Presentation delivered at Opal ACOs Summit: A Transitional Model to Full Risk Care Management, Austin, TX 24JAN12

1. theSCCIPAstory
waynepanmdmba
chief medical officer
SCCIPA
A Pacific Partners Medical Group

2. Early ACO learnings from the “Left Coast”

3. Who is
?

4. Individual Practice Association
Medical Group of
Santa Clara County

5. SCCIPA

6. largest IPA in Santa Clara County

7. Santa Clara County
size 1,304.01 sqmiles
pop 1,781,642 (2010)
medianincome $74,335

9. 5 PCP
80 Specialists
173 PCP
343 Specialists
57 PCP
104 Specialists
11 PCP
30 Specialists
SCCIPA
founded in 1986
physician-owned, physician-governed
800+ physicians - 240+ PCPs, 550+ specialists
all 9 hospitals - including a tertiary care center
9 health plans (Commercial and Medicare Advantage)
Anthem Commercial ACO pilot (2011)

10. urban/
suburban
rural
SCCIPA
founded in 1986
physician-owned, physician-governed
800+ physicians - 240+ PCPs, 550+ specialists
all 9 hospitals - including a tertiary care center
9 health plans (Commercial and Medicare Advantage)
Anthem Commercial ACO pilot (2011)

11. 130,000patients

12. 76,000
commercialACO

13. 50,000
commercialHMO

14. 5,000
MedicareHMO

15. no
original Medicare,
Medi-Cal,
CHIP, uninsured

18. = managementservicesorganization
medicalmanagement
casemanagement
networkmanagement
providercontracting
qualityimprovement
credentialing
memberservices
claims&encounterprocessing
clinicaldataanalytics&reporting
marketingoutreach
grievance&appeals
compliance&auditing
ITservices
finance&riskmanagement

19. partialrisk

20. managingDOFR

21. Division
Of
F inancial
Responsibility

22. outpatientservices

23. inpatientservices

24. capitatepcps

25. specialistspaidffs

26. performancebonus

27. IHAP4P&HCC

28. IPAcitizenship

31. = softwareservicescompany
Ex
Access Express TM
Utilization
Management
Case
Management
Quality
Management

32. = softwareservicescompany
Access Express TM
Excelicare TM

33. = softwareservicescompany
Coordinated Care Platform

34. Utilization
Access Express
TM
Management
Case
Access Express
TM
Management
Quality
Access Express
TM
Management
Clinical
Excelicare
TM
Integration
Engine

35. 130,000patients

36. 130,000patients

37. 130,000patients
“Living Laboratory”

38. peopleprocessesplatform

39. peopleprocessesplatform

40. 4 groupsofpeople

41. physicians
physicianofficestaff
medicalmanagementstaff
healthplanstaff

42. teamsport

43. howdoteamsworkbest?

44. communicate

45. communicate
collaborate

46. communicate
collaborate
coordinate

47. skatetowhere
thepuckwillbe
Walter Gretzky
(Wayne Gretzky’s father)

48. communicate
collaborate
coordinate
anticipate

49. playbook

50. careplan

51. coach?

52. managedcare:PCP

53. unmanagedcare:?

54. people:IPA/MSO
hospitalists
SNFists
onsite case managers
complex case managers
utilization review staff

55. patientcenteredness

57. MIND THE GAP

58. carecoordination
andtransitions

59. peopleprocesses
hospitalists
available 24/7
evaluation of patients for possible redirection to SNF
aggressive use of observation status
annual coding/documentation training for risk adjustment
notification of PCP of admission/discharge
discharge summary faxed to PCP

60. peopleprocesses
SNFists
ongoing evaluation of patients to reduce
rehospitalization
notification of PCP of admission/discharge
discharge summary faxed to PCP

61. peopleprocesses
onsite case managers
daily review of patients based on Milliman guidelines
actively involved with discharge planning
all discharge needs authorized/arranged prior to
discharge
post-discharge follow-up on all patients with
DME/HHC needs

62. peopleprocesses
complex case managers
warm hand-off between onsite and ccm
use of clinical and non-clinical staff to assist
patient and family caregivers with care coordination
insure follow-up with PCP/specialist within 2 weeks

63. peopleprocesses
utilization review staff
all authorizations/referrals reviewed using Milliman guidelines
working closely with PCPs/specialists/ccm to facilitate care
coordination
compliance with regulatory guidelines
generate member/provider letters regarding medical necessity
decisions
physician performance and quality reporting
identification of potential quality issues
continuous process improvement

64. people:physicians/staff
primary care physicians
specialists
ancillary providers

65. people:physicians/staff
primary care physicians
specialists
ancillary providers
front office staff

66. people:plan staff
case managers
disease managers
member outreach
benefit design

67. peopleprocessesplatform
communicate
collaborate
coordinate
anticipate

68. peopleprocessesplatform
common web-based communication platform
facilitates administrative functions
rules-based management of processes
intuitive user-interface
embed quality reminders into office/provider workflow
provider feedback

69. peopleprocessesplatform
common web-based communication platform
facilitates administrative functions
rules-based management of processes
intuitive user-interface
embed quality reminders into office/provider workflow
provider feedback
provide actionable clinical data at point of care
allow patients to access their own data

70. peopleprocessesplatform
common web-based communication platform
facilitates administrative functions
rules-based management of processes
intuitive user-interface
embed quality reminders into office/provider workflow
provider feedback
provide actionable clinical data at point of care
allow patients to access their own data
allow patients to provide feedback/enter their own data

71. more than an EHR
more than an HIE
clinicalintegrationengine

72. virtually integrated healthcare delivery system

73. designphilosophy

74. “put hot
triggers in
the path of
motivated
people”
BJ Fogg, PhD
Director, Persuasive Technology Lab
Stanford University

76. TRIGGERS: Are people being triggered at the
most appropriate time and in their workflow (path)?
ABILITY: Have I made it easy for people to act?
How can I make it even simpler?
MOTIVATION: Are incentives aligned
properly? How can I increase their motivation?

77. patient
front desk staff

78. patient
analog to digital
front desk staff
converter

79. 112
MARY SMITH 1/1/2011
1234567890
$5.00
$10.00
$25.00
analog to digital
analog to digital eligibility check
converter
converter

80. Quality
Access Express
TM
Management
Click here to register
for a password or
request more information
Powered by Access ExpressQ-v5.0.#.0.1 Build 2011.04.04.00

81. ACCESSEXPRESS
Q New Eligibility Response New Message (3)

82. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
ANTHEM BLUE CROSS

83. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
TH
PA
ANTHEM BLUE CROSS
E
TH
IN

84. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
SMITH, MARY
8/15/1945
POP-UP
1234567890
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD

85. digital to analog converter module

86. x
x
x
x
x
x
x
x
digital to analog converter module

87. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
SMITH, MARY
8/15/1945
1234567890
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD
CLICK HERE

88. ANTHEM BLUE CROSS

89. ANTHEM BLUE CROSS

90. ANTHEM BLUE CROSS

91. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
ER
SMITH, MARY
8/15/1945
G
1234567890
IG
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
TR
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD
T
O
H

92. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
ENABLING
SMITH, MARY
8/15/1945
1234567890
FRONT OFFICE
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
STAFF
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD

93. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
SMITH, MARY
8/15/1945
SIMPLE
1234567890
CARE PLAN
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD

94. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
SMITH, MARY
8/15/1945
1234567890
MAMMOGRAPHY, CRC, CARDIO CARE,
BLUE SHIELD OF CA
DIABETES CARE, HYPERTENSION,
GLAUCOMA, MED MONITOR, FLU VAC,
PNEUMO VAC, DEXA, OSTEOPOROSIS,
RHEUM, COPD

95. ACCESSEXPRESS
Q New Eligibility Response New Message (3)

96. ACCESSEXPRESS
Q New Eligibility Response New Message (3)

97. ACCESSEXPRESS
Q New Eligibility Response New Message (3)
N
O
TI
VA
TI
O
M

98. ACCESSEXPRESS
Q New Eligibility Response New Message (3)

99. ACCESSEXPRESS
Q New Eligibility Response New Message (3)

100. ACCESSEXPRESS
Q New Eligibility Response New Message (3)

101. Description of
measure

102. Capability for
physician office
entry

103. Capability for
physician office
entry
Y
IT
IL
AB

105. our healthcare journey
we
are
here
from: missclaudiawong.blogspot.com (January 30, 2011)

107. 4x4 healthcare

108. 4processes
x
4
dimensional
data

109. communication
anticipation collaboration
Case
Managers
Patients PCPs
Specialists
coordination

110. financial
administrative
behavioral
clinical

111. reactivecare

112. $$$$$$

113. predictive

114. proactivecare

115. From: Dan Roam, “American Healthcare: a 4-napkin explanation”
www.slideshare.net/danroam/healthcare-napkins-all

116. SCCIPAresults

117. 45.0%
50.0%
55.0%
60.0%
65.0%
70.0%
No
v%2
0
De 09%
c%2
0
Ja 09%
JA n
N%201
Fe 100%
b%
20
M 10%
ar
%2
0
Ap 10%
AP r
%
0
M
R21 1
ay 00%
%2
0
Ju 10%
n%
20
1
Ju 0%
%
JUl%2
0
Au L110%
g%2 0
0
Se 10%
p%
20
1
OOct% 0%
CT 0 2
No 110%
v%2 0
0
De 10%
c%2
01
Ja
JAn% 0%
N211 0
Fe 1 % 1
b%
20
M 11%
ar
%2
0
Ap 11%
APr
%2
0
Commercial*ADM*
M
R11
ay 1 % 1
%2
0
Ju 11%
n%
20
1
Ju
JUl% 1%
L211 0
Au 11%
g%2
0
commercialadmits/1000
Se 11%
Milliman ’11 Well-Managed
p%
20
O
Milliman ’11 Loosely-Managed
O ct 11%
CT0 %2
Milliman ’11 Moderately-Managed
1
SCCIPA
111%
53.6%

118. 150.0%
175.0%
200.0%
225.0%
250.0%
275.0%
No
v%2
0
De 09%
c%2
0
J
JAan 09%
2
1
N%10
Fe 00%
b%
20
M 10
ar %
%2
0
Ap 10%
AP r
R%201
M 1 0
ay 0 %
%2
01
Ju 0
n% %
20
1
Ju 0%
JU l%2
0
Au L110%
g%2 0
0
Se 10%
p%
20
1
OOct% 0%
CT20
No 110%
v%2 0
0
De 10%
c%2
0
Ja 10%
JAn%
0
N2111
Fe
b% 1 %
20
M 11
ar %
%2
0
Ap 11%
APr%
M 0
Commercial*BDAYS**
R2111
ay 1 %
%2
0
Ju 11%
n%
20
1
Ju 1%
JU l%2
0
Au L1 11%
g%2 1
0
Se 11%
Milliman ’11 Well-Managed
p%
20
1
Milliman ’11 Loosely-Managed
commercialbeddays/1000
OOct%2 1%
CT 01
Milliman ’11 Moderately-Managed
1 1%
SCCIPA
1
175.5%

119. 3.0#
4.0#
2.5#
3.5#
4.5#
No
v#2
0
De 09#
c#2
00
J
JAan 9#
N#20
Fe 100# 1
b#
20
10
#
SCCIPA
M
AAp ar#
PR2r#
01
100#
M
Ju ay#
n#
20
1
Ju
JUl# 0#
0
L211
Au 0 # 0
g#2
0
Se 10#
p#
20
O
O ct 10#
C#20
T
No 110#
v#2 0
0
De 10#
c#2
01
a
JJAn 0#
#2
commercialalos
N 01
Fe 11 # 1
b#
20
11
#
M
ar
#
Commercial*ALOS*
p
AAP
r#2
0
R11
1
1#
M
Ju ay#
n#
20
Ju
JUl 11#
#
0
L211
Au 1 # 1
g#2
01
1
Milliman ’11 Well-Managed
Se
p# #
20
Milliman ’11 Loosely-Managed
O
O c 11#
Ct#2
Milliman ’11 Moderately-Managed
T01
1
11#
3.3#

120. !200.0!!
!250.0!!
!300.0!!
!350.0!!
No
v!2
0
De 09!
c!2
J
JAa 009!
n
N!21 01
Fe 00!
b!
20
M 10!
ar
!2
AAp 010!
PR r!2
01
M 100
ay !
!2
01
Ju 0
n! !
20
Ju
!
JUl 10!
!
0
L211
Au 0 ! 0
g!2
0
Se 10!
p!
20
OOc 10!
CtT !2
0
No 110! 0
v!2
0
De 10!
c!2
0
JJA 10!
an
!
N21 0
Fe 11!
b!
1
20
M 11!
ar
!2
AAP 011!
pr
Medicare(ADM(
!2
R1 01
M 1
ay 1!
!2
01
Ju 1
n! !
medicareadmits/1000
20
Ju
JU 11!
!2
lL
0
11
Au 11!
g!2
0
Milliman ’11 Well-Managed
Se 11!
p!
20
Milliman ’11 Loosely-Managed
O 11!
OC ct
!2
T0
Milliman ’11 Moderately-Managed
111
SCCIPA
1!
!274.6

121. 1,000!
1,200!
1,400!
1,600!
1,800!
800!
No
v!2
0
De 09!
c!2
J
JAa 009!
n
N!20
Fe 00!
11
b!
20
M 10!
ar
!2
AAp 010!
PR2 r!
01
M 100
ay !
!2
0
Ju 10!
n!
20
1
Ju
JUl 0!
!
L2110
Au 0 ! 0
g!2
0
Se 10!
p!
20
OOct 10!
CT0 !2
No 110!
v!2 0
0
De 10!
c!2
01
a
JJAn 0!
!
N211 0
Fe 1 ! 1
b!
20
M 11!
ar
!2
0
Ap 11!
APr
!2
Medicare(BDAYS*(
0
M
R11
ay 1! 1
!2
0
Ju 11!
n!
20
1
Ju
JUl! 1!
0
L2111
medicarebeddays/1000
Au 1 !
g!2
0
Se 11!
Milliman ’11 Well-Managed
p!
20
O
Milliman ’11 Loosely-Managed
O ct 11!
CT0 !2
SCCIPA
Milliman ’11 Moderately-Managed
111!
1
!1192!!

122. 4.0!
5.0!
6.0!
3.5!
4.5!
5.5!
No
v!2
0
De 09!
c!2
00
Ja
JA n ! 9 !
N201
Fe 100!
b!
20
10
!
M
AApr ar!
PR!20
1
100!
M
Ju ay!
n!
20
1
Ju 0!
JUl!2
L0
Au 110!
g!2 0
0
Se 10!
p!
20
1
OOct 0!
C !20
T
No 110!
medicarealos
v!2 0
0
De 10!
c!2
01
a
JJAn 0!
!
N201
Fe 11 ! 1
b!
20
11
!
M
Medicare(ALOS(
ar
p
AAP !
r!2
R110
11!
M
ay
Ju
n! !
20
Ju
JU 11!
l!
0
L211
Au 11!
g!2
01
Milliman ’11 Well-Managed
Se 1!
p!
2
Milliman ’11 Loosely-Managed
OO 011!
c
Ct!
Milliman ’11 Moderately-Managed
20
T1
SCCIPA
11
1!
!4.3!!

123. readmissions%byquarter 12#Mo#Rolling#Readmits#%#by#Quarter#
Commercial$Acute$ Medicare$Acute$
20.0%$
18.0%$
16.0%$
14.0%$
12.0%$
10.0%$
8.0%$
6.0%$
4.0%$
2.0%$
0.0%$
12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$ 12$Mo$thru$
2009Q4$ 2010Q1$ 2010Q2$ 2010Q3$ 2010Q4$ 2011Q1$ 2011Q2$ 2011Q3$

124. *
*
*
*
*
increase/same scores in 21 of 26 measures

126. no

127. When you improve a little bit
each day, eventually big things
occur. Don’t look for big, quick
improvement. Instead, seek
small improvement one day at a
time. That’s the only way it
happens - and when it happens,
it lasts.
John Wooden

128. iteration

129. Virtually nothing comes
out right the first time.
Failures, repeated failures,
are finger posts on the
road to achievement. The
only time you don’t want
to fail is the last time you
try something. One fails
forward toward success.
Charles F. Kettering

130. don’t be afraid to FAIL....

131. failfast

132. what’snext?

134. shareddecision-making

135. unmanagedcare?

136. aco?

137. createdynamiccareplan
careplantoeverytouchpoint
incentivizecareteam
measurecompliance
includepatient

138. distributedpcmh

139. patientaspcp

140. patientself-coaching

141. pch care

142. CLINICAL
DATA
care plan
data integration/analysis
providers
ADMIN
DATA care team
BEHAVIOR
DATA
patient
caregivers
PATIENT
COLLECTED
DATA
care plan
adapted from Mary Cain’s diagram (HT3.com)

143. Patient flow Location Who Technology
adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)

144. Patient flow Location Who Technology
Assessment PCP’s office PCP paper/EHR
Measurement
PCP’s office PCP paper/EHR
Clinical Data
Care Plan PCP’s office PCP paper/EHR
Development
Care Plan patient PCP & patient paper/EHR
Implementation
Re-assessment PCP’s office PCP paper/EHR
adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)

145. Patient flow Location Who Technology
Assessment PCP’s office PCP paper/EHR
Measurement
PCP’s office PCP AE/
paper/EHR
Clinical Data EC
Care Plan PCP’s office PCP AE/
EC paper/EHR
Development
Care Plan patient PCP & patient paper/EHR
Implementation
Re-assessment PCP’s office PCP paper/EHR
adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)

146. Patient flow Location Who Technology
Assessment PCP’s office PCP paper/EHR
Measurement
PCP’s office PCP AE/
paper/EHR
Clinical Data EC
Care Plan PCP’s office PCP AE/
EC paper/EHR
Development
Care Plan patient PCP & patient paper/EHR
Implementation
Re-assessment PCP’s office PCP paper/EHR
adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)

147. Patient flow Location Who Technology
PCP’s/careteam PCP’s/careteam
Assessment patient patient paper/EHR
Measurement PCP’s/careteam PCP’s/careteam AE/
paper/EHR
Clinical Data patient patient EC
Care Plan PCP’s/careteam PCP’s/careteam AE/
EC paper/EHR
Development patient patient
Care Plan PCP’s/careteam PCP’s/careteam
paper/EHR
Implementation patient patient
PCP’s/careteam
Re-assessment patient patient paper/EHR
adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)

148. Patient flow Location Who Technology
Assessment PCP’s/careteam PCP’s/careteam AE/
paper/EHR
patient patient EC
Continuous
Measurement PCP’s/careteam PCP’s/careteam
Clinical/Personal Data patient patient
AE/
EC paper/EHR
Care Plan
PCP’s/careteam PCP’s/careteam
Development w/SDM
patient patient
AE/
EC paper/EHR
Care Plan paper/EHR
AE/
EC
PCP’s/careteam PCP’s/careteam
Implementation promotoras
patient patient
Continuous PCP’s/careteam
Re-assessment patient patient
AE/
EC paper/EHR
adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)

149. FUTURE PATIENT ENGAGEMENT STRATEGY
clinical adherence
med
data data
CHF Patient Technology
track symptoms mobile
app
AE/ PCP
mobile EC
track diet app data dynamic
& CareTeam
integra
tion care
track weight mobile wireless &
analysis
plan mobile patient
app scale app caregiver
track other mobile
behavior app
adapted from discussions with Mary Cain (HT3) and Ryan Baum (Jump Associates)

150. DYNAMIC CARE PLAN STRATEGY
AE/ AE/
EC EC
combine
clinical patient clinical evidence adjust clinical
ID & -based care
match patient algorithm plan
data
mobile mobile
app app
patient patient
collected

152. a patient-centered,
evidence-based,
high-quality,
cost-effective,
sustainable,
healthcare delivery model

154. ?
From: Dan Roam, “American Healthcare: a 4-napkin explanation”
www.slideshare.net/danroam/healthcare-napkins-all

155. get out of the rut

156. keep doing the same thing?

157. insanity:
doing the
same
thing over
and over
and
expecting
different
results

160. think about...

161. transformedhealthcare

164. 2
questions

165. how will the patient benefit from this?
does this make it easier for the patient?

167. welcome to
healthcare2.0

168. Thank you!
wpan@ppmsi.com
WWW.SNOOPY.COM