As noted in the recent HealthLeaders Media article, ACOs Population Health Management Share a Common Thread, “(as) the reimbursement environment transitions from volume-based to a value-based one focusing on quality care and efficiency, providers will be held accountable and could lose out financially if the health of their patients doesn’t improve.“ In an attempt to be ahead of the curve, one such group, Monarch HealthCare, is doing just that. As a participant in the Brookings-Dartmouth ACO Pilot Program, this large physician-led independent practice association (IPA) felt well suited to pursue the concept of patients first. And in the Commonwealth Fund’s January 2012 Case Study, Toward Accountable Care, the authors provide a comprehensive overview of the group’s journey towards this goal.
Located in the northern, southern and Orange county coastal California regions, this seventeen year old organization contracts with 2,200 independent private practice physicians to serve nearly 180,000 patients. With a license to take global risk under its own Medicare Advantage plan, Monarch specializes in providing managed care to seniors. Spurred by a perceived competitive threat from Kaiser Permanente’s move into Orange county, Monarch decided to leverage its extensive managed and preventive care experience in order to develop an accountable care organization. Extolling their “I CARE” values, standing for “Innovation, Communication, Accountability, Respect, and Excellence.”, Monarch partnered with Anthem in order to provide care coordination and care navigation support for 25,000 Anthem preferred provider organization (PPO) members in Orange County.
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In order to bear risk and successfully share in potential savings, Monarch had to develop sophisticated tools and infrastructure to manage both the quality and costs of care for this population of patients. Specifically, they engaged in the following:
ACO Structure
- Governance & Leadership – two complementary governance structures are involved in overseeing and driving the progress of Monarch’s single payer/provider ACO model. These include an internal Executive Steering Committee, which meets weekly, and an external Monarch-Anthem Partners Joint ACO Steering Committee, which meets monthly. The Joint ACO steering committee is also supported by the Attribution, Clinical Operations, Contracting, Cost of Care, HIT/Sys Ops, Marketing/Sales/Comms, Medical Management, Performance Metrics and Product Development/Benefit Design subcommittees. In addition, the SVP for Accountable Care position was created to execute ACO strategy.
- Payment – for the first year, the two groups have agreed on a care management fee and simple shared-savings model. They also have noted that for the ACO to be successful, they will eventually need to shift to a risk-bearing model and aim to phase in a global capitation model over the course of the five-year contract.
HIT Infrastructure
- Health Information Exchange (HIE) – when it is launched, this Web-based platform will provide internal connectivity between systems that are already in place at Monarch and between Monarch’s electronic systems and those of other institutions.
- NextGen – includes an EHR system, practice management system, internal HIE system and patient portal. The EHR is linked with laboratories, pharmacies, imaging services, and appointment reminder tools. And the patient portal will provide patients with secure access to physicians via e-mail and enable them to request appointments or medication refills and see test results.
- PracticeConnect – a web-based tool that deploys information to all independent practice providers and enables clinical information-sharing, patient status inquiry and messaging. With chronic care registries and claims submission/authorization/referral features, a variety of important metrics can also be monitored and reported.
Population Management Strategies
- Case Management – Monarch keeps a tight rein on care transitions for their elderly population by using the following “five pillars” as guidelines: 1) reconcile medications, 2) set a follow-up appointment, 3) educate patients about warning signs, 4) use effective patient–physician communication, and 5) use a personal health record. Key players in providing case management include inpatient case managers, ambulatory case managers in a centralized office, employed hospitalists and nurse practitioners on site at hospitals and skilled nursing facilities, social workers, patients’ primary and specialty care physicians, inpatient medical directors and ambulatory care medical directors .
- Disease Management and Registries – primary care providers and disease management coaches help asthmatic and diabetic patients write self-care management plans, with a case manager being assigned to each patient. The plans include recommendations for patients on routine care, sick-day planning, symptom recognition, and early intervention to prevent unnecessary emergency department visits.
- “Touch Teams” – an advanced nurse practitioner, case manager, social worker, and pharmacist—coordinate patients’ transition from hospital to home and make home visits. Monarch also hired two full-time social workers to integrate behavioral health clinical services and other community-based services into the overall plan of care for each high-risk patient.
- Personal Health Records and Advance Directives – these two paper-based tools are used to improve care transitions. The personal health record includes sections on medical history, medications, recent hospitalizations, emergency or urgent care visits and preventive maintenance. The Physicians Orders for Life Sustaining Treatment is recorded on paper, as well as online, for future reference.
- Urgent Care and ‘Alternative’ Providers – in order to reduce hospital re-admissions and emergency department visits, Monarch has employed hospitalists, skilled nursing physicians and nurse practitioners for better care transitions and, if appropriate, encouraged members to utilize urgent care facilities.
Performance Improvement
- Readmission Rounds – medical director or assistant medical director, hospitalists, and case managers conduct a root cause analysis of every readmission that occurs within 30 days of discharge to determine where the system broke down and how to improve care processes.
- Integrated Care Teams – a new initiative aimed at bringing together all of the people involved in managing a population of patients. These teams will focus on patients aligned with specific physician practices, according to geography. With local integration, Monarch hopes to facilitate more effective communication and alignment across specialties, geographic locations, and episodes of care.
- Reducing Waste – by pulling relevant data from the network using nearly 20 complementary data systems, as well as actuarial services to compare utilization with peer organizations, Monarch identified system-wide inefficiencies in duplicative or otherwise unnecessary tests, inadequate communication of information, excessive inpatient bed days, unnecessary utilization of specialists and over-utilization of emergency services.
- Quality Gate and Efficiency Scorecard – the quality gate is the minimum performance threshold that must be achieved by participating providers in order to receive a bonus. The draft efficiency scorecard identifies aggregate utilization and costs associated with efficiency measures. Once the ACO passes the quality gate, the efficiency scorecard will be used to determine the savings that will be shared between Monarch and Anthem.
Through strong executive leadership, trust and transparency in partnerships, use of care navigators, physician champions and economies of scale, Monarch HealthCare has the potential to revolutionize healthcare service delivery with its population management strategies. In light of Monarch’s recent acquisition by OptumHealth, a subsidiary of UnitedHealth Group, it will be intriguing to see if they remain the course. The proof, no doubt, will be in the pudding.
*image courtesy of the Public Health Agency of Canada
