© 2011 advocate physician partners advocate accountable care carrie e. nelson, md, ms, faafp...

© 2011 Advocate Physician Partners

Advocate Accountable CareCarrie E. Nelson, MD, MS, FAAFP

Stakeholder Health

September 25, 2015

© 2011 Advocate Physician Partners2

Advocate Health Care Advocate Health Care

13 Hospitals• 10 acute care hospitals• 1 children’s hospital• 1 critical access hospital• 1 clinically affiliated hospital • 5 level 1 trauma centers• 3 major teaching hospitals• 2 physician groups with 1,500 physicians • 250 sites of care

34,000 Employees

Advocate Physician Partners• 4,900 Participating Physicians• 25% PCPs / 75% specialists • 1400 Employed/3500 Aligned• 2nd Largest ACO in US - 745,000 covered lives


Clinical Integration (CI)• A structured collaboration among APP physicians

and Advocate Hospitals to improve the quality and efficiency of health care.

• Joint contracting with fee-for-service managed care organizations is a necessary component of this program in order to accelerate these improvements in health care delivery.

• CI forms the foundation for population health

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© 2011 Advocate Physician Partners4

Highlights of 2014 CI Program• A Generic Drug Prescribing Rate of 2 Percentage Points higher than

the Chicagoland market >$17 Million of overall health care drug expenditures were avoided by utilizing lower cost, equally-effective generics

• An Outstanding Asthma Control Rate – 24 Percentage Points Higher than the National Average Saving ~$17 Million in Direct and Indirect Medical Costs

• A Diabetes Care Initiative for HbA1c Control Saving >$1.4 Million • Childhood Rotavirus Immunization Initiative:

– Exceeded National HMO rates by 9.2% points– Exceeded National PPO rates by 19% points– Saving >$4 Million in Avoided Hospital Costs

• Combination 3 Childhood Immunization Rates Above the NCQA 75th Percentile for Combined HMO and PPO


Our Reimbursement Model is Shifting

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Accountable Care Entity (ACE)• Illinois Medicaid Expansion Bill Signed Into Law

July 22, 2013• Created provider-sponsored “Accountable Care

Entity (ACE)” to coordinate care for Medicaid eligible individuals

• ACE as an alternative for providers to reliance on other managed Medicaid organizations

• Eligible Medicaid populations are children and their family members and Affordable Care Act “newly eligible” beneficiaries

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Medicaid PCP and OB Capacity

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Physician Type% PCPs Enrolled with

Medicaid FFS Program

CurrentCapacity

Aligned 71% 228,253

Employed 76% 49,879

OB 15,336


APP ACE Eligible Population• Family Health Plan – Existing Medicaid FFS Patients

• Newly Eligible ACA Adults– APP will include this population in 2017

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120,00019,500

10,500

Estimated Lives

150,000


ACE 3-Year Risk Pathway – Originally Proposed• Program supports transition away from fee-for-

service with care coordination fees as ACEs accept more risk

• Months 1-18: Care coordination fees and shared savings

• Months 19-36: Prepaid capitation with individual and global stop-loss provided by HFS; transition to Managed Care Community Network (MCCN) or HMO

• Months 37+: Global capitation9


Key Considerations in Assuming Risk for Medicaid• Best opportunity for provider community to manage Medicaid

population• Aligned with Advocate mission and vision• Further moves the organization to one model of care for all

patients– Patients will move in and out of public Marketplace and Medicaid

• Maintains existing Medicaid lives managed by Advocate providers– Children’s Hospital and residency programs– Half of OB volume in Illinois, similar in Advocate Health Care

• Aligned incentives• Moves the organization progressively toward managing

financial risk10


BUT…• Illinois pays among the lowest in the nation

for Medicaid• Illinois is broke and hasn’t paid the managed

care organizations for 3 months• Not all our physicians want to do it – some

are very vocal

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So What Did We Do?

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Why?

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Medicaid Targeted Initiative: Community Health Worker Program• Medicaid ACE program prompted a need to look

for new approaches to engage patients• Look at two separate models/conditions to

gauge effectiveness– Trinity PHO: Asthma (Feb 2015)– Christ PHO: ED Use (2nd Qtr 2015)

• Design full program using consulting services from Sinai Urban Health institute

• Develop new approaches for patient outreach and education


Trinity Pilot: Overview• Patients with poor asthma control are visited by

CHWs in their homes up to six times during yearlong intervention– Physicians and claims identify patients to participate– Direct recruitment flyer sent monthly to members

• The CHW is an extension of the care management team

• The CHW sends physicians a summary of the patient’s evaluation and educational plan

• Results not yet complete

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Trinity Pilot: CHW team

Wakita Coleman Moet Sims-Denmark

Melinda Harville

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Trinity Pilot: Measuring Success• Decrease in asthma ED visits• Decrease in asthma hospitalizations• % Of patients who demonstrate their ability to

control their asthma (measured by ACT)• Improvement in quality of life measures• Decrease in asthma triggers in home• Increase in medication usage• Decrease in the frequency of asthma symptoms• Stories!

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Q&A

© 2011 advocate physician partners advocate accountable care carrie e. nelson, md, ms, faafp...

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