Clinical Integration Update Michele Madison [email protected] 404-504-7621.
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Transcript of 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 post-acute 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, LLCAccountable Care Coalition of Georgia, LLCAccountable Care Coalition of Greater Athens Georgia II, LLCAccountable Care Coalition of Greater Augusta & Statesboro, LLCAccountable Care Coalition of Southern Georgia, LLCAccountable Care Coalition of Western Georgia, LLCMorehouse Choice ACO-ESThe Premier Health Care Network, LLCMeridian Holdings, Inc.WellStar Health Network, LLCAccountable Care Coalition of Coastal GeorgiaAccountable Care Coalition of Greater Athens Georgia
Breakdown of ACOs
Networks of Individual Practices 121 55% Group Practices 90 41% Hospital/Professional Partnerships 66 30% Hospital employing ACO 44 20% professionalsFederally Qualified Health Center 15 7% Rural Health Clinic 11 5% Critical Access Hospital 4 2%
Bundled Payment1. 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 ACOChanges in the payer marketplace
United Purchases Physician PracticesHumana Purchases ConcentraCigna 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.