Cornerstone’s Journey from Fee-for-Service to

Pay-for-Value

Michael Ogden, MD, MMM, CPEChief Clinical Integration Officer

Cornerstone Health Care, PACornerstone Health Enablement Strategic Solutions

(CHESS)

An Unsustainable Future

2010 2012 2014 2016 2018 2020 2022 2024 2026$1.0

$2.0

$3.0

$4.0

$5.0

$6.0

$7.0

$8.0

Expected future trend (6.5% growth)

Sustainable trend (affordability followed by 4.5% growth)

1.5T

Indu

stry

spe

nd ($

T)

$2.6T (18% of GDP)

Time

Waste reduction

A period of growth below GDP growth will be necessary to reach affordability (30%

reduction in costs as a percent of GDP)

Trend reduction

After affordability is achieved, long-term growth must be at the same level of GDP

growth to ensure sustainability

$4.3T(21% of GDP)

$2.8T(14% of GDP)

$7.1T(24% of GDP)

$4.0T(14% of GDP)

Sources: National Health Expenditure data, Bureau of Economic Analysis, Oliver Wyman analysis

The funding gap is widening, creating a need for rapid transformation in the market

3.1T

The Value Proposition

• Health care cost and utilization trends are unsustainable

• Waste and variation in practice lead to 30% of costs that can be taken out of the system

• Lowering payments is not a good answer

• Incentivizing patients, providers, and payers around value and appropriate utilization should be a key strategy for improvement

The Healthcare Delivery System Model is Changing

Volume Based• FFS/DRGs• No payment for

readmits, never events, etc.

• Departmental

• Volume• Efficiency (on a

procedure level)

• Visits• Surgery / Procedures• Outpatient ancillary

• Capacity• Revenue-producing

assets• Patient referrals

Reimbursement

Organizational model

Value drivers

Profit pools

Investments

Value Based

• Outcomes & Quality based

• Global payments

• Populations• Conditions• Focused factories

• Quality and low variability

• Efficiency (on a population level)

• Wellness and prevention • Population

management• Chronic condition

management

• Health IT• Clinical integration• Commercialization

Sources of Revenue in Fee-for-Value

Fee for Service Quality

Shared Savings Management

Patient Satisfaction Risk

Value-Based Models are a Solution to the US Healthcare Crisis

• The US healthcare system is in a spiral

• Reform has created new models

• Aim to improve health, reduce cost, and enhance patient satisfaction

These Models Require Providers to Undergo Transformative Change

• Every facet of their operations

• Clinical care must focus on quality and results

• Reimbursement must incent new behaviors

• New technology must be adopted and utilized to its fullest potential

Willing Providers Need Substantial Capital to Achieve This Change

• Requires millions in investment

• Hospitals have the funds, but cannot move quickly due to their volume-based model and bureaucracy

• Physician groups can move faster but lack the capital base, settling for incremental change and suboptimal results

Problem Statement

New Capabilities Needed to Become Population Health Managers

1 Leadership and OrganizationalAlignment

Leadership, organizational, and governance structure and culture that is conducive to the transformation to a value-based care delivery model

2 Care Delivery Continuum Assets

Network management with, alignment with, ownership of, or employment of facilities and providers that deliver and coordinate care across the continuum

3 Core ClinicalTechnologyInfrastructure

Healthcare information technology infrastructure for the data storage, usage, and transfer need to enable coordinated, evidence-based care

4 Population Analyticsand Performance Management

Analytic capabilities, platforms, and tools to enable population management and performance management

5 Integrated Clinical Models

Care delivery roles, processes, activities, and behavior change, centered around value-based care across the delivery system and care continuum

6 Financial and Risk Management

Financial tools and capabilities needed to negotiate, execute, and manage risk-based contracts

Many of these areas are outside of providers’ typical core competency areas, increasing the likelihood that many ACOs will need outside support

Mission: To be your medical home

Vision: To be the model for physician-led

Health care in America

Values: As a physician owned and directed company,We are committed to ensuring that patient care is patient centered, efficient, effective,

equitable, safe, and timely.

• 1,800 employees• 89 locations

230 physicians• 185 shareholder physicians

111 advanced practice providers34 specialties and ancillary services

• 21 Practices with extended hours29 Primary Care practices recognized by

NCQA as PCMH Level 3 • Physicians on staff at 15 different hospitals and 6

health systems

Cornerstone Health Care 2013

Cornerstone Specialties• Allergy and Immunology• Bariatric Surgery• Breast Surgery (8/2013)• Cardiology• Endocrinology• Family Practice• Gastroenterology• General Surgery• Hematology• Hospitalists• Infectious Diseases• Internal Medicine• Nephrology• Neurology

• Oncology• Ophthalmology• Otolaryngology• Orthopedics• Pediatrics• Psychiatry• Plastic Surgery (7/2013)• Podiatry• Pulmonology• Rheumatology• Urology• Vascular Surgery

AudiometryAmbulatory Endoscopy CenterBehavioral MedicineClinical Pharmacy ImagingInfusion ServicesLaboratory ServicesPain ManagementPhysical TherapySleep Lab

Cornerstone Ancillary Services

ACO

Medicare Shared Savings Program (MSSP) – 2012

Cornerstone developed a five-pronged strategy for developing the population health

management capabilities required to become an ACO.

Accountable Care

Organization=

Medical Home

1

ClinicalIntegration

2

InformationIntegration

3

Cornerstone Population Health Management Strategy

Organizational Realignment

Reimbursement Model Transformation

4

5

Network Development and Support

Structure and Governance

Patient Engagement

Quality Management

Innovation

Care Transformation

Support

Information Continuity and Management

Operational Support

Financial Analysis and

Reporting

Infrastructure Needs for Accountable Care

PFV: Negotiating Contracts

Weekly Care Pathway Redesign meetings

July 2011Service Line Monthly Meetings

Dec 2010: CHC goes live on Humedica MinedShare

March 2011PCA Program Conceived

October 2011Shareholder Vote to move to PFV

Jan 2012CHC & Oliver Wyman Redesign

March 2012Personalized Cardiac Care Program

April 2012Personalized Cancer Care w/embedded Primary Care

February 2013Care Outreach

Personalized Primary Care

Program

July 2012

MSSP ACO

April 2013All lives under Shared Savings Contracts (except Medicaid)

Acceleration!!!

& CHESS launch

Cornerstone’s Timeline

Optum & Teradata Tech partners

February 2013

Transitions of

Care

Informatics Investment

Population Costs

Foundation for Care Management Redesign

• Reduce fragmentation• Reduce unexplained variation in care• Optimize patient engagement• Utilize best available evidence as basis for

care• Apply resources to the most appropriate level• Concierge medicine without the concierge

price

The Triple Aim of Population Health Management

• Improve patient satisfaction in physician interactions

• Provide tailored support services to help patients navigate the system

• Implement initiatives to reduce inequitable variation in outcomes

• Provide consistent access to care, reducing acute health crises and visits to the emergency department

• Optimize care for the entire population, not only the sick

• Use predictive modeling to anticipate key health needs of the population

• Increase prevention efforts to reduce number of at-risk patients

• Devote practice resources and support to improving quality

• Eliminate redundancy of services

• Reduce preventable utilization

• Drive care to lower cost settings and specialties

Reduce cost of healthcare

Improve patient experience

Improve population

health

Physician and Patient experience will also improve as a result of this transformation due to more meaningful patient interactions and improved health outcomes

PCAsPurpose: To provide an exceptional level of care to each Cornerstone patient, and facilitate those who are looking for a doctor and a place to call their medical home.

• Provide immediate and ongoing personal contact to enhance our patients’ experiences with Cornerstone

• Answer questions or concerns

• Help make appointments with Cornerstone physicians for new and established patients

• Help manage our patients’ diabetes, hypertension, or other conditions, and any other factors that may put patients at risk for serious complications

• Provide crucial outreach by identifying and contacting those patients who are overdue for important appointments

By providing personal phone reminders and making appointments with the appropriate doctor(s), the Advocates help our patients better manage serious diseases and improve their overall health.

PCA Program Results

• Identified population with opportunity: Diabetes

• Outreach to improve HgBA1C testing

• Achieved 30% improvement within 1 year

PCA Program Future

• Referral management

NavigationPurpose: To provide an exceptional level of care to each Cornerstone patient by extending the physician’s reach by enabling health navigators to educate and assist patients to better manage their chronic conditions and to improve overall patient health.

• Provide patients with educational materials relating to their chronic condition

• Coordinate follow up care

• Motivate patients to take control of their healthcare

• Offer support to the patient

• Help patients identify and overcome barriers

By assisting and educating patients with chronic conditions, health navigators have helped patients lose weight, quit smoking, increase physical activity, and regain their independence.

Cornerstone followed a disciplined process to identify areas of opportunity and quantify

savings for each care model

1

2

3

• Stratification of population into similar categories• High cost areas reveal several market specific opportunities

to reduce waste and curb increasing cost trends

• Opportunities bundled into a unified program called a ‘care model’ aimed at transforming care

• Market specific recommendation developed on staging of care models

• Savings estimates developed by site of service and population segment for each care model

• Savings assumptions applied to clinical spend matrix to identify the magnitude of savings per market

Identify Opportunity

Develop Care Model

Quantify Impact

July 2012: Personalized Cardiac Care Program

– Dedicated team of 3

physicians: Care transitioned

from existing providers to a

member of the team

– Embedded behavior health

psychologist (PhD)

– Embedded pharmacy

services

– 2 Health Navigators

– Nurse Practitioner

– Nutritionist

– Telemetric weight monitoring

(planned)

A Year in the Life of Patient #1

Red indicated CHF related incidentsBlue indicates non-CHF related incidents

A Year+ in the Life of HFC Patient #1

Pre HFC Post HFC 0

102030405060708090

85

26

Inpatient AdmissionsCHF Related

Pre HFC Post HFC 0

102030405060708090

17 12

Percent Reduction Percent Reduction

-69% -29%

Pre HFC Post HFC 0

1020304050607080

76

38

Inpatient AdmissionsNon CHF Related

Pre HFC Post HFC 0

1020304050607080

2730

Percent Reduction

-50% +11%

Pre HFC Post HFC 0

5

10

15

20

25

30

12

3

Emergency Department Visits

CHF Related (not resulting in hospitalization)

Pre HFC Post HFC0

5

10

15

20

25

30

26

16

-75% -38%

Pre HFC Post HFC 05

10152025303540

24

8

Emergency Department VisitsNon CHF Related

Pre HFC Post HFC05

10152025303540

3426

-67% -24%

Limitations of the Data• Manually extracted

– Inconsistent follow-up period– Lack of capture of all events in EMR– May overestimate positive results– Short follow-up period

• Claims Based– Limited data with small sample size; results annualized

from 6 months of data– Pre-enrolled utilization may be included– Accuracy of coding may have significant effect on event

categorization– May underestimate positive results– Short follow-up period

Patient Care Redesign

November 2012: Development of Personalized Primary Care Program

– Design team consists of

a group of 7 physicians,

(internists and family

physicians) plus CHESS

support team

– Launched November

19th, 2012

– Navigated patient

services mirror

Personalized Cardiac

Care

Selection: Charlson Score

Personalized Primary Care

• Psychology• Nutrition services• Social Work • Navigation• Team-based care

Goals for PPCP• Quality of Care

– Blood Pressure Controlled to <140/90 mmHg;– Glycemic Control among Diabetics (defined as

HbA1c < 8%);– Cholesterol Control: LDL-C < 100 mm/dL;– BMI: Reduce mean population BMI from baseline for

Personalized Primary Care Program by xx% within one year of program launch.

– Increase depression/distress screening among the target population (Behavioral Health subcommittee to decide upon screening tool at January meeting: PHQ-9 vs Mood Scale), and improve screening result scores over time.

• Cost of Care/Utilization– 30% Reduction in ED Visits within one year of

program launch;– 40% Reduction in Hospital Admissions within one

year of program launch;– Reduction/Avoidance of 30-day Readmissions;– Risk Score reduction for target population.  Through

predictive modeling, assesses patient’s relative risk for future cost based on predicted probabilities of hospitalizations/high utilization/high medical and/or pharmacy spend.

• Patient Experience of Care– Press Ganey provider-specific scores: physician in

comparison to other physicians in same office setting, as well as to CHC overall.

April 2012: Cornerstone Personalized Cancer

Care• Group of 5 hematologist/oncologists

breaking down responsibilities for different

tumor lines: breast, lung, GU, GI and TBD

• Director of Psychosocial Oncology (PhD

psychologist with specialty training in

oncology)

• Tumor line specific Health Navigators

• Nutritionist & Pharmacist & Chaplain

• Embedded Internist to handle primary

care needs

• Development of Palliative Care Program

• Concierge

Standardized Pathways for Biopsy and Surgery

Early Cornerstone Results• 2012 Press Ganey Award for Patient Satisfaction

• $7.3 million in Quality and other P4P incentive payments since 2010

• ACO contracts with Aetna, BCBS, Cigna, Coventry, and UHC

• Clinical Co-management Agreements in cardiology and oncology (~ $1 Million saved)

• July 2012 Medicare Shared Savings Program ACO

• All Primary Care Practices are NCQA recognized Level 3 PCMHs

• Top 5 Cigna Collaborative Care Collaborative national performer

• NC Business Journal top employer

Newer models: Extensivist

Life Care

Unsustainable Healthcare Delivery System

2010 2012 2014 2016 2018 2020 2022 2024 2026$1.0

$2.0

$3.0

$4.0

$5.0

$6.0

$7.0

$8.0

Expected future trend (6.5% growth)

Sustainable trend (affordability followed by 4.5% growth)

Indu

stry

spe

nd ($

T)

$2.6T (18% of GDP)

Time

Waste reduction

A period of growth below GDP growth will be necessary to reach affordability (30%

reduction in costs as a percent of GDP)

Trend reduction

After affordability is achieved, long-term growth must be at the same level of GDP

growth to ensure sustainability

$4.3T(21% of GDP)

$2.8T(14% of GDP)

$7.1T(24% of GDP)

$4.0T(14% of GDP)

Sources: National Health Expenditure data, Bureau of Economic Analysis, Oliver Wyman analysis

The funding gap is widening, creating a need for rapid transformation in the market

44* Represents savings on clinical spend for the target population (e.g., 20% clinical spend reduction for the top 3-5% of spenders for Extensivist care model)

Care model savings estimates – savings across the continuum of care

Est. Savings on Target Population Spend*

Cardiology Model

Oncology Model

• High touch care coordination with significant lifestyle management, medication management, and adherence to well accepted evidence-based medicine protocols

• High touch care coordination with significant lifestyle management, medication management, and adherence to well accepted evidence-based medicine protocols

~31%-39%

~7%-13%

Target PopulationCare Model

Patient Centered Medical Home Model

• Emphasis on wellness and prevention• Medical savings realized by having a more engaged

patient population, steerage towards lower cost settings, and avoided admissions

~1%-3%Healthy, At-risk, and Early Stage Chronic

CHC Chronic and Complex Care Clinic Model

• High touch care coordination (lighter staff to patient ratios than Extensivist model)

• Savings realized through reduced utilization (ER visits, imaging/testing, inpatient visits etc.)

~11%-18%Complex Conditions (and residual Late Stage & Poly Chronic)

Extensivist Model

• High touch care coordination with specialists, case managers and ancillary providers

• Savings realized through reduced utilization (ER visits, imaging/testing, inpatient visits etc.)

~17%-24%Late Stage & Poly Chronic (Top 3-5% of spenders)

Sickest 20% of CHF patients

Oncology patients

Services

Popu

latio

n Ba

sed

Cond

ition

Bas

ed

Healthcare organizations have an opportunity to change our

delivery system– ACO’s are one opportunity

what’s YOUR next m

ove?

For Physician Organizations, Several Indicators Will Likely Predict

Future Success

With scale comes operational efficiencies and capability advancements – increased scale additional drives market influence and power

Intense focus on created patient-centric solutions that drive quality of care while removing excess cost – organizations must achieve both standardization and innovation

New models of outreach, engagement and experience means surrounding patients with complete suite of product, services, clinical care and health management

Scale Value-Based Care Delivery Patient Engagement

Risk Adoption Strategic Partnerships Technology & Infrastructure Advancements

In order to fund the investment required and to gain the economic upside opportunities, providers will need to continue to adopt increasing levels of financial and clinical risk on their patients

Extending patient care beyond the walls of the provider office means forging key partnerships with organizations that provide services critical to an integrated patient care experience (e.g., home health, Rx, etc.)

Significant buildout of analytic intelligence, information sharing, health management infrastructure, etc. remains critical to win in a FFV environment

Focusing on the Triple Aim, Three Forward-Looking Strategic Goals

1 Create a potential for long-term return on investment in a successful contemporary business model.

Create an environment that permits a more enjoyable practice of medicine while enhancing the ability to deliver high quality, patient-centered care.

Provide financial stability for your providers in the changing health care economic climate.

2

3

Not just more care-the Right Care, at the Right Time, in the Right Setting,

with the Right Resources

Thank You!

Michael Ogden, MD, MMM, CPEMichael.OgdenMD@cornerstonehealthcare.com