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January 2011

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The Bridge to Accountable Care Organizations

TAL MA AZIN DIEGNIERAL EXCG E ELL G

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ACO

Case Study | Monarch HealthCare This is CASE STUDY 2 of 4 from HealthLeaders Media Breakthroughs: The Bridge to Accountable Care Organizations

In collaboration with

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B Y j o e cantl u pe

Case Study | Monarch HealthCare

Piloting the ACO in SoCal B

art Asner, MD, CEO of Monarch HealthCare, says that

how ACOs affect payment reform, with the hope that a model can

they believed was the inequity for its physicians’ PPO

be duplicated across the nation, building on health reform legisla-

“We have been taking care of HMO patients for 20 years, and

health system snapshot

really have been struggling with the fact that in our physician offic-

tion that calls for making ACOs a voluntary option in the Medicare program in 2012. Even before joining a formal pilot program, Monarch already

es, half of the patients they see are PPO and traditional Medicare

was exploring the ACO model. “It was a natural extension of our

patients, not HMO patients, and those patients have not gotten the

philosophy in which we feel accountable and responsible for the

true value of what a coordinated care delivery system can offer,”

health of our community and we were only able to do it with half

Asner says.

the patients,” Asner says. “The PPO side is not measured, and we all

“We were thinking, ‘How can we bring that value to the PPO and traditional Medicare patient population,’” Asner says. In effect, moving toward an ACO was simple math for Monarch:

©2011 HealthLeaders Media, a division of HCPro, Inc.

The Brookings-Dartmouth team will evaluate the pilots to see

for months, corporate leaders struggled over what

population compared to its HMO population.

share

ACO

understand the fragmented nature of care for PPO patients.” Each ACO site defines the patient population it serves and establishes a spending target that reflects the predicted costs for

It could increase its customer population beyond its 170,000 cus-

its patients. The ACO is designed to improve efficiency and effec-

tomers in Southern California, as well as upgrade care, Asner says.

tiveness and slow spending growth. Each ACO provider that HealthLeaders Media Breakthroughs: The Bridge to Accountable Care Organizations in collaboration with

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demonstrates it can meet these goals will receive a portion of the savings earned. Monarch is implementing the ACO model with a strategy to incorporate most of its physician base into the plan as well as show the value possibilities for patients in its current PPO plan. Under the plan, Monarch expects to review potentially 30,000 to 50,000 patients, and it is estimated from 5% to 17% of them could potentially benefit from care coordination under the ACO, according to Ray Chicoine, COO of Monarch. “We’re still working through the initial communication from Anthem to these patients.” “Within every model, you then have to make business decisions on what you want to include,” Chicoine adds. “It’s everything from geography to family members to newborns. All these things we really hadn’t thought about prior to doing something like this (ACO).” Asner says Monarch asked Anthem Blue Cross to join in the

“ “It’s been an enormous amount of work to figure out who the patients are, get information and data on these patients, and figure out ways that will make the information flow smoothly through the system going forward.” Bart Asner, MD, CEO, Monarch HealthCare

“I think, to be honest, we have trepidation about how this is going to work overall. It’s new territory and nobody’s ever done it before, so we’re creating a new organization, a new concept, a new

project, not only for evaluating the potential ACO as it moves

way of caring for a population of patients who really have been in

forward, but identifying physicians and patients for the project.

a fragmented care system, and that alone creates trepidation. That

“We’re working with Anthem Blue Cross in a very collaborative way to identify the subset of PPO patients that have Anthem Blue

being said, I will tell you that our physician leadership and administrative leadership are energized and excited about the opportunity.”

Cross insurance that will become part of a Monarch ACO,” says

Anthem Blue Cross was encouraged by the ACO model, says

Asner. “And it’s been an enormous amount of work to figure out

Mike Ramseier, vice president of provider engagement for Anthem

who the patients are, get information and data on these patients,

Blue Cross. “I would call it an equal shared commitment and part-

and figure out ways that will make the information flow smoothly

nership,” Ramseier says. “We all agree we needed to change the

through the system going forward.”

delivery model. We can’t continue to have conflicting goals.”

“We really have to prove the value, and we’re up for that challenge,” he says. But there are concerns, he says.

Monarch and its partners established committees to examine the necessary steps to move the ACO forward. At least eight

editor’s note share ©2011 HealthLeaders Media, a division of HCPro, Inc.

HealthLeaders Media Breakthroughs: The Bridge to Accountable Care Organizations in collaboration with

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teams have been created, including data management, clinical out-

Monarch HealthCare’s ACO blueprint

comes management, communications, and medical management,

Monarch HealthCare has joined Healthcare Partners Affiliates Medical Group and Anthem Blue Cross in establishing seven subcommittees to evaluate potential ACO structures for their programs. A steering committee is the lead organization that provides oversight to the other committees.

Ramseier says. Among the myriad areas they will address include breast cancer,

Bart Asner, MD, CEO, Monarch HealthCare

colorectal cancer, vascular disease and pneumonia. Overall patient

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patients, imaging and emergency department usage, he says. The

safety issues will be examined, as well as prescription use among plan is to carry out overall cost-effectiveness in each area, as well as attain sufficient quality, he says. “We are jointly working out a whole new medical management

Systems/ Operations

Contracting Attribution Model

design so we can give data to the group so their doctors can be electronically connected into our system and they can know where a member is almost at all times,” Ramseier says. Physicians are a particular focus, and certainly the ACO model is a transition for them, says Nancy Boerner, MD, chief medical

Performance Metrics

officer at Monarch. “The concept seemed to fit what we have done

ACO

steering committee —————————

subcommittees

monarch healthcare

with managed care with seniors and underserved populations in Medicare,” says Boerner. “What we are trying to do is engage our physicians to understand how to apply some of the best managed care principles.” Inevitably, physicians will make the ACO work, she says. “Patients look to their physicians—not the hospital, not

Medical Management

Marketing/ Communication

the ACO. It comes down to the physician interaction they know and trust.”

Product Development

Still, the plan is not without challenges, the first being to identify potential member patients, unlike an HMO in which a member selects a group.

share ©2011 HealthLeaders Media, a division of HCPro, Inc.

Source: Monarch HealthCare.

Roll over the chart to view responsibilities of each subcommittee.


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“It’s really a matter of educating the patient and consumers, and getting them to buy into this,” Asner says. “You start by telling them that they’re in an ACO, what an ACO is, and it’s going to come down to their doctors talking to them about this as something valuable. Ray Chicoine, COO , Monarch HealthCare Having trouble listening? Click here.

“It’s going to be at the critical level of the doctor-patient interaction in my mind, and we’re working with our doctors so that they can be part of how we create this ACO and how it will work,” Asner says. As Monarch moves forward in developing an ACO, one of the most complicated areas involves the IT structure, says Chicoine. “That’s probably the biggest, most complicated aspect, because it involves report requirements, exchange of data, just a lot of complexity.” Monarch has funded electronic medical records in the physician community to improve connectivity among the payers and provid-

—————————————-

“The data is critically important,” Asner says. “Everyone’s going to have to be far more transparent than they have ever been before about how they’re doing, so patients understand the value that they’re getting for the dollars being spent.” California is seen as a key incubator for ACOs. “The health care system in California is populated by physician organizations that fit the evolving definition of an ACO, and hence provides a robust laboratory for studying ACO performance,” noted the Integrated Health Association, a California leadership group that promotes quality improvement in healthcare, stated in a white paper study. Asner agrees that California’s system gives members of the pilot a head start in what they are trying to accomplish under the ACO model. While details of a financial structure are still being worked out, Asner says, “initially, it’s going to be a fee-for-service plan with some opportunities to share

share ©2011 HealthLeaders Media, a division of HCPro, Inc.

Monarch HealthCare in Irving, CA, is embarking on a journey toward becoming an ACO to broaden its population base and upgrade patient care. Monarch includes 2,600 independent physicians, 20 hospitals and more than 20 urgent care centers. Monarch is involved in a five-year pilot with two other participants, Healthcare Partners Affiliates Medical Group in Torrance, CA, which has more than 1,200 employed and contracted specialists and Anthem Blue Cross, the largest health insurer in California. The pilot program is spearheaded by the Engelberg Center for Health Care Reform at the Brookings Institute and the Dartmouth Institute for Health Policy and Clinical Practice.

165,000 patients

ers, says Boerner.

and save.”

The Bigger Picture

25,000 Medi-Cal (California Medicaid patients)

—————————————-

Under the ACO, an additional 30,000 to 40,000 patients in a PPO population will be included in Monarch’s coordinated care model the goal | Once Monarch begins its ACO with Anthem Blue Cross, an introductory letter will be sent to patients explaining the advantages of being part of the ACO. This communication will be endorsed by the patient’s personal physician and likely will be sent within the first quarter of 2011. Under the ACO, Anthem will match patients with familiar Monarch doctors.


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“But our firm belief is that, Roll over the chart to dig deeper into the findings.

ACO draft scorecard

rapidly as we can, we’re going to move to a prepayment model so that the dollars are paid upfront, that all the stakeholders have aligned financial incentives, and we have the dollars to continue to invest in the programs that bring value in the care of the patients.”

Nancy Boerner, MD, chief medical officer, Monarch HealthCare

the ACO offers a key benefit,

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particularly because of physi-

Physician Quality 70%

For an entity like Monarch,

cian involvement, Asner says. Under the ACO, Monarch will continue to help physicians not only thrive in private practice, but maintain their independence, he says.

Hospital Quality 30%

Preventive Measures

IHA - Breast Cancer Screening IHA - Colorectal Cancer Screeing IHA - Childhood Immunization Status (MMR + VZV) IHA - Chlamydia Screening in Women

Diabetes

IHA - HbA1C Screening IHA - LDL Screening IHA - Nephropathy Monitoring

Cardiology

IHA - Cholesterol Management LDL Screening (Pts with/Cardiovascular Conditions)

Imaging

IHA - Use of Imaging Studies for Low Back Pain

Pediatrics

IHA - Appropriate Testing for Children with Pharyngitis IHA - Appropriate Treatment for Children with Upper Respiratory Infection

Pulmonary

IHA - Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis

Medication Management

IHA - Medication Monitoring (ACE/ARBs, digoxin, diuretics)

JC/CMS NHQM

AMI Set / CHF Set / Pneumonia Set / SCIP Set

ACC Metrics

PCI Mortality Vascular Access injury Lipid lowering agents at discharge DTB for STEMI at 90 minutes Positive testing prior to PCI

STS Metrics Deep Sternal Wound Infection Prolonged Ventilation Operative Mortality for CABG Surgical Re-exploration Pre-operative Beta Blockade NHSN

Central line infections / VAP / Catheter UTI

Patient Satisfaction

CAHPS or local market survey

Total Score share ©2011 HealthLeaders Media, a division of HCPro, Inc.

Source: Monarch HealthCare.


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