Williamson-Chatman 3.23 Symposium

Copyright 2012Ohio State Medical Association 1

Clinical Integration and Quality Improvement

Jay C. Williamson, M.D.CMO, Summa Physicians Inc.

Robin Chatman, MDTrinity Family Medicine


The Integrated Healthcare Delivery System

Hospitals

Inpatient Facilities• Tertiary/Academic Campus• 3 Community Hospitals• 1 Affiliate Community Hospital• 2 JV Hospitals with Physicians

Outpatient Facilities• Multiple ambulatory sites• Locations in 3 Counties

Service Lines• Cardiac, Oncology, Neurology,

Orthopaedics, Surgery, Seniors, Behavioral Health, Women’s, Emergency, Respiratory

Key Statistics• 2,000+ Licensed Beds• 62,000 Inpatient Admissions• 47,000+ Surgeries• 660,000+ Outpatient Visits• 226,000+ ED Visits• 4,300+ Births• Over 220 Residents

MultipleAlignment Options• Employment• Joint Ventures• EMR• Clinical Integration• Health Plan

Summa Physicians, Inc.• 260+ Employed Physician

Multi-Specialty Group

Summa Health Network• PHO with over 1,000

physician members• EMR/Clinical Integration

Program

Geographic Reach• 19 Counties for Commercial• 18 Counties for Medicare• 60-hospital Commercial

provider network • 41-hospital Medicare

provider network• National accounts in

multiple states

191,000Total Members• Commercial Self Insured• Commercial Fully Insured• Group Process Outsourcing• Medicare Advantage• Individual PPO

Physicians Health Plan Foundation

System FoundationFocused On:• Development• Education• Research• Innovation• Community Benefit• Diversity• Government Relations• Advocacy

Net Revenues: Over $1.5 BillionTotal Employees: Nearly 11,000


The Next Evolution of the Integrated Delivery System

• We believe that the current healthcare payment system is unsustainable and that payment mechanisms will have to change to better align incentives toward reducing total healthcare costs while continuing to provide high-quality care

• Summa will use its Integrated Delivery System to provide continually improving, value-based, high-quality, transparently accountable care to patients, populations and payers it serves

• Summa will build upon its relationships to continually advance accountability by partnering in a deeper way with patients, populations, and payers toward improving the health of our communities while reducing costs

Summa fundamentally believes that accountability in healthcare is a moral imperative with Integration being a means to that end


Community Collaborations: Physician Joint Ventures• Summa Health Center at Lake Medina

– Joint venture outpatient surgery center with 2 ORs and 1 procedure room opening in conjunction with the new Summa Health Center at Lake Medina development

– Includes physicians from the following specialties: OB/Gyn, General Surgery, Pain, Podiatry, Ophthalmology, Hand

• Summa Western Reserve Hospital– Joint venture started in June 2009 between Summa Health System

and Western Reserve Hospital Partners– Began the for-profit Summa Western Reserve Hospital at the

current Summa Cuyahoga Falls General Hospital location

• Crystal Clinic Orthopaedic Center (CCOC)– Orthopaedic Hospital Joint venture between Summa Health

System and Crystal Clinic (a local group of approximately 30 orthopedic surgeons)

– Began operations in May 2009 on the Summa St. Thomas Hospital Campus


Critical IssuesThree critical issues threatening the stability of today’s healthcare system:

1. Uninsured and underinsured populations are increasing.

2. Healthcare costs are escalating.

3. Government regulations are expanding and government reimbursement is not keeping the pace with the cost of providing care.


Summa Physicians Inc. Governance• 501(c) 3 organization• Independent Board of Directors which include physicians and senior management appointed by system governance committee• Oversee all aspects of SPI operations and finance except compensation• Physician Advisory Council to CMO• Both fully employed and leased models


SPI Overview • 270 Physicians • 59 Advanced Practice Nurses and Physician Assistants• 671 non-Provider Employees • Summit, Medina, Portage, Wayne, and Stark • Physicians hired based on Community Need, Mission and preventing physician “leakage” from Summa• New planned growth to be based on System needs and focused strategic growth


SPI Growth as of December 2011 • Summa Physicians, Inc. continues to have success with its model for physician employment

7 8 14 1741

81

187220

255266

0

100

200

300

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Number of Employed Physicians

Satisfied, Engaged, and Aligned Physicians


SPI – Business Model• Physician Compensation is Productivity Based • Will soon be implementing a model looking at quality

metrics, patient satisfaction and issues such as community service and System performance

• Ancillary Services have transferred to Provider Based Billing under the Hospitals

• Mission focus helps eliminate unnecessary System costs• All physicians are employed under a Hospital or System

approved business plan• Reviewing Leased vs. Employed Model


2011 SPI ACCOMPLISHMENTS• Outstanding Budget

– Performance through December $3.9 million better than budget. • Vast Improvement in health risk assessment

– Over 1000 this year have been completed leading to better documentation of care provided to Medicare patients and enhanced reimbursement.

• Our newly added 24 physicians • Outstanding performance in light of a year of transition featuring three

different presidents in 2011.• EMR implementation with 113 providers and 37 doctors attested for

Meaningful Use at $18,000 each and 15 more by year end which aids in care coordination and integration.


The Future - SPI • Implement Strategic Plan

– Enhance Physician Engagement and System Integration

– Expand Market Penetration (selectively and strategically) and Increase our Patient Population

– Achieve superior Operative and Clinical Performance

– Improve Population Health through ACO and Medical Homes


Patient Center Medical Home (PCMH)

In order to achieve the objectives of reform, we need to transform our current delivery system from high cost, low value to low cost, high value through a strong primary care foundation

Healthy Consumer

Continued Health

Preventable Condition

No Hospitalization Acute Care Episodes

Successful Outcome

High Cost Outcome

Focus on Measurably Improving Population HealthOrganizational Accountability for Capacity, Cost and QualityPayment for Value, Not Volume

Meaningful Measures of System PerformanceRight Workforce

The Affordable Care Act Main Objectives

Complications, Readmissions

Overall Goal is to move healthcare cost from downstream to upstream

PCMHACO


PCMH Impact on Stakeholders Across Continuum Care

PCMH

Payer

Specialists

Government

EmployerHospital

PCP

Patient

Increased focus on the patient and their healthGreater access to health informationHigher reimbursementMore PCPs

Better, safer, less costly, more convenient care Better overall healthProductive long-term relationship with a PCP

Lower number of chronic care admissions and readmissions Increased focus on procedures.

Lower healthcare costsMore productive workforceImproved employee satisfaction

Lower healthcare costsHealthier population

Better referralsWhole patient care integrationBetter follow up

Improved member and employer satisfactionLower costsOpportunity for new business models


What is PCMH?A PCMH puts patients at the center of the health care system, and provides primary care that is “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.”

Features of PCMH

A personal physician who coordinates all care for patients and leads the team.

Physician-directed medical practice – a coordinated team of professionals who work together to care for patients.

Whole person orientation – this approach is key to providing comprehensive care.

Coordinated care that incorporates all components of the complex health care system.

Quality and safety – medical practices voluntarily engage in quality improvement activities to ensure patient safety is always being met.

Enhanced access to care – such as through open-access scheduling and communication mechanisms.

Payment – a system of reimbursement reflective of the true value of coordinated care and innovation.


How Features of PCMH are Implemented?

Enhanced Access Extended Hours, Open Schedule Internet, e-mail

Quality and Safety Evidence Based Medical care QI projects at the practice level

Coordinated/Integrated Care Registries Proactive care Information Technology Health Information Exchange Chronic care coordination

Internal/external care coordination Part of a patient’s health plan

Physician Directed Medical Practice TeamTeam approach

Low complexity tasks handled by other members of the team

Team members can be internal/externalCollaborative relationship between physician and non-physician practitioners

Personal Physician & Whole Person OrientationFirst contact, continuous and comprehensive careContextual Care

Increased same day access avoids ER and increase continuity

Reduced duplication and improved coordination across the spectrum of care

Having a usual source of care is associated with a greater likelihood that people receive appropriate care, preventive care, better outcomes, lower cost


Summa PCMH Pilot Project Roadmap

Offered at three level–basic, intermediate and advancedGoal is to obtain Level 3

Measure improvementsSupport ACO Initiatives

Publically report achievements

Highlights of Project6 practices involvedIT and Policy SubcommitteesPCMH Performance Metric TeamNCQA RecognitionTransformation

Gap AnalysisIdentification of PCMH Metrics EHR UpgradesPolicy Creation and Standardization

NCQA Recognition Program

TransformationCultural ChangeRedefining staffing rolesImprove Outcomes

SUMMAPCMH


PCMH

• ACO paying for part-time physician leader, full-time analyst, and project director.

• PHO will pay for NCQA Certification Fees.


Accountable Care Organization

Organizational Facts• Start Date – Began operations January 1, 2011• Initial Pilot Population – 11,000 SummaCare Medicare Advantage members that

currently see a participating primary care physician• Legal Entity – Non-profit taxable structure allows for physician majority on the Board• Board Composition – 4 community primary care physicians, 1 medical specialist, 1

surgical specialist, 3 Summa representatives

Our ACO is a clinician-led care collaborativethat partners with communities

to compassionately care for and serve our populationsin an accountable, value- and evidence-based manner.


PCMH

SpecialtyCare

PrimaryCare Ambulatory

Hospitaland ED

SkilledNursing

NursingHome

HomeHealth

Patients


Financials:PMPM Target and Results - 2011

Medical Spend PMPM

Shared Savings Annualized

Breakeven $793.62 $0SC Medicare NHC ACO $733.79 $7,400,000

Loosely Managed $752.45 $5,089,600Competitively Managed $639.56 $19,045,513

Well Managed $522.36 $33,534,246

2010 Milliman Benchmarks


Progress Milestones: 2011

• Began Operations

• Heart Failure Readmission Initiative

• Heart Failure Education

• Discharge-to-Home Care Transition


Progress Milestones

• Population-based Actuarial Analysis

• ACO Finance Committee

• ACO Clinical Value Committee

• ACO Medical Home Initiative

• Call Center Plan

• Harmony Plan


PHYSICIAN COMPENSATION PLAN

Summa Physicians, Inc. (SPI)


PHYSICIAN COMPENSATION PLAN• High Performance Team appointed in late 2011 by new SPI President to

outline a new compensation model by early 2012.• Multispecialty group including representatives from the following areas:

– Family Medicine– Psychiatry– Surgery (Colorectal)– Gastroenterology– Hematology / Oncology– Cardiology– General Internal Medicine– Geriatrics



• Began with weekly meetings with a goal for the new model to be part of new and updated contracts

• Agreement for a one year “shadow” program to see how the model works

• Outlined a set of Guiding Principles and an Incentive Plan Proposal was developed


GUIDING PRINCIPLESSPI CMO COMPENSATION COMMITTEE

GENERAL CONTRACTING PRINCIPLES

1. All should share in the success of the organization. 2. Incentive plan is calculated on 20% of base compensation. Base compensation is not reduced to

fund incentive plan. 3. A shadowing program will be used the first six months, the new system will start in 2013.

Standardized contract language will be used with an agreed upon compensation plan. 4. Incentive Dimensions required for all. Metrics include Success of SPI/Summa Health System,

Citizenship, Information Management, Quality/Service. (Incentive Plan Proposal attached) 5. Quality metrics for primary care and specialties are different and subgroups may be needed to

work out details. 6. Annual performance review required and passing review will be required to qualify for bonus

distribution. 7. Patient satisfaction review will be part of all metrics. One standardized survey will be used. 8. Changes in base compensation are being considered. 9. Incentives obtained from some bonus dollars and possibly ACO shared savings dollars. 10. MGMA should remain the salary benchmark of choice. 11. Blends of education, teaching, and work productivity will remain part of the contracts.


INCENTIVE PLAN PROPOSAL TARGET: TOP QUARTILE TOTAL POINTS = 20 Incentive Dimensions: 2/6/12

Success of SPI / Summa (Individual & Group)

Citizenship Information Management Quality / Service

Growth of Established and Loyal Patients - SPI Source: eCW counted charts, billings of unique patients during the prior year vs. next year 2 points

Attendance @ SPI meetings ≥ 75% of meeting Major Conditional Incentive ½ point Source: Attendance sign in and sign out sheets monitored by SPI ops.

Measures of Integration Keep the patient @ home Information Management

within Network In Network Use of Lab/

Radiology/PT-Rehab Source: Referral Tracking in eCW, lab/imagining/pt by ordering physician

3points

Access to Care – Same Day Established Patient and

New Patient (1% Group)

Source: Phone survey for established and new patients 2 points

Profitability of Summa Hospital Operations / Meet or Exceed Budget Expectations - Summa Hospital Source: Summa Financials, booked year end hospitals only 2points

Completion of Records on a timely basis Major Conditional Incentive ½ point Source: eCW “closed files report”, Med Records Procedures

Measures of Coordination Hand off Measures Two-way Communication Satisfaction with

Referring Physicians Info Collegiality / Stellar APR

Source: Referral Sender/Receiver survey 3 points

Inpatient SCIP & Core Measures at 98% attainment Source: CMS/JCHAO List of Top performers 3 points

Patient Satisfaction > 75th percentile Source: Press Ganey OP, C. Natale 2points

Inpatient patient satisfaction with physicians above 50th percentile Source: HCAHPS 2points

6 Dimensions of Quality (IOM) Safe Pt. Centered Effective Timely Efficient Equitable



• Further discussion by specialty of quality metrics


Example of Quality Metrics for Diabetic Care in Primary Care Practices

B D E F G H I J K L M N O

1 Insurer DOS HbA1c Date LDL Date Urine date Result BP Sys BP DiasEye Exam

DateFoot Exam CPT/ ICD

2 MC 7/ 9/ 11 6.4 7/ 19/ 11 59 3/ 22/ 11 N N 112 62 N N 250.00/ 2143 SC SEC 6/ 30/ 11 9.4 6/ 27/ 11 110 6/ 27/ 11 N N 150 67 5/ 5/ 11 N 250.00/ 2144 MC 3/ 22/ 11 7.3 3/ 16/ 11 94 6/ 16/ 11 1/ 21/ 10 Neg 115 49 9/ 2/ 01 N 250.00/ 2145 SC SEC 5/ 19/ 11 7.2 5/ 19/ 11 92 4/ 21/ 11 N N 149 75 N 8/ 16/ 10 250.00/ 2146 MC 3/ 30/ 11 10.9 8/ 15/ 11 73 8/ 3/ 11 N N 156 12 N 5/ 3/ 10 250.00/ 2147 MC 2/ 3/ 11 6.2 2/ 17/ 11 61 5/ 20/ 11 12/ 30/ 10 POS 153 74 N 12/ 20/ 10 250.41/ 2148 MC 7/ 22/ 11 6 7/ 15/ 11 High Trig 7/ 1/ 11 N N 146 63 11/ 10/ 11 N 250.00/ 2149 MC 7/ 11/ 11 7.5 6/ 9/ 11 67 6/ 9/ 11 N N 113 67 4/ 8/ 11 N 250.00/ 21410 MC 7/ 13/ 11 5.6 7/ 7/ 11 43 7/ 6/ 11 N N 129 61 N N 250.00/ 21511 MC 6/ 15/ 11 6.4 6/ 9/ 11 69 6/ 8/ 11 N N 117 62 8/ 2/ 11 N 250.00/ 21412 MC 4/ 19/ 11 8.4 4/ 19/ 11 74 1/ 11/ 11 4/ 19/ 11 Neg 140 102 N 5/ 11/ 11 250.02/ 20513 SC SEC 8/ 22/ 11 6.4 8/ 8/ 11 51 1/ 3/ 11 N N 150 85 8/ 1/ 11 N 250.00/ 21414 MC 8/ 18/ 11 6.6 10/ 18/ 10 83 1/ 10/ 11 1/ 10/ 11 Neg 133 61 4/ 11/ 11 N 250.00/ 21415 MC 8/ 17/ 11 7.3 8/ 10/ 11 160 8/ 10/ 11 N N 141 61 3/ 17/ 11 N 250.00/ 21416 MC 8/ 9/ 11 8.9 8/ 2/ 11 78 8/ 2/ 11 N N 144 68 11/ 18/ 10 N 250.02/ 21417 MC 2/ 1/ 11 6.5 1/ 26/ 11 78 1/ 26/ 11 N N 123 62 N N 250.00/ 21418 MC 3/ 25/ 11 6.8 3/ 9/ 11 59 6/ 15/ 11 N N 128 66 2/ 24/ 11 N 250.02/ 21419 MC 3/ 25/ 11 6.9 3/ 9/ 11 3/ 9/ 1900 3/ 9/ 11 9/ 15/ 10 Neg 126 73 N N 250.00/ 21420 MC 6/ 16/ 11 5.5 6/ 9/ 2011 42 1/ 25/ 2011 10/ 10/ 2011 Neg 124 3/ 3/ 1900 8/ 18/ 11 12/ 23/ 10 250.00/ 21421 MC 7/ 14/ 11 6.6 2/ 3/ 11 57 11/ 23/ 10 N N 128 65 4/ 27/ 11 N 250.00/ 214




1 Insurer DOS HbA1c Date LDL Date Urine date Result BP SysBP DiasEye Exam


22 MC 3/ 28/ 11 7.3 3/ 21/ 11 34 3/ 21/ 11 N N 140 85 N N 250.00/ 215

23 MC 6/ 29/ 11 6.2 6/ 22/ 11 71 6/ 22/ 11 N N 138 80 3/ 4/ 11 N 250.00/ 214

24 MC 7/ 11/ 11 6.9 7/ 5/ 11 51 3/ 2/ 11 N N 122 64 N N 250.00/ 214

25 MC 5/ 4/ 11 6.2 4/ 13/ 11 89 4/ 13/ 11 N N 95 60 N N 250.00/ 214

26 MC 7/ 27/ 11 5 7/ 20/ 11 126 7/ 13/ 11 7/ 13/ 11 POS 144 88 7/ 11/ 11 N 250.00/ 214

27 MC 8/ 23/ 11 6.4 5/ 13/ 11 102 5/ 13/ 11 9/ 17/ 10 NEG 126 68 10/ 2/ 11 N 250.00/ 214

28 MC 7/ 13/ 11 6.4 7/ 1/ 11 38 7/ 1/ 11 N N 123 66 9/ 8/ 10 2/ 11/ 11 250.00/ 214

29 MC 6/ 22/ 11 5.9 6/ 15/ 11 83 6/ 15/ 11 3/ 7/ 11 POS 138 80 N N 250.00/ 214

30 MC 8/ 23/ 11 7.1 8/ 16/ 11 76 6/ 14/ 11 N N 130 74 N N 250.00/ 214

31 MMO MC 8/ 25/ 11 7.3 6/ 17/ 11 63 8/ 18/ 11 N N 138 78 1/ 11/ 11 N 250.00/ 214

32 MC 2/ 1/ 11 5.8 1/ 4/ 11 55 1/ 4/ 11 N N 111 52 10/ 19/ 10 1/ 19/ 10 250.00/ 214

33 MC 2/ 1/ 11 6.9 6/ 7/ 11 89 1/ 4/ 11 5/ 21/ 10 POS 134 64 2/ 3/ 11 1/ 19/ 10 250.00/ 214

34 MC 1/ 5/ 11 6.5 3/ 2/ 11 87 12/ 30/ 10 N N 166 77 10/ 12/ 10 N 250.00/ 214

35 MC 9/ 6/ 11 7.5 9/ 1/ 11 52 5/ 10/ 11 N N 120 79 8/ 11/ 11 N 250.00/ 214

36 Anthem SR 6/ 15/ 11 6.5 6/ 7/ 11 56 6/ 8/ 11 N N 133 70 N N 250.00/ 214

37 MC 5/ 11/ 11 7.8 5/ 4/ 11 104 8/ 4/ 11 N N 137 75 4/ -/ 11 N 250.02/ 214

38 MC 8/ 3/ 11 6.2 7/ 20/ 11 57 7/ 20/ 11 7/ 20/ 11 Neg 114 63 9/ 13/ 10 N 250.00/ 214

39 MC 8/ 1/ 11 7.3 7/ 6/ 10 N N N N 150 96 1/ 20/ 11 N 250.00/ 203

40 MC 6/ 29/ 11 6.1 7/ 2/ 10 67 7/ 2/ 10 N N 144 82 4/ 9/ 11 N 250.00/ 214

41 SC SEC 7/ 20/ 11 7.4 7/ 6/ 11 97 3/ 8/ 11 3/ 8/ 11 Neg 160 70 6/ 22/ 11 N 250.00/ 214

42 MC 6/ 30/ 11 8.4 6/ 23/ 11 47 6/ 23/ 11 N N 151 81 5/ 12/ 10 N 250.02/ 214

43 MC 6/ 17/ 11 6.1 6/ 10/ 11 63 6/ 10/ 11 N N 126 77 5/ 11/ 11 N 250.00/ 214




1 Insurer DOS HbA1c Date LDL Date Urine date Result BP Sys BP DiasEye Exam


44 MC 5/ 12/ 11 6 4/ 5/ 11 56 4/ 5/ 11 N N 122 66 N N 250.00/ 214

45 MC 4/ 28/ 11 6.4 4/ 25/ 11 77 4/ 25/ 11 N N 134 71 10/ 10/ 11 N 250.00/ 214

46 MC 6/ 16/ 11 7.3 3/ 9/ 11 59 6/ 8/ 11 12/ 9/ 10 POS 122 64 4/ 7/ 11 N 250.00/ 214

SPI Dr.

Total # of Patients Studied 903 45

Average HbA1C 7.1 7.0

Average LDL 91 73

Percentage of Urine Samples collected 43% 29%

Average BP Systolic 133 133

Average BP Diastolic 75 70

Percentage of Eye Exams Performed 35% 67%

Percentage of Foot Exams Performed 21% 18%


COMPENSATION GUIDELINESA. Base Compensation

– Uses 85% of MGMA Median by Specialty to determine base. – Will be reset each year (WRVU target) based on prior year

WRVU production and market adjustments.– Adjusted upward if WRVU exceeds base target. Based on

tiered compensation formula.– Adjusted downward if WRVU is below base target.– Maximum amount of base compensation to be paid through

bi-weekly payroll = 80% of MGMA national 90% compensation.


COMPENSATION GUIDELINESB. Excess WRVU Above Base Compensation Targets

– Tiered structure adds a portion of excess WRVU to base compensation (not extra bonus) and a portion to incentive poolTier 1 = Nat Med to Avg Nat Med / Nat 75th

Tier 2 = Avg Nat Med / Nat 75th to national 75thTier 3 = all WRVUs over the Nat 75th

85% of Nat Median +Tier 1 - Base @ 50% of SPI rate +

Tier 2 - Base 45% of SPI rate +Tier 3 - Base 40% of SPI rate +

Total New Base

Tier 1 -Bonus 50% of SPI rate +Tier 2 - Bonus 55% of SPI rate +Tier 3 - Bonus 60% of SPI rate +

SPI added Perf $ (% PCP or % other) +Total Performance Bonus Funding

The level of Physician production utilized in the Tiers = higher of 2 yr avg production or the prior yr production

This component added to Base and paid through bi-weekly payroll

This component held until contract year end and amount to be awarded determined thorough annual

performance review - pre-defined performance metrics.

Base & Performance Bonus WRVU Tier descriptions

1.0 FTE New Base = 85% Nat Median + Tier 1 + Tier 2 + Tier 3 % to payroll For that Physician's specialty

1.0 FTE Performance Bonus Funding = Tier 1 + Tier 2 + Tier 3 + SPI % Perf Bonus Fund


COMPENSATION GUIDELINESC. WRVU Production Below WRVU Target

– At a certain level may not be eligible for a bonusD. Incentive Plan Pool

– Using tiered approach amount not added to base is placed in incentive pool.

– Physician has ability to add back a comparable amount using different incentives.

– 15% Primary Care addition for recognition of primary care.

– 5% Specialist addition to pool


COMPENSATION GUIDELINES

• There will always need to be market considerations.

• Outliers will have to be looked at on an individual basis.


Questions and Discussion