CAPG Health Summer Edition 2012 by America's Physician Groups

VOL. 6, NO. 4

JULY/AUGUST 2012

Healthcare Reform: A Time For Innovation

John Jenrette, MD Roundtable on Medicare Physician Payment Policy SOE Survey Results

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That’s why 3,700 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group. Get more information at www.HillPhysicians.com/Providers or contact: Bay Area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com

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Curb Rising Hospital Costs Frequent hospitalization of the terminally ill is a chronic condition affecting medical groups and their patients:

• A 2009 New England Journal of Medicine study

concluded that rehospitalization is a frequent, costly and sometimes life-threatening event that is associated with gaps in follow-up care.1

• Many studies suggest that end-of-life patients

who receive continuous curative care in lieu of appropriate hospice or palliative care can experience more pain and discomfort, a decreased quality of life and even a shorter life span. 2, 4

• At least two independent studies have shown

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1 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare Fee-for-Service Program. New England Journal of Medicine, 2009; 360:1418–1428. 2 Lynn J, Teno J, et al. Perceptions by family members of the dying experience of older and seriously ill patients. Annuals of Internal Medicine, 1997; 126:97–106. 3 Miller S, Mor V, et al. Does receipt of hospice care in nursing homes improve the management of pain at the end of life? Journal of American Geriatrics Society, 2002; 507–515. 4 Casarett D, Karlawish J, Morales K, Crowley R, Mirsch T, Asch DA. Improving the use of hospice services in nursing homes: A randomized, controlled trial. Journal of the American Medical Association. 2005;294(2):211–217. 5 Gozalo PL, Miller SC. Hospice enrollment and evaluation of its causal effect on hospitalization of dying nursing home patients. Health Services Research. 2007; 42(2):587–610.

VITAS can help. Serving California since 1995 For more information, please contact 1.800.723.3233 • VITAS.com

TABLE O F CO N T E N TS DEPARTMENTS: Notes From The President

20 Upcoming Events 21 Members List 26 Names In The News

COVER STORY: Healthcare Reform: A Time For Innovation John Jenrette, MDM

Publisher Valerie Okunami CAPG Health Editor-in-Chief: Don Crane Managing Editor: Lura Hawkins, MBA Cover Photo: Colleen Zobel Photography www.zstudio.net Contributing writers: Daryl Cardoza Don Crane Alison Fleury Jon A. Hultman, DPM, MBA Leigh Hutchins John Jenrette, MD Steven Niccoli Valerie Okunami Keith Pugliese Wells Shoemaker, MD Art Director Paul Galang CAPG Health Magazine is published by Valerie Okunami Media P.O. Box 674, Sloughhouse, CA 95683 Phone 916.761.1853 www.capghealth.org Please send press releases and all other information related to this issue of CAPG Health to capghealth@capg.org and/or c/o CAPG Health 915 Wilshire Blvd., Suite 1620 Los Angeles, CA 90017

FEATURES:

2012 CAPG Annual Conference Podiatric Medicine

President Obama Delivers Remarks At LGBT Gala Brown & Toland’s Pioneer ACO: Years In The Making

Roundtable On Medicare Physician Payment Policy: Lessons From Private Sector ACO Deployment From A Marketing and Communications Perspective

24 28

CAPG Groups Improving Capabilities in Patient Care Coordination Sharp Healthcare ACO – The Journey Begins

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Subscription Rates: $32 per year; $58 two years; $3.00 single copy. Advertising rates on request.

Bulk third class mail paid in Jefferson City, MO Every precaution is taken to ensure the accuracy of the articles published in CAPG Health Magazine. Opinions expressed or facts supplied by its authors are not the responsibility of CAPG Health Magazine. Copyright 2012, CAPG Health Magazine. All rights reserved. Reproduction in whole or in part without written permission is strictly prohibited.

Ever feel as if the costs of diabetes management just keep coming around?

Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed.1 One issue is medication adherence.2 Medication adherence may prevent hospitalizations for diabetes complications.2 Another major issue is hypoglycemia. Not only is it a barrier to successful diabetes management,1 but it can also be very costly3: • ER-to-inpatient costs: $10,3623 • ER plus outpatient costs: $9863 • Hospital admission costs: $7,3173

However, you may not be informed of all your members’ hypoglycemic events. In a multicenter, retrospective medical record review of 3 academic emergency departments, 83% of hypoglycemia visits, often excluded in prior hypoglycemia analyses, were coded as “diabetes with other speciﬁed manifestations,” while others may not be reported at all.4 For these reasons, diabetes management costs may be even greater than you know.

That’s why Novo Nordisk is committed to providing your organization with a broad range of solutions in glycemic management. For more information about Novo Nordisk, please visit novonordisk-us.com. References: 1. American Diabetes Association®. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35(suppl 1):S11-S63. 2. Healthcare Cost and Utilization Project. Economic and Health Costs of Diabetes. Rockville, MD: Agency for Healthcare Research and Quality; 2005. 3. Curkendall SM, Zhang B, Oh KS, Williams SA, Pollack MF, Graham J. Incidence and cost of hypoglycemia among patients with type 2 diabetes in the United States: analysis of a health insurance database. JCOM. 2011;18(10):455-462. 4. Ginde AA, Blanc PG, Lieberman RM, Camargo CA Jr. Validation of ICD-9-CM coding algorithm for improved identiﬁcation of hypoglycemia visits. BMC Endocr Disord [series online]. April 1, 2008;doc 8:4.

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0312-00007951-1

March 2012

N OT E S F R O M T H E P R E S I D E N T W

eâ&#x20AC;&#x2122;ve just received the results of the long-awaited Supreme Court decision on the Affordable Care Act (ACA) of 2010. There are things to like and dislike about the law, and we will all be assessing what works and what does not. But, regardless of where one stands on the political divide, it is clear that accountable careâ&#x20AC;&#x201D;the kind of healthcare practice that distinguishes CAPG groupsâ&#x20AC;&#x201D;will continue to thrive. It is the model of the future. CAPG groups have been practicing accountable care for years and will continue to do so irrespective of the law. It is simply the best way to deliver healthcare. Our patientcentered, team-based approach makes better and higher use of physicians, physician assistants, and a wide range of specialized staff and social services. Our members didnâ&#x20AC;&#x2122;t need a law to make that happen; they did it through hard work, innovation and experience.

The ACA has already served as an impetus to change, encouraging hospitals, insurers and other commercial organizations to develop new solutions to some of the systemâ&#x20AC;&#x2122;s problems. In addition, six of our own CAPG groups are participating in the governmentâ&#x20AC;&#x2122;s Accountable Care Pioneer program. All of these developments are positive, regardless of the rise or fall of the ACA. Access and capacity are still major concerns for all of us. With more people covered by insurance and the number of primary care physicians still limited, the challenges are clear. But our signature healthcare delivery model, with its emphasis on measurable quality and cost improvements, organized systems, and team-based care, is prepared to succeed. I am proud to be associated with the outstanding, forward-thinking physician groups that are the bedrock of CAPG. Sincerely,

Donald Crane President and CEO

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6/7/12 9:10 AM

COVER S TO RY

Healthcare Reform … A Time For Innovation

et me first say that it is an exciting time for healthcare, and I am proud to serve as Chairman of the Board of Directors for CAPG during these times of change, challenge and innovation. Thank you for this opportunity. I also wish to thank the entire staff, team, and executives of CAPG for a truly successful annual meeting. Congratulations to all of you! Healthcare reform represents a true time for innovation for CAPG groups and with it a world of tremendous opportunity. Whether measured by the attendance of over 1,500 or by the lively and controversial conversations during and after the general and breakout sessions, this year’s annual conference was the most successful CAPG event to date. I heard time and time again how CAPG is perfectly positioned in today’s world of healthcare reform to forward its message about accountable, coordinated health care driven by aligned incentives and efficient, high quality care through our various medical groups. And so, we have advanced the California coordinated care model in the evolution of the six Pioneer and two Sharedsavings ACOs in California, and through the development of numerous commercial ACOs throughout the state. California’s system of delivery is now recognized across the country as leading the way.

A large portion of the primary care workforce is now approaching retirement age and current medical school graduates are choosing higher paying specialty practice... In leading the way, two important and substantive processes of care delivery and innovation will see increasing efforts and opportunities for improvement and change: 1) the continued strong focus on managing complex chronic illness and 2) the need to transform primary care services to complement the California delivery systems of care that are unique to our model. The continued focus on managing complex chronic disease is of utmost impor-

tance based on the high cost of care for this subset of our population. Whether it is the top 5% of the commercial population that accounts for 60% of costs or the top 1to 2% of the Medicare population that accounts for 20 to 25% of costs, the need for us to innovate in the medical services we provide to these populations is essential. We must continue current effective programs and further advance new approaches to provide coordinated, accountable care in the correct setting of home and/or community, involving both patient and family. Ultimately, care of these patients must occur outside of the acute hospital setting. We need to educate the public and our physicians on the delivery of end of life care and services. In this message, we need to be comfortable with the dialogue and ignore the inflammatory rhetoric about death panels to focus on meeting the expectations and desires of our patients. The second urgency for California groups is the transformation of primary care. Primary care is the foundation of medicine and must evolve to remain vibrant. Healthcare delivery systems around the world that have primary care as their backbone are shown to deliver higher quality medical care at the lowest cost. The problem we face, however, is the erosion of the primary care foundation. A large portion of the primary care workforce is now approaching retirement age and current medical school graduates are choosing higher paying specialty practice which offers greater life balance. Residency graduates entering adult primary care have dwindled to less than half of the rate of 12 years ago, and this trend seems to be getting worse. The erosion of the primary care workforce is further driven by the changes and demands of healthcare reform, including: greater access challenges for patients to primary care services; additional paperwork (or EHR requirements) in primary care offices; keeping up with medical advances; increasing demands to provide wellness services; management of chronic disease; and the need to address important social determinants of health. These demands and the increased workload should have us all concerned about the future of primary care. How can we support primary care going forward? What are our plans for the future to replace our aging workforce and

By John Jenrette, MD CAPG Chairman, Board of Directors

to re-invent ourselves? What innovations are needed to create success for all of us? Ultimately, we need sustainable solutions. We must work collectively to advance primary care. We need primaries to be working at the “top of their licenses” and to engage their office support teams to help deliver outstanding care for patients. We must also provide the tools and technology that advance and streamline these changes and allow for greater focus on populations and gaps in care that lead to poor outcomes. If we focus our energy and are successful in our efforts, what would primary care look like? I envision success in the rejuvenation of primary care as a preferred career path for the majority of medical school graduates. Our success would return joy and fulfillment to the practice of primary care medicine and remove the scut work from physicians’ desks. It would also rectify and right-size compensation for primary care services, recognizing the real value of a strong healthcare delivery system with its foundation in primary care. You will be hearing more from CAPG about the advancement of primary care over the next few years as specific work initiatives are designed and implemented. I hope you will join us in this effort. These are just a few of the cases for innovation and a glimpse at the efforts that are underway and will continue for CAPG groups. These are the reasons I am proud, and the reasons that you should be proud, of what we have done and will continue to do in the future, reasons that CAPG will continue to be recognized across the country as a leader in healthcare reform. n

Transforming Care Coordination

e were pleased when CMS recognized NAMM California’s affiliate, PrimeCare Medical Network, Inc. (PMNI), as an organization capable of achieving better health, better care and lower cost for Medicare beneficiaries, and selected PMNI to participate as a Pioneer ACO. In the period since we submitted our application, we have encountered successes and challenges. We surmise that an organization considering any ACO program will experience similar challenges in the areas of: (1) Engagement and (2) Data Exchange.

Engagement For the most part, the ACO patient population made a conscious decision to remain in Medicare fee-for-service rather than join an HMO. Consequently, they are not accustomed to active outreach and may perceive care coordination as interference. So how do you mitigate that initial apprehension attributable to unfamiliarity with care coordination and the term ACO? Retaining the services of those they have entrusted with their care is the foundation from which to initiate the education process – their physicians. We cannot overemphasize the necessity of educating physicians and their office staff in the ACO concept, starting in the planning stage and throughout the operation of the ACO. They have the trust of the patients and will be the first ones contacted by patients with questions until the ACO is able to establish a relationship between its clinical care teams and the patient. One of the initial successes we experienced through early engagement is demonstrated by the low rate of less than three percent of patients choosing to optout of data sharing in our ACO. Some of the steps we undertook to accomplish this were: • Extending the invitation to participate in our ACO to only a select group of physicians within our 13 IPAs. These physicians demonstrated a high level of engagement in working with PMNI on other quality and performance initiatives. We obtained their written commitment as part of our application, thus initiating what will be continuous education.

• Informing the patients of their right to opt-out of data sharing by sending the letters under the name of the PCP. • Drafting FAQs on the ACO for the physicians, their staff and our ACO team. • Organizing and educating the physician Board to enable them to respond to questions from their colleagues. • Establishing a dedicated toll-free customer service line to handle inquires. While we achieved a rather low opt-out rate, we still could have improved upon our communications with providers. With competing priorities, the physicians and their staff need periodic updates and reminders. Our ongoing education efforts include: • Town Hall meetings with ACO providers and separate ones for their office staff • Customized provider and patient education material • Meetings with key hospitals, and their inclusion in select ACO Board meetings • Highly engaged physician Board members who are becoming “champions” in promoting the ACO • Regional education meetings for beneficiaries

By Leigh Hutchins President/COO of NAMM

Data Exchange As noted above, ACO patients are not accustomed to coordinated care, and under the Pioneer ACO, they fully retain their choice of providers with no auth/referral process. Complicating the effort is how to inform physicians and hospitals that a patient is part of our ACO. To address this challenge, we have focused on connecting our ACO physicians and primary admitting hospitals to our Health Information Exchange (HIE). The HIE will enable all connected providers to view the continuity of care document (CCD) record of a patient, as appropriate, and we intend to flag those patients that are part of the ACO. The CCD can be considered a summary medical continued on next page

continued from page 8 record of the patient that will be initially populated with the claims data provided by CMS and then updated in real-time by those providers with qualified access. To date, we have a total of 798 users connected to our HIE, including approximately 76 percent of our ACO primary care physicians, our ancillary providers, and one of the hospitals. Our ACO Board recently approved retention of a partner company, at the expense of PMNI, to assist the ACO physicians in qualifying for the meaningful use payments. This will be an additional supplement to the subsidy provided to physicians adopting a certified EHR. When fully deployed, the HIE will allow for medication reconciliation and will have bi-directional interfaces with certified EHRs to facilitate data exchange, including delivery of reminders to physicians for those patients requiring certain procedures or other special needs. The next hurdle is to connect the remaining hospitals either directly or through a regional exchange.

Conclusion We realize that building a sustainable

and effective care coordination platform in an environment of reduced reimbursement focused on outcomes will require more active engagement and collaboration between provider, patients and payers. The programs and systems that will be refined through our participation in the Pioneer

ACO will support the culture change that must occur, but we acknowledge that there is much work to be done. Leigh Hutchins is the President/COO of NAMM California and a member of the CAPG Board of Directors. n

ARE YOU PREPARED FOR COORDINATED CARE? COMPLETE YOUR PLAN FOR ADVANCED CARE MANAGEMENT. Provider organizations moving toward risk-bearing, ACO-style models must manage diverse (and often unfamiliar) activities ranging from disease and case management, to in-network referrals, to quality performance trackingâ&#x20AC;&#x201D;the control levers for cost and quality. Health Access Solutions can help fill the gaps so your patients receive the appropriate level of care, at the right time and place, with the best possible outcomes. Visit us at www.HealthAccessSolutions.com

CAPG Conference photos Colleen Zobel Photography

2012 CAPG ANNUAL CONFERENCE

By Lura Hawkins, MBA Director of Member Services, CAPG

ollaboration and innovation was the dominant theme at the annual CAPG Healthcare Conference, which took place May 17 - 20 at the JW Marriott Desert Springs Hotel in Palm Desert, California. This year’s annual conference attracted more than 1500 attendees. Highlights included Keynote speaker Don Berwick, M.D., former Director of the Center for Medicare and Medicaid Services (CMS), U.S. Department of Health and Human Services, who evoked the first standing ovation so far recorded at a CAPG Conference. Harold Miller and Shannon Brownlee also delivered excellent and thought-provoking

presentations to the record crowd. There was a special session on Dual Eligible’s, which proved to be very popular. Howard Kahn, CEO of LA Care and Martha Smith, Chief Program Officer for Health Net led this session. Also featured was an expert panel of California healthcare executives represented by payers, medical groups, a major hospital and a health plan -- Ann Boynton, Deputy Executive Officer, Benefits Administration, CalPERS; Bruce Bodaken,Chairman, President and CEO, Blue Shield of California; John Jenrette, MD, CEO, Sharp Community Medical Group; and Thomas Priselac, President & CEO, Cedars-Sinai Health Systems. Moderator for this session was Don Crane, President & CEO of CAPG. Once again, our post-conference survey identified networking as the number one reason to attend the CAPG conference, by almost 70% of attendees. To foster that opportunity, group meals and several

networking events were included in the agenda. The Welcome Reception on Thursday night kicked off the conference and gave people an opportunity to meet new friends and renew friendships. The Friday night “It’s a Jungle Out There” Strolling Dinner and Exhibit Fair featured more than 100 companies with products and services to complement the coordinated care model. To conclude Saturday evening’s activities, The Dwight Kennedy Entertainment Band, complete with dancers and singers, kept the Saturday evening Gala Dinner/Dance lively. CAPG wishes to thank all of the sponsors and exhibitors that make such an enjoyable and intellectually rewarding conference possible, particularly the following Diamond Sponsors: Aetna; Anthem Blue Cross; Blue Shield, Health Net; Novo Nordisk; and United Healthcare. Plan now for the CAPG Annual Healthcare Conference 2013, June 6-9 at the JW Marriott, LA Live! n

Numbers that matter to you and your members

Numbers that demonstrate significant clearance STELARA® (ustekinumab) is indicated for the treatment of adult patients (18 years or older) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. STELARA®, available as 45 mg and 90 mg, is a subcutaneous injection that should only be administered by a healthcare provider to patients who have regular follow-up with a physician.1 In clinical trials, significantly more STELARA®-treated patients with moderate to severe plaque psoriasis achieved PASI* 75 at Week 12 after only 2 starter doses vs placebo.1 In PHOENIX 1 and PHOENIX 2 clinical trials, the primary endpoint was a PASI 75 response at Week 121-3

100

67%

†

66%†

60 50 40 30 20 10 0

45 mg

Placebo (n=8/255)

STELARA® (n=171/255)

90 mg

Patients responding (%)

PASI 75 response at Week 121-3

80 70

PHOENIX 1

76%†

60 50 40 30 20 10 0

STELARA® (n=170/256)

67%

†

45 mg

90 mg

Placebo (n=15/410)

STELARA® (n=273/409)

STELARA® (n=311/411)

PHOENIX 2

PHOENIX 1 evaluated 766 patients who received STELARA® or placebo. The study design was identical to PHOENIX 2 through Week 28. Inclusion criteria were consistent with PHOENIX 2. At Week 40, patients initially randomized to STELARA® who were PASI 75 responders at both Weeks 28 and 40 were rerandomized either to continue every–12-week dosing with STELARA® or to placebo. Patients randomized to placebo at Week 40 were retreated with their original dosing regimen when they lost ≥50% of the PASI improvement achieved at Week 40. The primary endpoint was PASI 75 at Week 12.1,2 PHOENIX 2 evaluated 1230 patients who began the study receiving STELARA® 45 mg or 90 mg or placebo. Patients randomized to STELARA® received STELARA® at Weeks 0 and 4, followed by the same dose every 12 weeks through Week 28. Patients in the placebo group (N=410) crossed over to receive either STELARA® 45 mg or 90 mg at Weeks 12 and 16, followed by the same dose every 12 weeks. Eligible patients were adults with a diagnosis of plaque psoriasis for ≥6 months involving ≥10% Body Surface Area (BSA), PASI score ≥12, and who were candidates for phototherapy or systemic therapy. The primary endpoint was PASI 75 at Week 12.1,3 P<0.0001 vs placebo.

†

In PHOENIX 1 Treatment success (defined as PGA score of Cleared or Minimal) was achieved at Week 12 in 6 out of 10 patients in the 45 mg and 90 mg groups (59% [151/255] and 61% [156/256], respectively) compared with 4% [10/255] of placebo patients (P<0.0001) vs placebo for each dose1,2 PASI 90 was achieved by more than 4 out of 10 patients at Week 12 in the 45 mg and 90 mg groups (42% [106/255] and 37% [94/256], respectively) compared with 2% [5/255] of placebo patients (P<0.0001) vs placebo for each dose2‡ In PHOENIX 2 Treatment success (defined as PGA score of Cleared or Minimal) was achieved at Week 12 in 7 out of 10 patients in the 45 mg and 90 mg groups (68% [277/409] and 73% [300/411], respectively) compared with 4% [18/410] of placebo patients (P<0.0001) vs placebo for each dose1,3 PASI 90 was achieved by more than 4 out of 10 patients at Week 12 in the 45 mg and 90 mg groups (42% [173/409] and 51% [209/411], respectively) compared with 1% [3/410] of placebo patients (P<0.0001) vs placebo for each dose3‡ Psoriasis Area and Severity Index. PASI 90 was a prespecified endpoint, not a primary endpoint.

‡

2 12

Generally well tolerated in clinical trials Plaque psoriasis clinical trials Infections and serious infections1§ Controlled and non-controlled periods

Placebo-controlled period Incidence (%)

Infections Serious infections

Per patient-year of follow-up

Incidence (%)

Per patient-year of follow-up

STELARA®

Placebo

STELARA®

Placebo

STELARA®

27% 0.3%

24% 0.4%

1.39 0.01

1.21 0.02

61% 0.9%

1.24 0.01

Malignancies1

Malignancies|| Non-melanoma skin cancers

Controlled and non-controlled periods Incidence (%)

Per 100 patient-years of follow-up

STELARA®

0.4% 0.8%

0.36 0.80

In clinical trials, serious malignancies included breast, colon, head and neck, kidney, prostate, and thyroid cancers1

The incidence of malignancies, excluding non-melanoma skin cancers, in STELARA®-treated patients over 1 year of follow-up was similar to that expected in the general US population according to the Surveillance, Epidemiology and End Results (SEER) database4 Average follow-up of 12.6 weeks for placebo and 13.4 weeks for STELARA®-treated patients.1 Excluding non-melanoma skin cancers.1

§ ||

Selected Safety Information STELARA® is an immunosuppressant and may increase the risk of infections, reactivation of latent infections, and malignancies. Serious adverse reactions have been reported in STELARA®-treated patients, including bacterial, fungal, and viral infections, malignancies, serious allergic reactions and one case of Reversible Posterior Leukoencephalopathy Syndrome (RPLS). STELARA® should not be given to patients with any clinically important active infection. Patients should be evaluated for tuberculosis prior to initiating treatment with STELARA®. Live vaccines should not be given to patients receiving STELARA®. If RPLS is suspected, discontinue STELARA®.

Please see related and other Important Safety Information for Stelara® on page 4 of this advertisement.

STELARA® is dosed once every 12 weeks after 2 starter doses at Weeks 0 and 41 For patients weighing ≤100 kg (220 lbs), the recommended dose is 45 mg initially and 4 weeks later, followed by 45 mg every 12 weeks. For patients weighing >100 kg (220 lbs), the recommended dose is 90 mg initially and 4 weeks later, followed by 90 mg every 12 weeks In patients weighing >100 kg (220 lbs), 45 mg was also shown to be efficacious. However, 90 mg resulted in greater efficacy in these patients

3 13

IMPORTANT SAFETY INFORMATION Infections

STELARA® (ustekinumab) may increase the risk of infections and reactivation of latent infections. Serious bacterial, fungal, and viral infections were reported. Infections requiring hospitalization included cellulitis, diverticulitis, osteomyelitis, gastroenteritis, pneumonia, and urinary tract infections. STELARA® should not be given to patients with a clinically important active infection and should not be administered until the infection resolves or is adequately treated. Instruct patients to seek medical advice if signs or symptoms suggestive of an infection occur. Exercise caution when considering use of STELARA® in patients with a chronic infection or a history of recurrent infection.

Theoretical Risk for Vulnerability to Particular Infections

Individuals genetically deficient in IL-12/IL-23 are particularly vulnerable to disseminated infections from mycobacterium, Salmonella, and Bacillus Calmette-Guerin (BCG) vaccinations. Serious infections and fatal outcomes have been reported in such patients. It is not known whether patients with pharmacologic blockade of IL-12/IL-23 from treatment with STELARA® will be susceptible to these types of infections. Consider appropriate diagnostic testing as dictated by clinical circumstances.

Pre-Treatment Evaluation of Tuberculosis (TB)

Evaluate patients for TB prior to initiating treatment with STELARA®. STELARA® should not be given to patients with active TB. Initiate treatment of latent TB before administering STELARA®. Patients should be monitored closely for signs and symptoms of active TB during and after treatment with STELARA®.

Malignancies

STELARA® is an immunosuppressant and may increase the risk of malignancy. Malignancies were reported among patients who received STELARA® in clinical studies. The safety of STELARA® has not been evaluated in patients who have a history of malignancy or who have a known malignancy.

Hypersensitivity Reactions

Serious allergic reactions, including angioedema and possible anaphylaxis, have been reported. Discontinue STELARA® and institute appropriate therapy if an anaphylactic or other serious allergic reaction occurs.

Reversible Posterior Leukoencephalopathy Syndrome (RPLS)

One case of RPLS has been reported in a STELARA®-treated patient. If RPLS is suspected, discontinue STELARA® and administer appropriate treatment. RPLS is a neurological disorder, which is not caused by an infection or demyelination. RPLS can present with headache, seizures, confusion, and visual disturbances. RPLS has been associated with fatal outcomes.

Immunizations

Prior to initiating therapy with STELARA®, patients should receive all immunizations recommended by current guidelines. Patients being treated with STELARA® should not receive live vaccines. BCG vaccines should not be given during treatment or within one year of initiating or discontinuing STELARA®. Exercise caution when administering live vaccines to household contacts of STELARA® patients, as shedding and subsequent transmission to STELARA® patients may occur. Non-live vaccinations received during a course of STELARA® may not elicit an immune response sufficient to prevent disease.

Concomitant Therapies

The safety of STELARA® in combination with other immunosuppressive agents or phototherapy has not been evaluated. Ultraviolet-induced skin cancers developed earlier and more frequently in mice genetically manipulated to be deficient in both IL-12 and IL-23 or IL-12 alone. The relevance of these findings in mouse models for malignancy risk in humans is unknown.

Theoretical Risk of Immunotherapy

Most Common Adverse Reactions

The most common adverse reactions (≥3% and higher than that with placebo) in clinical trials for STELARA® 45 mg, STELARA® 90 mg, or placebo were: nasopharyngitis (8%, 7%, 8%), upper respiratory tract infection (5%, 4%, 5%), headache (5%, 5%, 3%), and fatigue (3%, 3%, 2%), respectively.

25ST10209

STELARA® may decrease the protective effect of allergy immunotherapy and may increase the risk of allergic reaction to allergen immunotherapy. Exercise caution in patients receiving or who have received allergy immunotherapy, particularly for anaphylaxis.

Please see Brief Summary of Prescribing Information for STELARA® on the following pages. References: 1. STELARA® Prescribing Information. Horsham, PA: Janssen Biotech, Inc. 2. Leonardi CL, Kimball AB, Papp KA, et al; for the PHOENIX 1 study investigators. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1). Lancet. 2008;371(9625):1665-1674. 3. Papp KA, Langley RG, Lebwohl M, et al; for the PHOENIX 2 study investigators. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2). Lancet. 2008;371(9625): 1675-1684. 4. Data on file. Janssen Biotech, Inc.

4 14

25STSB12013

Brief Summary of Prescribing Information for STELARA® (ustekinumab) STELARA® Injection, for subcutaneous use See package insert for Full Prescribing Information INDICATIONS AND USAGE: STELARA® is indicated for the treatment of adult patients (18 years or older) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. CONTRAINDICATIONS: None. WARNINGS AND PRECAUTIONS: Infections STELARA® may increase the risk of infections and reactivation of latent infections. Serious bacterial, fungal, and viral infections were observed in subjects receiving STELARA® (see Adverse Reactions). STELARA® should not be given to patients with any clinically important active infection. STELARA® should not be administered until the infection resolves or is adequately treated. Instruct patients to seek medical advice if signs or symptoms suggestive of an infection occur. Exercise caution when considering the use of STELARA® in patients with a chronic infection or a history of recurrent infection. Serious infections requiring hospitalization occurred in the psoriasis development program. These serious infections included cellulitis, diverticulitis, osteomyelitis, viral infections, gastroenteritis, pneumonia, and urinary tract infections. Theoretical Risk for Vulnerability to Particular Infections Individuals genetically deficient in IL-12/IL-23 are particularly vulnerable to disseminated infections from mycobacteria (including nontuberculous, environmental mycobacteria), salmonella (including nontyphi strains), and Bacillus Calmette-Guerin (BCG) vaccinations. Serious infections and fatal outcomes have been reported in such patients. It is not known whether patients with pharmacologic blockade of IL-12/IL-23 from treatment with STELARA® will be susceptible to these types of infections. Appropriate diagnostic testing should be considered, e.g., tissue culture, stool culture, as dictated by clinical circumstances. Pre-treatment Evaluation for Tuberculosis Evaluate patients for tuberculosis infection prior to initiating treatment with STELARA ®. Do not administer STELARA® to patients with active tuberculosis. Initiate treatment of latent tuberculosis prior to administering STELARA®. Consider antituberculosis therapy prior to initiation of STELARA® in patients with a past history of latent or active tuberculosis in whom an adequate course of treatment cannot be confirmed. Patients receiving STELARA® should be monitored closely for signs and symptoms of active tuberculosis during and after treatment. Malignancies STELARA® is an immunosuppressant and may increase the risk of malignancy. Malignancies were reported among subjects who received STELARA® in clinical studies (see Adverse Reactions). In rodent models, inhibition of IL-12/IL-23p40 increased the risk of malignancy (see Nonclinical Toxicology). The safety of STELARA® has not been evaluated in patients who have a history of malignancy or who have a known malignancy. Hypersensitivity Reactions Serious allergic reactions, including angioedema and possible anaphylaxis, have been reported post-marketing. If an anaphylactic or other serious allergic reaction occurs, discontinue STELARA® and institute appropriate therapy [see Adverse Reactions]. Reversible Posterior Leukoencephalopathy Syndrome One case of reversible posterior leukoencephalopathy syndrome (RPLS) was observed during the clinical development program which included 3523 STELARA®-treated subjects. The subject, who had received 12 doses of STELARA® over approximately two years, presented with headache, seizures and confusion. No additional STELARA® injections were administered and the subject fully recovered with appropriate treatment. RPLS is a neurological disorder, which is not caused by demyelination or a known infectious agent. RPLS can present with headache, seizures, confusion and visual disturbances. Conditions with which it has been associated include preeclampsia, eclampsia, acute hypertension, cytotoxic agents and immunosuppressive therapy. Fatal outcomes have been reported. If RPLS is suspected, STELARA® should be discontinued and appropriate treatment administered. Immunizations Prior to initiating therapy with STELARA®, patients should receive all immunizations appropriate for age as recommended by current immunization guidelines. Patients being treated with STELARA® should not receive live vaccines. BCG vaccines should not be given during treatment with STELARA® or for one year prior to initiating treatment or one year following discontinuation of treatment. Caution is advised when administering live vaccines to household contacts of patients receiving STELARA® because of the potential risk for shedding from the household contact and transmission to patient. Non-live vaccinations received during a course of STELARA® may not elicit an immune response sufficient to prevent disease. Concomitant Therapies The safety of STELARA® in combination with other immunosuppressive agents or phototherapy has not been evaluated. Ultraviolet-induced skin cancers developed earlier and more frequently in mice genetically manipulated to be deficient in both IL-12 and IL-23 or IL-12 alone (see Nonclinical Toxicology). Theoretical Risk of Immunotherapy STELARA® has not been evaluated in patients who have undergone allergy immunotherapy. STELARA® may decrease the protective effect of allergy immunotherapy and may increase the risk of an allergic reaction to a dose of allergen immunotherapy. Therefore, caution should be exercised in patients receiving or who have received allergy immunotherapy, particularly for anaphylaxis. ADVERSE REACTIONS: The following serious adverse reactions are discussed elsewhere in the label: Infections (see Warnings and Precautions);

STELARA® (ustekinumab) Malignancies (see Warnings and Precautions); and RPLS (see Warnings and Precautions). Clinical Studies Experience The safety data reflect exposure to STELARA® in 2266 psoriasis subjects, including 1970 exposed for at least 6 months, 1285 exposed for at least one year, and 373 exposed for at least 18 months. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Adverse reactions listed below are those that occurred at a rate of at least 1% and at a higher rate in the STELARA® groups than the placebo group during the placebo-controlled period of STUDY 1 and STUDY 2. The numbers (percentages) of adverse reactions reported for placebotreated patients (n=665), patients treated with 45 mg STELARA® (n=664), and patients treated with 90 mg STELARA ® (n=666), respectively, were: Nasopharyngitis: 51 (8%), 56 (8%), 49 (7%); Upper respiratory tract infection: 30 (5%), 36 (5%), 28 (4%); Headache: 23 (3%), 33 (5%), 32 (5%); Fatigue: 14 (2%), 18 (3%), 17 (3%); Diarrhea: 12 (2%), 13 (2%), 13 (2%); Back pain: 8 (1%), 9 (1%), 14 (2%); Dizziness: 8 (1%), 8 (1%), 14 (2%); Pharyngolaryngeal pain: 7 (1%), 9 (1%), 12 (2%); Pruritus: 9 (1%), 10 (2%), 9 (1%); Injection site erythema: 3 (<1%), 6 (1%), 13 (2%); Myalgia: 4 (1%), 7 (1%), 8 (1%); Depression: 3 (<1%), 8 (1%), 4 (1%). Adverse drug reactions that occurred at rates less than 1% included: cellulitis and certain injection site reactions (pain, swelling, pruritus, induration, hemorrhage, bruising, and irritation). One case of RPLS occurred during clinical trials (see Warnings and Precautions). Infections In the placebocontrolled period of clinical studies of psoriasis subjects (average follow-up of 12.6 weeks for placebo-treated subjects and 13.4 weeks for STELARA®-treated subjects), 27% of STELARA®-treated subjects reported infections (1.39 per subject-year of follow-up) compared with 24% of placebo-treated subjects (1.21 per subject-year of follow-up). Serious infections occurred in 0.3% of STELARA®treated subjects (0.01 per subject-year of follow-up) and in 0.4% of placebotreated subjects (0.02 per subject-year of follow-up) (see Warnings and Precautions). In the controlled and non-controlled portions of psoriasis clinical trials, 61% of STELARA®-treated subjects reported infections (1.24 per subjectyear of follow-up). Serious infections were reported in 0.9% of subjects (0.01 per subject-year of follow-up). Malignancies In the controlled and non-controlled portions of psoriasis clinical trials, 0.4% of STELARA®-treated subjects reported malignancies excluding non-melanoma skin cancers (0.36 per 100 subjectyears of follow-up). Non-melanoma skin cancer was reported in 0.8% of STELARA®-treated subjects (0.80 per 100 subject-years of follow-up) (see Warnings and Precautions). Serious malignancies included breast, colon, head and neck, kidney, prostate, and thyroid cancers. Immunogenicity The presence of ustekinumab in the serum can interfere with the detection of anti-ustekinumab antibodies resulting in inconclusive results due to assay interference. In STUDIES 1 and 2, antibody testing was done at time points when ustekinumab may have been present in the serum. In STUDY 1 the last ustekinumab injection was between Weeks 28 and 48 and the last test for anti-ustekinumab antibodies was at Week 52. In STUDY 2 the last ustekinumab injection was at Week 16 and the last test for anti-ustekinumab antibodies was at Week 24. In STUDY 1 (N=743), antibody results were found to be positive, negative, and inconclusive in 38 (5%), 351 (47%), and 354 (48%) patients, respectively. In STUDY 2 (N=1198), antibody results were found to be positive, negative, and inconclusive in 33 (3%), 90 (8%), and 1075 (90%) patients, respectively. The data reflect the percentage of subjects whose test results were positive for antibodies to ustekinumab in a bridging immunoassay, and are highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody positivity in an assay may be influenced by several factors, including sample handling, timing of sample collection, concomitant medications and underlying disease. For these reasons, comparison of the incidence of antibodies to ustekinumab with the incidence of antibodies to other products may be misleading. Postmarketing Experience Adverse reactions have been reported during postapproval use with STELARA®. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to STELARA® exposure. Immune system disorders: Serious allergic reactions (including angioedema, dyspnea and hypotension), hypersensitivity reactions (including rash and urticaria). DRUG INTERACTIONS: Drug interaction studies have not been conducted with STELARA®. Live Vaccines Live vaccines should not be given concurrently with STELARA® (see Warnings and Precautions). Concomitant Therapies The safety of STELARA® in combination with immunosuppressive agents or phototherapy has not been evaluated (see Warnings and Precautions). CYP450 Substrates The formation of CYP450 enzymes can be altered by increased levels of certain cytokines (e.g., IL-1, IL-6, IL-10, TNFα, IFN) during chronic inflammation. Thus, STELARA®, an antagonist of IL-12 and IL-23, could normalize the formation of CYP450 enzymes. Upon initiation of STELARA® in patients who are receiving concomitant CYP450 substrates, particularly those with a narrow therapeutic index, monitoring for therapeutic effect (e.g., for warfarin) or drug concentration (e.g., for cyclosporine) should be considered and 15

® will berisks nursing woman. The unknown to the infant from expected that STELARA present in human milk. gastrointestinal It is not known orif systemic exposure to ustekinumab be weighed against the known ustekinumab is absorbed systemicallyshould after ingestion; however, published data benefits that of breast-feeding. Ustekinumab excreted in the milk ofand lactating suggest antibodies in breast milk doisnot enter the neonatal infant monkeys administered IgG is excreted in human milk, so it of is circulation in substantialustekinumab. amounts. Pediatric Use Safety and effectiveness ® will be expected®that STELARApatients present in human milk. It is notUse known STELARA in pediatric have not been evaluated. Geriatric Of theif ®, a total however, ustekinumab absorbedexposed systemically after ingestion; published data 2266 psoriasisis subjects to STELARA of 131 were 65 years or suggest antibodies in breast do notAlthough enter the neonatal and infant older, andthat 14 subjects were 75 yearsmilk or older. no differences in safety circulation in substantial Pediatric Use Safety and effectiveness or efficacy were observedamounts. between older and younger subjects, the number of ® in pediatric STELARAaged patients not been evaluated.whether Geriatric Userespond Of the subjects 65 and over is nothave sufficient to determine they 2266 psoriasis STELARA®, a Single total ofdoses 131 were or differently from subjects younger exposed subjects.toOVERDOSAGE: up to65 4.5years mg/kg older, and 14 subjects were 75 years orinolder. Although differences in safety intravenously have been administered clinical studiesnowithout dose-limiting or efficacy wereofobserved between older and younger subjects, of toxicity. In case overdosage, it is recommended that the patientthe be number monitored subjects aged or 65 symptoms and over is ofnotadverse sufficient to determine whether respond for any signs reactions or effects andthey appropriate differently fromtreatment younger subjects. OVERDOSAGE: Single doses upCOUNSELING to 4.5 mg/kg symptomatic be instituted immediately. PATIENT intravenously have been patients administered in the clinical studies without dose-limiting INFORMATION: Instruct to read Medication Guide before starting toxicity. In® case of overdosage, is recommended thateach the patient monitored STELARA therapy and to rereaditthe Medication Guide time thebeprescription forrenewed. any signsInfections or symptoms adversethat reactions and the appropriate is Informofpatients STELARAor® effects may lower ability of symptomatic treatment be instituted PATIENT COUNSELING their immune system to fight infections.immediately. Instruct patients of the importance of INFORMATION: Instruct patients to read the Medication before starting communicating any history of infections to the doctor, Guide and contacting their ® therapy STELARA andany to reread the Medication Guide each time Patients the prescription doctor if they develop symptoms of infection. Malignancies should ® may is renewed. Infections Inform that STELARA lower the ability ®of. be counseled about the riskpatients of malignancies while receiving STELARA their immune system to fight infections. patients of theattention importance of Allergic Reactions Advise patients to seekInstruct immediate medical if they communicating any history infections to reactions. the doctor, and contacting their experience any symptoms of of serious allergic doctor if they develop any symptoms of infection. Malignancies Patients should ®. Prefilled Syringe by: Janssenwhile Biotech, Inc., STELARA Horsham, be counseled aboutManufactured the risk of malignancies receiving PA 19044, License No. 1864 toatseek Baxter Pharmaceutical Solutions, Allergic Reactions Advise patients immediate medical attention if they Bloomington, 47403 of serious allergic reactions. experience anyIN symptoms Vial Manufactured by: Janssen Biotech, Inc., Horsham, PA 19044, License Prefilled Syringe Manufactured by:Switzerland Janssen Biotech, Inc., Horsham, No. 1864 at Cilag AG, Schaffhausen, PA 19044, License No. 1864 at Baxter Pharmaceutical Solutions, © Janssen Biotech, Inc. 2012 25ST12050 Bloomington, IN 47403

STELARA® (ustekinumab)

the individual dose of the drug adjusted as needed (see Clinical Pharmacology). USE IN SPECIFIC POPULATIONS: Pregnancy Pregnancy Category B There are no studies of STELARA® in pregnant women. STELARA® should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. No teratogenic effects were observed in the developmental and reproductive toxicology studies performed in cynomolgus monkeys at doses up to 45 mg/kg ustekinumab, which is 45 times (based on mg/kg) the highest intended clinical dose in psoriasis patients (approximately 1 mg/kg based on administration of a 90 mg dose to a 90 kg psoriasis patient). Ustekinumab was tested in two embryo-fetal development toxicity studies. Pregnant cynomolgus monkeys were administered ustekinumab at doses up to 45 mg/kg during the period of organogenesis either twice weekly via subcutaneous injections or weekly by intravenous injections. No significant adverse developmental effects were noted in either study. In an embryo-fetal development and pre- and post-natal development toxicity study, three groups of 20 pregnant cynomolgus monkeys were administered subcutaneous doses of 0, 22.5, or 45 mg/kg ustekinumab twice weekly from the beginning of organogenesis in cynomolgus monkeys to Day 33 after delivery. There were no treatment-related effects on mortality, clinical signs, body weight, food consumption, hematology, or serum biochemistry in dams. Fetal losses occurred in six control monkeys, six 22.5 mg/kg-treated monkeys, and five 45 mg/kg-treated monkeys. Neonatal deaths occurred in one 22.5 mg/kg-treated monkey and in one 45 mg/kgtreated monkey. No ustekinumab-related abnormalities were observed in the neonates from birth through six months of age in clinical signs, body weight, hematology, or serum biochemistry. There were no treatment-related effects on functional development until weaning, functional development after weaning, Vial Manufactured by: Janssen Biotech, Inc., Horsham, PA 19044, License morphological development, immunological development, and gross and No. 1864 at Cilag AG, Schaffhausen, Switzerland histopathological examinations of offsprings by the age of 6 months. Nursing © Janssen Biotech, Inc. 2012 25ST12050 Mothers Caution should be exercised when STELARA® is administered to a nursing woman. The unknown risks to the infant from gastrointestinal or systemic exposure to ustekinumab should be weighed against the known benefits of breast-feeding. Ustekinumab is excreted in the milk of lactating monkeys administered ustekinumab. IgG is excreted in human milk, so it is expected that STELARA® will be present in human milk. It is not known if ustekinumab is absorbed systemically after ingestion; however, published data suggest that antibodies in breast milk do not enter the neonatal and infant circulation in substantial amounts. Pediatric Use Safety and effectiveness of STELARA® in pediatric patients have not been evaluated. Geriatric Use Of the 2266 psoriasis subjects exposed to STELARA®, a total of 131 were 65 years or older, and 14 subjects were 75 years or older. Although no differences in safety or efficacy were observed between older and younger subjects, the number of subjects aged 65 and over is not sufficient to determine whether they respond differently from younger subjects. OVERDOSAGE: Single doses up to 4.5 mg/kg intravenously have been administered in clinical studies without dose-limiting toxicity. In case of overdosage, it is recommended that the patient be monitored for any signs or symptoms of adverse reactions or effects and appropriate I0026_CAPG_JrnlAd.indd 6 symptomatic treatment be instituted immediately. PATIENT COUNSELING INFORMATION: Instruct patients to read the Medication Guide before starting STELARA® therapy and to reread the Medication Guide each time the prescription is renewed. Infections Inform patients that STELARA® may lower the ability of I0026_CAPG_JrnlAd.indd 6 DRAFTFCB HealthCare CAD Router their immune system to fight infections. Instruct patients of the importance of File Name: I0026_CAPG_JrnlAd.indd Art Director: Krista H. (x2450) communicating any history of infections to the doctor, and contacting their doctor if they develop any symptoms of infection. Malignancies Patients should Location: PrePress Production: Joseph B. (x 2895) be counseled about the risk of malignancies while receiving STELARA ®. Client: Centocor Traffic Person: Kyra A.(x 3379) DRAFTFCBStelara HealthCare Allergic Reactions Advise patients to seek immediate medical attention if they Product: MM Mac Operator: Lloyd, WC CAD Router File #: Name: 3CNT_STEL_I0026 I0026_CAPG_JrnlAd.indd Art Director: 05.17.12 Krista H. (x2450) experience any symptoms of serious allergic reactions. Job Date:

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Save the Dates for Two Co-Located Conferences at the Beverly Hilton Hotel, Los Angeles, CA Hybrid Conferences/Internet Events — participate onsite or online. Details on Website.

The THIRD NATIONAL

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The Leading Forum on Accountable Care Organizations (ACOs) and Related Delivery System and Payment Reform

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October 30 – November 1, 2012 The NATIONAL

The Leading Forum on Managing the Care and Cost of Medicare/Medicaid Dual Eligibles

Dual Eligibles Summit October 30 – 31, 2012 www.DualEligiblesSummit.com

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PODIATRIC MEDICINE An Essential Benefit

cian also works as a multidisciplinary team member with vascular and infectious disease specialists, general surgeons, diabetologists, and orthopedic surgeons. Their participation in the early diagnosis and treatment of diabetic and Karen Wrubel, DPM, President-Elect, California Podiatric Medical vascular problems prevents Association (viewing an x-ray of a diabetic patient) ulcerations, infections, hospitalizations, and potential loss of limbs. When ulcers and other types of wounds t the National Governors’ Asare not seen in a timely manner, podiatsociation winter meeting in February, 2012 ric physicians serve as particularly skilled – in spite of differing opinions on a wide wound management, debridement, and variety of healthcare issues – all agreed on – when necessary – limb salvage specialthe goals of: 1) improving outcomes and 2) ists, performing procedures that maintain reducing costs. At this meeting, Howard functionality of the affected limb. Sixty K. Koh, MD, MPH, HHS Assistant Secretary percent of all amputations are diabetes for Health, stated, “We need to move from related, and eighty-five percent of these sick-care to a prevention system where are preceded by an ulceration. Many ulcare is delivered as early as possible.” In a cerations are preventable, and those that managed care environment, wellness and do occur are treatable, with amputations preventing the complications of chronic being avoidable when access to care is disease are areas in which effectively rapid. utilizing the skills of podiatric physicians The “Thomson Reuters Healthcare adds significant value in terms of both Study” published in 2011 demonstrated improving outcomes and reducing costs. that over a three-year time period, comSome of this value is already recognized mercial insurance saved an average of by managed care organizations. However, $19,686 per commercially insured patient, what may not be fully recognized is the and Medicare saved an average of $4,271 expanded training and role of today’s pofor those patients who had visited a podiatric physicians as integral members of diatrist at least once. Also determined was care teams, which contributes significant that among Medicare-eligible patients, value. each $1 invested in podiatric care results Today’s podiatric physicians complete a in $9 to $13 in savings. Extrapolating from four year curriculum at accredited podiatthe results of this study, it is estimated that ric medical schools, followed by comprepodiatric visits could potentially save the hensive three-year residency programs healthcare system $3.5 billion per year in in which the required medical rotations complications related exclusively to diaare completed side-by-side with MDs and betic foot complications. DOs. The podiatric resident is expected to It is not just in the prevention and treatperform at the same level as those in other ment of the complications of diabetes that medical specialties. podiatric physicians are able to improve While podiatric surgical training is fooutcomes while saving money. In addition cused primarily on foot and ankle reconto reducing patients’ pain and improving structive procedures, the podiatric physitheir function, “keeping people walking

By Jon A. Hultman, DPM, MBA, Executive Director, California Podiatric Medical Association

and active” is one of the outcomes of just about every type of care provided by doctors of podiatric medicine – whether that care is biomechanical, medical, or surgical, and a minimum of thirty minutes of “walking” each day has been proven through numerous studies to have a significant impact on the reduction or even prevention of the costly complications of chronic conditions such as obesity, diabetes type II, ischemic heart disease, stroke, hypertension, osteoporosis, depression, and even some cancers. Prevention and treatment of complications related to these chronic conditions are best achieved through a coordinated care team approach in which podiatric physicians are integral members of the team. In California, expectations are that managed care organizations and ACOs will be able to coordinate care more effectively among physicians and hospitals, reducing the cost of care while improving outcomes – especially in the area of wellness and the management and prevention of the complications of chronic disease. 1.3 million dual eligible Californians (those on both Medicare and Medi-Cal) are expected to be moved into managed care programs, and this population of patients typically has chronic conditions for which the potential for complications is high. There is mounting evidence demonstrating that when podiatric physicians are an integral part of the medical care team, costs are reduced and outcomes improved – especially when continuity of care is maintained and patients have relatively quick access to prevent “simple” problems from progressing to something more serious. Link to Thompson Reuters study: htttp://www.apma.org/TRstudy n

President Obama Delivers Remarks At LGBT Gala

resident Obama was in Los Angeles on June 6, 2012 where he delivered remarks to a standing ovation at the LGBT Leadership Council Gala at the Regent Beverly Wilshire. Approximately 600 gay rights supporters attended the event, paying $1250 a ticket. Speakers included: Ellen DeGeneres; L.A. Mayor and 2012 Democatic National Convention Chair, Antonio Villaraigosa; CA Attorney GeneralKamala Harris; Speaker of the California State Assembly and 46th District Representative John Perez; and Founder of City of Refuge United Church of Christ, Bishop Yvette Flunder. Also in attendance were:Chad Griffin, incoming president of the Human Rights Campaign; Barry Karas, LGBT Leadership Council Chair; and Actor Dana Perlman, LGBT Leadership Council Co-Chair; Pauley Perrette, NCIS, Actor; Jesse Tyler Ferguson of the hit TV show, Modern Family; and Peter Roth, CEO of Warner Brothers Television. Also in attendance was Cher, who has a transgender son, Chaz Bono. Dr. Vito Imbasciani, a urological surgeon from Los Angeles, a Colonel in the Army National Guard and Chief Medical Officer for the California State National Guard, introduced President Obama to the celebratory crowd with a powerful story of his experience as a gay man in the military: “Twenty-six years ago, as a surgery intern at Yale New Haven Hospital, I raised my hand and took the oath that made me an officer in the Medical Corps of the United States Army. I have maintained that Presidential

commission to this day. It has allowed me the privilege, through four deployments in two wars, to care for hundreds of American soldiers, men and women, on battlefields whose names you are all familiar with. The Army did not finance my medical education, which means that my service to the Nation has been and continues to be completely voluntary. And until September 20th of last year, the price of my service and patriotism was to live a lie. Because of Don’t Ask Don’t Tell, each time I went off to war, no one was at the armory to see me off. No one was waiting at the airport when I returned. My partner, George Di Salvo, and I started a family 5 years ago by adopting two wonderful boys of Mexican heritage born here in California. I kept their existence secret because that’s what the law required. But not anymore. Thanks to the unyielding efforts of President Obama, I can serve my country openly and proudly, with my family at my side. I think back to all the soldiers and Marines – some sick, some wounded, some dying – I have cared for on the Nation’s battlefields, from Saudi Arabia in Desert Storm, and from little hellholes in Iraq, to the great surgical amphitheaters at the American Hospital in Landstuhl, Germany, and finally, last year, tending to the Wounded Warriors in Salt Lake City. I didn’t talk about myself to my patients, but if I had, I know in my heart that not a one of them would have cared whether I was gay or straight. I persevered in my military career in part because military service is a proud tradition in my family, iIn which we find great honor in giving back to the country that has given so much to us. And so I was not willing to sacrifice that service or honor to the unfounded fears of others. I always knew that, someday, the values that make our country great – fairness and opportunity, justice and equality – would

By Valerie Okunami

endure. And so they have. If the Army calls again, and they might, you can be sure that George and our sons, Raymond and Isaak, will be there, waving American flags with all the other military families at the armory or the coming home ceremony. And if you had told me 25 years ago, when I first took the oath to serve, that this would be my story, and that I would meet the man who has enabled me to tell it, I would not have thought it possible. But this is a President who has challenged every one of us to expand our imagination of the possible. And as he has made clear, “we are not a nation that says ‘don’t ask, don’t tell.’ We are a nation that says, ‘out of many, we are one.’ “ So, ladies and gentlemen, it is my honor and privilege to present to you the man you all call the President of the United States, and whom I call my Commander in Chief, President Barack Obama.” The evening came nearly a month after President Obama announced his support for same-sex marriages and was in contrast with a similar gala held in New York City a year ago. This year, the Gala raised at least $2.5 million and was so successful that it was moved to a larger venue. A star-studded, private, celebrity dinner followed for 70 people, with ticket prices at $25,000 each, or $40,000 a couple. The dinner was held at the Beverly Hills home of Ryan Murphy, creator of “Glee,” and his fiancé, photographer David Miller. Among the stars in attendance were Reese Witherspoon, Jane Lynch of “Glee” and Julia Roberts. Proceeds from the events went to the Obama Victory Fund, a joint fundraising committee of Obama for America, the Democratic Committee and several state Democratic parties. n 19

NAMES I N T H E N E W S ANDREW SNYDER, M.D., JOINS BROWN & TOLAND PHYSICIANS AS CHIEF MEDICAL OFFICER Andrew Snyder, M.D., is joining Brown & Toland Physicians as chief medical officer beginning April 23. A board-certified pediatrician providing primary care and specializing in children with special healthcare needs and chronic disease, Dr. Snyder has a very broad background in healthcare. Most recently he was the founder, president and chief executive officer of Stamford Health Integrated Practices (SHIP), of Stamford, Conn., where he managed the clinical and corporate operations. In addition to his professional experience, Dr. Snyder has held faculty positions with Brown Medical School. He is a graduate of the University of Connecticut Medical School. “The healthcare industry is quickly evolving,” said Richard Fish, Brown & Toland Chief Executive Officer. “Our goal as an organization is to remain industry leaders and to find creative solutions to problems or issues that affect independent physicians. We are excited to have Dr. Snyder join us at Brown & Toland, and look forward to his many contributions to our organization.” Added Dr. Snyder, “Brown & Toland has a national reputation, a strong physician network, and an innovative company culture. I am excited to join the Brown & Toland team and look forward to working with its physician network.” Dr. Snyder is replacing Stan Padilla, M.D., who is stepping down after serving 12 years as Brown & Toland’s chief medical officer.

DAVITA AND HEALTHCARE PARTNERS ANNOUNCE MERGER AGREEMENT DaVita Inc. a leading provider of kidney care services for those diagnosed with chronic kidney disease (CKD), and HealthCare Partners, the country’s largest operator of medical groups and physician networks, announced today that they have entered into a definitive merger agreement. The two companies expect to close the transaction early in the fourth quarter of this year. Upon closing, the combined company will be named DaVita HealthCare Partners Inc. Robert Margolis, MD, the Chairman and CEO of HealthCare Partners, said, “The entire 20

HealthCare Partners leadership team is excited to find in DaVita a partner who shares our passion for and commitment to clinical quality. We were also attracted to its highly respected culture and demonstrated ability to grow in this time of unparalleled opportunity for accountable care organizations.” Upon completion of the merger, HealthCare Partners will operate as a separate subsidiary of DaVita HealthCare Partners. The current HealthCare Partners senior management team has committed to stay and continue to manage the existing business, and Dr. Margolis will join the board of directors and become Co-Chairman of the combined enterprise alongside Kent Thiry, Chairman and CEO of DaVita.

CHILDREN’S HEALTH DISCREPANCIES The health of children is all over the map as evidenced by the first-ever release of childhood overweight and obesity by city. Over 250 California cities were analyzed for the study conducted by the UCLA Center for Health Policy Research and the California Center for Public Health Advocacy. The report reveals shocking discrepancies based on locale. While 38 percent of the state’s children are overweight or obese, city ranges are as low as 11 percent to as high as 53 percent. Nationally, the incidence of overweight and obesity has tripled for adolescents (ages 12 to 19) and quadrupled among children 6 to 11 years old. In addition to immediate physical and mental health consequences, obesity among youth significantly increases the potential for diabetes, heart disease and some cancers and costs California families, employers, the healthcare industry and the taxpayers more than $21 billion each year. Given the impact of obesity on children, even cities that registered relatively low overweight/obesity percentages need to act. These new numbers provide community leaders with a barometer of their community’s health and place renewed emphasis on the need to develop local policies that make the health of children a top priority. Here is the link to the public health advocacy website where you can find the entire report, state and county fact sheets, and recommendations: http://www. publichealthadvocacy.org/research_overweight2010.html

“LET’S GET HEALTHY CALIFORNIA” TASK FORCE APPOINTED California Health and Human Services Agency Secretary, Diana S. Dooley announced today the members appointed to the Let’s Get Healthy California Task Force and the Expert Advisors charged with developing a 10-year plan to make Californians healthier. The Task Force will be Co-Chaired by Secretary Dooley and Don Berwick, MD MPP who is a senior fellow at the Center for American Progress, is the former president and CEO of the Institute for Healthcare Improvement and served by appointment of President Obama as the Administrator of the Centers for Medicare and Medicaid Services until December, 2011. The Task Force and the Expert Advisors will work together to gather, evaluate and prioritize the best ideas and practices and organize them into a 10-year plan to improve quality, control costs, promote personal responsibility for individual health, and advance health equity. The report will establish baselines for key health indicators, identify obstacles, inventory best practices, provide fiscally prudent recommendations and create a sensible framework for measuring improvements in key areas including: • Reducing diabetes, asthma, childhood obesity, hypertension, and sepsis-related mortality. • Reducing hospital readmissions with 30 days of discharge. • Increasing the number of children receiving recommended vaccines by age three.

UCSF RECEIVES TRANSFORMATIVE GIFT FOR NEUROSCIENCE RESEARCH AND CARE FROM SANDLER FOUNDATION UCSF has received a challenge gift of $20 million from the Sandler Foundation that will provide major support for the university’s groundbreaking research and clinical care efforts regarding neurological diseases. The Sandler Neurosciences Center signifies a milestone in the evolution of UCSF’s world-class neuroscience enterprise. The five-story, 237,000 square foot building will bring under one roof several of the continued on next page

UPCOMING E VENTS CAPG Pharmaceutical Care Committee

CAPG Inland Empire Regional Committee

July 10, 2012 Los Angeles, CAPG Office *

August 15, 2012 Riverside, CA *

CAPG Medical Policy Committee

CAPG Contracts Committee (So Cal)

July 17, 2012 Los Angeles, CAPG Office *

August 23, 2012 Los Angeles, CAPG Office *

CAPG Information Technology Committee

CAPG General Membership (So Cal) & Human Resources Committee

July 24, 2012 Los Angeles, CAPG Office *

September 11, 2012 Los Angeles, CAPG Office *

CAPG San Diego Regional Committee

CAPG General Membership (No Cal)

July 25, 2012 San Diego, CA *

CAPG Public Relations/Marketing Committee July 31, 2012 Los Angeles, CAPG Office *

CAPG San Diego Regional Committee August 1, 2012 San Diego, CA *

September 12, 2012 Oakland, CA *

CAPG Contracts Committee (No Cal) September 20, 2012 Oakland, CA*

CAPG State Government Programs Committee September 25, 2012 Los Angeles, CAPG Office * For more information contact CAPG at (213) 642-CAPG

If you have an event to submit for this column, please do so at CAPGHealth@CAPG.org Please include the name of the event, the date, location and where to get additional information. continued from page 20 worldâ&#x20AC;&#x2122;s leading clinical and basic research programs, providing an environment that encourages a cross-pollination of ideas and collaboration. The goal of the building is to support UCSFâ&#x20AC;&#x2122;s efforts to find new diagnostics, treatments and cures for a number of intractable neurological disorders, including Alzheimerâ&#x20AC;&#x2122;s disease, Parkinsonâ&#x20AC;&#x2122;s disease, multiple sclerosis, stroke, migraine, epilepsy, autism and other neurological diseases. At full capacity, the building will house approximately 100 principal investigators and their research teams, who will use cutting-edge neuroimaging, genetics and other technologies to advance understanding of the brain and neurological diseases. The space itself was designed to support the movement of discoveries from the basic science labs on the top floors of the building to the clinical research space on the first floor. n

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Understanding and anticipating the evolution of group practices is fundamental to our nature. Innovation is accompanied by risk and we support your ongoing investment in the improvement of cost-efﬁcient and quality patient care. We want to help your practice overcome the inherent barriers to achieving these goals. To reinforce your efforts, we offer a variety of unique resources and programs that range from disease state education to guidance on the latest health care trends and quality measures. As your identity continues to evolve, so does our commitment to you. MedGroupResources.com is your dedicated online connection to Pﬁzer group practice services and resources. Log on to begin our partnership. We look forward to a shared future of innovating and improving patient care.

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Printed in USA/May 2012

Brown & Toland’s Pioneer ACO: Years in the Making

ith the popularity of HMO products declining and fee-for-service products gaining traction in Northern California in the early 2000s, Brown & Toland Physicians, San Francisco’s largest independent practice association, launched a clinical integration initiative to coordinate the delivery of care and to improve the health of the hundreds of thousands of Brown & Toland HMO and PPO patients. That program, which included deployment of an electronic health record to hundreds of independent physician practices, combined with innovative health and care management programs, helped form the foundation of Brown & Toland’s accountable care model. This model is the basis for our Pioneer Accountable Care Organization (ACO). Brown & Toland’s ACO model embraces the three-part aim of improving the health of populations of patients, improving the patient experience and delivery of care through care coordination, and reducing the cost of care. Selected physicians in both San Francisco and the Bay Area’s East Bay are participating in Brown & Toland’s Pioneer ACO program, and the CMS Innovation Center has aligned about 17,000 Medicare fee-for-service (FFS) patients with Brown & Toland’s Pioneer ACO program. Brown & Toland’s approach to the Pioneer ACO program is a “care management convener” model. This care management model concentrates on patients who have several chronic conditions. Brown & Toland’s care managers work closely with patients’ physicians and under the guidance of the group’s medical directors. The model focuses on key diseases and aims to reduce avoidable acute inpatient admissions and unnecessary visits to emergency rooms. Brown & Toland’s “Transitions of Care” program facilitates the coordination of patients’ needs when they are discharged from an acute inpatient or emergency department setting. Services include patient safety checks, chronic condition self-management education, medication instructions, and other services. Brown & Toland also of-

fers proactive care management services to patients who are identified by our risk stratification tool. This tool helps the care teams identify patients who need immediate assistance and those who may be at risk in the near future.

Challenges Providing care management services to Medicare beneficiaries aligned with Brown & Toland’s Pioneer ACO program has its challenges. While these Medicare beneficiaries have previously accessed care from Brown & Toland doctors, they may not be familiar with the Brown & Toland organization or its care management services. One challenge is to help beneficiaries understand the value provided by Brown & Toland’s care management services. To bridge this gap, Brown & Toland’s care managers work closely with the patients’ doctors and group physicians to coordinate these services and to demonstrate their value. An additional challenge has been aggregating and integrating multiple data sources for Pioneer ACO-aligned patients. This required Brown & Toland to build data receptacles, integrating data from multiple sources, in various formats, to support the program. We have been able to leverage our health IT infrastructure to streamline the implementation of a successful Pioneer ACO system. Finally, Medicare beneficiaries aligned with Brown & Toland’s Pioneer ACO do not have network or access restrictions typically associated with HMO products. Pioneer ACO beneficiaries may access care or services from any Medicare-participating provider or supplier in the country, and prior authorizations for care are not required. This presents a challenge when beneficiaries receive care or services outside of our area and outside of our reach for coordination. Brown & Toland needs to continually evaluate our care management programs to determine if they demonstrate added value – not just to CMS in terms of improved health care quality and reduced costs, but also to beneficiaries in their experience of accessing health care. Continual evaluation often means considering workflow changes and system

By Keith Pugliese Vice President, ACO and Compliance Brown & Toland Physicians

modifications at the IPA level.

Patient/Consumer Advisory Board Provides Guidance Brown & Toland’s Board established a Patient/Consumer Advisory Group to provide a forum for discussion of the needs of patients and a channel for meaningful input that can be integrated into our programs. The group participates in discussions on the needs of current and prospective patients incare management, customer service, community needs, and communication. With benefit of the knowledge, ideas, and experiences of patients, Brown & Toland strives to improve the effectiveness and adoption of its programs. The committee includes members of our Board of Directors, key executive leadership, and representatives from the San Francisco Institute on Aging and CalPACE (the California PACE Association), which is dedicated to the expansion of comprehensive health care services to the frail elderly through the Program of All-inclusive Care for Elderly (PACE). Developing and providing a comprehensive accountable care program for thousands of patients requires a financial commitment to build sophisticated health information and financial reporting technology infrastructures, innovative care management programs, and a talented and dedicated network of physicians and other healthcare providers. With the right tools in place, much hard work, and a core value system that places an emphasis on doing what’s right for the patient, an organization can ultimately improve health care outcomes for patients and reduce costs. n 23

Roundtable on Medicare Physician Payment Policy: Lessons from the Private Sector Statement from Darryl Cardoza, CEO, Hill Physicians Medical Group to United States Senate Committee on Finance June 14, 2012

hairman Baucus, Ranking Member Hatch, and members of the Finance Committee. Thank you for the opportunity to participate in this roundtable to discuss Medicare physician payment reform – it is a privilege and an honor. I believe this issue is an important ingredient to the financial solvency of Medicare and I commend the Committee in its efforts to hear from all stakeholders in the public and private sectors. My name is Darryl Cardoza and I am the Chief Executive Officer of Hill Physicians Medical Group (“Hill Physicians”). Hill Physicians was formed in 1983 and is now one of the nation’s largest independent physician associations (IPAs). We have more than 3,500 participating primary care physicians and specialists across Northern California, serving 300,000 patients. Hill Physicians’ organization is based on the “delegated model” framework, which has had good success in California. Under the delegated model, a health plan contracts with physician organizations on a capitated basis and delegates responsibilities to these organizations to arrange for the medical care of the plan’s enrollees. A delegated physician organization generally accepts responsibility for all physician services provided to enrollees that select the physician group for their physician services. Operating under this model, Hill Physicians’ services go beyond simply providing medical care. We use our organizational infrastructure to enable and encourage care coordination, credential physicians, ensure appropriateness in the provision of clinical services, drive quality improvement, and manage risk associated with population-based payments. Hill Physicians is responsible for paying its affiliated physicians for the services provided to patients assigned to us by the health plans. I will discuss below some payment innovations we use to encourage physicians to optimize value for the people we serve by 24

providing quality services, while striving to improve affordability . Hill Physicians has been committed to developing and operating a coordinated care model as the key to achieving an efficient, high quality health care delivery system. Hill Physicians has been operating under this principle and implementing a model to support this vision since its inception. As such, we believe that we serve as a good, real-world example of how an accountable care organization can achieve the goals of the Affordable Care Act. Hill Physicians can be described as a “virtual physician organization,” in that we have organized a large number of independent, self- employed physicians into a single, accountable organization that is able to provide a specified scope of services for a specified price. Most of the physician practices that constitute our group are comprised of less than six physicians. In a country in which most physician practices are small and provide only a narrow scope of services, our organization creates an environment that enables integration and care management across a wide spectrum of services and providers so that the whole is greater than the sum of its parts. Hill Physicians thus allows individual, small physician practices to be a part of a broad system of coordinated care. Hill Physicians’ organizational and management infrastructure has allowed it to be a nationally recognized leader in clinical quality, technological adoption, and the development of innovative healthcare delivery approaches such as Accountable Care Organizations (ACOs). Hill Physicians was among the initial organizers and proponents of the “Pay for Performance” program developed by the Integrated Healthcare Association in California and has consistently been rated as among the top performing medical groups in California by independent oversight organizations. In 2009, Hill Physicians became the physician organization component of an ACO to serve 40,000 members of CalPERS in the Sacramento area. This nationally watched program, a collaboration with Dignity Health hospitals and Blue Shield of California, reduced costs during the first year of operation by $20 million. Those cost reductions have been sustained and even increased in years two and three, as the program continues.

By Darryl Cardoza

CEO, Hill Physicians Medical Group

PHYSICIAN COMPENSATION MODELS As noted above, Hill Physicians receives a capitated per-member, per-month payment from health plans and is responsible for paying each participating provider. This has allowed us to use innovative physician payment models to reduce practice variability, improve quality and moderate escalation of costs. Hill Physicians’ compensation plan for our physician network is primarily feefor-service based, but with some material innovations as outlined below:

Primary Care Compensation Hill Physicians pays primary care physicians using a hybrid model of fee-for-service and performance based compensation. The fee-for-service component encourages physician access and availability for our patients. The fee-for-service rate is lower than the Medicare fee schedule and less than what is generally regarded to be required to sustain a viable practice. However, this rate is supplemented by a quarterly primary care management fee (“PMF”) that results in our network physicians being paid at an average rate that is considerably higher than Medicare. The amount of this fee earned varies based on individual practice performance. Performance metrics are established for quality of care, using industry standard, evidence-based measures, such as HEDIS measures, and for utilization performance, using measures based on services provided in the practice, referrals to specialists, use of diagnostic services, E.R. usage, and inpatient utilization. Additionally, physicians are evaluated based on their participation in activities that support care coordination and the Hill Physicians organization and infrastructure as a whole, including regular continued on next page

meeting attendance to review data, use of our e-solutions to foster communication and coordination of care, and continuing education. A minimum of 200 Hill Physicians patients must receive care from a primary care physician to qualify for performance measurement and compensation. This helps to address concerns related to random statistical variation in results and the statistical credibility of the measures. The patient population is risk adjusted using industrystandard external software. Appropriate stop loss protections are in place to protect practices from uncontrollable factors. The program has worked well to encourage high quality and efficient care in our primary care network, and reduce practice variability, and sustain the viability of primary care practice.

Specialty Capitation: While our specialists are generally paid on a fee-for-service basis, in our Sacramento region we have implemented a system of specialty capitation for selected specialties. We have contracted with certain group practices to make them our exclusive provider for their specialty. These practices are paid on a capitated, per-member, per-month basis. We monitor their practice patterns and include performance measures in our agreement with them. This system has worked well in this market.

Specialty Case Rate: Two years ago, we developed a case rate pilot program in which our largest medical oncology practice volunteered to participate. Whereas capitated payment arrangements establish payments based on a population (i.e., on a per-member, per-month basis), a case rate typically reflects a set amount paid for a defined episode of care or set of services. In our oncology case rate program, payments are based on nine distinct “cohorts,” or cancer diagnosis groups. For example, the three most common cohorts are breast, lung, and colon cancers. A predetermined amount is paid to participating providers for each patient over a 36-month period. Case rate payments for each cohort mirror anticipated costs as they are incurred by participating providers for the total care provided to each cancer patient. Currently, approximately 50% of our oncology services are provided through this program. The program has succeeded in maintaining quality, which is measured using certain American Society of Clinical Oncology metrics, while moderating the escalating cost trend for use of chemotherapy drugs. We are pleased with its results thus far, as are

the oncology practices working with us in it. As we gain experience, we intend to expand our case rate program to other specialties in the future.

KEY STRENGTHS AND CHALLENGES Our model has been successful for us, our physicians, our contracting health plans, our patients, and we believe the health care system overall. While we believe our model can provide benefits elsewhere, it is important to note that it may require some adaptation to work in a different environment. I want to thus discuss some of the attributes of our model that have been the foundation of our success. As the Medicare program experiments with population and valuebased payment models, it may be helpful to consider how these attributes are reflected or treated in a given model.

Infrastructure A key component of Hill Physicians’ ability to manage and foster high value care is our organizational framework and infrastructure, which is a distinguishing characteristic of the successful delegated model in California. The acceptance of population-based payments requires the use of sophisticated management, technology, intelligent use of data and interactive clinical-level communications, as well as a broad patient base, in order to effectively coordinate care, align incentives, and manage risk. Hill Physicians’ infrastructure brings these resources and innovations to bear to create an enabling environment that encourages physician engagement and organization –an essential condition to creating an integrated and high value experience for patients.

Small Providers While providing coordinated care requires a broad range of providers, small, independent practices can still contribute significantly to coordinated care efforts. The organizational structure of Hill Physicians allows small practices to participate in a larger, coordinated care system. As noted above, most of our practices have fewer than six physicians.

Network Holding a network of providers accountable for the cost and quality of patient care becomes less viable to the extent that patients choose to seek care from outside of the network. Thus, there are significant challenges in developing a structure that enables providers to be accountable while also preserving the availability of unrestricted patient choice models such as broad

network PPOs. Appropriate incentives need to be in place to encourage patients to stay within a given network while preserving their ability to have reasonable choices for where to get their care. We have been leaders in working with our health plan partners to determine the most effective methods for striking a balance.

Provider engagement While our organization infrastructure provides significant support, Hill Physicians is driven by physicians, and physician engagement with our management support structure is key to our success. Physicians should be free to focus on doing what they do best – practicing medicine. To encourage physician engagement, we establish financial incentives for participation in care management activities and maintain various outreach programs to educate physicians about their performance within the network. For instance, every primary care provider receives a quarterly report that details their performance relative to their peers. Our medical directors and staff hold numerous individualized and group meetings with physicians to review the data and discuss their performance and ways to improve.

CONCLUSION Medicare is seeking to make greater use of population and value-based payment structures. There is something to be learned from the private sector and organizations like ours in understanding the conditions and investment in organization and infrastructure required for these models to succeed. Medicare Advantage is a well-established population-based payment model and we see value in efforts to explore the expansion of population-based payments to traditional fee-for-service Medicare. However, across all these models, our experience is that certain variables need to be in place. Most importantly, organizing care on a population or value-based payment method requires significant infrastructure and technical expertise. Additionally, population and value-based care requires a strong network of providers who are engaged in the network. The goal of organizations like ours is to provide the necessary infrastructure and expertise upon which these models are built. Again, I’m most appreciative for the opportunity to appear before you today, and I look forward to participating in the discussion today and in the future. Thank you very much. n 25

O R G A N I Z AT I O N A L Children’s Physicians Medical Group*

High Desert Medical Group

Chinese Community Health Care Association

High Desert Primary Care Medical Group

Choice Medical Group IPA

Hill Physicians Medical Group, Inc. *

Cigna Medical Group

Independence Medical Group

Samuel Rotenberg, MD, Medical Director Craig Kaner, Administrator

CMS CAP Management Systems

Inland HealthCare Group, Inc.

Allied Physicians of California

• AKM Medical Group • Amvi Medical Group • Exceptional Care Medical Group • Family Choice Medical Group • Family Health Alliance • Huntington Park Mission Medical Group • Medicina Familia Medical Group • New Horizon Medical Group • Noble Community Medical Associates • OmniCare Medical Group  Premier Physician Network • Seoul Medical Group • United Care Medical Group

ORGANIZATIONAL MEMBERS Accountable Health Care IPA

George M. Jayatilaka, MD, President & CEO Druvi Jayatilaka, MD, Vice President

Affinity Medical Group

Richard Sankary, MD, President Scott Ptacnik, COO

AllCare IPA

Randy Winter, MD, President Matt Coury, CEO

All Care Medical Group

Thomas Lam, MD, CEO Kenneth Sim, MD, CFO

Alta Bates Medical Group *

Richard L. Oken, MD, President and Chairman of the Board

AltaMed Health Services Corporation

Martin Serota, MD, Chief Medical Officer Castulo de la Rocha, JD, President/CEO

AppleCare Medical Management*

Surendra Jain, MD, Chief Medical Officer Vinod Jivrajka, MD, President/CEO

Arch Health Partners

Scott Flinn, MD, Chief Medical Officer Victoria Lister, CEO

Arta Health Network, APMC Baruch Fogel, MD, President Karri Rodgers, CEO

Bakersfield Family Medical Center

Ju Hwan Lee, MD, Medical Director Robert O’Keefe, Chief Executive Officer

Bay Valley Medical Group, Inc. *

Eric Kohleriter, MD, President/Medical Director Shelley Horwitz, Chief Executive Officer

Beaver Medical Group, L.P. *

Charles Payton, MD, VP/Chief Medical Officer John Goodman, CEO

Bright Health Physicians

William Stimmler, MD, President, Physician Services

Brown & Toland Physicians *

Andrew M. Snyder, MD, Chief Medical Officer Richard Fish, CEO

California Pacific Physicians Medical Group, Inc. Dien V. Pham, MD, Chief Executive Officer Carol Houchins, Administrator

Catholic Health Initiatives

Clifford Deveny, MD, SVP Physician Practice Mgmt. James Slaggert, VP Physician Practice Mgmt.

CareMore Medical Group

Donald Furman MD. Chief Medical Officer Tom Tancredi, Dir. of Practice Operations

Cedars-Sinai Medical Group *

Stephen C. Deutsch, MD, Chief Medical Director Thomas D. Gordon, CEO 26

Tanya Dansky, MD, Medical Director Leonard Kornreich, MD, Board President Edward A. Chow, MD, Executive Director Polly Chen, Director of Operations Manmohan Nayyar, MD, President Blair Bryson, IPA Administrator James Burrell, MD, Chief Medical Officer Edward Kim, President and General Manager Megan North, CEO

Community Health Center Network

Ralph Silber, CEO Melissa Marshall, MD, Chief Medical Officer

DCHS Medical Foundation

Dean M. Didech, Chief Medical Officer Ernest Wallerstein, CEO

Desert Oasis Healthcare*

Marc Hoffing, MD, Medical Director Dan Frank, Chief Operating Officer

Empire Physicians Medical Group

Steven Dorfman, MD, President Yvonne Sonnenberg, Executive Director

Facey Medical Foundation *

Erik Davydov, MD, Medical Director Bill Gil, President/CEO

Golden Empire Managed Care, Inc. * Glen Singer, MD, Medical Director Robert Severs, CEO

Good Samaritan Medical Practice Association

Charles Lim, MD, FACP, Medical Director Anthony Dulgeroff, MD, Assistant Medical Director Ziad El-Hajjaoui, MD, Medical Director Niki Balginy, CEO Tom Long, MD, Chief Medical Officer Darryl Cardoza, CEO

Armi Lynn Walker, MD, Medical Director Gary M. Bohamed, Executive Director Carey Paul, MD, President Lisa Perko, Controller

John Muir Physician Network *

Ravi Hundal, MD, Medical Director Paul Swenson, President/CEO

Lakeside Community Healthcare

Kerry Weiner, MD, Chief Medical Officer Jonathan Gluck, Counsel

Lakeside Medical Group, Inc.

TK Desai, MD, Senior VP/ Medical Director

Lakewood IPA

Steven Villalobos, MD, Medical Director Cynthia Guzman, CPA, Chief Executive Officer • Alamitos IPA • St. Mary IPA • Brookshire IPA

Loma Linda University Health Care

J. Todd Martell, MD, Medical Director Jane Arden, Director, Quality Management

Marin•Sonoma IPA

J. David Andrew, MD, Medical Director Joel Criste, CEO

McKinley Medical Group, Inc.

Stanley Schwartz, MD, President John Mukherjee, CEO

MED3000

Gary Proffett, MD, Medical Director Lynn Stratton Haas, CEO

Kathy Hegstrom, Administrator

• SeaView IPA • Valley Care IPA

Greater Newport Physicians Medical Group, Inc. *

Med Point Management

HealthCare Partners *

• Apollo Healthcare • Bella Vista Medical Group IPA • Centinela Valley IPA • El Proyecto Del Barrio, Inc. • Global Care Medical Group • HealthCare LA IPA • Mission Community IPA • Riverside Family Health Medical Group • Watts Health Care Corporation

Alan Puzarne, COO Diane Laird, CEO

Robert Margolis, MD, CEO Matthew Mazdyasni, CFO

Heritage Provider Network *

Richard Merkin, MD, President/CEO Richard Lipeles • Affiliated Doctors of Orange County • Bakersfield Family Medical Group • California Coastal Physician Network • California Desert IPA • Desert Oasis Healthcare • Greater Covina Medical Group • Heritage Physician Network • Heritage Victor Valley Medical Group • High Desert Medical Group • Regal Medical Group • Sierra Medical Group

Rick Powell, MD, Medical Director Kimberly Carey, Administrator

Memorial HealthCare IPA

Ronald Zent, MD, Medical Director Patty Page La Penn, MPH, CEO

MemorialCare Medical Group *

Mark Schafer, MD, Chief Medical Officer Patrick E. Kapsner, CEO

Midcoast Care Inc., A Medical Group John Okerblom, MD, President Barbara Cheever, Executive Director

L M E M B E R S & PA RT N E R S Molina Medical Centers

Steve O’Dell, Regional Vice President Gloria Calderon, Vice President

Monarch HealthCare *

Bart Asner, MD, CEO Jay Cohen, MD, Executive Chairman

Muir Medical Group, IPA

Steve Kaplan, MD, President Ute Burness, RN, CEO

NAMM California *

Leigh Hutchins, President, COO Elizabeth Haughton, Vice President, Legal Affairs • Coachella Valley Physicians of PrimeCare, Inc., • Mercy Physicians Medical Group • Primary Care Associated Medical Group, Inc. • PrimeCare Medical Group of Chino • PrimeCare of Citrus Valley • PrimeCare of Corona • PrimeCare of Hemet Valley Inc • PrimeCare of Inland Valley • PrimeCare of Moreno Valley • PrimeCare of Redlands • P rimeCare of Riverside • PrimeCare of San Bernardino • PrimeCare of Sun City • PrimeCare of Temecula • Redlands Family Practice Medical Group, Inc.

Omnicare Medical Group

Toni Chavis, MD, President Ashok Raheja, MD, Medical Director

Pacific IPA

Thomas Chiu, MD, President Peder Lindblom, Executive Director

The Permanente Medical Group, Inc. Oakland (North)*

• Korean American Medical Group • Providence Care Network

River City Medical Group, Inc.

Jose Abad, MD, President/Medical Director Gordon Wong, MD, CEO

Riverside Medical Clinic

Steven Larson, MD, Chairman Judy Carpenter, President/COO

Riverside Physician Network * Paul Snowden, COO Howard Saner, CEO

St. Joseph Heritage Healthcare

Khaliq Siddiq, MD, Chief Medical Officer C.R. Burke, Chief Executive Officer

San Bernardino Medical Group Thomas Hellwig, MD, President James Malin, CEO

San Diego Physicians Medical Group James Cordell, MD, President Joyce Cook, CEO

San Luis Obispo Select IPA

Barbara Cheever, Executive Director

Sansum Clinic *

Kurt Ransohoff, MD, President/Medical Director

Santa Clara County IPA (SCCIPA)

J. Kersten Kraft, MD, President of the Board Randall Frakes, CEO

Sharon Levine, MD, Associate Executive Director Gerard Bajada, VP/Director, Financial Services

Santé Health System, Inc *

Anthony Ausband, President Lisa Serratore, Chief Operations Officer

Scripps Coastal Medical Center

Physicians DataTrust

• Greater Tri-Cities IPA • Noble AMA IPA • St. Vincent IPA

Physicians Medical Group of Santa Cruz Marvin Labrie, CEO Nancy Greenstreet, MD, Medical Director

Pioneer Medical Group, Inc. * Jerry Floro, President John Kirk, CEO

Preferred IPA of California

Daniel Bluestone, MD, Medical Director Scott B. Wells, CEO Louis Hogrefe, MD, APC, Chief Medical Officer Elena Cresap, Senior Administrative Director

Sharp Community Medical Group *

John Jenrette, MD, Chief Executive Officer Christopher McGlone, Chief Operating Officer • Graybill Medical Group

Sharp Rees-Stealy Medical Group *

Donald C. Balfour, III, MD, Chief Medical Officer Stacey Hrountas, Senior VP & Chief Executive Officer

Mark Amico, MD, Medical Director Zahra Movaghar, Administrator

Southern California Permanente Medical Group*

Jeereddi Prasad, MD, President Mitchell Lew, MD CEO

Sutter Health Foundations & Affiliated Groups *

Mitchell Lew, MD, CEO Mark Marten, Chief Operating Officer

• Palo Alto Medical Foundation • Sutter Medical Foundation • Sutter North Medical Foundation • Sutter West Medical Group • Sutter North Medical Group • Sutter Medical Group • Sutter Region Medical Foundation • Sutter Independent Physicians • Solano Regional Medical Group • Sutter Gould Foundation • Camino Medical Group • Sutter Gould Medical Group • Santa Cruz Medical Clinic • Sutter Medical Foundation—North Bay • Sutter Medical Group of the Redwoods • Physician Foundation—California Pacific Medical Center

ProMed Health Care Administrators

Prospect Medical Group*

• AMVI/Prospect Health Network • Prospect Corona • Gateway Medical Group • Genesis Healthcare • Prospect HealthSource • Prospect Huntington Beach • Prospect Orange County • Prospect Northwest Orange County • Nuestra Familia Medical Group • Prospect Professional Care • Prospect Van Nuys

Providence Medical Management Services

Marvin Kanter, MD, Chief Physician Integration Officer Joan Rose Baranov, Chief Operating Officer

Mark Bird, MD, Sr. Physician Executive James Malone, Medical Group Administrator Tom Blinn, CEO, Sutter Medical Foundation Jeffrey Burnich, MD

SynerMed, Inc. *

George Ma, MD James Mason, President & CEO • Angeles IPA • Community Family Care • Employee Health Systems • Hollywood Presbyterian Medical Group • Mid County Physicians IPA • Multicultural IPA • Pacific Alliance Medical Group • Redlands IPA • Southern California Children’s Network

Talbert Medical Group *

Keith Wilson, MD, President/CEO

Torrance Hospital IPA

Norman Panitch, MD, President Stephen J. Linesch, CEO

U.C.L.A. Medical Group *

Sam Skootksy, MD, Medical Director David Hartenbower, MD, COO

USC Care Medical Group, Inc.

Donald Larsen, MD, Medical Director Minor Anderson, CEO

CORPORATE PARTNERS Adventist Health Physicians Network Anthem Blue Cross of California Boehringer Ingelheim Pharmaceuticals, Inc. Merck & Co. Novartis Pharmaceuticals Novo Nordisk SCAN Health Plan

ASSOCIATE PARTNERS Abbott Amgen Inc. AstraZeneca Pharmaceuticals Crescent Healthcare, Inc. Daiichi Sankyo Eisai, Inc. GenPath Diagnostics Genomic Health Genzyme Genetics GlaxoSmithKline Johnson & Johnson Family of Companies Kindred Healthcare, Inc. My Health Direct NORCAL Mutual Insurance Company Pfizer, Inc. Ralphs Grocery Company Sanofi Sunovion Pharmaceuticals Inc. Vertex Pharmaceuticals Vitas Healthcare Corporation of California

AFFILIATE PARTNERS Altura Ascender Software, LLC Childrens Hospital Los Angeles Medical Group DPS Health Group Practice Forum MedVentive, Inc. MedVision, Inc. MZI HealthCare, LLC Redlands Community Hospital Saint Agnes Medical Group Sullivan/Luallin, Inc. Unlimited Innovations, Inc. Ventegra, LLC 27

ACO Deployment from a Marketing and Communications Perspective

he Pioneer ACO Pilot program began in early 2012. As an organization, Heritage Provider Network eagerly anticipated participating in the ACO model, as we believed it would allow us to bring the advantages of our successful managed care programs to a different audience. While we understood that it would be challenging to convince a fee for service audience of the benefits of managed care we believed, that once the beneficiaries understood that enhanced benefits came with no strings attached, they would eagerly participate in the program. Although challenging, we also understood that partnering with the provider community and winning over the beneficiary community was going to be critical to the success of the program. As a first step, we simultaneously reached out to both our physician and beneficiary audiences, explaining the nuts and bolts of the ACO model, as well as the benefits the providers and beneficiaries could expect from the program. While we had anticipated some resistance from both audiences, we did not anticipate the level of misunderstanding that existed in the provider community regarding the program, or the level of antipathy in the beneficiary community. In hindsight, perhaps we should not have been so surprised, considering the degree of change and confusion in the healthcare landscape during the past few years. As soon as we understood the concerns regarding the program, we immediately redoubled our efforts to engage and educate both communities. We began the process by examining the methods by which we as a company and the healthcare industry in general, traditionally market our services and programs. In the healthcare services industry we have multiple end-user categories, and the audience within each category is known by multiple names. Depending on the context, we might call one audience providers, PCPs, or physicians. Another audience may be referred to as patients, members or beneficiaries. With all the labels, we sometimes forget that, ultimately, these are our customers. As 28

customers they are also consumers. This distinction is important because consumers behave in a very specific way. Whether they are selecting a product or service, a laundry detergent or medical provider, consumers will always follow a set decision pattern. In marketing, this process is referred to as a decision tree or a marketing or purchase funnel. (See Figure 1.) Although a consumer will follow the established, stepwise path illustrated in the marketing funnel, the final selection is ultimately made from an emotional perspective rather than a reasoned one. In fact, the entire decision process can often be an exercise in rationalizing an already established emotional choice. In other words, our customers are not going to choose our ACO because it’s good for them. They are going to choose it because their decision process makes them feel good about it being good for them. To gain a clearer understanding of how our two audiences would weigh their options, and what would connect with them on the critical emotional level, we engaged them through a series of town hall and focus group discussions. These discussions were populated with members of the community and were split between provider and beneficiary audiences. All sessions were lively and productive, providing us with new information and giving us a deeper understanding of some customer perceptions with which we were already familiar.

By Steven “Nick” Niccoli Marketing and Communications Specialist, Regal Medical Group

program, neither doctors nor patients would lose any freedom to choose and direct their care, our audiences remained resistant and dismissive of any related benefits. Overall, this and other discussion topics provided invaluable insight into key logical and emotional elements that will help us to more effectively market our ACO, and to develop more effective tools and processes for operating the ACO itself. We can no longer simply offer and promote programs that help physicians and beneficiaries manage complex conditions. We must deliver solutions that maintain a level of health and vitality necessary for our audience so they can continue to do the things that they most value in life.

If the ACO program is to be a new paradigm for healthcare, one that shifts focus from primarily treating the sick to proactively combating disease progression to create For instance, though we were aware that and sustain a healthier population, the tools managed care is often viewed in a negative to successfully educate and light, we gained additional foster advocacy within Fig. 1 perspective through our audiences must our discussion groups. make the same Both audiences esshift. sentially believed that managed care Nick Niccoli has over handcuffs doctors and 12 years of experience in impedes treatment, rather marketing and communithan seeing it as something cations in the entertainment, that improves health. This averhigh-tech, financial and medision runs deep, as the ACO health cal services industries. He is curmanagement tools we described rently the Senior Communications were viewed with skepticism even Project Manager at Regal Medical though the descriptions carried no Group, Inc., a member of Heritage reference whatsoever to managed Provider Network, a CAPG Partner. care. Participants repeatedly asked, Heritage Provider Network is partici“How is this not an HMO?” Even with pating in the Pioneer ACO Program as consistent reassurance that, under the Heritage California ACO. n

CAPG Groups Improving Capabilities in Patient Care Coordination

he California Association of Physician Groups (CAPG) kicked off their annual healthcare conference today in Palm Desert, CA, with the results of the organization’s sixth annual Standards of Excellence member survey that reveals how “well-equipped” physician groups are to provide high-value patient care. “California has long been at the forefront of accountable care, which is the ability to bring value in both quality and affordability to patients,” said Donald Crane, President and CEO of CAPG. “This annual assessment clearly illustrates the leadership of California’s physician groups to continually improve the sophistication and efficiency of the care they provide to patients. We’re not waiting for Federal directives or for the outcome of the Supreme Court decision on the Accountable Care Act. We are innovating reforms right now to integrate a disjointed healthcare delivery system that can serve as a model for the rest of the country.” The Standards of Excellence survey is the first known voluntary large scale, critical self-assessment for medical groups in the United States. According to CAPG’s Medical Director, Wells Shoemaker, M.D, “CAPG developed the Standards of Excellence survey to annually assess and publicly report on the progress physician groups are making toward being a national leader in coordinating a patient’s care. The survey is a blueprint for how to assess the tools and processes physician groups have in place to meet the escalating expectations of healthcare purchasers and patients. The survey helps set the bar for healthcare consumers to evaluate a physician group’s technical quality, responsive patient experience, and affordability,” said Dr. Shoemaker. “The significance of this survey is that it provides anyone involved with healthcare, whether purchasers, providers, or government and regulatory agencies, with an evaluation of how well-equipped physician groups are to provide high-value patient care,” said Dr. Shoemaker. “In this year’s survey, 30 physician groups, more than any previous survey, reached the highest “Elite” status despite the fact that the

survey featured more stringent documentation requirements and increased transparency thresholds,” said Dr. Shoemaker. “We’re not surprised, but we’re particularly proud, that all of the six California-based groups that were chosen by the Centers for Medicare and Medicaid to participate in the Pioneer Accountable Care Organization project scored in the “Elite” category of the survey. Our physician groups already have a high-level of expertise in coordinating care for patients in a way that lowers costs, improves care, and makes populations healthier,” said Crane. The Standards of Excellence survey analyzes physician group infrastructure capabilities in five areas, each considered central to providing quality, consistency, responsiveness, and affordability for CAPG’s estimated 12 million HMO patients and approximately 6 million PPO patients. Survey results can be found at http://www.capg. org/home/index.asp?page=274. The five key survey elements include: • Care Management Practices – inpatient and outpatient systems to support physicians and patients to achieve reliability, safety, continuity and affordability. • Health Information Technology – electronic registries to support chronic care, preventive care, professional communication, and advanced electronic record systems. • Accountability and Transparency – participation in measuring and public reporting, including compliance with stringent fiscal responsibility regulations of the State of California. • Patient Centered Care – features to accommodate individualized patient needs and preferences, embracing a responsible role in a culturally diverse community.

Wells Shoemaker, MD Medical Director, CAPG

vital to the creation of high performance Accountable Care Organizations nationwide. The 2012 survey results revealed the following: • 73 medical groups caring for nearly 11 million Californians participated in the voluntary survey. • 30 organizations – caring for a population of more than 9 million people – qualified for the “Elite” category, meaning they surpassed a stiff, peerdefined threshold in all four categories. This total is up from 20 groups in 2009 and 25 in 2011, despite this year’s more stringent criteria. • 6 organizations, caring for 400,000 people, qualified for “Exemplary” performance, meaning they surpassed the threshold in three of the four categories. CAPG conducts its Standards of Excellence survey annually among its 150 member physician groups to gain an understanding of their “infrastructure” and to offer metrics to measure progress in clinical quality, affordability, access, technology, public accountability, and individual responsiveness to their patients. To view the survey results visit: http://www.capg.org/home/indexasp?page=274.

• Fiscal and Administrative Capability – was tested (scores not reported) to monitor the complex infrastructure needed to manage multiple revenue streams, create novel payment methodologies, maintain complex network relationships, and handle intricate contractual relationships that are all 29

Sharp HealthCare ACO – The Journey Begins

“C

oming together is a beginning. Keeping together is progress. Working together is success.” This quote by Henry Ford is an apt reflection of the initial journey of Sharp HealthCare ACO. Sharp ACO is a collaboration between Sharp HealthCare, a non-profit integrated regional healthcare delivery system based in San Diego, and its two affiliated medical groups, Sharp Community Medical Group, San Diego’s largest Independent Practice Association, and Sharp Rees-Stealy Medical Group, San Diego’s first multi-specialty medical group. Collectively, these organizations have managed care for decades, with over 280,000 individuals covered through population-based health plan contracts alone. This history of care coordination through a medical home model provided the foundation for Sharp ACO. The goal of Sharp ACO is the best health, the best care, and the best experience for our 32,000 aligned beneficiaries. To begin our work, we established a limited liability company with equal ownership by the three members – Sharp HealthCare, Sharp Community Medical Group, and Sharp Rees-Stealy Medical Group. Governed by an eight-member Board, including two representatives from each member, a patient representative and a consumer advocate, Sharp ACO established eight sub-committees to champion its work in the areas of care management, performance management, network operations, marketing and communications, transaction processing, analytics, finance, and compliance. These committees are led by representatives from each member, and representation on the committees includes physicians and operating leaders from across the health system and medical groups. Coming together to operate Sharp ACO has been an enlightening experience. More than 16 percent of Sharp ACO’s beneficiaries have not seen a primary care physician in over three years; and over 20 percent have not established a primary care relationship with a Sharp ACO provider. The cost of care for beneficiaries that have a primary care relationship outside of the Sharp system is nearly 30 percent higher than the cost of care for Sharp-aligned 30

beneficiaries. Establishing a Sharp medical home is our first priority as an ACO. With an opt-out rate of only 2.6 percent, the Medicare claims files we received for Sharp ACO’s beneficiaries were rich with information and insights. Over sixtyseven percent of beneficiaries access their inpatient care through the emergency department, and 53 percent of our beneficiaries’ care is provided by non-aligned facilities. Three percent of our beneficiaries account for more than 20 percent of our costs, making case management and coordination of care across the inpatient and ambulatory settings key tactics within our medical home model. Keeping together is our biggest challenge and opportunity from the standpoint of patient engagement. Coordinating care for Sharp ACO beneficiaries relies heavily on a true partnership between the patient, his or her physician and care team, and the facilities providing care. To begin our patient engagement efforts, we are making outreach calls to help our unaligned beneficiaries select a personal Sharp primary care physician and arrange an appointment. Additionally, our first offering to our Sharp ACO beneficiaries is a single contact number that provides 24/7 access to a Sharp professional, including after hours nurse triage services. We have already seen great success in working together. Our joint efforts are uncovering numerous opportunities to improve care and services for our aligned beneficiaries. In just five months, we have completed the attribution of aligned beneficiaries to Sharp ACO’s two medical group members, identified beneficiaries who lack a Sharp medical home, classified Sharp ACO patients within our legacy systems, and loaded and analyzed our beneficiaries’ historical Medicare claims. We have assessed the 33 ACO quality metrics and selected six measures for initial emphasis, and begun the roll-out of communication plans and patient engagement tactics. But our ACO journey has just begun. Even within our established integrated health care delivery system, we will make significant investments and improvements in the areas of care management, informatics, patient engagement, and

By Alison Fleury Senior Vice President of Business Development for Sharp HealthCare and Chief Executive Officer of Sharp HealthCare ACO

transitions of care. These improvements will not only improve the care and experience for our ACO beneficiaries, but will make Sharp a better organization for every patient we see. Coming together as Sharp ACO marks the beginning of a journey to achieve the three part aim – better care for individuals, better health for populations and reduced healthcare costs. Keeping together through this journey – through the sharing of best practices across the care continuum – will be key to our success and the progress made toward this goal. But success will only come from working together – as patients, physicians, care teams, and facilities – to ensure that care coordination results in the right care given at the right time and in the right setting. Sharp ACO is a work in progress. We are pleased to have been selected to participate in the Pioneer ACO pilot so that we may continue to improve care and outcomes – and to make a meaningful difference – in the lives of our patients. n Advertisers Index: AVERINFORMATICS..........................Page 21 BROWN & TOLAND....Outside Back Cover HEALTH ACCESS SOLUTIONS..........Page 8 HILLS PHYSICIAN..........Inside Front Cover MZI....................................Inside Back Cover NEXTGEN HEALTHCARE...................Page 6 NOVO NORDISK..................................Page 5 PFIZER.................................................Page 22 STELARA.............................................Page 10 VITAS.....................................................Page 3

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