Integrated Systems and Payment Models

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• PEAK Symposium

• Integrated Systems and Payment Models

• Connie March
• President CEO, Presence Life Connections
• March 16, 2014
• Washington, D.C.

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Mission
Vision

• Inspired by the healing ministry of Jesus Christ,
  we, Presence Health, a Catholic health system,
  provide compassionate, holistic care with a
  spirit of healing and hope in the communities we
  serve.

• We will be a leader in transforming health care
  by delivering clinical excellence, outstanding
  value and exceptional experience to achieve
  better health for our communities.

• Honesty

• Oneness

• People

• Excellence

• The Value of Honesty instills in us the courage
  to always speak the truth, to act in ways
  consistent with our Mission and Values, and to
  choose to the right thing.

• The Value of People encourages us to honor the
  diversity and dignity of each individual as a
  person created and loved by God, bestowed with
  unique and personal gifts and blessings, and an
  inherently sacred and valuable member of the
  community.

• The Value of Oneness inspires us to recognize
  that we are interdependent, interrelated and
  interconnected with each other and all those we
  are called to serve.

• The Value of Excellence empowers us to always
  strive for exceptional performance as we work
  individually and collectively to best serve those
  in need.

Values
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• Presence Health At a glance
• Midwest Regional Catholic-sponsored Healthcare
  System

• Acute care hospitals
• Long-term acute care hospital
• Nursing rehab centers
• Senior housing communities
• Adult day centers
• Primary specialty care clinics
• Home care agencies
• Comprehensive behavioral health network
• Occupational health
• Immediate care centers
• Outpatient surgery centers
• Employed physician network
• Hospice agencies
• Medical residency programs
• Clinical pastoral education program
• School of radiology

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• Presence Life Connections At a glance
• . A division of Presence Health that provides a
  peri-acute constellation of care, support and
  services that enhances lives by connecting the
  right person to the right service at the right
  time.

• Primarily serve older adults
• Provide services/support to 6,000 people daily
• 172,000 annual home health visits last year
• 1.9 million residents days in our nursing rehab
  centers and housing communities last year
• 1,800 Lifeline customers
• 3,600 employees
• Provide management services
• 50 sites in Illinois and Indiana, including
• 20 nursing and rehabilitation centers
• 14 senior housing communities
• 6 home care agencies
• 3 hospice agencies
• 2 adult day centers
• 1 child day center (part of intergenerational
  center)
• Misc. HCBS
• 2 centralized LTC pharmacies

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Peri-acute Constellation
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Vision We will be a leader in transforming
health care by delivering clinical excellence,
outstanding value and exceptional experience to
achieve better health for our communities.
Growth Integration
Finance
Operating Model
Innovative Care Model
Portfolio
Culture Transformation
Presence Health Strategic Plan
Status Quo
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• Presence Health is moving toward an integrated
  operating model

Holding company Strategic guidance Strategic control Integrated operating company Fully integrated operating company

• System directives with some ministry autonomy
• System participates in all major decisions
• Many key processes standardized
• Some integration

• Stand alone functions
• Decisions at ministry level
• Decentralized
• Not integrated

• Integrated common functions
• Major decisions made at the System level
• All key capabilities standardized
• Highly integrated
• Unified/consistent brand experience

• System guidance to ministries
• System input into some operating decisions
• Some standardization
• Little integration

• System directed operations
• System makes all operating decisions
• All processes standardized
• Wholly integrated

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• Culture Transformation Core Competencies
• that Support Population Health Management

• A culture that can embrace change
• A clinical delivery system that has care
  coordination at its center
• A very sophisticated information technology
  platform
• A cost structure that can cope with an
  unpredictable revenue platform
• Capability to take risk all the way to full
  capitation
• A physician alignment strategy that supports all
  of the above

A Very Demanding Going-Forward Agenda
Reference Kaufman Hall
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• Presence Health Partners
• Innovative Care Models

• Goal Create integrated network (Presence Health
  Partners) capable of supporting Presence Health
  in managing 50 of top-line revenue from
  value-based contracts in 2017
• Requires Presence Health to enroll 520,000
  covered lives by 2017
• Assumes 50 of Presence Healths current
  Medicare, Medicaid and commercially insured
  patients will be seen through some form of
  value-based payment
• ACO, ACE, capitation, of premium, etc.

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• Presence Health CMS Innovative Care Model Pilots
• Medicare Shared Savings Program
• Bundled Payment for Care Improvement, Models 2
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• Presence Health has two internal shared risk care
  models and one external risk care models
• Medicare Shared Savings Program (MSSP)
• Bundled Payment for Care Improvement (BPCI),
  Model 2
• Bundled Payment for Care Improvement (BPCI),
  Model 3
• Presence is participating in these projects to
  develop the capabilities to manage the health of
  populations and assume risk for the outcomes
• Quality, Cost and Patient Experience
• Presence believes that developing expertise in
  this arena is a critical strategy and will
  position the organization and our partners for
  success in the evolving healthcare environment

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• Recent National Reports Indicate Some Medicare
  Shared Savings Program (MSSP) ACOs will be
  Successful

• There are 400 CMS MSSP and Pioneer ACOs in
  operation today
• 50 have generated savings
• 15 have generated sufficient savings to
  distribute shared savings to network
  participants.

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• Presence Healths Accountable Care Organization
  (ACO)
• Medicare Shared Savings Program (MSSP)

• Presence is
• Serving as an accountable care organization
• Taking risk on overall health cost and outcomes
  for Medicare population
• Medicare Value Partners (PH) ACO began operations
  January 1, 2013
• Medicare Shared Savings Program
• 20,000 beneficiaries attributed to ACO
• 94 of beneficiaries in Cook County (Chicago)
• 400 providers in two Presence Health acute care
  Chicago regions

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• Presence Healths ACO
• Medicare Value Partners PLC Participation

• ACO Board Membership
• Participation in service development
• Participating PLC providers within ACO Geographic
  Area
• Nursing Facilities
• Home Care
• Exploring HCBS participation

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• Bundled Payment for Care Improvement, Model 2

• Presence Health is
• Serving as awardee convener
• Taking risk on outcomes and cost for Medicare
  total hip and knee replacement episodes of care 3
  days pre-op through 90 days post acute
• Three year pilot start date January 1, 2014
• Rewards performance Fee for Value vs Fee for
  Service
• Providers may assume risk

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• Bundled Payment, Model 2
• PLC Participation

• Care design teams
• PLC providers within BPCI Geographic Area
• Nursing and Rehab Centers
• Home Care
• Assuming risk for quality and cost outcomes for
  hip and knee replacement for PLC post-acute care
  for 90 days
• Gainsharing participant

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• BPCI Overview
• Care Model Redesign and Support

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• PH Network Provider Network

• Selection Criteria
• Historical volumes
• Physician preference
• Geographic distribution
• Engagement in the project
• Value added to the network

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• Gainsharing Overview
• Bundled Payment for Care Improvement, Model 2

• To encourage innovation, CMS and the Office of
  the Inspector General (OIG) are waiving rules
  that prohibit gainsharing
• Providers have flexibility in determining how
  savings will be distributed among participating
  providers
• CMS will reconcile Presence performance against a
  Target Price, which is the historical payments
  per episode trended forward to 2013 and then
  discounted by pre-determined percentage
• CMS savings (CMS payment reductions) may be
  shared among the participating providers
• Presence has a Gainsharing Committee that
  oversees the gainsharing accounting and fund
  distributions

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• Bundled Payment for Care Improvement, Model 3

• Awardee convener is Illinois Bone and Joint
  Institute (IBJI)
• Taking risk on outcomes and cost for Medicare
  total hip and knee replacement post-acute care
  for 90 days
• Northern Chicago area market
• Three year pilot
• Start date January 1, 2014
• Providers may assume risk

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• Bundled Payment for Care Improvement, Model 3

• Presence Life Connections is
• Post-acute provider
• Assuming risk for outcomes and cost for Medicare
  hip and knee replacement for PLC site post-acute
  care within 90 days

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• PLC Participation in Non-Presence Medicare ACOs

• Service Providers
• Selected Nursing and Rehab Centers within
  Geographic market
• Selection Criteria Varies
• Typically 4 or 5 star CMS overall rating, may
  specify quality star rating
• Low hospital readmission rate
• Short post acute length of stay
• Preferred referral services within ACO system
  services
• Physician and/or patient preferences
• Program designed by ACO, typically with little or
  no post acute provider input
• Requires quality data submission to ACO
• Participation at discretion of ACO
• Fee for service

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• Presence Innovative Care Model Outcomes

• Medicare Shared Savings Program-Presence Health
  ACO
• Quality data submission end of March
• Must attain quality metric targets to access
  shared savings
• Initial cost data promising but too early for
  final determination
• Reviewing placement criteria based on early data
  analysis
• Learning importance of physician provider
  collaborations
• BPCI, Model 2 and Model 3
• Initiated January 1, 2014
• Too early for meaningful outcomes data
• Learning importance of clear communication as
  model is refined
• Medicare Shared Savings Program-Non-Presence ACO
• Insight into ACO metrics prior to PH ACO started
• Hospital readmissions, Emergency Dept. visits
  reduced
• Progressive shortening of post acute patient
  lengths of stay

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• Challenges with Innovative Models

• Communication
• Identification of participating patients
• Hand offs from provider to provider
• Key software, hardware, interface installation
  and implementation
• Multiple pilots at same provider locations
  concurrently
• Patient/pilot identification and differentiation
• Patient, staff, physician, community education
  awareness for each pilot
• Data
• Access to pilot and site specific data
• Timely receipt and submission of data
• Risk assumption
• Financial uncertaintybudget vs
  actualretrospective review
• Quality metrics

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• Business model is transitioning from pre-reform

Source Kaufman, Hall Associates, Inc.
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to a post-reform business model
The Post Post-Reform Business Model
Source Kaufman, Hall Associates, Inc.
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• OpportunitiesValue-based Care
• Peri-acute Providers

• Determine your path
• Make the tough decisions and start now
• Drive down per unit costs
• Use evidence to demonstrate value to partners
• Ability to assume care for higher acuity and/or
  specialty population care
• Care management
• Good quality outcomes
• High participant satisfaction
• Market your value
• Fill the care/service gaps
• Be open to new opportunities

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