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A Conversation About MGOand
Physician Driven Clinical Integration
Who/What is MGO? What is Clinical Integration? Why is MGO Clinically Integrating? When/How is MGO Clinically Integrating?
What’s it to you?John Schmeling, MDVP Physician [email protected]
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Who? MGO is…
• 640 practices/groups in 32 Ohio counties– 501 (78%) of groups comprised of 1-3 physicians
• 2,001 physicians– 659 (33%) primary care physicians– 1342 (67%) specialists – all specialties
• > 150 Physicians engaged in leadership roles• MGO Physicians responsible for > 90% of
OhioHealth’s revenue
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What ? MGO’s Mission
The Medical Group of Ohio (MGO) is an organization of health care professionals
working together, as a business, to improve the process of delivering health care and to enhance
the professional satisfaction of its members.
A physician business for –Quality–Enhancing Satisfaction
Obtain Fair Reimbursement Increase EfficiencyReduce Hassles Reduce Overhead
A physician business for –Quality–Enhancing Satisfaction
Obtain Fair Reimbursement Increase EfficiencyReduce Hassles Reduce Overhead
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What ? Business Services
• MGO Practice Resources (MGO PR) – Billing/claims processing, coding, collections, group
purchasing, PMS and EMR, and more• Communications
– Written: MGO Update, Quality Matters, Business Matters, Burgundy Book
– Electronic: www.theMGO.com, MGO E-news • Professional Liability by Physicians for Physicians
(PLPP)– Physician owned and controlled professional liability program – Long term stability with rates based on MGO physician’s
experience
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What ? Contracting – via OHG
50/50Ownership
andGovernance
A Physician-Hospital Organization
OhioHealth Group
Aetna, Cigna, Great West, and others
and
to the Market
OhioHealth Group
PhysiciansFacilities
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What ? Clinical Integration A Definition
and
a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs.
6
Clinical Integration is characterized by an active and ongoing program to evaluate and modify practice patterns
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Why ? Clinical Integration
To meet your needs in fulfillment of MGO’s Mission
• Purchaser’s/Market’s Expectations
• Legal considerations
• Prove, Improve and be Fairly Reimbursed for the Quality Care you deliver
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Why ? Purchaser’s Expectations
What do you consider when you purchase something important?
• Quality• Cost
Quality/Cost = Value
• Service
As a purchaser, You want value!
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Why ? Purchaser’s Expectations
The purchasers of health care want value too!
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The Purchasers of healthcare
are increasing their
expectation / pressure for providers to: • Prove and improve quality• Decrease cost (or reduce the rate of rise) • Improve service / access
(government,
employers, patients, and plans)
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Why ? Purchaser’s Expectations
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• Evidence based care processes• Support for prevention and wellness• Effective management of chronic diseases• Measure/prove, communicate and improve
our performance
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Why ? Purchaser’s Expectations- Quality -
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• Reduce waste and needless repetition–Right service, right time, every time
• Support prevention and wellness –Primary and secondary–Coordinated with employer driven programs
• Increase efficiency
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Why ? Purchaser’s Expectations- Cost -
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• Utilize Information Systems – Enhance communication– Provide better, more timely information
• Provide Patient Centered Care– Comprehensive, Coordinated, Convenient and
Compassionate– Across many conditions, services and settings
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Why ? Purchaser’s Expectations- Service -
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Conclusion 1:
The best way for Physicians to meet the
purchasers’/market’s expectations is by
collaborative clinical efforts
Why ? Clinical Integration
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Why ? Clinical Integration
To meet your needs in fulfillment of
MGO’s Mission
• Purchaser’s/Market’s Expectations
• Legal considerations
• Prove, Improve and be Fairly Reimbursed for the quality care you deliver
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Why ? Legal Considerations- Anti-Trust -
• For the FTC to allow “competitors” to jointly negotiate as one, there must be a compelling Benefit– i.e. new product/service that meets market needs
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• Two legal standards – at least one must be met– Clinical Integration– Financial Integration
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• 2002 - sold the HMO– no longer financially integrated– not clinically integrated
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Why ? Legal Considerations
• 1995 – 2001 MGO was financially integrated via 50% ownership of HealthPledge HMO – MGO negotiated contracts utilizing a single
signature contracting model
Financial Integration (financial risk)
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• MGO delivers the payers, terms/rates, the message, to the physicians and then delivers the physicians’ individual responses back to the payer
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Why ? Legal Considerations
• Negotiation (even commenting on the terms of the offer) is NOT allowed
Messenger Model
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While the FTC doesn’t provide a precise definition or checklist for Clinical
Integration, there are a growing number of organizations the FTC has recognized as
clinically integrated.
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Why ? Legal Considerations
MGO has been learning from them!
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• New systems and programs to improve quality and efficiency
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Why ? Legal ConsiderationsCharacteristics of FTC Recognized Programs
• Physician Standards of Care - develop, measure, provide feedback and assure compliance
• Commitment by physicians to participate in the systems and programs
• Investment of human and monetary capital
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Every organization the FTC has
recognized as Clinically Integrated has
found collective negotiations to be
necessary in order to achieve these
characteristics.
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Why ? Legal Considerations
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Conclusion 2:
Physicians’ ability to attain fair reimbursement is related to their ability to negotiate
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Why ? Legal Considerations
Conclusion 3:
To achieve Clinical Integration it may be necessary to negotiate on behalf of physicians
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Why ? Clinical Integration
To meet your needs in fulfillment of
MGO’s Mission
• Purchaser’s/Market’s Expectations
• Legal considerations
• Prove, Improve, and be Fairly Reimbursed for the quality care you deliver
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What ? Clinical Integration A Definition
and
a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs.
24
Clinical Integration is characterized by an active and ongoing program to evaluate and modify practice patterns
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Programs to Evaluate and Modify Practice Patterns
How ? Prove, Improve, Reward
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Pay for Quality (P4Q) Pilot Program
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An employer, OhioHealth, wanted to work with MGO physicians to assure that a high
percentage of their associates / insureds received prevention and wellness services.
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How ? Prove, Improve, Reward
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Quality of Care Measures for theOhioHealth Insured Patients (OHIPs)
P4Q PilotBreast Cancer
0%
50%
100%
2006 2007 Nat'l
67% 68% 67%
The proportion of female OHIPs age 40-64 having received a mammogram in the last 2 years.
Reference: U.S. Preventive Services Task Force Recommendation 2002
Cervical Cancer
The proportion of female OHIPs age 18-64 having received a Pap test during the last 3 years..
Reference: U.S. Preventive Services Task Force Recommendation 2003
0%
50%
100%
2006 2007 Nat'l
68% 70% 80%
Colo-rectal Cancer
Reference: U.S. Preventive Services Task Force Recommendation (modified) 2002
0%
50%
100%
2006 2007 Nat'l
29% 35%43%
Preventive Health Visits
2008 Baseline for Rewards
The proportion of OHIPs having received at least one coded preventive health service visit last year.
0%
50%
100%
2006 2007
40%
Asthma
The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma last year.
Reference: HEDIS – modified 2007
0%
50%
100%
2006 2007 Nat'l
63%78% 90%
0%
50%
100%
2006 2007 Nat'l
A1C in Diabetics
For every 1% reduction in blood sugar level, the risk of developing eye , nerve or kidney disease is reduced by 40%
44%53%
88%
44%
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Quality of Care Measures for theOhioHealth Insured Patients (OHIPs)
P4Q Pilot
Cervical Cancer
The proportion of female OHIPs age 18-64 having received a Pap test during the last 3 years..
0%
50%
100%
2006 2007 Nat'l
68% 70%80%
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Quality of Care Measures for theOhioHealth Insured Patients (OHIPs)
P4Q PilotBreast Cancer
0%
50%
100%
2006 2007 Nat'l
67% 68% 67%
The proportion of female OHIPs age 40-64 having received a mammogram in the last 2 years.
Reference: U.S. Preventive Services Task Force Recommendation 2002
Cervical Cancer
The proportion of female OHIPs age 18-64 having received a Pap test during the last 3 years..
Reference: U.S. Preventive Services Task Force Recommendation 2003
0%
50%
100%
2006 2007 Nat'l
68% 70% 80%
Colo-rectal Cancer
Reference: U.S. Preventive Services Task Force Recommendation (modified) 2002
0%
50%
100%
2006 2007 Nat'l
29% 35%43%
Preventive Health Visits
2008 Baseline for Rewards
The proportion of OHIPs having received at least one coded preventive health service visit last year.
0%
50%
100%
2006 2007
40%
Asthma
The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma last year.
Reference: HEDIS – modified 2007
0%
50%
100%
2006 2007 Nat'l
63%78% 90%
0%
50%
100%
2006 2007 Nat'l
A1C in Diabetics
For every 1% reduction in blood sugar level, the risk of developing eye , nerve or kidney disease is reduced by 40%
44%53%
88%
44%
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Patient Name Age
AKERS, BOB 50.3
BENDER III, TIM 44.9
BENDER, LORETTA 43.0
CLARK, KATHY 56.4
MCNAMARA, TONY 52.4
PORGE, SANDY 57.8
TAYLOR, MINDY 47.1
WILLIS, BETTY 48.9
Patient Counts 8 3 of 3 0 of 1 0 of 1 1 of 1 0 of 1 3 of 4 0 of 1 2 of 7
2 of 2 0 of 1 0 of 1 1 of 1 0 of 1 2 of 3 0 of 1 1 of 5
1 of 1 0 of 0 0 of 0 0 of 0 0 of 0 1 of 1 0 of 0 1 of 2
Target Performance for Bonus 38%0%
*
No
0% 0%
67%
69%
*
CECE
CECENo
YesNoNoCENoYesNoNo
YesCE
YesYes
YesNo
Yes
YesYes
20%
41%
68% 70% 44%
100% 0% 50%
No No
35% *
Preventive
Elig/Met Elig/Met Elig/Met Elig/Met Elig/Met Elig/Met Elig/Met Elig/Met
ColorectalOHG DIABETIC
COMBINEDHBa1C* LDL* Nephropathy* Mammogram
OH
CA
ETN
A
Your Performance
Your Performance
Your Performance (%) 100%
Pap
100%
*
0%
*
*Your Performance (%)
Target Performance for Bonus
100%
41%
0%
32%0% 0%
0%
68%
2009 Actionable Report on OhioHealth Insured Patients for Dr. SMITH DO, BILL FAMILY PRACTICE 5111111
Based on Claims Received and Paid as of 12/31/2008)
You are a MGO Physician
Instructions: Please review this report
For cells with a "Yes" - Congratulations as the service has been rendered and we have claims history on it.
For cells with a "No" - Consider a review of your records to confirm (to the best of your knowledge) a need for the service and then assist your patients in realizing same. If a service has recently (e.g. approximately the last three months) been performed, it may not show up on this report but will in future reports.
Note: Some patients will be listed on multiple physician reports - all receive "credit" when the patient receives the service.
* When diabetes is present, all 3 measures must be met (HBa1C, LDL, Nephropathy).
0
Aetna Patients
Not Eligible For Measure
Report Example: MGO physician report w/ Aetna patients. Shaded Performance % (Green = met/exceeded target, Red=Did not meet). Includes key for grey non-fields.
Actionable
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Baseline Measures Forming the Standards of Eligibility for Rewards for
MGO Physicians Caring for OhioHealth Insured Patients (OHIPs)
The proportion of OHIPs having received at least one coded preventive health service visit in 2007. (99381 thru 99396)
The proportion of adult diabetic OHIPs having received all 3 of the following last year: 1) HBA1c test at least 2/year 2) annual LDL level and 3) annual urine microalbumin or prescribed an ACE/ARB
The proportion of female OHIPs age 18-64 having received a Pap test during 2005-2007.
Cervical Cancer Colo-rectal Cancer
The proportion of OHIPs age 50-64 having received either a fecal occult blood test in the last year, or barium enema, flexible sigmoidoscopy or colonoscopy since 2004
Preventive Health Visits Diabetes
The proportion of female OHIPs age 40-64 having received a mammogram in 2006 or 2007.
68 %68 %
Breast Cancer
Reference: U.S. Preventive Services Task Force Recommendation 2002
Reference: U.S. Preventive Services Task Force Recommendation 2003 Reference: U.S. Preventive Services
Task Force Recommendation (modified) 2002
Asthma
70 %70 % 35 %35 %
38 %38 %78 %78 %44 %44 %
The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma in the previous year.
Reference: HEDIS – modified 2007
$11.80 $8.43 $22.62
$9.82 $20.57 $21.37
P4Q Pilot
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Baseline Measures Forming the Standards of Eligibility for Rewards for
MGO Physicians Caring for OhioHealth Insured Patients (OHIPs)
The proportion of female OHIPs age 18-64 having received a Pap test during 2005-2007.
Cervical Cancer
Reference: U.S. Preventive Services Task Force Recommendation 2003
70 %70 % $8.43
P4Q Pilot
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Baseline Measures Forming the Standards of Eligibility for Rewards for
MGO Physicians Caring for OhioHealth Insured Patients (OHIPs)
The proportion of OHIPs having received at least one coded preventive health service visit in 2007. (99381 thru 99396)
The proportion of adult diabetic OHIPs having received all 3 of the following last year: 1) HBA1c test at least 2/year 2) annual LDL level and 3) annual urine microalbumin or prescribed an ACE/ARB
The proportion of female OHIPs age 18-64 having received a Pap test during 2005-2007.
Cervical Cancer Colo-rectal Cancer
The proportion of OHIPs age 50-64 having received either a fecal occult blood test in the last year, or barium enema, flexible sigmoidoscopy or colonoscopy since 2004
Preventive Health Visits Diabetes
The proportion of female OHIPs age 40-64 having received a mammogram in 2006 or 2007.
68 %68 %
Breast Cancer
Reference: U.S. Preventive Services Task Force Recommendation 2002
Reference: U.S. Preventive Services Task Force Recommendation 2003 Reference: U.S. Preventive Services
Task Force Recommendation (modified) 2002
Asthma
70 %70 % 35 %35 %
38 %38 %78 %78 %44 %44 %
The proportion of OHIPs with asthma having received at least 1 prescription filled for long term control of asthma in the previous year.
Reference: HEDIS – modified 2007
$11.80 $8.43 $22.62
$9.82 $20.57 $21.37
P4Q Pilot
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Breas
t Can
cer S
cree
ning
Cervi
cal C
ance
r Scr
eeni
ng
Color
ectal
Can
cer S
cree
ning
0%
20%
40%
60%
80%
46%
70%
34%
68% 70%
35%
75% 76%
49%
2008 Baseline (claims through 12/31/07)2008 Target Performance (claims through 12/31/08)
MGO Physician Performance Preventive and Wellness Measures
(based on claims paid through 10/31/08)P4Q PilotMulti-Year Measures
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Comparison of Compliance Rates for Preventive and Wellness Measures Based on claims paid through 12/31/2008
Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening
0%
10%
20%
30%
40%
50%
60%
70%
80%
46%
70%
34%
68% 70%
35%
75% 76%
49%
Multi-Year Measures
2008 Baseline (claims through 12/31/2007)2008 Target Claims through 12/31/2008
Com
plia
nce
Rate
Preventive Visits Asthma Management Diabetes Management
0%
20%
40%
60%
80%
100%
120%
0% 0% 0%
44%
78%
38.%
51%
100%
28%
One-Year Measures
2008 Baseline (claims through 12/31/2007)2008 Target Claims through 12/31/2008
Com
plia
nce
Rate
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Conclusion 4:The pilot program is demonstrating marketable quality improvement results
How ? Clinical Integration Prove, Improve, Reward
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Conclusion 5: Clinical Integration program can work well for physicians – both in quality and fair reimbursement
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What ? Clinical Integration A Definition
and
a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs.
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Clinical Integration is characterized by an active and ongoing program to evaluate and modify practice patterns
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Programs to Evaluate and Modify Practice Patterns
How ? Prove, Improve, Reward
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Clinical Guidelines
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• Evidence based
How ? Clinical Guidelines
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• Developed/modified by MGO physicians
• Accountable, via measurement
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How ? Clinical Guidelines
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Many more to follow• Broad clinical array
– Specialty and Primary Care– Inpatient, Ambulatory and Office related
• Market and data driven
First 5 have been established• Asthma and Diabetes Management• Cancer Screening – Breast, Cervical and Colo-rectal
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• Add other Data Sources, potentials include– Physician Office 100% of your patients– Hospital, ……….
How ? Clinical Guidelines
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It’s ALL about DATA
Data Warehouse• Start with Claims Data
– Employer (OhioHealth) 20,000 patients– Payer (Aetna) 60,000+ patients
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Conclusion 6:Clinical guidelines and their supporting data are a framework around which MGO physicians can Prove, Improve, and be Fairly Reimbursed for the Quality care we deliver
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Conclusion 7:Clinical Integration provides MGO physicians the opportunity to distinguish themselves in the market based on quality and value
How ? Clinical Guidelines
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What ? Clinical Integration A Definition
and
a high degree of interdependence and cooperation among physicians, aligned to ensure quality and to control costs.
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Clinical Integration is characterized by an active and ongoing programs to evaluate and modify practice patterns
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Interdependence and Cooperation
Among Physicians
How ? Prove, Improve, Reward
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Non-clinical Metrics and Rewards
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• Develop interdependence and cooperation
How ? Non-Clinical Metrics
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• Build infrastructure - to support quality/cost initiatives
• Metrics/rewards for physicians in specialities where clinical metrics are not yet developed
• Data capture
MGO’s Clinical Integration is available to ALL MGO physicians
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Examples being considered
How ? Non-Clinical Metrics
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• High speed internet; ORB use• Secure messaging through a common web
portal, etc.• Use of E-prescribing or Disease Registries• Intra-MGO referrals
And get rewarded for meeting non-clinical metrics
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Conclusion 8:
Non-Clinical metrics can build infrastructure that supports the ongoing development and implementation of Clinical Integration
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How ? Non-Clinical Metrics
Conclusion 9:
Non-Clinical metrics allow all MGO physicians to participate in and be rewarded by our Clinical Integration program from the outset
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What ? Your Role?
Participate now by: • Remain attentive to communications • Engage in developing/utilizing MGO practice
guidelines • Reinforce the importance of and your commitment
to Clinical Integration • Refer to other MGO physicians
More steps in the future
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When ? Timeline
• Steps in Progress• Spring - Summer 2009
– Finalize initial criteria for participation– Communicate our pilot results to the market
• Summer - Fall 2009– Be prepared to deliver our new Clinically
Integrated product to the market
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Conclusion 10:
Clinical Integration is attainable for me and my practice
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When ? Timeline
Conclusion 11:
Clinical Integration is a realistic goal and has an achievable timeline for initial implementation
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Edward T. Bope, MD Chair Family Practice Dale A Michalak, MD Vice Chair Family Practice Carl A. Krantz, MD Treasurer Obstetrics/GynecologyMaurice C. Mast, MD Secretary Internal Medicine Kevin J. Anderson, MD Internal Medicine David T. Applegate, II, MD Family Practice Gregory A. Barrett, MD Pediatrics Nicholas J. Davakis, MD Cardiovascular Disease Steven B. Duff, MD Thoracic Surgery Dennis Flynn, MD Family Practice Daniel C. Hiestand, MD Anesthesiology Jeffrey T. Innes, MD General Surgery Howard B. Levin, DO Cardiovascular DiseaseLarry J. Lilly, MD General Surgery James J. Powers, MD Physical Medicine/Rehabilitation Barbara B. Rayo, MD Pediatrics Steven A. Santanello, DO General Surgery Terry S. Slayman, MD Family Medicine Michael Sprague, MD Obstetrics/Gynecology Kendall L. Stewart, MD PsychiatryCassandra Suggs, MD Family Practice
2008 MGO Board of Managers
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Thoughts ! Comments !Questions ?
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