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1/31/2012
1
HASC Blurring the Lines: Eliminating Healthcare Industry Silos
Hospital Association of Southern CaliforniaLos Angeles, California
February 1, 2012
2/01/2012 ι 1THE CAMDEN GROUP
The Time is Now
“The greatest threat to America’s fiscal health is not Social Security; it’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nations' balance sheet is the skyrocketing costs of health care”
President Barack Obama, March 2009
2/01/2012 ι 2THE CAMDEN GROUP
Institute for Healthcare Improvement: The Triple Aim
The Triple AimTM set forth by the Institute for Healthcare Improvement:
Optimal care delivery within and across the continuum
Focused on improving the health of the population and cost of care
Right care, Right place, Right time
Triple Aim
Experienceof Care
Per CapitaCosts
PopulationHealth
Source: http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm
1/31/2012
2
2/01/2012 ι 3THE CAMDEN GROUP
Health Plan Activities: 2012
Use their huge cash reserves
Buy health plans (prefer Medicare)
Acquire medical groups and hospitals
Health plans are diversifying: 85 percent medical loss ratio (“MLR”) will impact profit margins
Market individuals in anticipation of the exchanges
Build BRAND
Partner with hospitals/medical groups
ACO (joint risk sharing)
Narrow network delivery systems
Be the data supplier/infrastructure
Who is going to manage the population’s healthcare?
2/01/2012 ι 4THE CAMDEN GROUP
Destination: Start with the End in Mind
Destination:Better Health. Better Care. Lower Cost.
Patient Safety and Throughput
Hospitalist and Hospital-based
Physicians
Reduce Re-admissions
Bundled Payment
Patient-centered
Medical Home
Transactions/ Network
Development
ACDs/ACOs
Physician Relationships/
Leadership Development
Hospital Case Management Improvement
Clinical Co-management
Physician Enterprise
Restructure
System Wide Care
Management Restructuring
Clinical Integration
2/01/2012 ι 5THE CAMDEN GROUP
ACO Structure
HospitalSNF
Outpatient Clinics/Centers
Physicians
Home HealthRehab
Behavioral MedicinePharmacy
ACO
Accountable care organization (“ACO”) responsible for:
Clinical care management (clinical integration)
Capture data for continuum of care
Measure and monitor costs and quality
Infrastructure(Provided or Contracted
ACO Operations)
Information Technology EMR, CPOE, PACSData warehouseReportingHIE
Care ManagementHospitalists and
IntensivistsCMODisease managementClinical protocols Advanced analytics and
modelingCall centerUtilization management Knowledge management
Health NetworkDelivery network
Financial/Payment Systems
1/31/2012
3
2/01/2012 ι 6THE CAMDEN GROUP
ACO: How Do You Generate Savings
50%Care Management
15-20% Lower Cost Site
15-20% Throughput
(Volume)
15-20%
Post acute, outpatient, ER use
Extended hours, higher occupancy, narrower network
Generic use, GPO, standardization
Population management
Well care Chronic disease
management Effective use of
appropriate clinicians
Medical home Bundled payment
Appropriate Economic Indicators
2/01/2012 ι 7THE CAMDEN GROUP
Where Sacramento Area
Who CalPERS (41,000 members)
When January - December 2010
Savings
$20 million ($15 million to BS and $5 million to Hill and CHW)
Reduced 30-day re-admissions (by 15 percent)
Reduced length-of-stay
No premium increase for some of employers
Reduced out-of-network treatment at hospitals
Reduced elective surgeries by 13 percent
12 percent of population uses 70 percent of the healthcare services
Pilot Program Results: CalPERS in 2010 (California)
2/01/2012 ι 8THE CAMDEN GROUP
ACO Potential Market Segments
ACO(IDN)
Medicare Medi-Cal Commercial Self Funded
FFS MA FFS HMO HMO PPO(tiered)Benefit
YourEmployees
CommunityEmployers
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4
2/01/2012 ι 9THE CAMDEN GROUP
Accountable Care Building Blocks
ClinicalIntegration
PopulationAnalytics
SupportInfrastructure
MedicalManagement
Tools
ClinicalProtocols
Continuumof Care andTransitions
CareModels
InformationTechnology
PaymentModels
Incentives/Metrics
DeliveryNetwork
Development
ACOAssessment
ProviderEducation
Governance andManagement
Structure
EmployeesDefined Population
Self-funded EmployersMedicare Health Plans
Improved Qualityand Access
Reduce Costsand Waste
2/01/2012 ι 10THE CAMDEN GROUP
Destination: Bump in the Road – The Payment System
Destination:Better Health. Better Care. Lower Cost.
Patient Safety and Throughput
Hospitalist and Hospital-based
Physicians
Reduce Re-admissions
Bundled Payment
Patient-centered
Medical Home
Transactions/ Network
Development
ACDs/ACOs
Physician Relationships/
Leadership Development
Hospital Case Management Improvement
Clinical Co-management
Physician Enterprise
Restructure
System Wide Care
Management Restructuring
Clinical Integration
CAUTION
2/01/2012 ι 11THE CAMDEN GROUP
Critical Success Factor: Payment Method
Align the payment BEFORE you start making care improvement:
Set, maintain, and reward individual provider performance metrics tied to overall goals
Severity – adjust – HCC and RAF scores
Re-insurance
Keep it simple
ProviderExample:
Payment Method Pools
PCP FFS plus “coordination fee” Participate in Pools (IP, OP, Diagnostic)
Specialists Captation/Case Rate Participate in Pools (IP, OP, Diagnostic)
Hospital Per Diem – if payer Case Rate/DRG – if hospital
Participate in hospital Pools (IP, OP)
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2/01/2012 ι 12THE CAMDEN GROUP
ACO(set medical targets and pools)
ACO Financial Model: General Flow of Funds - Pools
Pools are established using actuarial data tied to CMS filing
Actual claims expenditures are charged against the pool based on claims paid throughout the year
Surpluses available for distribution/deficits absorbed by health plan
Hospital,SNF, and
Rehabilitation Budgeted
Pool
Outpatient Ancillary Budgeted
Pool
Outpatient ServicesBudgeted
Pool
Outpatient Diagnostics Budgeted
Pool
POOLS
2/01/2012 ι 13THE CAMDEN GROUP
ACO Financial Model: How Does it Work? – Example
There will be pre-determined quality measures established by the ACO Quality and Service Committee to monitor and ensure appropriate care provision.
Continuum of Care Component Proposed Payment Type Incentivized Behaviors
PCPs FFS + Surplus distribution from Budgeted Pools
Treat patients in office (which also maximizes PCP’s income) instead of referring care that is appropriately done in PCP’s office to specialists
Specialists FFS + Surplus distribution from Budgeted Pools
Treat patients appropriately and will return patients to PCP if care is more appropriately done there
Will look for the provider of best value for services
Hospitals Per diems + Surplus distribution from Budgeted Pools
Physicians (including Hospitalists and Intensivists) will work to keep patients out of the hospital and, if they are admitted, work to maximize care with appropriate resources
Hospitals will work to keep costs low
2/01/2012 ι 14THE CAMDEN GROUP
2011 Medical Expenditures
Physician Services
31%
Other(non-RX)
7%
Hospitals and Skilled
Nursing Facilities
62%
Distribution of Expenditures(Current - $88.2 million)
Distribution of Expenditures(Target - $74.4 million)
* Target based on Moderately Managed Midwest Utilization Targets - Milliman
Physician Services
35%
Other(non-RX)
6%
Hospitals and Skilled
Nursing Facilities
59%
1/31/2012
6
2/01/2012 ι 15THE CAMDEN GROUP
Destination: Redesign Care Management and Become More Patient-centered
Destination:Better Health. Better Care. Lower Cost.
Patient Safety and Throughput
Hospitalist and Hospital-based
Physicians
Reduce Re-admissions
Bundled Payment
Patient-centered
Medical Home
Transactions/ Network
Development
ACDs/ACOs
Physician Relationships/
Leadership Development
Hospital Case Management Improvement
Clinical Co-management
Physician Enterprise
Restructure
System Wide Care
Management Restructuring
Clinical Integration
2/01/2012 ι 16THE CAMDEN GROUP
Example of Fragmentation in the Continuum of Care
Community ED Hospital Post-acute Community
Complex CM:CHFCOPDNephrologyNeuroCV
CM1 CM2
Health Plan
Medical Group
CM3 CM4 CM5 CM2 CM1
A patient experience in an episode of care could result in many different Care Models (“CM”) with a perspective of their specific care setting (model) serving the patient.
Hospital
Fragmented Patient Care Can Lead To: Poor patient quality outcomes Inefficiencies in transition of care High-cost Poor patient satisfaction
Physician Office
2/01/2012 ι 17THE CAMDEN GROUP
Patient Accessand
Communication
Facilitiesand Technology
Principles of Patient-Centered Medical Home
“When and how” based on patient preference and needs
Metrics used to define performance: quality, access, efficiency
Culture of continuous improvement
Clear lines of authority/ responsibility and process for
decision-making
Team orientation
Work to top of license
Share resources to maximize efficiency
Orientation and training
Standardized roles and work flows
Facilities support teamwork, and efficient work flow
Technology facilitates aims of care model
Aligned providers
Facilitate physician-physician communication
Proactive in identifying patient needs
Patient-Centered Quality and
Efficient Care
Ensure patients have goals for their care and responsibility for health related behaviors
Processes assure smooth transition of care and communication between providers (across continuum)
Source: The Camden Group
1/31/2012
7
2/01/2012 ι 18THE CAMDEN GROUP
Delegated“Carveout Expertise”
Specialists
The Care Team
Care Management
Behavioral HealthComprehensive Care Clinics
Social ServicesHealth Education
PrimaryCare
Physician
2/01/2012 ι 19THE CAMDEN GROUP
Conceptual Model for Patient-centered Coordination
Patient-centered Coordination
Hospital PHOHealth Plan Medical Group
RolesAdminMedical StaffClinicalIT
OutcomesQualityDiseaseFinancialSatisfaction
Populations Hospital Health Plan PHO Med Group
Complex CaseManagement
Coordination, UM and DCP
when admitted
Intensive outpatient management for high-risk patients provided by RN, MSW, Pharmacist, APN
Disease Management NoneIndividualized patient management provided by a dedicated healthcare team member (e.g., Clinical Nurse Specialist)
Population Wellness NonePatient monitoring and education specific to individuals’ chronic illnesses
Preventative NonePatient screening and education from healthcare team
2/01/2012 ι 20THE CAMDEN GROUP
Stratify Patients into a Level of Care Based on Care Needs
Level 4Home Care Management
Level 2Complex Care and Disease
Management
Level 1Self-management and Health Education
Programs
Home Care Management – End StageProvides in-home medical and palliative care management by Specialized Physicians, Nurse Care Managers, and Social Workers for chronically frail seniors that have physical, mental, social, and financial limitations that limits access to outpatient care, forcing unnecessary utilization of hospitals.
Complex Care and Disease ManagementProvides long-term whole person care enhancement for the population using a multidisciplinary team approach.Diabetes, COPD, CHF, CKD, Depression, Dementia.
Self-management, PCPProvides self-management for people with chronic disease.
Level 3 High-risk Clinics
High-risk Clinics and Care ManagementIntensive one-on-one physician/nurse patient care and case management for the highest risk, most complex of the population. As the risk for hospitalization is reduced, patient is transferred to Level 2. Physicians and Care Managers are highly trained and closely integrated into community resources, physician offices or clinics.
High Cost Patient
Low Cost Patient
Hospice/Palliative Care
BaselinePreventive Care/Wellness programs
Population MonitoringPreventive care, education and monitoring for the community.
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8
2/01/2012 ι 21THE CAMDEN GROUP
Destination: Obstacles on the Road
Destination:Better Health. Better Care. Lower Cost.
Patient Safety and Throughput
Hospitalist and Hospital-based
Physicians
Reduce Re-admissions
Bundled Payment
Patient-centered
Medical Home
Transactions/ Network
Development
ACDs/ACOs
Physician Relationships/
Leadership Development
Hospital Case Management Improvement
Clinical Co-management
Physician Enterprise
Restructure
System Wide Care
Management Restructuring
Clinical Integration
CAUTION
2/01/2012 ι 22THE CAMDEN GROUP
Potential Obstacles and Critical Success Factors: Care Management
Potential Obstacles
Breakdown in information/communication
Provider-centric information/communication
Reporting relationships = Control and emphasis (e.g., CFO maximize revenue)
Payment method: FFS
Lack continuum
Lack of coordinate transition
Turf wars
Critical Success Factors
Integrated IT backbone and coordinated communication
Patient-centric education, communication, patient accountability
Reporting relationship that matches patient-centric goals (e.g., capitated medical group quality at lowest cost)
Payment method = cap or case rate
Partner/Align/Acquire continuumComprehensive discharge communicate plan for patients
Comprehensive discharge communicate plan for patients
Align incentives (e.g., incentive pools, co-management)
2/01/2012 ι 23THE CAMDEN GROUP
Destination
Destination:Better Health. Better Care. Lower Cost.
Patient Safety and Throughput
Hospitalist and Hospital-based
Physicians
Reduce Re-admissions
Bundled Payment
Patient-centered
Medical Home
Transactions/ Network
Development
ACDs/ACOs
Physician Relationships/
Leadership Development
Hospital Case Management Improvement
Clinical Co-management
Physician Enterprise
Restructure
System Wide Care
Management Restructuring
Clinical Integration
1/31/2012
9
2/01/2012 ι 24THE CAMDEN GROUP
Bundled Hospital Payments Will Increase Care Collaboration
Source: Medicare Payment Advisory Commission (MedPAC)
Me
dic
are
sp
en
din
g fo
r th
e h
osp
italiz
atio
n e
pis
od
e
$6,500
Episode A (higher utilization)
Episode B (lower utilization)
X X X X X X X X
X X X X X
HospitalizationRehabilitation Hospitalization Readmission
HospitalizationHome Health
Services
Episodes A and B Have Same Bundled Payment
Acute Care Episodes
2/01/2012 ι 25THE CAMDEN GROUP
PhysicianGroup/Venture
Hospital
ExecutivePhysicianDirector
Service Line/Department
DirectorClinical
Co-management Committee
HospitalCEO/COO/VP
Cath LabMedical
CardiologyCardiac Surgery
Interventional Cardiology
Electro-physiology
Benchmark and
Performance
Cost EffectivenessProcess ImprovementLeadershipQuality assuranceClinical standardsResearch
Non-physician staffing BudgetingPurchasing/InventoryLicensingDatabase tracking
Phy
sici
an A
dvis
ors
Clinical and cost goalsBusiness development
Which Clinical Areas Will Be Included?
Management Service Agreement
2/01/2012 ι 26THE CAMDEN GROUP
Physicians Are Involved In Each Aspect of Operations
Co-management company governance structure includes various committees for managing all aspects of planning and care delivery (i.e., Quality Care Committee, Technology Committee,
Operations Committee, Finance Committee, Research Committee)
Possible Co-management Responsibilities
Financial and Operations
• Management oversight of staffing• Negotiation of service arrangements• Operating and capital budgets• LOS management and patient throughput
Planning and Business Development
• Strategic plan development• Technology planning• Marketing strategies• Clinical research plan
Quality of Care
• Development of care protocols• Quality management and improvement policies• Quality outcomes• Patient experience
Hospital
Physicians
1/31/2012
10
2/01/2012 ι 27THE CAMDEN GROUP
Destination: Obstacles on the Road to Bundled Payment
Destination:Better Health. Better Care. Lower Cost.
Patient Safety and Throughput
Hospitalist and Hospital-based
Physicians
Reduce Re-admissions
Bundled Payment
Patient-centered
Medical Home
Transactions/ Network
Development
ACDs/ACOs
Physician Relationships/
Leadership Development
Hospital Case Management Improvement
Clinical Co-management
Physician Enterprise
Restructure
System Wide Care
Management Restructuring
Clinical Integration
CAUTION
2/01/2012 ι 28THE CAMDEN GROUP
Bumps in the Road: Bundled Payment
Obstacles Critical Success Factors
Politics Vision and perseverance Transparency Participation Communication
Lack of Physician Participation Physician leadership and co-management and gainsharing/financial incentives
Current Performance Not Optimal – Need90th + Percentile Clinical Quality/Patient Satisfaction
Robust report card and incentives Cost accounting system/infrastructure Gainsharing models Best Practices
Volume/Market share Target marketing and education to distribution channels
How it fits with the population management?
Determine where the risk is and where the care management resources need to be
2/01/2012 ι 29THE CAMDEN GROUP
Destination: Initiatives to Start the Journey
Destination:Better Health. Better Care. Lower Cost.
Patient Safety and Throughput
Hospitalist and Hospital-based
Physicians
Reduce Re-admissions
Bundled Payment
Patient-centered
Medical Home
Transactions/ Network
Development
ACDs/ACOs
Physician Relationships/
Leadership Development
Hospital Case Management Improvement
Clinical Co-management
Physician Enterprise
Restructure
System Wide Care
Management Restructuring
Clinical Integration
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11
2/01/2012 ι 30THE CAMDEN GROUP
Example Initiatives to Start the Journey Reduce readmissions CMS estimates that readmissions cost $26 billion in a decade Congestive heart failure, heart attack, and pneumonia Additional disease added in 2014
Hospitalists/Hospital-based physicians Expanded roles (SNFist, laborists) Compensation methods that measure LOS, readmissions, satisfaction Share performance data Coordination with case managers
Patient throughput Patient placement in the right level of care Coordinated care through the acute care stay Design the internal processes for the professional staff, case managers, and
hospital based physicians Coordination with other levels of care Transfers out of ED Partnerships with TCUs Integration of hospice and palliative care in acute setting Health plan benefit coordination with disease management
Case Study Example
2/01/2012 ι 32THE CAMDEN GROUP
Centralized Care Management Model – Organizational Chart
Disease Management
Case Managers
RN Case Managers (“CM”)
Medical Social Workers (“MSW”)
Behavioral Specialists
Pharmacists
Embedded into PCMH
Advanced Practice Nurse (“APN”)
CM
Medical Office Assistants (“MOA”)
Hospital
Hospitalist
Inpatient Case Management
Patient Centered Medical Home
(“PCMH” or the “Medical Home”)
PCMH Primary Care Providers
(“PCP”)
Hospitalists
PhysicianAdministrator
Support Functions
Finance
Information Technology (“IT”)
Contracting/Network
Performance Improvement
Post-acute Services
Regulatory Compliance Director
Advisory BoardBaystate Hospitals
Baycare Health Partners
Health New EnglandCommunity Physicians
BH Management
Post-acute
Clinic Providers
Home Health CM
Phase 1 Prototype Phase 2 Post-prototype
Baystate Health System
1/31/2012
12
2/01/2012 ι 33THE CAMDEN GROUP
Framework to Categorize Interactions Between Medical Staff
PCMHProvider—each patient has an ongoing relationship with a personal provider trained to provide first contact and continuous and comprehensive carePhysician-directed medical practice—the personal physician leads a team of individuals at the practice level that collectively takes responsibility for the ongoing care of patientsWhole-person orientation—the personal physician is responsible for providing all the patient’s healthcare needs or taking responsibility for appropriately arranging care with other qualified professionalsCare is coordinated and/or integrated—across all elements of the healthcare system. Care is facilitated by registries, information technology, health information exchange, and other means
Medical Staff
Hospitalist
Provision of inpatient care 24/7 for a designated patient population based on evidence-based protocols
Physician assignments may be physician, specialty, or PCMH aligned
Engages the healthcare team in the Care Progression of the patient
Consistent communication and hand-offs with the Primary Care Team throughout the hospitalization
Specialist
The principle care provider for the disease will be negotiated by the PCMH and the specialist active in the treatment. Examples of patient management are:
The PCMH maintains responsibility for patient care and is the first contact for the patient
Shared management: the specialty practice would provide expert advice, but not manage the disease on an ongoing basis
Specialty practice assumes the role of the PCMH after consultation with the PCMH and approval by the patient i.e., end-stage renal disease
2/01/2012 ι 34THE CAMDEN GROUP
Care Transition Strategies to Acute Care and Post-acute Services
Post-acute Care
Services
HH, SNF, LTACH, ClinicsRehab
Acute CareServices
Inpatient
Transition Transition
Care Transitions Management Strategies (cont’d.)
The hospitalist confirms the post acute services with the PCP The inpatient CM engages the patient and family to evaluate the post acute
services and make a decision regarding discharge/transfer The UR nurse confirms eligibility and obtains authorization as necessary and
documents in the medical record The inpatient CM facilitates communication with the patient and facility
regarding transfer data Provider communicates all relevant information to the PCP post-acute care
services and documents in the medical record The MH-CM arranges for a post discharge office visit with the PCP within two
to four days The MH-CM completes all required patient education and documents a follow-
up plan to facilitate compliance
Escalation due to: Interventions Failed outpatient
care Acute event
PCP with Care Management
Support
5
4
3
2
1
Baseline
5
4
3
2
1
Baseline
2/01/2012 ι 35THE CAMDEN GROUP
Continuum of Care Provider Transitions
Pre-Admit Admit Concurrent Discharge Post-discharge
PCP to Hospitalist/Attending DM-CM or MH-CM to Inpatient CM Medical Home CM to Inpatient CM
Hospitalist/Attending to PCP Inpatient CM to DM–CM/Medical Home CM Inpatient CM to nurse in Post-acute Care
Services CM transitional home visit Outpatient DC follow-up to PCMH
PCP to Hospitalist/Attending Hospitalist/Attending to Specialist Multi-disciplinary Care Progression Rounds
with patient and family involvement MH–CM to Inpatient CM
PCP to Hospitalist/Attending Hospitalist to Specialist Inpatient CM to DM-CM or DM -CM Staff Nurse to staff nurse Patient and family education Inpatient CM to aftercare providers
1/31/2012
13
2/01/2012 ι 36THE CAMDEN GROUP
Continuum of Care Communication Hand-offs
Pre-admit Admit Concurrent Discharge Post-discharge
Verbal and e-mail communication
Verbal and e-mail communication Discharge plan and treatment plan Post-acute services communication Medication reconciliation Home visit
Verbal and e-mail communication Treatment and Discharge plan Medication reconciliation Multi-disciplinary Care Progression Rounds Patient and family education Bedside hand-offs Readmission meetings
Bedside hand-offs Readmission meetings Patient/family discharge rounds Care transition strategies Medication reconciliation Discharge planning with aftercare services
Integrated IT: EMR, CPOE, pathway, and discharge plan
2/01/2012 ι 37THE CAMDEN GROUP
Guiding Principles for Care Coordination Between Medical Staff
Type of referral consultation and co-management available
Accountability for processes and outcomes Content of the patient record – directional Process to initiate secondary referrals Patient-centered approach: patient choice,
clarification of referrals, diagnosis, and treatment plan
Inpatient process: notification of admission, secondary referrals, data exchange, transitions into and out of hospital
Emergent circumstances: if PCMH not available role of the specialist to secure appropriate medical care
Incentive structure
Agreement BetweenPCMH and PCMH-N
Principles may be used to distinguish the roles between the PCMH Provider and PCMH (Neighbor) Specialist
2/01/2012 ι 38THE CAMDEN GROUP
Framework to Categorize Interactions Between PCMH and PCMH-N
Pre-consultation Exchange
Answers a clinical question Prepares the patient for a
specialty assistant
Establishes referral guidelines Provides guidance on what is
an “urgent” consult
PCMHand
PCMH-N
Formal Consultation
Process to deal with a discrete
question/procedure
A detailed report and discussion
would be provided to the PCMH
Sub-specialty practice would not manage the case on ongoing
basis
Co-management
Shared management: the specialty practice would provide expert advice, but not manage the disease on an ongoing basis
Principle care for the diseased: PCMH and specialty are active in the treatment, the PCMH maintain responsibility for patient care and is the first contact for the patient
Principle care for the patient for a limited period and subspecialty becomes the first contact of care for the patient
Transfer of the Patient for the Entirety of Care
Specialty practice assumes the role of the PCMH after consultation with the PCMH and approval by the patient i.e., end-stage renal disease
1/31/2012
14
2/01/2012 ι 39THE CAMDEN GROUP
Follow the Money: He Who Has the Risk Will Need to Blur the Lines with Care Management Resources
Who Has Risk? Level of Risk Concern/FocusCare Management
Focus
Health Plan Pays providers FFS
Low rates Decreased utilization
Wants to keep utilization review/approvals
Caps Providers
Grow membership/revenue
Case management at provider level
Medical Group/PHO Full capitation Shared
Savings on whole population
Professional cap with hospital risk pool
Decreased utilization Patient focus Whole continuum
Hospital Case rate/bundled for episode
Decrease resource consumption for episode
Eliminate readmits
Care management pre-/during/post episode
2/01/2012 ι 40THE CAMDEN GROUP
Single Biggest Challenge:
When Will My Market Change?
ProceduresDriven
PopulationHealth Management
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