Disruptive Transformation and the Accountable Care Organization

Bob Roth
Managing Partner, Cypress HomeCare Solutions
(602) 264-8009 bobroth@cypresshomecare.com
John Marchica
President/CEO, Darwin Health
(480) 652-0008 jm@darwinhealth.net
“Disruptive Transformation and the
Accountable Care Organization”

• ACOs and Value-Based Care
Defined
• Creating a winning value
proposition: The Readmission Story
• Working with ACOs
• Targeting and approaching the right
ACO partner
• Discussion, Q&A
AGENDA
Disruptive Transformation and the Accountable Care Organization
Presentation by Bob Roth, Managing Partner, Cypress HomeCare Solutions and John Marchica, President/CEO, Darwin Health

“Health information about total
populations is a prerequisite for
sound decision-making and planning
in the health care field. Experience
with a population-based health data
system in Vermont reveals that there
are wide variations in resource input,
utilization of services, and
expenditures among neighboring
communities.”
- John E. Wennberg

GENESIS OF ACOs
• Accountable Care Organization coined by Dr. Elliott
Fisher (Dartmouth) in 2005 at a MedPac meeting to
describe “Groups of doctors, hospitals, and other health
care providers, who come together voluntarily to give
coordinated high quality care”
• Fisher and former Medicare and FDA chief Mark McClellan
(Brookings), along with Jonathan Gruber (M.I.T.), were
highly influential in shaping health care reform and
included ACOs as a key piece of the ACA
• Dartmouth-Hitchcock Medical Center and nine other IDNs
part of a Medicare demonstration project testing the
concept (2009-2012)

• In general, comprised of physician groups,
health systems, hospitals, insurers—and any
combination of these providers
• In most cases, they form a separate LLC
• Contract states some form of baseline for
quality and budget, set annually
• Bonus for beating budget, penalty for
exceeding budget
• ACOs are NOT managed care, like an HMO
• Mission-driven to achieve the Triple Aim
ACOs DEFINED

Patient
Experience
Lower Costs
Population
Health
Achieving all
Three
•Improve the health of
populations of people
•Improve the patient
experience with
healthcare
•Reduce per-capita
healthcare costs
THE TRIPLE AIM

ACO MODELS
• Medicare: Pioneer, Shared Savings Program,
Advance Payment, Investment, Next Generation
• Commercial
• Medicaid
• Employer
• Specialty
• Local Government
ACO TYPES
• Physician-Led
• Hospital-Led
• Insurer-Led

HospitalHospital Hospital
MONTEFIORE HEALTH
SYSTEM
Care
Management
Organization
University
Behavioral
Associates
Managed
Behavioral
Care IPA
Montefiore
IPA
Department of
PsychiatryMontefiore
Home Care
EXAMPLE: MONTEFIORE
• Montefiore has largest
commercial agreement
with UnitedHealthcare -
1,000 affiliated facilities
and 4,000 docs
• Also has an ACO
Agreement with Empire
BCBS, started in 2012
• Pioneer ACO: 40,287
assigned beneficiaries,
and 2,200 docs

2014 Actual: $356M
Difference: $13M
Monteﬁore’s cut: $8.4M (63% of total savings)
SHARED SAVINGS
2014 Target: $369M
Per Beneﬁciary: $549
HOW IT WORKS
Important: Wouldn’t have earned shared savings if quality goals were not met!

INTEGRATED HEALTH NETWORK OF WISCONSIN
Agnesian HealthCare
Columbia St. Mary’s
Froedtert & The Medical College of Wisconsin
Hospital Sisters Health System
Ministry Health Care
SSM Health
Wheaton Franciscan Healthcare
• 8,400 Caregivers
• 1,180 Clinics
• 53 hospitals
• 100 associated providers, including DME, SNF & HHC
FoundingHealthSystems

• Founded on the idea that “coopetition”
would optimize patient care
• Wisconsin market fragmented
• IHN’s formation was an alternative to
mergers and acquisitions, allowing for
economies of scale
• Four key areas of focus:
- Centralized data analytics
- Patient care coordinated across member
health systems
- Emphasis on patient/provider
relationships
- Shared contracting capabilities
✓ Competition
promotes innovation
and lower costs
✓ Collaboration drives
best practice and
improved efﬁciency
✓ Shared data and
management
infrastructure
✓ Unique contracting
structure

• IHN’s platform aggregates disparate
data from 3.1 million individuals
• Includes clinical data from patients in
all eight health systems

• Comprehensive payer claims data
provides a 360° view of approximately
200,000 lives managed through 12
contracts

• IHN’s care model requires clinical data,
claims data and ﬁnancial data
✓ Clinical claims submitted to payers
✓ EMR – vitals and health maintenance
✓ Laboratory
✓ Eligibility
✓ Post-adjudicated claims
✓ Risk score
✓ Transitions of care outreach
✓ Complex conditions care coordination
✓ Frequent ﬂier outreach
✓ Care gap closure
Source: Kurt Janavitz, “Moving Beyond the ACO: Four ‘Game-Changing’ Approaches to Value-Based Contracting.” Adapted
from July 17, 2016 presentation from Janavitz at the Health Forum Leadership Summit.

• 2015 case study: 3,500 IHN members
✓Identify high-risk members for care navigation

✓Align with IHN Member system

✓Contact member

✓Schedule PCP visit

✓Correctly code visit to minimize risk adjustment variability

• Results after one year:
✓Readmissions declined below national expected rate

✓Breast cancer screenings up 7%

✓Colorectal cancer screenings up 5%

✓Diabetes screenings up 4%

✓Increase in generic prescriptions (2%)
Total Spend Inpatient Outpatient Physician Pharmacy
Non-engaged patients 10% 2% 17% 0% 20%
Engaged patients -26% -40% 4% -14% 14%
Percent spending change over 1-year period, 2014-2015
from July 17, 2016, presentation by Janavitz at the Health Forum Leadership Summit.

Forecasted 2014
& 2015 Spend
Increase
Actual %
Spend
Increase
% Savings
Actual vs.
Forecast
Savings per
Employee
Total Savings
2014 & 2015
Health System
1
21.0% 1.3% 19.5% $3,473 $23,113,393
Health System
2
15.6% 2.1% 13.2% $2,497 $18,119,039
Conclusion: signiﬁcant savings were achieved in calendar
years 2014 and 2015 for two of IHN’s Member self-insured
groups. The most signiﬁcant factors were reduced
readmissions and emergency room utilization.

from July 17, 2016, presentation by Janavitz at the Health Forum Leadership Summit.

VALUE-BASED CARE
• Maximizing value for patients: the best
care at the lowest cost
• Move away from supply-driven system
to patient-centric system
• Move away from volume and profitability
of services to patient outcomes
• Move away from fragmented care to
coordinated care
• Right person, right place, right time
“It’s time for a fundamentally different strategy.”

- Michael Porter
VALUE =
QUALITY
COST

PRICE
QUALITY
VALUE-BASED CARE

• “Single payment to a provider or health care facility
for all services to treat a given condition or provide a
given treatment. Providers assume financial risk for the
cost of services for a particular treatment or condition,
as well as costs associated with preventable
complications.” (Health Affairs 1/15)
• Bundled payment can be triggered by a hospitalization
(such as CMS BPCI) or by a diagnosis (heart failure,
diabetes)
• Bundles work best for procedures or conditions with
measurable and somewhat predictable outcomes
BUNDLED PAYMENTS

“Have you had any formal meetings or discussions with an ACO?”
PercentYesResponse
0
20
40
60
80
Home Health Hospice Private Duty
39
43
72
June 2016, n=63
Source: Darwin Health

“Do you currently have a preferred provider relationship with an ACO?”
PercentYesResponse
0
12.5
25
37.5
50
6
20
33
June 2016, n=63

“Have you ever entered into a risk sharing agreement?”
PercentYesResponse
0
12.5
25
37.5
50
9
6
28
June 2016, n=63

“Financially speaking, what was the effect on your business?”
REVENUE
Home Health
Hospice
Private Duty
Percentage Response
0 25 50 75 100
0
0
60
33
0
0
66
100
40
Increased
Decreased
Stayed the Same
June 2016, n=63

“Financially speaking, what was the effect on your business?”
NET PROFIT
Home Health
Hospice
Private Duty
Percentage Response
0 25 50 75 100
60
0
60
15
0
10
0
100
30
Increased
Decreased
Stayed the Same
June 2016, n=63

“Do you currently have a contractual relationship with…?”
PercentYesResponse
0
7.5
15
22.5
30
Hospital/Health System Skilled Nursing/Rehab Health Plan/MCO
2424
18
June 2016, n=33
PRIVATE DUTY ONLY

24Hr HomeCare
• Question: Where does in-home care services fit in the new
world of bundled payments and value-based care?
• First MHC contract in 2012 (ongoing)
- High-risk patients selected by payer to receive home
care for the first 24 hours following discharge
- High-risk patients sent to home care if refuses SNF or
don’t meet the criteria for SNF
- Provided the payer a discount for services, no risk
- Tracking at 7% readmission rates
• Bundled payment for joint replacement with HealthSouth
- 60-day period
- $1000 per patient
• Currently about 20 MHC and hospital relationships for
“funded care” in Orange County, AZ and TX

24Hr HomeCare: LESSONS LEARNED
• Hospitals, ACOs and payers are willing to pay out of pocket for home
care services for high-risk patients and to prevent readmissions
• Collect your data, as difficult as it may be
• Build the right relationships over time to establish trust and confidence
• Need a warm introduction and a capable workforce
• Invest in strategic research and development!
• Establish criteria with your partner: teach the case managers
• Sometimes meet patient in the hospital
• Always get a signed agreement for 30 day minimum
• Look for clients with little support in the home: establish this up front
with your partner

I think we are interested because at the end of the
day, if you don't manage those patients well, you're
going to wind up paying fines or get denials or be in
a penalty phases. There is a little bit of money that
we are willing to pay to make sure this happens.
Source: Darwin Health personal interview, January 29, 2016
“Would you be willing to come out-of-pocket to pay for non-medical home care?”
ONE HOSPITAL CEO SAYS…

I'd like to see the patients that they're monitoring,
readmission rates. That's a big one I'd like to see. I'd like to
see for ones that they're treating with wound, I'd like to
see their would healing rates.
Clinical types of how many visits they're providing on
average per patient because there are metrics to see what
the appropriate number of visits should be.
Are there any national rankings or any national databases
that they submit to or state databases? Are they on specific
prohibited lists? Things like that.
Source: Darwin Health personal interview, January 29, 2016
“What kind of metrics would you like to see? Would you like to see a
financial argument? What do they come to the table with?”
ONE HOSPITAL CEO SAYS…

Domain: Patient/Caregiver Experience
ACO-1 Getting timely care, appointments, and information
ACO-2 How well your providers communicate
ACO-3 Patients’ rating of provider
ACO-4 Access to specialists
ACO-5 Health promotion and education
ACO-6 Shared decision making
ACO-7 Health status/functional status
Domain: Care Coordination and Patient Safety
ACO-8 Risk standardized all condition readmission
ACO-9
Ambulatory Sensitive conditions admissions: COPD or
asthma in older adults
ACO-10
Ambulatory sensitive conditions admissions: heart
failure (HF)
ACO-11
Percent of primary care physicians who
successfully qualify for an EHR program incentive
payment
ACO-12 Medication reconciliation
ACO-13 Falls: screening for future fall risk
Domain: Preventive Health
ACO-14 Preventive care and screening: influenza immunization
ACO-15 Pneumonia vaccination status for older adults
ACO-16 Body mass index screening and follow-up
ACO-17 Tobacco use: screening and cessation Intervention
ACO-18 Screening for clinical depression and follow-up plan
ACO-19 Colorectal cancer screening
ACO-20 Breast cancer screening
ACO-21
Screening for high blood pressure and follow-up
documented
Domain: At-risk Population—Diabetes
ACO-22 High blood pressure control
ACO-23 Low density lipoprotein control
ACO-24 Hemoglobin A1c control
ACO-25
Daily aspirin or anti-platelet medication use for
patients with diabetes and IVD
ACO-26 Tobacco non-use
ACO-27 Diabetes: hemoglobin A1c poor control
Domain: At-risk Population—Hypertension
ACO-28 Controlling High Blood Pressure
ACO-29
Ischemic vascular disease: complete lipid panel and LDL
control
ACO-30
Ischemic vascular disease: use of aspirin or another
antithrombotic
ACO-31
Heart failure: beta-blocker therapy for left ventricular
systolic dysfunction (ACO-31)
ACO-32 Drug therapy to lower LDL
ACO-33
ACE inhibitor or ARB therapy—diabetes or left
ventricular systolic dysfunction
Composite Scores
Diabetes Management Composite (ACO 22-26)
Coronary Artery Disease Composite (ACO 32-33)
Which metrics can you improve?
That leads to the Value Proposition…
ACO QUALITY METRICS

Domain: Patient/Caregiver Experience
ACO-1 Getting timely care, appointments, and information
ACO-2 How well your providers communicate
ACO-3 Patients’ rating of provider
ACO-4 Access to specialists
ACO-5 Health promotion and education
ACO-6 Shared decision making
ACO-7 Health status/functional status
ACO QUALITY METRICS

Domain: Care Coordination and Patient Safety
ACO-8 Risk standardized all condition readmission
ACO-9
Ambulatory Sensitive conditions admissions: COPD or asthma
in older adults
ACO-10
Ambulatory sensitive conditions admissions: heart failure
(HF)
ACO-11
Percent of primary care physicians who successfully qualify
for an EHR program incentive payment
ACO-12 Medication reconciliation
ACO-13 Falls: screening for future fall risk
ACO QUALITY METRICS

Domain: Preventive Health
ACO-14 Preventive care and screening: influenza immunization
ACO-15 Pneumonia vaccination status for older adults
ACO-16 Body mass index screening and follow-up
ACO-17 Tobacco use: screening and cessation Intervention
ACO-18 Screening for clinical depression and follow-up plan
ACO-19 Colorectal cancer screening
ACO-21
Screening for high blood pressure and follow-up
documented
ACO QUALITY METRICS

CREATING A WINNING VALUE
PROPOSITION

Master Marketing Plans that Attract New Clients

1. Utilizing Home Care as a part of the solution to
transitioning a patient from a hospital or post
acute setting to the home
2. Communication is paramount to the success of
making this transition
3. Strategies together will keep the patient, in our
case client, from re-entering your facility
PREVENTING HOSPITAL READMISSIONS

REDUCING HOSPITAL READMISSIONS: 
Partnering for success
State of the Industry: What has changed?
20% readmission rate = $17 Billion annual cost to Medicare
• CMS Mandates major cuts to Medicare Programs
• First Focus is on:
✓Heart Failure (broader than CHF)
✓Pneumonia
✓AMI (heart attack)
✓Diabetes
✓Will be adding more chronic conditions in the future

CMS reports that up to 75% of re-admissions to
hospitals are potentially preventable.*

(New England Journal of Medicine reported that half of all patients re-admitted
within 30 days hadn’t visited a doctor since discharge)

3 Main Reasons most patients are re-admitted to the hospital:
1) They miss follow-up visits

2) They have difficulty complying with their medication schedule

3) They have a poor understanding of “red flag” symptoms

*Medicare Payment Advisory Commission (MedPac), “Report to the Congress: Promoting Greater Efficiency in Medicare” June 2007
REDUCING HOSPITAL READMISSIONS: 
Partnering for success

Hospitals are being financially penalized 3% of each
payment for readmission for the following diagnosis:

• Congestive heart failure
• Myocardial infarction (heart attack)
• Pneumonia
• Chronic obstructive pulmonary disease (COPD)
• Orthopedic Hip and Knee
HOSPITAL READMISSIONS: 
What’s the Problem?

DEVELOPING A STRATEGY TO
REDUCE READMISSIONS

“Not all of the responsibility is the hospital’s” said Arnie
Kimmel, CEO, MetroSouth Medical Center in Blue Island, IL,
referring to why patients are readmitted within 30 days. “A
significant part of the reason we have to attribute to (patients)
lack of compliance with medical recommendations.”
Hospitals are a little upset (and they deserve to be) about
being penalized for something that they have very little control
over: HUMAN BEHAVIOR.
DON’T PLACE ALL THE BLAME ON THE HOSPITAL!

The Goal: Disease or condition management during
the 30 day post acute discharge and beyond
• Who will help the patient understand the challenges
of disease/condition management?
• Who will provide solutions for a smooth transition to a
lower level of care?
• Who else is involved in helping patients stay at home
for 30 days and beyond?
DEVELOPING AN EFFECTIVE STRATEGY

Older adults are particularly vulnerable to poor
transition outcomes:
• Multiple medical conditions
• Multiple care providers
• Multiple medications
• Physical and cognitive limitations
• Health literacy
• Burdened caregivers
PATIENT CONFUSION UPON DISCHARGE

Illinois Study* – 83% of patients had problems identified
by the social worker during the assessment at 2 days
post-discharge – “surprises”
• Management of post-discharge care – 25%
• Obtaining community services – 24%
• Understanding discharge plan – 17%
• Caregiver Stress – 35%
• Patient stress/coping – 35%
• Social support – 10%
*The Illinois Transitional Care Consortium (ITCC) presentation at the 2011 American Society on Aging
Conference the Bridge Model of Transitionary Care.
PATIENT CONFUSION UPON DISCHARGE

Gut reaction – Medicare Home Health will take care of all of this
Reality – Medicare nurse – 30 minute visit, 2-3x/week for 2-3 weeks
We believe preventing readmissions is a shared responsibility –
private duty homecare can take much of the burden off of the
family and help pull the team together.
WHO PULLS IT ALL TOGETHER?

Basics of Private Duty Homecare

• ADL’s
• Meal Prep
• Laundry/linens
• Light Housekeeping
• Transportation
Historically seen as something a select minority of older
adults could afford

Increased competition in the private duty homecare
industry has resulted in:

• Lower cost to consumer
• Greater flexibility in scheduling around the client’s needs
• Higher expectations of the caregiver and agency
PRIVATE DUTY HOMECARE: THE BENEFITS

Role of Private Duty Homecare in delivering high quality care
and reducing readmissions:

• Private Duty Homecare aides spend more time in the home with patient
than any other provider

• Medicare home health aide – 30 to 60 minute visit, 2-3x/week for 2-3
week – personal care only

• Average Cypress HomeCare Solutions client that discharges from a
hospital or post acute provider receives 60 hours of care/week!
Main Reasons Patients are

Re-admitted to Hospital
What Private Duty Homecare can do
1. Miss follow-up visits Arrange and accompany clients to
follow-up physician visits
2. Difficulty complying with medication
schedule
Medication reminders
3. Poor understanding of “red flag”
symptoms
Not all private duty agencies are the
same
PRIVATE DUTY HOMECARE: THE BENEFITS

“It costs too much.”

It will cost you more if the patient gets readmitted to the hospital.
“The patient is already getting Medicare home health services –
we don’t need private duty home care also.”

• They can go home with both – the first 48 hours is critical! 50% of the Cypress
HomeCare Solutions clients discharge from the hospital discharge from the
hospital with both Medicare and Private Duty home care, it should be 100%!
• Patients often come home weak, debilitated and tired – have challenges
because too tired to eat, take meds, get out of bed.
• Home health cannot be there to ensure proper nutrition, medication
compliance, help a patient get to the bathroom, etc.
COMMON BARRIERS TO PRIVATE DUTY HOMECARE

“The patient is going to rehab.”

Rehab typically lasts around 20 days, leaving 10 days left when they could
still be readmitted during the 30 day period. Who will be there to support
them and what will their needs be when they leave rehab?
“Some patients are in and out so quickly, we don’t have time to set up a
lot of services.”

Tag them early so they can get appropriate referrals.
“We have transitional specialist working with the patient.”

• Great! We can begin coordinating the discharge plans with him/her as
soon as the patient steps into the ER.
• The transitional specialist is not going to be with the patient in the home
environment, that’s where our expertise comes in.
COMMON BARRIERS TO PRIVATE DUTY HOMECARE

• Private duty homecare needs to share the
responsibility of preventing hospital readmissions

• Private duty homecare is the only post-acute
provider who can be in the home consistently with
the patient after discharge (avg. 60 hours/wk)
CONCLUSIONS

CHANGING YOUR SALES PARADIGM
• Multiple decision makers

• Complex problems to solve

• Frequently create buying criteria

• Long time to make decisions

• Contracts

STRATEGIC SELLINGTRANSACTIONAL SELLING
• Few decision makers

• Simple problems to solve

• May create buying criteria

• Short time to make decisions

• One-time transaction

(Fee-for-service) (Value-based care)

MILLER HEIMAN’S 4 BUYING INFLUENCES
User Buyer

Economic Buyer

Technical Buyer

Coach
Selling complex solutions is
defined as more than one
buyer, more than one sales
call, with a service and
solution that is not cookie
cutter. Selling complex
solutions and services require
that you have a complete
understanding of how the
client decides.
Source: Joseph Murphy. A Short Primer on Strategic Selling.

THE RELATIONSHIP LADDER
CHAMPION

PARTNER

CLIENT

VENDOR

PROSPECT
T
R
U
S
T
“You can get what you want by giving them what they want.”
Advocates for you

Relies on you

Trusts you

Heard of you

Doesn’t know you

• The stereotypes are true: the industry is viewed with
skepticism, cynicism and distrust

• BEHAVIORS build or erode trust

• At a minimum, what ACOs want: DATA

• Data will get you in the door, but won’t create champions

• Are you a problem solver? What problems do they face?

• What is your position relative to your competition?

• What is your message?

• What is your strategy for engagement?
PREPARING FOR PARTNERSHIPS

Collecting 53 data points on every client
• “Does the client have this diagnosis…”

- CAD

- COPD

- Depression/Anxiety

- Diabetes, etc.

• Do you record:

- DNR

- Advance Directive

• Has the client been hospitalized during
our service?
24-Hour HomeCare Example

© 2016 Darwin Advisory Partners, LLC. Darwin Health is a division of Darwin Advisory Partners, LLC.
ACOs, Philadelphia-Camden-Wilmington CBSA
ACO Name ACO Type City State Patient
PopulationDelaware Valley ACO MSSP Radnor PA
Aetna - Delaware Valley ACO Commercial ACO Radnor PA
Aetna - Childrens Hospital of Philadelphia (CHOP) ACO Commercial ACO Philadelphia PA
Aetna - Virtual Medical Group ACO Commercial ACO Marlton NJ
Independence Blue Cross - Lumeris - Abington Health ACO Commercial ACO Abington PA
Aetna - LHS Health Network ACO Commercial ACO Camden NJ
LHS Health Network MSSP Camden NJ
Horizon Blue Cross Blue Shied of New Jersey and LHS Health Network ACO Commercial ACO Camden NJ
Horizon Blue Cross Blue Shield of New Jersey - LHS Health Network ACO Commercial ACO Camden NJ
Virtua MSSP Marlton NJ
Aledade Pennsylvania ACO LLC MSSP Exton PA
Keystone First - Jeﬀerson Health System ACO Medicaid ACO Radnor PA
AmeriHealth - Cooper Health ACO Commercial ACO Camden NJ
Christiana Care Quality Partners ACO LLC MSSP Newark DE
Mercy Accountable Care Network LLC MSSP Conshohocken PA
Aetna - Virtua ACO Commercial ACO Marlton NJ
Advanced Comprehensive Care Organization Commercial ACO Philadelphia PA
Inspira Care Connect LLC MSSP Elmer NJ
Quality Health Alliance-ACO LLC MSSP Langhorne PA
Camden Coalition of Healthcare Providers ACO Medicaid ACO Camden NJ
Fresenius Seamless Medical Care of Philadelphia LLC ESRD Philadelphia PA
Delaware Care Collaboration DCC LLC MSSP Wilmington DE
Genesis Healthcare ACO LLC MSSP Kennett Square PA
Delaware Valley/Humana ACO (Commercial ACO) Commercial ACO Villanova PA
Philadelphia - Camden Integrated Kidney Care LLC ESRD Philadelphia PA
United Medical LLC MSSP Bear DE
Noble Health Alliance (To close by Dec 2016) Commercial ACO Fort Washington PA
Independence Blue Cross - University Of Pennsylvania Health System ACO Commercial ACO Philadelphia PA
Childrens Hospital Of Philadelphia ACO Commercial ACO Philadelphia PA
Geisinger Health Plan - Christiana Care Quality Partners ACO Commercial ACO Newark DE
DBA: Delaware Valley ACO (Independence Blue Cross - Jefferson Health System) Commercial ACO Philadelphia PA
TABLE OF CONTENTS
JEFFERSON HEALTH

Top IDNs, Detroit-Warren-Dearborn CBSA
By Number of Beds
IDN Name
City
(headquarters)
State
Net Patient
Revenue*
Number
of Beds*
Member
Hospitals*
Beaumont Health System Royal Oak MI $3,524,660,571 2,976 8
Ascension Health St. Louis MO $2,160,479,674 2,199 10
St. John Providence Health System Warren MI $1,951,586,190 1,967 8
Henry Ford Health System Detroit MI $2,652,997,376 1,588 6
Detroit Medical Center (Tenet) Detroit MI $1,686,872,669 1,318 8
McLaren Health Care Corporation Flint MI $731,988,100 753 4
St. Joseph Mercy Health System (Trinity) Ypsilanti MI $760,697,046 676 3
Prime Healthcare Services Ontario CA $222,411,979 307 2
Vibra Healthcare Mechanicsburg PA $36,542,143 260 3
Department Of Veterans Aﬀairs Washington DC 218 1
Universal Health Services King Of Prussia PA $44,859,678 205 1
Acadia Healthcare Franklin TN $48,846,523 191 2
Select Medical Corporation Mechanicsburg PA $83,486,683 167 5
Blue Water Health Services Port Huron MI $167,252,923 163 1
Michigan Department of Health & Human Services Lansing MI 161 2
Kindred Healthcare Louisville KY $26,365,823 77 1
Borgess Health Kalamazoo MI $20,566,993 43 1
National Surgical Hospitals Chicago IL $16,122,078 13 1
TABLE OF CONTENTS
HENRY FORD
* Net patient revenue, number of beds and member hospitals refers only to revenue, beds and hospitals within this CBSA.

Advocate Physician Partners Accountable Care (MSSP)
149,633 Medicare beneficiaries (2015); 4,000 physicians

AdvocateCare ACO
375,000 Blue Cross Blue Shield of Illinois beneficiaries

UnitedHealthcare - Advocate ACO
80,000 commercial and 5,500 Medicare Advantage beneficiaries

BlueCare Direct (Advocate Health Care - Blue Cross Blue
Shield of Illinois ACO)
Commercial ACO on GetCoveredIllinois (healthcare exchange)
and for small businesses; 4,000 physicians

Aetna Whole Health - Advocate Health Care
Commercial ACO on GetCoveredIllinois (healthcare exchange)
and for small businesses; 4,000 physicians

Advocate Accountable Care - Meridian Health Plan
Medicaid ACO, 4,000 physicians, 90,000 Medicaid beneficiaries
ACOs
MSSP ACO Performance
ADVOCATE PHYSICIAN PARTNERS ACO
Performance Year 1 (2013)
Savings: $2.9M

Savings Per Beneficiary: $21

Loss: -$5.3M

Loss Per Beneficiary: -$39 
Quality Score (CMS): 90.96%

Savings: $72.7M 
Savings Per Beneficiary: $486 
Quality Score (CMS): 94.19%
Value-Based Initiatives
Accountable Care Entities (ACE)
Illinois was required to transition at least half of its 3 million Medicaid
beneficiaries into managed care by January 1, 2015, to reduce
costs, and as part of that effort has given nine Chicago-area health
care groups—including Advocate Accountable Care—preliminary
approval to establish accountable care entities (ACEs), which are
similar to accountable care organizations. The ACE model will
replace the existing fee-for-service Medicaid payment model.

The major rollout of the state’s ACE program was to be completed in
July 2014 but delays occurred. Advocate’s chief medical officer, Dr.
Lee Sacks, said his organization’s ACE, which could cover more
than 150,000 Medicaid patients, would not happen until at least the
September 1. No further updates have been available since.

According to Michael Randall, Advocate Physician Partners’ vice
president for clinical innovation, one of the state’s goals for the
Advocate ACE is to strengthen its ties with community clinics.
ADVOCATE
TABLE OF CONTENTS
Primary Contact
Rick Goddard

Director of Clinical Innovation

wrichard.goddard@advocatehealth.com

847.375.2226

1701 W. Golf Road, Suite 2-1100

Rolling Meadows, IL 60008

http://www.advocatehealth.com/mssp

Pioneer ACO Quality Scorecard—Beth Israel Deaconess Care Organization
Value-Based Initiatives
^ Lower scores are better
10.0 percent below average or worse
5.0-9.99 percent below average
5.0 percent or more above average or better
Average
Darwin’s Visual Scorecard compares
this ACO to the mean score for all
MSSP model ACOs, by each measure.
Each measure is color coded for a
quick visual representation of how the
ACO is performing relative to its peers.
In 2015, CMS added several new
measures, such as Depression
Remission at 12 Months (ACO-40).
CMS also stopped reporting some
metrics and has changed the way the
DM Composite is measured.
Caution is advised when interpreting
ACO-9 and ACO-10, which utilize a
standardized score. Below 1.0 means
the rate of discharge was better than
expected, while above 1.0 means the
rate of discharge was worse than
expected.
A detailed description of CMS’
methodology can be found here:
https://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/sharedsavingsprogram/
Downloads/2016-ACO-NarrativeMeasures-
Specs.pdf
BETH ISRAEL DEACONESS
TABLE OF CONTENTS
2012 2013 2014 2015
Patient/Caregiver Experience Score Score Score Score
ACO-1 Timely care, appointments and information 82.4 177.35%84.17 309.73%83.48 186.57%83.19 384.47%
ACO-2 Provider communication 93.26 66.42%94.23 137.47%93.95 103.02%93.87 158.43%
ACO-3 Patients’ rating of provider 91.88 23.45%93.36 92.45%93.17 82.73%93.86 236.58%
ACO-4 Access to specialists 84.36 -35.84%82.29 -310.99%83.34 -70.12%84.43 111.93%
ACO-5 Health promotion and education 59.89 494.36%65.91 1062.92%66.09 987.71%65.82 1160.53%
ACO-6 Shared decision making 75.1 99.22%72.78 -163.54%76.68 274.83%75.54 98.41%
ACO-7 Health status/functional status 72.53 311.30%72.89 186.66%74.65 322.25%74.65 379.95%
ACO-34 Stewardship of patient resources 0.00% 0.00% 0.00%24.02 -1217.36%
Care Coordination / Patient Safety
ACO-8^ Risk standardized, all condition readmissions 16.11 404.88%15.32 243.92%16.12 532.85%16.05 801.73%
ACO-35^ Skilled nursing facility 30-day all-cause readmission measure 0.00% 0.00% 0.00%20.30 1242.69%
ACO-36^ All-cause unplanned admissions for patients with diabetes 0.00% 0.00% 0.00%55.99 259.30%
ACO-37^ All-cause unplanned admissions for patients with heart failure 0.00% 0.00% 0.00%86.34 1219.00%
ACO-38^ All-cause unplanned admissions for patients with multiple chronic conditions 0.00% 0.00% 0.00%67.82 778.94%
ACO-9^ COPD or asthma in older adults admissions 1.12 476.47%1.24 1149.34%1.21 1398.96%1.28 1547.99%
ACO-10^ Heart failure admission 1.04 66.55%1.22 560.78%1.3 1685.39%1.12 739.99%
ACO-11 % physicians on EHR (Meaningful Use) 74.63 1731.91%81.54 584.77%86.14 1.16%88.76 1026.69%
ACO-39 Documentation of current medications in the medical record 0.00% 0.00% 0.00%87.44 400.38%
ACO-13 Falls: screening for fall risk 28.63 -1967.03%55.63 -653.49%72.33 1194.60%79.00 3959.10%
Preventive Health
ACO-14 Inﬂuenza immunization 57.14 706.51%72.01 431.96%76.42 831.04%76.11 2271.93%
ACO-15 Pneumonia vaccination status for older adults 61.75 783.85%75.54 483.12%76.3 -90.84%80.52 2624.43%
ACO-16 Body mass index screening and follow-up 60.62 1412.30%61.23 -589.88%72.19 632.05%69.09 -292.28%
ACO-17 Tobacco use: screening and cessation intervention 86.85 1159.74%94.62 505.57%95.9 234.30%92.83 285.60%
ACO-18 Screening for clinical depression and follow-up plan 8.82 -6265.04%30.08 -3959.26%64.08 739.96%73.88 6299.52%
ACO-19 Colorectal cancer screening 68.03 1709.63%80.82 1229.41%78.44 535.08%79.37 3220.19%
ACO-20 Breast cancer screening 74.27 1466.67%76.03 605.96%76.58 74.06%78.34 1933.00%
ACO-21 Screening for high blood pressure & follow-up 68.44 831.15%48.31 -2182.85%44.79 -2034.86%78.15 1158.59%
At-Risk Population
ACO-40 Depression remission at 12 months 0.00% 0.00% 0.00%2.44 -6018.02%
DM CompositeDiabetes management composite (based on ACO-27 and ACO-41) 23.56 -767.23%30.9 -710.90%31.93 -1315.82%50.00 4106.23%
ACO-27^ Diabetes: hemoglobin A1c poor control 16.86 -3772.93%12.97 -1944.97%12.2 -1353.65%16.03 -2151.23%
ACO-41 Diabetes: eye exam 0.00% 0.00% 0.00%56.41 3712.39%
ACO-28 Percent with hypertension whose BP < 140/90 61.82 -332.08%68.64 -752.79%69.23 -766.38%69.21 -56.92%
ACO-30 Percent with IVD who use of aspirin or another antithrombotic 85.61 1254.15%90.78 771.85%89.07 158.76%93.50 1155.70%
ACO-31 Heart failure: beta-blocker therapy for LVSD 80.51 -187.09%83.7 -165.52%83.46 -603.41%86.08 -128.08%
ACO-33 ACE inhibitor or ARB therapy for patients with diabetes or LVSD 75.13 563.79%81.9 929.31%80.84 -20.86%89.58 1522.75%

TABLE OF CONTENTS
OCHSNER HEALTH SYSTEM
Leadership Team
Warner Thomas
President & CEO
Richard Guthrie
Chief Quality Officer
Michael Hulefeld
Executive Vice
President & Chief
Operating Officer
Stephen Robinson
CEO, Ochsner Medical
Center-Kenner
Tim Allen
CEO, Ochsner St. Anne
General Hospital and
Leonard J. Chabert
Medical Center
Robert Hart, MD
Executive Vice
President & Chief
Medical Officer
Pete November
Executive Vice
President & Chief
Administrative Officer
Mark Muller
Senior VP of Strategy
and Business
Development
Bradley Goodson
CEO, Ochsner North
Shore Region
Ritchie Dupre
CEO, St. Charles Parish
Hospital
Robert Wolterman
Center-Jefferson Highway
Dawn Anuszkiewicz
CEO, Ochsner Baptist
Scott Posecai
Executive Vice
President & Chief
Financial Officer
Eric McMillen
Center-Baton Rouge
Tracey Moffatt
Chief Nursing Officer
Randy Peak
System Vice President
and General Counsel
Michelle Dodenhoff
Chief Development
Officer
Anthony DiGerolamo
Center-West Bank
Hospital CEOs
Executive Management Team
Bobby Brannon
Executive Vice
President & Treasurer
David Gaines
CEO – System Retail
Services & System Vice
President of Public Affairs
William McDade, MD
PhD
Executive Vice President
& Chief Academic Officer
Patrick Quinlan, MD
CEO - Ochsner Clinic
Foundation
Richard Milani, MD
Chief Clinical
Transformation Officer
Kristy Nichols
System Vice President,
Partnerships and
Innovation
Alan Hodges
CEO, Hancock Medical
Center
David Carmouche, MD
SVP and President,
Ochsner Health
Network
Senior Management Team

Measure Shea Lincoln Osborne
Thompson
Peak
Deer
Valley
National
Rate
All Cause Hospital-Wide Readmission 14.50% 15.30% 15.10% 14.40% 15.50% 15.20%
Rate of unplanned readmission for COPD patients 18.90% 21.00% 19.70% 21.30% 21.50% 20.20%
Death rate for COPD patients 8.10% 7.80% 10.00% 6.40% 7.50% 7.70%
Rate of unplanned readmission for heart attack
patients
16.20% 16.40% 15.80% 16.50% 16.90% 17.00%
Death rate for heart attack patients 12.20% 15.60% 14.70% 13.00% 13.20% 14.20%
Rate of unplanned readmission for heart failure
patients
22.70% 20.00% 20.80% 22.20% 24.00% 22.00%
Death rate for heart failure patients 11.20% 11.90% 9.40% 10.70% 11.00% 11.60%
Rate of unplanned readmission for pneumonia patients 17.00% 17.90% 16.00% 16.60% 16.10% 16.90%
Death rate for pneumonia patients 10.50% 11.80% 11.90% 9.00% 10.00% 11.50%
Rate of unplanned readmission for stroke patients 11.20% 13.10% 12.20% 12.50% 13.00% 12.70%
Death rate for stroke patients 12.30% 15.40% 16.60% 12.20% 13.20% 14.80%
Rate of unplanned readmission after CABG surgery 13.50% 15.90% 14.60% n/a 14.40% 14.90%
Death rate following Coronary Artery Bypass Graft
CABG surgery
3.70% 2.70% 2.90% n/a 3.50% 3.20%
Rate of unplanned readmission after hip/knee surgery 3.80% 5.50% 5.20% 4.00% 4.50% 15.20%
Rate of Complications for Hip and Knee Replacement
Patients
2.40% 3.30% 2.80% 2.70% 2.80% 3.10%
© 2016 Darwin Advisory Partners, LLC. Darwin Health is a division of Darwin Advisory Partners, LLC.HONOR HEALTH
Comparative Statistics for HonorHealth locations
30-Day Readmission and Mortality Rates (Medicare FFS)

DRG Description
Total
Claims
Readmission
Rate
Total Days
Avg Length
of Stay
(Days)
470 MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC 1,579 4.40% 3,699 2.3
871 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS W MCC 681 16.80% 3,941 5.8
392 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC 496 15.80% 1,501 3
194 SIMPLE PNEUMONIA & PLEURISY W CC 320 16.50% 1,331 4.2
460 SPINAL FUSION EXCEPT CERVICAL W/O MCC 310 7.20% 827 2.7
378 G.I. HEMORRHAGE W CC 309 13.70% 1,058 3.4
872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS W/O MCC 308 15.50% 1,255 4.1
603 CELLULITIS W/O MCC 306 10.40% 1,076 3.5
552 MEDICAL BACK PROBLEMS W/O MCC 306 15.50% 1,474 4.8
292 HEART FAILURE & SHOCK W CC 289 23.10% 1,109 3.8
690 KIDNEY & URINARY TRACT INFECTIONS W/O MCC 284 15.40% 889 3.1
65 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC 251 16.20% 1,649 6.6
310 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC 240 9.30% 517 2.2
641 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC 240 16.90% 727 3
291 HEART FAILURE & SHOCK W MCC 239 22.70% 1,332 5.6
481 HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC 237 10.30% 993 4.2
683 RENAL FAILURE W CC 231 19.40% 876 3.8
0 UNKNOWN 226 14.50% 0 0
309 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC 214 18.80% 675 3.2
536 FRACTURES OF HIP & PELVIS W/O MCC 213 7.10% 1,776 8.3
© 2016 Darwin Advisory Partners, LLC. Darwin Health is a division of Darwin Advisory Partners, LLC.HONOR HEALTH
Top 20 Readmissions by Number of Claims
HonorHealth Readmissions

Patient
Experience
Lower Costs
Population
Health
Achieving all
Three
• Improve the health of
populations of people
• Improve the patient
experience with healthcare
• Reduce per-capita
healthcare costs
What data do you have that proves:
ALIGN YOUR MESSAGE
ALIGN WITH ACO METRICS!

ALIGN YOUR MESSAGE
Preventive Health
ACO-14
Preventive care and
screening: inﬂuenza
immunization
ACO-15
Pneumonia vaccination
status for older adults
ACO-16
Body mass index screening
and follow-up
ACO-17
Tobacco use: screening and
cessation Intervention
ACO-18
Screening for clinical
depression and follow-
up plan
ACO-19
Colorectal cancer
screening
ACO-21
Screening for high blood
pressure and follow-up
documented
% Vaccina(on Check
Inﬂuenza Pneumonia
CLIENT Comp1 Comp2 Comp3 CLIENT Comp1 Comp2 Comp3
68.9%
70.7% 71.3%
69.6% 70.0%
71.3%
85.1%
79.2%

Know your ROI: What is the
Lifetime Value of a client?
Know the ACO
Market Potential:
How many covered
beneficiaries?
$/hour, hours per week,
average number of weeks per
client
Quantify the relationship.
Estimate expected market
share using traditional
marketing. Now estimate
estimated share under a
preferred partnership. What’s
the benefit?
Are they willing to listen to
your story?
Some people simply won’t.
What is your value
proposition?
And have you quantified it?
Know your capacity.
What’s the right ACO
size?
Are you willing to go
at risk?
Or reduce fees? Alter
payment schedule?
CHOOSING THE RIGHT PARTNER

ACO Name
States where
beneficiaries reside
Number of
Beneficiaries
Readmission
%
Atlantic ACO New Jersey, Pennsylvania 73,694 15.37
Meridian Accountable Care Organization, LLC New Jersey 40,133 13.73
Palm Beach Accountable Care Organization, LLC Florida 36,268 15.56
Optimus Healthcare Partners, LLC New Jersey 34,542 15.14
Memorial Hermann Accountable Care Organization Texas 34,430 14.41
Scott & White Healthcare Walgreens Well Network, LLC Texas 34,149 14.14
Accountable Care Coalition of Texas, Inc. Texas 33,739 13.89
ProHealth Physicians ACO, LLC Connecticut 32,216 14.92
Millennium Accountable Care Organization Florida 28,957 14.23
Accountable Care Clinical Services, PC
Iowa, Pennsylvania, Connecticut,
Massachusetts, California
19,637 15.08
Central Jersey ACO LLC New Jersey 19,340 15.43
Saint Francis HealthCare Partners ACO Inc. Connecticut 19,210 15.17
Medical Practitioners For Affordable Care, LLC Florida 17,974 16.46
BHS Accountable Care LLC Texas 17,210 14.07
Hackensack Alliance ACO New Jersey, New York 16,383 15.52
Accountable Care Coalition of Mount Kisco, LLC New York, Connecticut 16,326 14.60
Northern Maryland Collaborative Care LLC Maryland 15,470 15.58
Maryland Collaborative Care, LLC. District of Columbia, Maryland 15,465 14.78
Methodist Patient Centered ACO Texas 15,013 14.70
Largest ACOs in Client high-performing states
Average readmission rate, target market: 14.97
Average readmission rate, national: 14.89
ACO TARGETING

ACO Name
States where
beneficiaries reside
Number of
Beneficiaries
Atlantic ACO New Jersey, Pennsylvania 73,694
Palm Beach Accountable Care Organization Florida 36,268
Optimus Healthcare Partners, LLC New Jersey 34,542
Accountable Care Clinical Services, PC
Iowa, Pennsylvania, Connecticut,
Massachusetts, California
19,637
Central Jersey ACO LLC New Jersey 19,340
Saint Francis HealthCare Partners ACO Inc. Connecticut 19,210
Medical Practitioners For Affordable Care, LLC Florida 17,974
Hackensack Alliance ACO New Jersey, New York 16,383
Northern Maryland Collaborative Care LLC Maryland 15,470
TOTAL ELIGIBLE BENEFICIARIES 252,518
Largest ACOs, Client high-performing states with
higher-than-average readmission rates
ACO TARGETING

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