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Independent Health
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Regional not‐for profit health plan upstate NY 370,000 members 172,000 Commercial 72,000 Medicare Advantage 51,000 Medicaid 74,000 Self‐funded Open network Primary (1,200) and Specialty Care (2,500)
Buffalo
Redefining the Role of Primary Care: The Primary Connection Thomas - - PowerPoint PPT Presentation
Redefining the Role of Primary Care: The Primary Connection Thomas - - PowerPoint PPT Presentation
Redefining the Role of Primary Care: The Primary Connection Thomas J Foels, MD MMM Chief Medical Officer November 14, 2012 Independent Health Regional not for profit health plan upstate NY 370,000 members Buffalo 172,000 Commercial
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Primary Care Physicians & Independent Health
- Long history of collaboration with physician community
- Unwavering in goals to improve quality, affordability and
experience of care
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Fee-For-Service Fee-For-Service Fee-For-Service (P4P) Practice Excellence (P4P) Practice Excellence Prospective Payment (monthly) Retrospective
Quality & Satisfaction
Maximum Prospective Payment (monthly) Maximum Retrospective
Quality, Satisfaction & Efficiency
PCMH Reimbursement Evolution: 2008-2011
90 10 100 90 10 130 20 10 90 10 20 30 150
(P4P) Practice Excellence (P4P) Practice Excellence (P4P) Practice Excellence (P4P) Practice Excellence
2008 2008 2009-10 2009-10
50 % Global Budget Increase over 2008 Reimbursement
2011 2011
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PCMH Results: 2008-2011
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Cardiovascular Risk
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PCMH Results: 2008-2011
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PCMH evolves to Primary Connections 2012 Reimbursement Goals
Achieve Triple Aim Move Beyond Fee for Service for PCP Transition from “pay-for-volume” to “pay-for-value” Support team based care Support alternative care pathways (Telephonic Visits, E-visits, Nurse Visits) Provide compensation for Care Management Influence and Transform Specialty and Hospital Care Provide opportunities for shared savings and incentives for global delivery system re-design and efficiencies
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Enable and Incentivize Practices to Expand Capacity Expand patient access and availability (2014 Exchange) Foster Inter-Dependencies Among PCP Practices (Provide a sustainable model for shared resources: MTM pharmacists, care coordinators, dieticians, co-located behavioral health, etc.) Potential Savings Opportunity: Commercial (11%) Medicare (17%)
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PCMH evolves to Primary Connections 2012 Reimbursement Goals
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PCMH evolves to Primary Connections 2012 Operational Goals
- Administrative simplicity
- Transparency
- Provide extensive and timely analytics to support performance
improvement
- Support sufficient cash flow in transition from FFS via monthly
patient management payments
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PCMH evolves to Primary Connections 2012 Reimbursement Model
- Provides up to 2x traditional compensation
- No downside risk
- Pay for value, not volume
- Focus on quality and efficiency
- Rewards the right activities and results
- Fully vetted by the PCP Physician Advisory Board
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Primary Connections Reimbursement: 2011-2014
2011-June 2012 June 2012 - 2014
Transitioned FFS into pre-paid care mgt payment New incremental opportunity for Shared Savings
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Primary Connections: alliance among independent PCP practices influences specialty and hospital based care
PCP PCP PCP PCP PCP PCP PCP PCP PCP PCP SCPs SCPs Hospitals Hospitals Ancillary Providers Ancillary Providers Community Services Community Services IHA IHA Urgent Care Urgent Care
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PCP PCP
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Primary Connections: supportive resources provided by Independent Health
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- PCP led collaborative meetings with cardiology, gastroenterology, radiology:
- Enhanced communication patterns
- Moving from “proceduralists” to “consultants”
- Establishing virtual consultations
- Direct access to Specialty by phone
- Programs created for dedicated geriatric center and dedicated hospitalists
evolving
- Enhanced patient engagement
- Hospitals reposition themselves for value
- Urgent Care partner identified:
– Restructuring to position itself as “extended primary care” – Creating common clinical treatment algorithms
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