Kristofer Smith, MD, MPP North Shore-LIJ Health System May 15, 2014 ©AAHCM

2 Payment Models Driving Demand for Home Care Medicine Program Type Description Full Risk Receive all or portion of premium. Responsible for total cost of care. Shared Risk Share in upside/downside savings/losses relative to pre-established spending target. Responsible for all or portion of medical spend. Quality Gate Shared Savings Eligible to share upside savings with payer relative to pre-established spending target. Quality Gate P4P Incentive payments based on meeting program criteria. ©AAHCM

Source: Conwell LJ, Cohen JW. Characteristics of people with high medical expenses in the U.S. civilian non- institutionalized population, Statistical Brief #73. March Agency for Healthcare Research and Quality, Rockville, MD. Where to Start 50% Tier 1 Minimal disease 40% Tier 2 Chronic disease Tier 3 49% 3% 25% 23% Medical Spend 5% Tier 3a 3©AAHCM

4 CHRONIC DISEASE Case Management Medical Homes 2-20 Years HOSPICE < 6 months Program Gap months Clinical + Financial Imperative = Opportunity ©AAHCM

What is your product? What does your product cost? How does the health system make money today? Tomorrow? What revenue or quality opportunity does your product solve? Who are your potential allies? Make your pitch ©AAHCM

 Advanced Illness Management ◦ Complex medical management for patients with multiple chronic illnesses and functional impairment ◦ Palliative care focus ◦ High quality care transitions ◦ Admission abatement ◦ Death at home ©AAHCM

Care Coordination ©AAHCM

Admission Abatement A 37% reduction in hospital admissions after coming on to the program ©AAHCM

 Fixed costs  Variable costs  Step variable costs  PMPM rate ©AAHCM

 Fee for Service  Pay for performance/Quality  Full Risk  Shared Risk  Shared Savings ©AAHCM

 Pay for performance/quality  Shared Risk  Full Risk  Shared Savings  Fee for service ©AAHCM

 Revenue ◦ Full or partial risk ◦ P4P ◦ Hedis/Star ratings  Quality ◦ Mortality ◦ Readmissions ◦ Efficiency ©AAHCM

 Senior leadership  Contracting  Quality  Finance  Post acute services ©AAHCM

 Who is in the audience?  Stay flexible  Don’t overpromise ©AAHCM