Accountable Care ImplementationCollaborative

People Centered Foundation Workgroup

November 18, 2010

Workgroup Members

1

Name Title Participating Organization

Carl Rosenbaum, DO Family Medicine Aria Health

Terri Schieder VP Clinical Development & Integration AtlantiCare

Suzanne Hendery VP, Marketing & Communications Baystate Health, Inc.

Lu Byrd Vice President Hospital Operations/CNO Billings Clinic

Peggy Wharton Vice President Clinic Operations Billings Clinic

Johnna Reed VP Ancillary & Ambulatory Services Bon Secours

Teri Ficicchy EVP/CNO Bon Secours

Andrea Serra VP, Research & Wellness Development CaroMont Health

Terry Martinson Executive Medical Director Fairview Medical Group Fairview Health Services

Heather Taylor RN FirstHealth of the Carolinas

Bev Blaisure, M.D. GHP Regional Med Director Geisinger

James Lehman, MD VP, Quality Genesis Health System

Lisa Michaelis Administrator /CNO Heartland Health

Marcy Brown Hoag - Director Imaging Services Hoag Memorial Hospital

Jessica Lerner Exec. Director of Integrated Health Memorial Healthcare System

Keith Knepp MMG Methodist Medical Center

James Crawford, MD PhD SVP, Laboratory Services, Chairman, Laboratory & Pathology

Medicine North Shore – Long Island Jewish

Pranav Mehta, MD, MBA VP, Ambulatory Performance Improvement North Shore – Long Island Jewish

J.J. Parsons Vice President - Performance Excellence Presbyterian Healthcare System

Peter Aran Senior Vice President/Chief Medical Officer Saint Francis Health System

Carol Conley Chief Nursing Officer Southcoast Hospitals Group

Lynn Lenker, M.D. Regional VP/Chief Nursing Office SSM Health Care - St. Louis

Carolyn Holder Manager Transitional Care Summa Health System

Annette Ruby VP Health Services Manager Summa Health System

Dr. Michael Deegan Exec VP Chief Clinical and Quality Officer Texas Health Resources

Sherpri Small Strategic Revenue Services Texas Health Resources

Elliott Kellman Chief HR Officer University Hospitals

Marcia Delk Sr. VP Medical Affairs & Chief Quality Officer WellStar Health System

Agenda

2

5:00 p.m. – 5:05 p.m. Welcome and Roll CallRoll Call

Parker Marsh

5:05 p.m. – 5:10 p.m. Level Set of PrioritiesClinical Workgroup Priorities

Lynne Rothney-Kozlak

5:10 p.m. – 5:35 p.m. Member PresentationEngaging Your Patients & Community in Healthcare

Reform Efforts

Suzanne Hendery

VP Marketing &

Communications

Baystate Health

5:35 p.m. – 5:45 p.m. Joint WG Meeting with ACO Leadership, People

Centered Foundation and Payor PartnershipsDr. Peter Aran

5:45 p.m. – 5:55 p.m. Other UpdatesMedical Home Training

Patient Centered Primary Care Collaborative Discussion

Care Management Presentation

QUEST/ACO External Advisory Panel

Lynne Rothney-Kozlak

5:55 p.m. – 6:00 p.m. Care Management Sub-group Development Lynne Rothney-Kozlak

6:00 p.m. Next Steps and Closing Lynne Rothney-Kozlak

PCF Capabilities OverviewPriority 1 (CMS Application)

3

Out of 18 responses as of 10/1/10

Priority 1=CMS Application Priority

Operating Activity Scoring

Priority 1 Capabilities Operating Activity "0" "1" "2" "3" "4" Approach TimelineOther Work

Group

Dependence

A. Involve People in Decisions

that Affect their Health Care

Defined Pathway for Individuals

from the ACO Community to

Provide Input to Health System

Changes

7 4 4 1 2

Individualized Care Plans 0 6 6 0 6

B. Provide People with Easy

Access to Health Care

Direct Care Management Support

System 2 3 4 2 7

System for Providing People

24X7 Access to Services4 4 2 4 4

C. Activate Individuals to Take

Responsibility for their Own

Health

Systems that Give People Access

to Health Information

4 1 3 8 2

D. Regularly Assess and

Address Individuals' and

Population's Needs

Needs Assessment System5 3 6 0 4

Care Disparities Program1 2 3 7 5

PCF Capabilities OverviewPriority 2 (CMS Contract 01/2012)

4

Out of 18 responses as of 10/1/10

Priority 2=CMS Contracting Priority

Operating Activity Scoring

Priority 2 Capabilities Operating Activity "0" "1" "2" "3" "4" Approach TimelineOther Work

Group

Dependence

B. Provide People with Easy

Access to Health Care

Open Access Scheduling

System8 5 2 2 0

C. Activate Individuals to Take

Responsibility for their Own

Health

Patient Remote Monitoring

System5 7 2 2 2

D. Regularly Assess and

Address Individuals' and

Population's Needs

Population is Segmented by

Health Care Needs4 4 4 3 3

E. Measure and Improve the

Experience of People within

the ACO Population

Patient Experience Monitoring

System0 1 3 6 8

ACO Clinical Workgroups – Priority Items

Priority ItemHigh Value Network

Health Home

People Centered Foundation Others Lead WG

Defined Pathway for Individuals from the ACO

Community to Provide Input to Health System Changes a PCF

Open Access Scheduling System a a HH

Needs Assessment System a a a - PHDM PCF

Patient Experience Monitoring System a a- Measures and PHDM PCF

Patient Experience Improvement System a PCF

Team Based Care System a a HH

Care Management / Predictive Modeling

(encompasses several operating activities) a a a a - PHDM HH

Individualized Care Plans a a a PCF

Patient Remote Monitoring System a a a a - PHDM PCF

Health Home Transitions of Care Program a a a HH

Evidence - Based Design of Care Models a a a HVN

Physician Evaluation & Selection System a a a a- ACOL and PHDM HVN

Health Home Training Program

(encompasses several operating activities) a a a HH

5

Presentation to Premier ACO Collaborative, People-Centered Foundation WorkgroupNovember 18, 2010

Suzanne Hendery, Vice President, Marketing & CommunicationsBaystate Health, Springfield, MA suzanne.hendery@baystatehealth.orgBaystatehealth.org

Engaging Your Patients & Community

in Healthcare Reform Efforts

The importance of Asking, Listening and Delivering a consistently excellent experience

Today’s Objective

Update members of the People-Centered Workgroup on:

Importance of engaging patients

Changing expectations

Listening posts

The Listen, Learn & Loyalty model

Some of the ways we engage:

Patient & Family Advisory Councils

Employee Advisory Council

Loyalty Clubs: Seniors, Women, MDs

Mini-Medical School

Patient Experience design

Message testing

Measurement, results and benchmarks

Considerations for the future

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● “One of the great ironies in medicine is that

the system often excludes the very person for

whom it exists. It treats patients but doesn‟t

empower them. It talks more than it listens.”

● IOM: Quality care is Safe, Timely, Effective,

Efficient, Equitable and Patient-centered.

(STEEEP)

• continuous healing relationships

• customized to a patient‟s needs and values

• the patient is the source of control

• knowledge is shared, information flows freely

• transparency is necessary

• patient‟s needs are anticipated.

Engaged Patients Achieve the Best Outcomes: 2001, 2004

Patient‟s opinion is the best measure

of the quality of care they receive

8

We ask ourselves…

What business would design its products and systems without asking its customers what is

important to them?Patients need to be told they are in an ACO!

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Engaged Patients Have Better Outcomesand become your raving fans!

“Patients are more likely to make good decisions and do positive things on behalf of their health if they are more engaged, better informed and feel confident that they can take care of themselves well.”

“Conversely, the uninformed,

unassertive, unengaged patient

who lacks confidence in his

ability to influence his health is

less likely to fare well with his

illness.”

Institute for Patient & Family Centered Care

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Why Patient Perceptions are Important

• High patient-satisfaction scores = improved organizational performance, improved quality, brand reputation and improved financial performance.

• A strategic tool in a competitive market and negotiations with managed care organizations, payers. A marketing and recruitment toolfor those with high scores; a challenge for those without.

• A patient relationship tool. Patients who are satisfied:

• Comply and follow treatment protocols more completely. Get well faster. Are less likely to need follow up visits.

• Litigate less.

• Even if the medical outcome is not positive, tend to view the healthcare provided as a quality experience.

• A new government, insurance mandate for reimbursement.

“Baystate Health’s vision is to be one of the leading healthcare systems in the nation.”

An excellent healthcare organization produces an excellent healthcare experience.

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The New Healthcare Consumer

• Want to understand their medical care and make decisions regarding their care

• Question credentials, staffing, processes, testing, medications

• Better informed, tech savvy; immediate feedback through social media.

• Due to media attention on healthcare quality, safety and errors, patients and families are less trusting and have higher expectations.

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Satisfying & Engaging Patients: Now a Quality Imperative

• Patients are now active consumers-review “report cards” to make choices; comment on social media

• Hospital and Doctor “grades” are widely posted on the Internet and in media

• Patients participate in national CAPHS surveys tied to reimbursement rates; and local surveys and focus groups

• Consumers expect more than just “satisfaction.” Patients are increasingly more demanding of the experience they expect and more difficult to attract and retain.

So many choices!

All things equal, individuals make choices based on their past experience and level of satisfaction.

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The Ways We Ask & Listen

Listening & Learning Tools/Posts (Frequency)

Customer: Current BH Patients/Members & Families

Satisfaction & loyalty surveys (Continuous) Focus group, feedback sessions (PRN)

In-person, e-mail, mail, meetings, letters, interviews (Continuous) QI teams (Continuous)

Customer call center & sales reps: Bi-lingual reps (Continuous) Customer advisory boards (PRN)

Primary/secondary market research, focus groups (Annually/PRN) Greeter concierges & escorts (Continuous)

Complaint system, Complaint Log & informal feedback (Continuous) Leader, MD, RN, chaplain, volunteer rounds (Continuous)

Selected patient follow-up calls (Continuous) Internet-web response system (Continuous)

”Administrator On-Call” & log (Continuous) Patient Relations office-in-person, phone, email (Continuous)

Customers: MDs & Entire Provider Network, Insurance Brokers

Case management model (Continuous) Managed care university (Continuous)

Satisfaction surveys (Continuous) Remote-access internet portals (Continuous)

In-person, calls, letters, e-mail, meetings, interviews (Continuous) Customer call center (Continuous)

New product/service surveys, feedback sessions (PRN) “What’s on Your Mind” feedback sessions (Continuous)

Mystery shopping, competitor intelligence (Continuous) Sales representatives/visits /direct marketing (Continuous)

Primary/secondary market research, focus groups (PRN) Committees and task forces (Continuous)

Community, Potential Patients and Future Markets

Consumer study, interviews w/ community leaders (Annually/PRN) Baystate Best note cards (Continuous)

Primary/secondary market research, focus groups (PRN) Complaint system & informal feedback (Continuous)

Mystery shopping, competitor intelligence (Continuous) Internet-web response system (Continuous)

Volunteers and vendors (Continuous) Health magazines/annual reports, newsletters(Continuous)

Customer call center: MD referral service (Continuous) Fairs, speakers, screenings , open houses (Continuous)

Loyalty programs (Continuous) Organization involvement/sponsorships (Continuous)

Formal participation in business, community, civic groups/boards (Continuous) Research publications, professional associations, courses, journals, and e-mail newsletters, subscriptions, news abstracts, consultant visits, In-service ed (Continuous)

15

The Baystate Health Listen, Learn & Loyalty Model

#3 ESCALATE#4 ACT#5 EVALUATE

#6 HARDWIRE #1 GATHER #2 FILTER

The L3 ModelUses customer focused data to make

decisions and provide continuous

feedback. The voice of the customer

is the single most important piece of

market intelligence.

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Some of the Ways We Engage

1. Patient & Family Advisory Councils

2. Loyalty Clubs: Seniors, Women, Parents, MDs

3. Mini-Medical School

4. Patient Experience design

5. Message testing

17

Patient & Family Advisory Councils

Proactively offers advice, information and recommendations on planning, policies, and procedures.

This group provides leadership with an enhanced understanding of how to improve quality, program development, service excellence, communications, patient safety, facility design, patient and family education, staff orientation and education and patient/family satisfaction and loyalty.

Mass DPH Amendment to 105CMR 130.000 Hospital Licensure, 3/30/2009

18

Patient & Family Advisory Council Goals & Roles

Goal• Strengthen decision-making “live focus group”• Offer insights, recommendations for improvement• Enhance relationships; direct link to community• Reflect unique culture of hospital, patient base, community• Spurs quality improvement in the area of patient and family-centered care.

RoleThe role of the PFAC is solely consultative. Members serve as “the voice of the customer—Baystate Health’s

patients and families.” Members may:• Present how patients and families might feel and think about issues concerning quality, program

development, service excellence, communications, patient safety, facility design, patient and family education, staff orientation and education and patient/family satisfaction and loyalty;

• Assist in developing a better understanding of patient and family needs and expectations; • Recommend refinements to BH operations, policies and/or procedures; • Reviews selected communication materials to help rewrite them from the patient and family perspective

making them more understandable and user friendly; • Review patient satisfaction survey results and makes recommendations for addressing concerns identified; • Identify structural and cultural barriers to patients obtaining health care services and recommends strategies

to overcome these; • Act as a sounding board for new (existing) services, policies, health related programs, communications, and

business strategies; and• Identify issues and opportunities for BH consideration; • Consider matters referred to them by the Hospital Quality Council.

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Organizational Structure

The PFAC serves in an advice-giving capacity and reports to the Hospital Quality Council/Patient Care Improvement Council* at each BH hospital.

Twice annually, the PFAC coordinator will attend the BH Board Performance Improvement Council to provide an update on issues addressed and any outstanding issues needing resolution. An annual report is written documenting ideas suggested, implemented and results.

Each hospital has a Hospital Quality Council/Patient Care Improvement Committee which meets monthly. The group is comprised of operational vice presidents/directors, physician leaders and senior leadership. Members receive:

•Updates and recommendations from the PFAC (at least quarterly);•Meeting minutes of the PFAC.•Members will provide:•Written and/or oral reports of PFAC recommendations undertaken, findings, recommendation(s), and results of actions taken. PFAC recommendations may be transmitted to pertinent committees and/or individuals as

appropriate.

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Loyalty Clubs; Women, Seniors

Senior Class began: 1990

Members: 23k, 55+ men and women, region-wide, hospital based

Staff: 1 FTE & volunteers

Spirit of Women began: 2000

Members: 15k, women of all ages, region-wide, hospital based.

Goal: Inform, engage and enroll important market segment with programs, services, staff, and

provide social opportunities.

Costs: $5-$7 per member, total budget for each program: approx. $120,000 includes staff.

Programs are “self supporting” with sponsorships.

Benefits to members: newsletter (print and email) with programs with MDs, RNs at each

location, social events, relationship with 1 person who cares, a community, discounts.

Major benefit to Medicaid Managed Care program, Marketing, Development, Legislative

Affairs, Volunteers, Community Relations

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The Emeritus Club; Retired MDs

“The Emeritus Club is a wonderful idea.

I wonder why no one thought of it before.

I miss the place, I miss my patients, my friends and colleagues.

Eckart Sachsse, MD; Former chairman of Radiology, Baystate Medical Center

Began: 2001

Members: 90 MDs; spouses; 5-10 new per year

Goal: Inform and engage retired medical staff about activities, programs and staff while

retaining some medical staff privileges.

Costs: Under $10,000 yr; Medical Staff Office

Benefits:

•Invitations w/ guest to luncheon meetings (4x) from the CMO; and hospital events.

•Emeritus Club Gold ID badge (Café discounts). “We remember who you are.”

•Continuing Education offerings; discounted fees; one class at no charge.

•Library privileges w/ Internet access and email accounts.

•Senior Class,

•Baystate Employee Discount Program with discounted rates at retail merchants.

Spin offs: Resident & Family Association; MD “Thank You” Program

22

Other Ways We Engage

1. Mini-Medical School, Teen Mini Medical School

2. Patient Experience design for programs, service lines,

facilities

3. Message testing

23

What Patients Want

Lane & Lindquist

In the hospital

Personal, compassionate treatment

Availability of nurse when needed

Friendly and courteous staff (medical/admin)

Willingness to listen

Understandable explanations of treatment

Availability of latest technology/equipment

Availability of specialists, regional/national reputation

Comfort, cleanliness and appearance of room

Outpatient; Doctor’s Office

• Access to care; wait times

• Personal, compassionate treatment

• Location of facility to office

• Convenient, well lit, safe parking

• Services on weekends/evenings

• Reputation and recommendations24

Overall PRC Results

• Overall, BH compares favorably to our benchmark target, the PRC top quartile (75%) for patients responding “Excellent” nationally. Outpatient scores higher than inpatient.

• The 75th percentile increases yearly, as organizations improve service. There has been a gain for 3-5 points each year, over the last 5 years, except for this year.

2009 was our highest scoring year. 2010 saw a 15% drop in scores. Units now showing some increases.

25

Results reported quarterly

via electronic dashboard

Communication

The key is to collect the data and know what to do with it to obtain meaningful and lasting results.

Results reported BH-wide

Quarterly; against targets, over time

Specific results for units, showing

Key Drivers

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ACO Considerations

Levels of satisfaction across the ACO continuum assume critical importance.

How can we follow patient rather than the unit? How do we measure their

experience over time instead of per episode.

How do we maintain our brand and ensure that across the continuum everyone

understands customer service standards, behaviors, and organizational focus on

the patient.

How can we survey patients via the patient portal? and maintain response rates,

„mediocre middle?”

Do we need a separate measurement for the family/friend?

Can we make every staff member aware and accountable, via their performance

review, for the team‟s quality and service measures?

Can we account via LEAN financial reporting, the amount of $$ lost to poor

quality and service? Value Based Purchasing as flaming platform for change.

29

Joint Payor Partnership, Patient Centered Foundation & ACO Leadership Workgroup Call Update

Value Based Benefit Design- presented by

UnitedHealthcare

November 11, 2010

Joint PP/PCF/ACOL Workgroup Call Update

UnitedHealthcare (UHC) presented on the topic of Value Based Benefit

Design at the request of CaroMont Health

There was excellent dialogue between members and with UHC presenter

All slides and a recording from the November 11th joint Payor Partnership,

People Centered Foundation & ACO Leadership call will be available on the

PIP portal

The purpose of the update is to provide the workgroup with a brief

overview of the call and to encourage review of the materials on the PIP

portal

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Joint PP/PCF/ACOL Workgroup Call Update

David Sturkey provided an overview of UHC‟s approach to Value Based Benefit

Design using an example of their „Diabetes Health Plan‟

UHC‟s Diabetes Health Plan Overview:•Based on 2 Triple Aim objectives (reduce costs, improve quality)

•Targets pre-diabetic population, as well as diagnosed diabetics

•Utilizes predictive modeling and use of Health Risk Assessments (HRA)

•Supports biometric screenings

•Augments medical management- doesn‟t replace it

•Created „Top Tier‟ or „Premium Plan‟ for patients who choose to participate

•Participation requires patient compliance (to receive rewards)

•Rewards include reduced pt. OOP expenses/co-pays, family included in plan, better pt.

outcomes

•Compliance requires completing a HRA, participating in the „Diabetes Management

Program‟, biometric screening and cancer screening, etc.

•Patient‟s have access to electronic personalized care plan tracker, tracker can be viewed

by family member if designation provided or tracker can be sent to patient

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Joint PP/PCF/ACOL Workgroup Call Update (cont.)

UHC‟s Challenges and Recommendations:

•Lab turnaround is lengthy, ~ 3 weeks, and creates challenge for the patient‟s

care plan tracker information

•Demonstrating a return on investment in year 1 or 2 can be difficult- employer

must be committed for long term outcomes

•Communication is critical to ensure appropriate participation regarding service

offering and should occur pre-enrollment process

•UHC accomplishes this by using a multi media approach and bases on the

employers unique setting and infrastructure, i.e., some require on-site meetings

at various locations

•When asked how UHC would advise a provider in moving forward with a payor,

UHC responded to ensure that the vendor not only has the critical data

elements, but more importantly the informatics to analyze the data accurately

•If an employer has a low employee retention rate, employer will not likely see

long term benefits of value based benefit plan, including ROI

33

34

• Drive consumer behavior by incorporating

self-management into a benefit design

• Improve health outcomes and cost with

compliance requirements

• Provide meaningful ROI

Personalized Health Plans can offer an

important VBID opportunity that may help:

• Targeted financial incentives

• Clinical sophistication into benefit design

• Technology support

Value Based Plan Plans are designed

to influence consumer behavior

Current "VBID-lite" approaches including communication

strategies and

indiscriminant co-pay reductions hold limited clinical or

economic value

Value-Based Design ContinuumValue-Based Plan Design“VBID – lite” approaches

Personalized Health Plan:

- Significant benefit design

enhancements linked to targeted

evidence-based behaviors

Communication efforts:

- Target mailings to promote

services

Unilateral Service Reduction

- Isolated specific service

co-pay Reduction

(i.e., anti-hypertensives)

Marketplace Demand: Influence consumer behavior to help improve health and reduce costs

35

Current Diabetic Health Plan

In-network Out-of-networkIn-network Out-of-network

Premium Other

Basic Provisions

Deductible $500/$1500 $1000/$3000 $500/$1500 $500/$1500 $1000/$3000

Coinsurance 90% 70% 90% 90% 70%

Out-of-Pocket $2500/$7500 $3000/$9000 $2500/$7500 $2500/$7500 $3000/$9000

Office Visit Co-pays$25 PCP/$50

Specialist

70% after

deductible

Waive co-pay on

first evaluation

visit

$25 PCP/$50

Specialist

70% after

deductible

Rx Co-pays--RetailRetail $5 / 30%(Min:$30, Max:$50) /

30%(Min:$50, Max $75)

No co-pay for specific Rx, meters, supplies related to

diabetic condition; other wise, Retail $5 / 30%(Min:$30,

Max:$50) / 30%(Min:$50, Max:$75)

Rx Co-pays--Mail OrderMail Order $10 / 30%(Min:$75,

Max:$125) / 30%(Min:$125, Max:$180)

No co-pay for specific Rx, meters, supplies related to

diabetic condition; other wise, Mail Order $10 /

30%(Min:$75, Max:$125) / 30%(Min:$125, Max:$180)

Medical Management Features

- Health Risk Assessment N/A N/A Required

- Diabetes DM/Weight Mgmt (if offered) N/A N/A Required

- Online Tracking and Compliance N/A N/A Required

Screening

- Diabetes (biometric screening) OptionalRequired

- Cancer Optional

Diabetes Health Plan: The Difference Illustrated

Collaborative Updates

• Medical Home Training– Link to survey of preference for timing, location and content of Geisinger training

• Patient Centered Primary Care Collaborative (PCPCC) Discussion – Follow this link for rich information with built in web-links

– Premier is a member and Kathy Bradshaw will represent us on future meetings

• Care Management Presentation by Dr. Allan Goldstein – Choice: receive link to taped presentation to HH WG or have him present a future meeting

• Care Management Sub-group development– Proposal: joint sub-group of PCF, HH, HVN, chaired by Dr. Goldstein and a member (see next slide

for composition recommendation)

• QUEST/ACO External Advisory Panel Meeting– See upcoming slide on key takeaways from the discussion on ACO measures

36

QUEST/ACO External Advisory Panel Meeting

• The first ACO/QUEST External Advisory Panel (EAP) meeting occurred on

October 28. Wes Champion and Dr. Bankowitz provided an overview of the

ACO Collaboratives and the Phase I measures.

• Dr. Bankowitz led the EAP through a working session around Phase 2

measures to look at understanding the gaps in the Phase I measures, and

how to address these gaps in the next phase of measurement

development.

• Feedback on the ACO Collaboratives was positive. Comments include:

– The EAP encouraged the collaboratives to more fully integrate the

community and people the ACOs will serve into the Phase II

Measurement strategy.

– The Collaboratives need to be able to demonstrate value to the

consumer of the ACO.

– The Collaboratives should consider articulating more clearly the

learning that is taking place in the Collaborative by the membership.

37

Proposed Joint Care Management Sub-group (HH, HVN, & PCF)

– Premier Lead – Dr. Allan Goldstein

– Composition –

• This group can be comprised of other delegates from your

organizations

• Multi-disciplinary representation

– MDs

– EHR/informatics

– Administration / Operations staff

– Health educators

– Nutritionists

– Mental health providers

– Volunteers

• Workgroup members

• Co-Leader

38

Next Steps

• Two Liaison Volunteers Needed: One liaison to attend the Health Home workgroup

call and one liaison to attend the High Value Network workgroup calls

– Liaisons would attend the other workgroups monthly calls

– Provide a monthly report out to the People Centered Foundation workgroup

• Next People Centered Foundation Workgroup Meeting

– Thursday, December 16th 5:00 – 6:00p.m. EST (Dr. Aran to lead)

39

Closing Discussion