1. Northern Colorado IPA: Laying the Groundwork for aPhysician-Driven Clinically Integrated Accountable Care Organization May 12, 2011 1 May 12, 2011

3. NCIPA’S Current Situation

4. IPA Profile

5. SWOT

6. PVHS Offer to NCIPA re UMA

7. Scenarios of Future Vision, Roles and Functions

8. Group Discussion May 12, 2011 2

9. Market Trends, PPACA and Health Reform PPACA is mostly about health insurance reform; it significantly impacts health care delivery reform For doctors and hospitals, the clearest aspects of PPACA spell out payment reduction schedules Health Reform’s government payment schedules are not keeping pace with inflation Providers must retain current commercial insurance base to ensure economic sustainability Kaiser May 12, 2011 3

11. Goal: Increase the scope of insurance coverage and access to a greater number of Americans and reduce costMay 12, 2011 4

13. Start with Value & Triple Aim VALUE = Quality/Cost … as compared to peers TRIPLE AIM = Improved Outcomes, Lower Costs & Higher Patient Satisfaction May 12, 2011 6

14. & add Payment System Change May 12, 2011 7

15. Payment Reform = New Ways to Deliver Care If PPACA covers more lives, and payment reform is in place, what mechanisms do we have to ensure quality care? PPACA contemplates an Accountable Care Organization

17. Premier ACO Model May 12, 2011 10

19. Medicare population

20. Draft Rules & Regs have not had positive reception

21. Small “a” accountable care organization (aco)

22. PVHS Employee & other ERISA Health Plans

23. Defined population

24. Self-funded

25. ERISA allows flexible plan design and reimbursement

26. Care coordination principles applyMay 12, 2011 11

27. Cornerstones of an “aco” May 12, 2011 12

29. Significant contributions of financial and “sweat” capital by participating physicians

30. Development and adoption of clinical protocols

31. A performance-monitoring process

32. Care review based on the implementation of protocols

33. Mechanism to ensure adherence to the protocols

34. Use of common information technology to ensure an exchange of all relevant patient data

35. Aligned financial incentivesMay 12, 2011 13

36. Definition of Care Coordination “Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.” May 12, 2011 14 Source: AHRQ

38. Screening and Prevention

39. Acute intervention and Referrals

40. Diagnosis and treatment

41. Chronic Disease management

42. Palliation and EOL Care15

44. Provide the right information, at the right time, in the right form

45. Appropriate infrastructure to assure security, maintenance, and use

46. Permit practitioners to make decisions based on current, comprehensive information and patient history

47. Ability to pay providers; redistribution of funds or claims processingMay 12, 2011 16

49. Make established clinical guidelines available for all providers

50. Compliance reporting showing variations in care at the provider and network level

51. Track physician performance against benchmarks and peers

52. Clinical decision support based on network determined guidelines including point of care alerts

53. Secure mechanism for provider communication

54. Facilitate PCP and specialty coordination

55. Support care transitionsMay 12, 2011 17

57. Must have complete physician data as well as hospital information

58. Typical payor data sets won’t be enough – incomplete and far too old to help manage care and COST of careMay 12, 2011 18

59. NCIPA Profile Physician owned and operated Colorado corporation Consists of 667 providers 168 Primary Care Physicians 328 Specialist Physicians 171 Other Contracted Providers Holds multiple contracts Health Plan Direct ERISA May 12, 2011 19

60. NCIPA Membership February 28, 2011 20

61. Membership Breakdown

62. 22 February 28, 2011 NCIPA Primary Care Profile

63. 23May 12, 2011 NCIPA Specialist Profile

64. Current Situation May 12, 2011 24 Services: - Provider Network - Claims Adjudication and Payment Customers: - PVHS - Poudre School District - Columbine (400 lives) 50 % ownership 50 % ownership

65. PVHS Proposal “We (PVHS) would purchase NCIPA’s fifty-percent (50%) interest (in UMA), becoming the sole owners of UMA.” May 12, 2011 25

66. How Can We Help PVHS Do This? May 12, 2011 26 By collaborating with PVHS to become the physician driven vehicle through which UMA can quickly develop a Clinically Integrated accountable care organization

67. Infrastructure May 12, 2011 27

68. Administrative Driven Infrastructure Components Third Party Administration Financial Management Healthcare Operations Management Utilization Management Quality Assurance CVO Case Management Business Operations Management IT Systems and Analysis Payor Contracting & Contract Management Legal May 12, 2011 28

69. Physician Driven Infrastructure Components &/or Committees Clinical Integration Care Coordination Health Information Technology & IT Management Credentialing Network Development Contracting and Finance May 12, 2011 29

70. Role & Functions to Consider To be the physician driven vehicle through which UMA can: Provide clinically integrated services Perform Utilization Management Develop, approve and implement EBM practice guidelines for all specialties (HealthTeam Works) Monitor physician compliance to practice guidelines and report compliance to participating providers (Verisk Health – Sightlines Medical Intelligence) Counsel non-compliant providers and discipline them if non-compliance continues Implement and assist Systems of Care supporting patient centered medical homes and medical neighborhoods (CO Medical Society initiative) May 12, 2011 30

71. Role & Functions to Consider (continued) To be the physician driven vehicle through which UMA can: Prove that value to those who are paying for healthcare is critical to receiving fair reimbursement for services rendered in that receiving fair reimbursement is essential to achieving the professional satisfaction of NCIPA providers Ensure only high quality providers satisfying established criteria participate in the network (Credentialing) Promote clinical HIE interconnectivity in collaboration with CORHIO Establish compensation options such as P4P, bundled payments and shared savings arrangements (starting with PVHS as the Beta site) May 12, 2011 31

72. PHO vs ACO May 12, 2011 32

73. Examples of “aco” Models Physician-only “aco” (Summit) For Profit Corporation (HWHN modified) Hospital Division or Single-Member LLC (LHP) LLC Model (UMA?) May 12, 2011 33

74. May 12, 2011 34 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

75. May 12, 2011 35 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

76. May 12, 2011 36 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

77. May 12, 2011 37 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

78. May 12, 2011 38 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

79. May 12, 2011 39 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

80. May 12, 2011 40 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

81. May 12, 2011 41 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

82. May 12, 2011 42 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

83. May 12, 2011 43 Source: Ropes & Gray 11/16/10 “ACO Strategy and Organizational Structure” webinar

85. Convene a team

86. Inventory existing projects and initiatives that align with strategic goals

87. Identify strengths and gaps

88. Critically examine:

89. Structure

90. Governance

91. Financial alignment

92. Systems integration

93. Clinical integrationMay 12, 2011 44

95. Mitigation of unnecessary 30 day readmits

96. Expedient provision of meaningful clinical information to PCP upon patient admission or discharge

97. Identify ACE and Bundled Payment opportunities

98. Facilitate medical management of the ERISA health plans

99. Identify and manage the most costly disease categories

100. Manage the most costly ETG’s

101. Manage to appropriate site of serviceMay 12, 2011 45

103. Create a Clinically Integrated Network

104. Success factors

105. High quality and appropriate utilization

106. Performance demonstrated through quality metrics

107. Care coordination and collaboration among hospitals, physicians, other providers

108. Data collection and data sharing

109. Implement – Just do it!May 12, 2011 46

110. May 12, 2011 47 DISCUSSION A Walter Hankwitz, MBA, FACHE, CMPE Highlands Health Management, Inc. awhankwitz@highlandshealth.com B: 423/863-1363 C: 423/534-0212