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© 2011 Advocate Physician Partners
Advocate Accountable CareCarrie E. Nelson, MD, MS, FAAFP
Stakeholder Health
September 25, 2015
© 2011 Advocate Physician Partners2
Advocate Health Care Advocate Health Care
13 Hospitals• 10 acute care hospitals• 1 children’s hospital• 1 critical access hospital• 1 clinically affiliated hospital • 5 level 1 trauma centers• 3 major teaching hospitals• 2 physician groups with 1,500 physicians • 250 sites of care
34,000 Employees
Advocate Physician Partners• 4,900 Participating Physicians• 25% PCPs / 75% specialists • 1400 Employed/3500 Aligned• 2nd Largest ACO in US - 745,000 covered lives
© 2011 Advocate Physician Partners
Clinical Integration (CI)• A structured collaboration among APP physicians
and Advocate Hospitals to improve the quality and efficiency of health care.
• Joint contracting with fee-for-service managed care organizations is a necessary component of this program in order to accelerate these improvements in health care delivery.
• CI forms the foundation for population health
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© 2011 Advocate Physician Partners4
Highlights of 2014 CI Program• A Generic Drug Prescribing Rate of 2 Percentage Points higher than
the Chicagoland market >$17 Million of overall health care drug expenditures were avoided by utilizing lower cost, equally-effective generics
• An Outstanding Asthma Control Rate – 24 Percentage Points Higher than the National Average Saving ~$17 Million in Direct and Indirect Medical Costs
• A Diabetes Care Initiative for HbA1c Control Saving >$1.4 Million • Childhood Rotavirus Immunization Initiative:
– Exceeded National HMO rates by 9.2% points– Exceeded National PPO rates by 19% points– Saving >$4 Million in Avoided Hospital Costs
• Combination 3 Childhood Immunization Rates Above the NCQA 75th Percentile for Combined HMO and PPO
© 2011 Advocate Physician Partners
Our Reimbursement Model is Shifting
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© 2011 Advocate Physician Partners
Accountable Care Entity (ACE)• Illinois Medicaid Expansion Bill Signed Into Law
July 22, 2013• Created provider-sponsored “Accountable Care
Entity (ACE)” to coordinate care for Medicaid eligible individuals
• ACE as an alternative for providers to reliance on other managed Medicaid organizations
• Eligible Medicaid populations are children and their family members and Affordable Care Act “newly eligible” beneficiaries
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© 2011 Advocate Physician Partners
Medicaid PCP and OB Capacity
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Physician Type% PCPs Enrolled with
Medicaid FFS Program
CurrentCapacity
Aligned 71% 228,253
Employed 76% 49,879
OB 15,336
© 2011 Advocate Physician Partners
APP ACE Eligible Population• Family Health Plan – Existing Medicaid FFS Patients
• Newly Eligible ACA Adults– APP will include this population in 2017
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120,00019,500
10,500
Estimated Lives
150,000
© 2011 Advocate Physician Partners
ACE 3-Year Risk Pathway – Originally Proposed• Program supports transition away from fee-for-
service with care coordination fees as ACEs accept more risk
• Months 1-18: Care coordination fees and shared savings
• Months 19-36: Prepaid capitation with individual and global stop-loss provided by HFS; transition to Managed Care Community Network (MCCN) or HMO
• Months 37+: Global capitation9
© 2011 Advocate Physician Partners
Key Considerations in Assuming Risk for Medicaid• Best opportunity for provider community to manage Medicaid
population• Aligned with Advocate mission and vision• Further moves the organization to one model of care for all
patients– Patients will move in and out of public Marketplace and Medicaid
• Maintains existing Medicaid lives managed by Advocate providers– Children’s Hospital and residency programs– Half of OB volume in Illinois, similar in Advocate Health Care
• Aligned incentives• Moves the organization progressively toward managing
financial risk10
© 2011 Advocate Physician Partners
BUT…• Illinois pays among the lowest in the nation
for Medicaid• Illinois is broke and hasn’t paid the managed
care organizations for 3 months• Not all our physicians want to do it – some
are very vocal
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© 2011 Advocate Physician Partners
So What Did We Do?
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© 2011 Advocate Physician Partners
Why?
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© 2011 Advocate Physician Partners
Medicaid Targeted Initiative: Community Health Worker Program• Medicaid ACE program prompted a need to look
for new approaches to engage patients• Look at two separate models/conditions to
gauge effectiveness– Trinity PHO: Asthma (Feb 2015)– Christ PHO: ED Use (2nd Qtr 2015)
• Design full program using consulting services from Sinai Urban Health institute
• Develop new approaches for patient outreach and education
© 2011 Advocate Physician Partners
Trinity Pilot: Overview• Patients with poor asthma control are visited by
CHWs in their homes up to six times during yearlong intervention– Physicians and claims identify patients to participate– Direct recruitment flyer sent monthly to members
• The CHW is an extension of the care management team
• The CHW sends physicians a summary of the patient’s evaluation and educational plan
• Results not yet complete
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© 2011 Advocate Physician Partners
Trinity Pilot: CHW team
Wakita Coleman Moet Sims-Denmark
Melinda Harville
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© 2011 Advocate Physician Partners
Trinity Pilot: Measuring Success• Decrease in asthma ED visits• Decrease in asthma hospitalizations• % Of patients who demonstrate their ability to
control their asthma (measured by ACT)• Improvement in quality of life measures• Decrease in asthma triggers in home• Increase in medication usage• Decrease in the frequency of asthma symptoms• Stories!
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© 2011 Advocate Physician Partners
Q&A