CCOO Organizationscontent.hcpro.com/pdf/content/261719-5.pdfowners of Advantage Health solutions,...

This is CASE STUDY 1 of 4 from HealthLeaders Media Breakthroughs: The Bridge to Accountable Care Organizations

ACOACO

Case Study | Franciscan Alliance/St. Francis Hospital and Health Centers

In collaboration with

The Bridge to Accountable Care

Organizations

January 20112010 AS

BPE GOLD

DIGITAL MAGAZINEGENERAL EXCELLENCE

2010 ASBPE GOLD

DIGITAL MAGAZINEGENERAL EXCELLENCE

share HEAltHlEAdERS MEdiA BREAktHRougHS: the Bridge to Accountable Care organizations

in collaboration with©2011 HealthLeaders Media, a division of HCPro, Inc.

10

share

ACOACO

To many hospital executives who have been in healthcare long enough to see a few cycles of change, the thought of going back toward integration and carrying risk for covered lives fills them with dread. Many of them were only too happy to

sell off their health plans from the mid-1990s, disband HMo-style

networks and return to a core business of fee-for-service.

The alternative view is a bit more hopeful: that ACos can be

built on the lessons and mistakes of the HMo era. In the 1990s,

many hospitals built health plans and referral networks, but not

the necessary infrastructure, governance and physician alignment

to make the ventures successful. For those hospitals, ACos may

represent a chance to redeem their honest efforts to better manage

a patient population’s health quality and expenses by rebuilding the

foundation from scratch.

For example, Indianapolis-based Franciscan Alliance/st. Francis

Hospital and Health Centers—which owns 13 hospitals in Indiana

and Illinois—have managed to keep their networks alive and

thriving, creating a solid foundation to which they may only need to

bolt on additional applications to make an entire ACo network.

st. Francis Health Network is a physician-hospital corporation

founded in 1993, which now coordinates care for approximately

35,000 covered lives, among them the Franciscan Alliance’s own

5,000 health system employees in the region. Its physician network

is made up of almost 500 physicians, including 60 primary care

physicians and another 60 specialists employed directly by the

health system. In addition, Franciscan Alliance/st. Francis Hospital

and Health Centers is one of four Catholic health systems that are

owners of Advantage Health solutions, which offers HMo and Pos

plans to employers.

While the network does not have every piece of the ACo machin-

ery, what it does have is the experience and physician culture on

managing health and carrying risk that gives it a decided head start.

B Y j I M M o L P u s

Pieces in PlaceCase Study | Franciscan Alliance/St. Francis Hospital and Health Centers

10

While many hospitals took down their integration after the last round in the 1990s, Franciscan Alliance/St. Francis Hospital and Health Centers are thankful they held onto theirs.

http://www.facebook.com/HealthLeadersMediahttp://twitter.com/HealthLeadershttp://www.healthleadersmedia.com/breakthroughs/

HEAltHlEAdERS MEdiA BREAktHRougHS: the Bridge to Accountable Care organizations

in collaboration with

11

share

©2011 HealthLeaders Media, a division of HCPro, Inc.


“We’ve had a very strong shared responsibility approach to

managing the care of the patients within the st. Francis Health

Network, and that’s forced us to utilize our resources efficiently

and appropriately,” says Robert j. Brody, CEo, Central Indiana

Region for Franciscan Alliance. “By sharing decision-making with

physicians with respect to performance improvement and clinical

quality initiatives, we are better prepared than most in this chang-

ing environment.”

“other organizations are probably—I won’t say scrambling—

but they’re trying to figure out the infrastructure development

question,” CFo jay Brehm says. “We’re not. The infrastructure is

there. so that enables us to slide right into meaningful discussions

with payers about working more closely on the overall healthcare

of their members.”

Keeping the network through years where most hospitals

divested them was not always easy, says sFHN executive director

jennifer Westfall. It helped that both Brody and Brehm knew that

managing care was a strength they needed to keep.

“so when other organizations across the country began to

experience the risk environment, our hospital management stayed

the course,” Westfall says. “They saw the future. Westfall says it

helped that “part of our commercial lives are our own 5,000

hospital employees and their dependents, so we’ve been able to

make a real difference in the cost of the health insurance that the

hospital pays as a self-funded group.”

When the health reform debate started to include pilots and

other signs directed toward accountable care organizations,

Westfall and the team knew there were pieces that sFHN would

need to build.

“It gives us an opportunity to continue to build upon the founda-

tion of the st. Francis Health Network that we developed over the

last 16 years,” she says, which includes boosting their post-acute

care strategy, population management and the development of pri-

mary care medical home models.

one of the first goals is to work with the primary care network

on three or four large disease states, including diabetes, so that

every patient is treated with uniform care protocols.

“The focus now is on getting patients in and out of the hospital as

quickly as possible. The renewed focus will be to manage the patient

earlier so hospitalization may never be necessary,” Westfall says.

Physician building blocksone of the complaints that many physicians had with capitated

plans was that it forced too much interpretation and denial of

care on the physicians. joseph LaRosa, MD, medical director for

st. Francis Health Network, says the 500 physicians in the group

have worked together to come up with consistent preauthorization

guidelines, backed up by external medical necessity criteria from

Milliman.

“We have made the preauthorization process simple,” LaRosa

says. “The physicians know from the beginning that here are the

rules and this is what qualifies for this or that. They know well in

advance what’s going to fly and what’s not going to fly. Decreasing

the hassle for the physicians has been another buy-in factor.”




12

share


Westfall and LaRosa recognize that the physician network and

alignment created for the current health network will have to be

updated to reach a fully functioning accountable care organization,

including the creation of medical homes.

“I think that our doctors are on board with the process of medi-

cal homes,” LaRosa says. “It’s a different mind-set though. We don’t

know until we really push it through what the total reaction will be.

The challenge is not going to be our primary care doctors. The chal-

lenge may lie with our subspecialists. Medical homes and ACos rely

Administrative costs for

the plan are kept at 4.6%—

compared to a national

average of 9.18%, according

to a study by the BlueCross

Blueshield Association.

Physicians are contracted at

full capitation. Both the net-

work and contracted physi-

cians assume the risk through

withholds, says Westfall.

All ancillary testing, lab

work, and imaging are

performed at the hospital,

which removes potential phy-

sician overuse, Westfall says.

“Therefore, overutilization of

services for revenue enhance-

ment was never an issue in our cost model.”

Another cost that the network does not have to bear is paying

physicians to participate in committees or quality initiatives.

“This is just incredible,” LaRosa says. “We’ve got all these com-

mittees and stuff like that. We give them a meal. We give them

breakfast or we’ll bring sub sandwiches in. They continue to come

to these meetings and it’s unheard of for an insurance company—

which is basically what we are—to have physicians with that kind

of buy-in.”

SFHN Ed/uC utilizAtioN tRENd RAtES AFtER iNitiAtioN oF AFtER HouRS CliNiCS

Case Study | Franciscan Alliance/St. Francis Hospital and Health Centers 12

Roll over the chart to view utilization trend rates

25%

46%

Source: Franciscan Alliance/St. Francis Hospital and Health Centers

Medicaid ED/UC visits/1,000 members Commercial ED/UC visits/1,000 members




13

share



“I suppose it reinforces the kind of dialogue and planning necessary

with members of the medical staff, whether employed or indepen-

dent, to assure that we are both successful in the new environment.

We have a successful history in working with our medical staff

over the years with a PHo structure that has operated in a full risk

arrangement with a variety of payers. so this is not new to us. It’s a

situation that will impose even higher performance expectations on

us but we stand ready to accept that challenge and to perform.”

heavily on an holistic approach of care. The subspecialists and st.

Francis Health Network, which are capitated for services, are used

to dealing with a fee-for-service environment as their main payer

source.”

one of the biggest switches will be that in a medical home envi-

ronment, much more transparency and discussion will be around

“which doctors are costing us money and which ones are saving

us money,” LaRosa says. “We know which doctors who are part of

this fleet that are going to make this work financially. I have never

shared that with the doctors. That has not been our strategy yet. I

think it may be our strategy in the very near future.”

Another challenge will be to push the health system’s current

electronic medical record implementation from Epic systems

through from the hospital and employed physicians to the inde-

pendent physicians. The network has been able to provide some

data and analytics over the years since it has all of the data as a

third-party administrator. so while the health plan has been able

to identify cost drivers through data, the need for a medical home

and an accountable care organization will be for more current data

than can be found in claims data that may be 60 to 90 days old. “In

the future, the EMR will allow us to have access to real-time clinical

data,” Westfall says.

Timing is always a factor whenever healthcare goes through a

major change. Brody says timing and history are on their side as they

work with their physicians through the next wave.

“We’re finding that physicians are far more receptive than ever

before to working within a more integrated framework,” Brody says.

13

Robert J. Brody, Regional CEO, Franciscan Alliance/ St. Francis Health NetworkHaving trouble listening? Click here.

PERCENtAgE oF diABEtES PAtiENtS oBtAiNiNg lABSLab percentage rose as incentives were added for the patients.

Source: Franciscan Alliance/St. Francis Hospital and Health Centers

Roll over the chart to view labs drawn trend rates

http://www.facebook.com/HealthLeadersMediahttp://twitter.com/HealthLeadershttp://www.healthleadersmedia.com/breakthroughs/http://content.hcpro.com/breakthroughs/7/BT7_SSF_Brody_v2.mp3

Copyright ©2011 HealthLeaders Media, 5115 Maryland Way, Brentwood, TN 37027 • Opinions expressed are not necessarily those of HealthLeaders Media. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

About HealthLeaders MediaHealthLeaders Media is a leading multi-platform media company dedicated to meeting the business information needs of healthcare executives and professionals.

To keep up with the latest on trends in physician alignment and other critical issues facing healthcare senior leaders, go to: www.healthleadersmedia.com

SponsorshipFor information regarding underwriting opportunities for HealthLeaders Media Breakthroughs, contact:

Paul Mattioli, Senior Director of Sales800/[email protected]

About PricewaterhouseCoopersCommitted to the transformation of healthcare through innovation, collaboration and thought leadership, PricewaterhouseCoopers’ Health Industries Group offers industry and technical expertise across all health-related industries, including providers and payers, health sciences, biotech/medical devices, pharmaceutical and employer practices.

The firms of the PricewaterhouseCoopers global network (www.pwc.com) provide industry-focused assurance, tax and advisory services to build public trust and enhance value for clients and their stakeholders. PricewaterhouseCoopers has aligned its professional service offerings around the future direction of the health system. By applying broad understanding of how individual, specialized sectors work together to drive the performance of the overall health system, the Health Industries Group is positioned to help clients, industry and governments address the changing market forces of globalization, consumerism, consolidation and expansion, regulation, technology, and margin compression. More than 163,000 people in 151 countries across our network share their thinking, experience and solutions to develop fresh perspectives and practical advice.

DiSClAimEr: © 2010 PricewaterhouseCoopers llP. All rights reserved. “PricewaterhouseCoopers” refers to PricewaterhouseCoopers llP, a Delaware limited liability partnership, or, as the context requires, the PricewaterhouseCoopers global network or other member firms of the network, each of which is a separate and independent legal entity. This document is for general information purposes only, and should not be used as a substitute for consultation with professional advisors.

To view this full issue of HealthLeaders Media Breakthroughs: The Bridge to Accountable Care Organizations, please click here to download: www.healthleadersmedia.com/breakthroughs

Looking for the rest of the issue?

Button 195: Page 10: Page 11: Page 12: Page 13:

Button 196: Page 10: Page 11: Page 12: Page 13:

Button 199: Page 10:

Button 200: Page 10:

Fran Tab 2 X: Fran Tab 4: Button 201: Page 11: Page 12: Page 13:

Button 202: Page 11: Page 12: Page 13:

Ed Note Up 5: ED NOTE 3: BB1: BB2: BB3: BB4: BB5: BB6: BB7: BB1A: BB2A: BB3A: BB4A: BB5A: BB6A: BB7A: OB1: OB2: OB3: OB4: OB5: OB6: OB7: OB1A: OB2A: OB3A: OB4A: OB5A: OB6A: OB7A: BB D1: BB D2: BB D3: BB D1A: BB D2A: BB D3A:

CCOO Organizationscontent.hcpro.com/pdf/content/261719-5.pdfowners of Advantage Health solutions,...

Documents

Transcript of CCOO Organizationscontent.hcpro.com/pdf/content/261719-5.pdfowners of Advantage Health solutions,...