19. Achieving Savings
• Inpatient Hospital Utilization
Potentially Avoidable Admissions
Readmissions
• Imaging – MRI, CT, PET, Nuclear Medicine
• Post Acute
– Skilled Nursing Home Length of Stay
– Home Care Services
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20. Sharing Savings Issues
• Pay for Performance is the catalyst for clinical
integration
• Physicians versus Hospitals
• Primary care versus Subspecialists
• Replace lost revenue vs incentive for work
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21. In Network Care Coordination
• Electronic Medical Record Available
• Avoids Duplication
• Better Communication and Handoffs
• Access to Care Managers
• Variety of Access Points
• Cost Effective for Patient
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22. Challenges of Patient
Communication
• Medicare Rules
• Physician Office is key resource
• Customize for condition, cultural issues, etc.
• Keep in mind – “What’s In It For Me”
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23. Challenges of Patient
Communication
• Resources
– Outbound Call Center
– Targeted Mailings
– Web Site
– Coaches
– Care Managers
– Asynchronous / Virtual Visit- E Mail
– Group Visits
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24. Questions?