Driving to Value: Transitioning from Fee for Service. Walter LeStrange

Transcription

1 Driving to Value: Transitioning from Fee for Service Walter LeStrange 1

2 2015 ProHEALTH Profile 700+ Providers 225 Adult PCP s 100 Peds 35 OB/GYN 350 Sub-Specialty 800,000+ Unique Patients 2 million Visits Annually 227 Locations 2

3 Geographic Distribution Primary Care KEY Specialist Corporate Office ProHEALTH is represented by over 225 healthcare access points primarily located on Long Island with continuous expansion into the New York Metropolitan Area. 3

4 The Market is Changing * Medicare 23% 21% 21% Commercial/Other 76% 74% 70% Managed Medicaid 1% 3% 5% Value/Risk 0% 2% 4% * 2016 Forecast 4

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6 ProHEALTH Advantage Care Coordination Primary Care Optum July 2014 Preparing for Risk Resources Optum Analytics Care Management Population Health Specialist Urgent Care Hospitalist Palliative Care 6

7 Accountable Care/Risk Contracting 5 Shared Savings Contracts P4P Agreements Value Based Contracts January 1, 2017 Managed Medicaid January 1, 2017 Medicare Advantage July 1, 2017 Commercial 7

8 ACO Population by Home Zip Code Q Q3 2015

9 ACO Population vs Per Bene Expenditures 30,000 25,000 20,000 15,000 10,000 5,000 0 Population Expenditures Benchmark Population Expenditures Benchmark Population Expenditures PY1 Interim PY1 PY2 Population 22,766 25,154 28,211 Expenditures $9,180 $9,266 $9,165 Benchmark $9,992 $9,774 $9,773 Benchmark 9

10 Montefiore ProHEALTH WestMED NYC HHC Mt. Sinai 10

11 Accountable Care 2014 QUALITY MEASURES Final Score: Total Points Earned out of 60: Exceeded the mean and median when compared to all other ACOs for 32 of 33 measures. Beat our own 2013 scores in 28 of 33 measures. 11

12 ACO 2014 Quality Performance Report Measure Name PY1 ACO Performance Rate PY2 ACO Performance Rate Performance Rate Needed for 90% Getting Timely Care, Appointments, and Information How Well Your Doctors Communicate Patients Rating of Doctor Access to Specialists Health Promotion and Education Shared Decision Making Health Status/Functional Status Risk Standardized, All Condition Readmissions ASC Admissions: COPD or Asthma in Older Adults ASC Admission: HF Percent of Primary Care Providers Who Successfully Attested for the EHR Incentive Program Incentive Payment Medication Reconciliation Falls: Screening for Fall Risk Influenza Immunization Pneumococcal Vaccination Adult Weight Screening and Follow-up

13 ProHEALTH Utilization Rates Per 1,000 Person Years PY1 Interim PY1 PY2 Hospitalizations PY1 Interim PY1 PY2 Emergency Department Visits Emergency Department Visits that Lead to Hospitalizations Computed Tomography (CT) Magnetic Resonance Imaging (MRI) PY1 Interim PY PY PY1 Interim PY1 PY2 PY1 Interim PY1 PY2 PY1 Interim PY1 PY2 13

14 Secret Sauce for Success Physician & Provider Engagement Provider Feedback/Report Cards Customized EMR Clinical Integration Imbedded Quality Measures (Hard Stops!) Urgent Care & Specialty Specific RAF Score Calculator Claim Data Analytics 14

15 ACO Performance Data Hospital & ER Utilization Hospital Admissions per 1,000 members YOU ProHEALTH Avg National Benchmark ER Visits without Hospital Admission per 1,000 members YOU ProHEALTH Avg National Benchmark 15

16 ACO Emergency Department Utilization Report 16

17 ProHEALTH Urgent Care ProHEALTH's first Urgent Care opened in December A majority of the Company s centers operate 7 days a week, 12 hours a day and 9 hours a day on weekends & holidays. Centers range in size from 3,000-7,000 sf with 6-10 exam rooms. Current staffing model is Board Certified Emergency Medicine Physicians. 17

18 Urgent Care 136 Million ED visits annually 71% unnecessary or avoidable!* * Truven Health Analytics, reported in Becker s Hospital Review, April

19 Urgent Care Geographic Footprint 19

20 Urgent Care Patient Volume Visits per Quarter Q Q Q Q Q Q Q

21 Urgent Care Payor Mix & Conditions Treated Payor Type Commercial Medicaid Medicare Self Pay Worker's Comp Total % Total Visits 74.0% 12.5% 8.3% 4.2% 0.9% 100.0% Conditions Treated Respiratory System Injury or Poisoning Nervous System or Sense Organ Symptom, Sign, Ill-Defined Condition Infectious and Parasitic Disease Skin or Subcutaneous Tissue Musculoskeletal Sys or Connective Tissue Genitourinary System Digestive System Endocrine or Nutritional Health Status Circulatory System Mental Disorder Hematology Oncology Total % Total 39.4% 15.2% 9.5% 9.3% 5.6% 5.5% 5.2% 4.1% 2.4% 2.2% 0.9% 0.5% 0.2% 100.0% 21

22 Advanced Illness/ Palliative Care Patient and Family centered Dosing of intervention; visits titrated to patient need 24/7 coverage (eg. Phone/virtual visits) Align treatments with patient preferences Patients die in location of preference People live longer with Palliative Care Appropriate referral to hospice 22

23 Advanced Illness/ Palliative Care MSSP ACO (n=215) 90 Day PreEnrollment PH Care Support Enrollment 90 Day Post Enrollment Medicare PartA Spend $1,446,975 $651,898 55% Reduction #ED Visits in 90 Days 101 Visits 67 Visits 34% Reduction Location of Death is Home Baseline Population (Control) 25% ProHEALTH Care Support 91% (n=100/110)

24 Advanced Illness Management 2014 Deaths PH Avg. Cost Last Year of Life 843 $65,000 $55,000,000 Opportunity 2014 Deaths Target Avg. Cost Last Year of Life 843 $46,000 $39,000,000 SAVINGS $16,000,000 24

25 Care Coordination/ Care Management Programs COPD Diabetes Transitions of Care Pre-visit Planning Gaps in Care HCC Assessments 25

26 Pediatric ACO Initiative Follow up calls from ED and Urgent Care Extended hours to improve access Ask Me about Call First button Quality Metrics Neonatal Program 26