1. 1 “The Integrator” Accountable Care Across the Continuum BRENDA BRUNS, MD EXECUTIVE MEDICAL DIRECTOR, HEALTH PLAN ACHP Medical Directors, March 2, 2011

2. 2 Who We Are  Founded 1947 –Financing & Delivery System –Consumer Governed, Not for Profit  Washington and North Idaho  675,000 Members/patients –Group Practice GH Physicians – 2/3 –Contracted Network - 1/3  1,281 Providers (27 Different Specialties) in Group Practice –26 Primary Care sites/4 Multispecialty sites  Contracts with 6,000 physicians & 44 hospitals  $23.4M Research Grants (2008)

3. 3 The Integrator’s Role Responsible for the Triple Aim  Partnership with Individuals and Families  Redesign of Primary Care  Population Health Management  Financial Management  Macro System Integration Proprietary - do not duplicate

4. 4 Group Health Goals & Tactics A major component of Group Health’s 2007-2012 strategic plan is to achieve a significant (~10%) cost advantage over leading competitors Tactics to “bend trend” include:  System wide primary care medical home deployment  Emergency department/hospital inpatient utilization (EDHI)  Shared decision making/preference sensitive conditions  Content of care/clinical variation

5. 5 Clinical Integration Model Our current strategies are a necessary foundation Benefit design Contracting EDHI Content of Care Medical Home Clinical Integration (CI) takes a ‘value stream’ approach for the development and management of a competitive, cost effective network CI model includes strategies to evaluate and modify network physicians’ practice patterns and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. The program would result in a competitive network that relies on strong contracted relationships as well as unique features of the Group Practice to create a distinctive experience for GH members Evolving to a “Macro” Clinical Integration Model

6. 6 Information systems Entire care team has real- time transparency about patients, with effective coordination Patients supported to manage their own care, driven by proactive outbound treatment Patient centered Collaborative organizations that are under clinical leadership with aligned management systems and cultures Practice structure A single, coordinated, transparent, and evidence- based approach to patient care that supports continuous improvement Common care approach Community partners A broad set of community stakeholders that are fully aligned on a common care model Payment structures The right payment structures in place to drive alignment on a common care approach Care Model for Clinical Integration

7. 7 … each of which have specific enabling sub-components Practice structure –Leadership roles –Management systems –Practice locations –Care team culture Payment structures –Salary components –Incentive structures for patients and providers –Benefit design Patient centered –Self-management tools and motivation –Patient education, knowledge, and skills Common care approach –Clinical vision –Care team structure –Common care processes –Performance management –Population management Information systems –Tools and functionality –Physical location and accessibility of tools Community partners –Coordinated efforts for wellness –Care extension

8. 8 Group Health ACO Strategy  Form key provider partnerships in major markets to control EDS trend and expand Group Health medicine more broadly into the communities we serve  Deploy and build in our best clinical practices; primary and specialty care; information technology; care management; premium, contracts, membership and claims administration; marketing and sales capability as infrastructure to support the partnership network  Build a financial model which yields profitable growth in every market through best medicine at the lowest per capita cost

9. 9 Strategy and Goals Grow the Group Practice by expanding our footprint in markets and through clinical integration with strategic partners Engage in markets through a continuum of clinical integration models that control financing and delivery of care Growth in market share through a coherent network that is attractive and affordable to our members Improve per capita cost through selective and enhanced strategic partnerships Improve quality of care through reduction of clinical variation throughout the delivery system Increase Group Health’s influence on the member experience and how care is delivered

10. 10 Group Health ACO Structure

11. 11 Group Health as Integrator Financial stability  Contracting support  Business expertise  Clinical initiatives and pay-for-performance Patient services and programs  Consulting Nurse Service  Case management and outreach services  Health and wellness programs  Hospitalist programs  Community health care programs/initiatives Urgent care access  Take Care Stores (on-line ordering)  Physician continuing medical education Access to medical practice support services  Health insurance  Purchasing network – medical/surgical supplies  Vaccine programs Access to clinical quality programs, tools and expertise  Disease predictive modeling, registries and management protocols  Evidence-based tools and clinical practice guidelines  Patient population research  Patient safety monitoring and reporting  Collaboration on clinical quality initiatives  Shared best practices Access to technological leadership and support  Electronic health record  E-prescribing  On-line patient tools: email physicians, prescription refill, request appointments, online records Access to patient partnership programs  Healthy living and wellness resources  Shared decision-making materials  Preference-sensitive care  Patient health education courses

12. 12 Necessary Internal Competencies  Knowledge about fee-for-service medical practices  Knowledge about new contracting models  Portability of business model  Data capability to provide transparency  Revised infrastructure to support a CI model  Grouper approaches in reimbursement  Marketing capabilities of care effectiveness  Risk tolerance  Expertise on legal models for integration

13. 13 MAKING IT WORK  Aligned financial incentives that promote collaboration across the continuum of care  Payment reform from pay for volume to pay for value  Common medical management  Shared values  Cultural change  Community partnerships  Administrative simplicity  Consistent patient experience  Management of patient flow and transitions  Electronic medical records for coordinated care

14. 14 Essential Characteristics of Strategic Partners  Same philosophy of care  Level of IT commitment  Using common standards and practice guidelines  Commitment to an integrated patient care revenue model (vs. acute care / FFS revenue model)  Sharing performance data  Providing preferred access to GH enrollees

15. 15 Going Forward  Developing standard process to assess markets in which we operate.  Includes evaluation of market demographics & trends; current delivery systems in those markets, our performance in those markets; forecast of goals for that market  A set of criteria that can be used to evaluate "potential fit" of potential partners with GHC's care philosophy  Business model that can forecast number and type of primary care and specialty providers to serve projected volumes  New Payment Models

16. 16 Adjust Strategy to Provider Environment  Single hospital, current state includes challenging contracting relationship  Single hospital unsure/uninterested regarding ACO’s  Community wherein single hospital is purchasing key medical groups to form ACO  Multiple hospital communities without ACO development  Multiple hospital communities with developing ACO’s by one or more players

17. 17 ACO Approach