Innovations in ACO Development

Massachusetts Alternative Quality Contract

Barbara Spivak, M.D.Mount Auburn Cambridge Independent Practice Association, Inc., (MACIPA)

Mount Auburn Cambridge IPA (MACIPA)

Founded in 1985 to organize physicians and negotiate managed care contracts513 physician members who admit to Mount Auburn Hospital and/or Cambridge Health AllianceMACIPA takes full risk capitation from three major local health plans since mid 90’s

Blue Cross Blue Shield of MATufts Health Plan and Tufts Medicare PreferredHarvard Pilgrim Health Care

48 employees40,000 capitated lives

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MACIPA Membership Practice Statistics

MAPS (Hospital owned) 166Private Practices 250Cambridge Health Alliance 103Belmont Medical 20________________________________________________PCPs 98Specialists 403PCP/Specialist 18_________________________________________________

180

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PracticesPractices PhysiciansPhysicians

Total Number of Office SitesTotal Number of Office Sites

MACIPA and Mount Auburn Hospital

Managed Care partners since 1985Long history of investment in systems and programs to manage costsTeaching level hospital care without the costs of a major academic medical centerSystems established to prevent leakage to costlier hospital careActive and engaged leadership at hospital and IPA willing to partner with payers to achieve mutual goals

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MACIPA and Mount Auburn Hospital

Independent entities with no legal structure joining them.Contracts with payers are signed as 3-way agreements, signed independently.Risk sharing between Hospital and IPA is defined and agreed-to outside the agreements with payers.Service agreements are in place between Hospital and IPA defining:

Who provides service (e.g. MACIPA provides data warehousing; Mount Auburn administers reinsurance program)Compensation to be provided for each serviceTerms of the service to be provided

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MACIPA Structure

Board Committees involve over 50 physiciansPrimary Care Centric-touching every PCP monthly through Pod systemFocus on education and qualityData drivenPhysician leaders all practice medicine at least 50% of time

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MACIPA Pod Structure

Topics discussed include:New physicians & servicesPharmacy management and medication recommendationsData & reportsNew programs/initiativesPod meetings attended by MACIPA case managers, other staffQuality improvement programs-focus on preventive care

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MACIPA Infrastructure

Case ManagementMedical ManagementReferral ManagementPharmacy ManagementData and ReportingContractingQuality ImprovementEHR DepartmentIT Department

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What makes MACIPA unique?

Leadership and culturePCP focusEducation first with rewards before penaltiesWin/Win relationships between PCPs, Specialists and Mount Auburn HospitalQuality focusData driven

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Challenges

Culture changes for physicians & administrators take time to developManaging “leakage” delivered outside the systemPatient & Physician acceptance of the team approach Getting to “yes” on a contract with the payor, the Hospital and the physicians all feeling positive

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Challenges

Need for capital investment for infrastructure and IT before payoutsYears before rewards are seenNeed for reserves and reinsuranceTax implicationsLeadership voidGetting to win/win with less funds availableDifficulty evaluating program efficiency, planning services and developing programs

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MACIPA Surplus

PCP Surplus Distribution

MACIPA Surplus

Specialists Surplus Distribution

MACIPA Surplus

Distribution Criteria includeParticipation/Engagement in IPA ActivitiesLeakage avoidance Pharmacy compliance

NOT TIED TO COST OR UTILIZATION

Focus on Quality, Improvement & Effort

AQC Initiatives

AQC OrientationsPCP SummitPhysician EducationMonthly Joint MACIPA/MAH Steering Committee MeetingDefect Lists

Cancer Screenings for Breast, Colon and CervicalWell Child Visits

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AQC Initiatives

DiabetesDiabetes Outcomes reports – Action PlanPre-signed Lab slipsDiabetes Management Reports

Depression Talking points for PCPsPatient Education materials

Patient ExperienceEHR - order sets, flow sheets

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Depression Talking Point for PCPsDep

Keys to Success

Leadership believes that managed care is better careIPA brings value to physicians and improves care for patientsHospital believes in and supports the model

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