1. David Swieskowski, MD, MBA
Mercy ACO A Statewide Clinically Integrated network to Improve Value in Health Care
David Swieskowski, MD, MBA
CEO – Mercy ACO

2. Outline What is a Clinically Integrated network Why are we doing it
Data & IT systems
Care management model
Results
Conclusions

3. Mercy ACO- Mission Improve the health of the patients we serve
Manage population segments not just individuals
Lower cost of care
Healthier patients will use less healthcare resources
Capture payment for the value we create
Shift payment from Volume to Value

4. Mercy ACO – CIN Formed in Feb. 2012
More than 1800 Providers of health care who agree to:
Share data to measure performance
Work together to improve performance
Seek new payments to reward improved performance
Knoxville
New Hampton
MMC
West Lakes
Winterset
Greenfield
Dallas County
Webster City
Iowa Falls
Hampton
Osage
Cresco
Britt
Algona
Emmetsburg
Mason City
Centerville
Oakland
Audubon
Mount Ayr
Leon
Corydon
Bloomfield
Albia
Burgess
Denison
Manning
Primgahr
Hawarden
Grinnell
Dubuque
Dyersville
Clinton
MHN Urban Hospital
Owned CAH Hospital
Managed CAH Hospital
Managed Rural Hospital
Primary Care Clinic

5. The Clinically Integrated Network
Providers who agree to work collaboratively to improve the health of the patients they serve
CIN functions:
Evaluates the care provided by the CIN
Creates programs to modify practice patterns to control costs and ensure quality
Holds providers accountable for outcomes
Legal structure to
Negotiate contracts to capture the value created
Accept and distribute funds to align incentives
Physician Leadership Structure
To lead change

6. Why would a Health System Implement programs that reduce utilization and revenue?

8. USA Healthcare Spending is not Performance Based
Healthcare Spending per Capita vs. Life Expectancy in OEC Countries 2008
Value Gap
USA
Data Source: OECD

9. When Providers “Do the Hard Work” of Decreasing Costs & as Margins are Compressed a “Value Gap” is Created
All the Savings / Value, Accrues to Payers and Purchasers Unless We Are in Shared Savings or Other Risk Arrangement
Bending trend to meet CPI creates $300 million to $400 million in annual value capture opportunity in the DM market in future years.
Government, insurance companies, individuals, employers and integrated networks will compete to capture the value. $
savings
Historical Medical Inflation
Annual %age Increase
CPI
Time
Introduction of ACO Care Management & Other Efforts to Increase Value

10. Shifting Risk to Providers
High
Insurance product
Degree of Complexity
Global capitation
Partial Capitation
Shared Savings / Losses
Bundled episodes (pre- and post-care included)
Bundled episodes (inpatient only)
P4P programs
Inpatient case rates (DRGs)
Fee for service
Low
Scope of Risk
High

11. How does a Shared Savings Contract Work?
Patients “attributed” by primary care doctor
Risk adjusted cost target is calculated
Wellmark is about $80M for 23,000 patients
Fee for service payments made as usual
At the end of one year
Costs below or above the target are shared with the ACO
Quality and Patient Satisfaction targets must be met to share savings
ACO distributes savings to stakeholders

12. How Is This Different From an HMO?
ACO
HMO
Patients are free to self-refer
Primary care must authorize referrals
Sophisticated risk adjustment
Want the sickest patients
Risk adjustment only by age and sex
Want the healthiest patients
Data warehouse and metric
Rudimentary data
Risk Borne at system level
Risk Borne at provider level

13. Mercy ACO Care Delivery Vision
Manage patients as populations and individuals
Planned patient visits
Measure population based outcomes like % with BP controlled
IT systems
Disease registries and data warehouse
Engage patients with Health Coaches
Identify high risk patients most likely to benefit
Coordinate care
Communication and sharing information
Plan transitions
Continuous Quality Improvement
Measurement and reduction in variation for Diabetes and HTN
Access to care
Develop models to be reimbursed for value,
not just volume
P4P, Shared savings, Capitation

14. How This Reduces the Cost of Care
Relatively low cost care delivery system changes can improve the health of patients
Health coaching
Coordination of care
Reduction in variation
Improving the health of patients will reduce
Hospitalizations
ED use
Drug costs
Denying needed care would NOT be effective

15. Data is Essential for Population Heath
Track populations of patients and their status
HTN and most recent BP
Diabetes and most recent labs
Opportunity lists
List of patients overdue for care or not meeting goals
ACO contacts them to come in for follow-up
Risk segmentation of the patient population
Performance reports at the organization, Clinic, and provider levels
Measure the effectiveness of interventions
Engage Physicians
Social pressure and incentive programs
Gap reports – at the point of care
Data needs to be near real time
for patient management and QI

16. McKesson Data Warehouse: Data Acquisition & Normalization
Reports:
% BP Control
Due for visit
High ED visits
Cost Variation
Pharmacy use
Predict high risk
Episode groups
Network use

17. Dashboards ‘Provider Level’

18. Provider Level - Pt. Lists

19. Stratification of Patients by Risk is Essential
10% of the Population Accounts for 68% of All Health Care Costs
Mean Annual
Percent of Percent of Total Per Person
Population Health Care Expenses Cost 1% 9%
20%
70%
29%
39%
21%
11%
Advanced Illnesses
Multiple Chronic Conditions
$101,000
At Risk
$ 15,000
$ 3,700
Stable $
National Sample of 21 Million Americans Between 2003 and 2007
Source: Truven Health Analytics, Market Scan, 2012

20. Mercy ACO Care Management Model
Triple Aim Goals
pursued through a comprehensive care model
Better Care / Patient Experience
Data Management
Population-Based Care
Primary Care Transformation
Disease Management
Extensivist Clinic
Care Transitions
Hospitalists
Reducing Variation
Palliative, Post-Acute
Healthier Communities
Lower Costs

21. Primary Care Transformation – Medical Home All 26 Mercy Des Moines primary care clinics are NCQA PCMH certified
Greater Access to needed services
Greater focus on prevention
Early management of health problems
Cumulative effect of the main primary care delivery characteristics
Care focused on the whole person leads to better outcomes than care focused on a disease or organ
Coordination of care
Avoid duplication and low value care
Team Based Care
Self Management support
Health coaches

22. Health Coaches Currently staffed at 1 per 3000 ACO patients
Self-Management Support
Health Behavior change and Motivational interviewing
Connection to community resources
Coordination of care
Closing the loop on referrals and transitions
Review population data for opportunities
Gaps in Care
Shared decision making
Distribution and decision aids and f/U
Quality Improvement
Point person for introduction of new care processes
High Risk Patient case manager
Proactive follow up
Care access point – direct phone &

24. Transition Coaching ACO patients identified while in the hospital
Risk Assessed by LACE scores
LOS, Admit through ED, Co-Morbidities, ED visits in last 6 months
Transition back to the medical home is facilitated
Appointment for joint F/U with doctor and health coach
Patient is encouraged to bring all meds to the office visit
Discharge info Communicated to the medical home Health Coach
Patient is tracked by the Coach until seen back in the medical home
High Risk Coaching initiated with the office visit
Teach warning symptoms and what to do if they occur
Assesses medication issues
Goal setting and motivational interviewing
Office coach makes weekly calls for 4 -6 weeks

25. Mercy ACO CMS Readmit Rate

26. Disease Case Management
Most commonly done for Heart Failure, COPD, Diabetes
Care guideline standards by disease
Proactive outreach between visits
Tele-monitoring
Protocols for intervention based on symptoms
Immediate intervention if needed
Multiple Chronic Diseases
This is the most common high risk presentation
Common factors across all chronic diseases are more significant than disease specific factors
Treatment plan adherence, depression, mental status, functional status, social issues

27. Customer Relationship Management (CRM) Software
Allows the ACO to know and track the patient and their health relationships across the continuum
Tracks patients goals and preferences
Links patients to community resources
Consolidates community resources into a dynamic electronic guide
Ratings to develop preferred resources
Highlights non-clinical barriers and needs that impact health, cost and risk for providers
Embeds care management work flow into an electronic format
Standardize care management work
Assigns tasks and prioritizes work lists
Library of work documents and patient handouts
Tracks productivity

28. Mercy ACO Covered Lives

30. Quality – CMS 2014 GPRO Results
GPRO is composed of 33 quality metrics which all MSSP ACOs are required to report on
Mercy ACO results average about the 65%ile
Results for area for ACO QI focus
30 day readmission rate (ACO: 8) = 13.63%
The CMS 90%ile is 15.45% (lower is better)
Diabetes care composite (ACO: 22-26) = 38.44%
% of patients meeting all 5 measures of diabetes control
HgA1c, LDL, BP, Tobacco non-use, Aspirin use
The CMS 90%ile is 36.5%
BP control < 140/90 (ACO: 28) = 71.81%
This represents the CMS 73%ile

31. Conclusions Shared savings is not the end game
Stepping stone to assuming risk
Health care providers will increasingly assume risk
Covered lives will be the measure of growth not hospital admissions
The only way to reduce cost is to have healthier patients
Volume based system penalizes you for healthy patients
Health Coaches and PCMH are keys to early success in value based payment systems
ACOs align the reimbursement system with our mission and values
Better Health instead of more services