Baptist Physician Partners 2020-2023 Value Report

Michael A. Mayo, DHA,

President and CEO Baptist Health

Advancing our Population Health Journey

The United States health care landscape is undergoing a gradual, yet dramatic transformation driven by a multitude of factors, such as payer reform, advances in science and technology, and evolving consumer demands. Care delivery that has been historically provided in the acute setting is beginning to shift to the ambulatory setting. Value-based changes in reimbursement are responsible for the exponential growth of outpatient encounters; however, many health care systems continue to view inpatient care as a major economic driver. Despite this, the cost of health care in the United States continues to increase. In 2021, it accounted for 18.3% of the Gross Domestic Product (GDP), with Medicare spending totaling just over $900 billion.

This gradual shift in care is apparent in the way health care organizations are making monetary and non-monetary investments. Hospitals are extending their reach into communities to invest in preventative and post-acute care to balance the shift in inpatient case acuity and the decrease in volume. This presents a conflict where systems must manage infrastructure, operations, and leadership as payment models advance toward value- and risk-based payment all while functioning in the present fee-for-service model where incentives compensate output.

Baptist Physician Partners (BPP) is Baptist Health’s vehicle for value-based care. As we advance our population health journey, we continue to focus on providing patient care at the right time and in the right place. We have made significant progress toward reducing unwarranted clinical variation, decreasing avoidable utilization, and enhancing clinical quality.

Since our inception in 2014, we have generated just over $125 million in total savings from our value-based agreements. We became an accountable care organization (ACO) through the Medicare Shared Savings Program (MSSP) in 2018 and by 2021, ranked in the top 4% for total savings for all participating ACOs.

BPP is shaping the future of health care in our community through integrated partnerships and physician-led initiatives. As we improve quality, safety, efficiency, and outcomes for patients, we are poised to advance our valuebased strategy with innovative programs and risk-bearing agreements to ultimately change health care for good.

FACHE

Timothy Groover, MD Senior Vice President and System CMO, Baptist Health

Ilene Levenson, MD Chair, Board of Managers Baptist Physician Partners

Mary Leen, DNP, ARNP Vice President, Baptist Physician Partners

BPP’s Journey Since Inception

2014-2016

2017

2018

- CIN formed

- Governance structure established

- Care coordination program implemented

- Data analytics strategy adopted

- New contracts: AvMed, Aetna, Baptist Health Employee Health Plan

870 Physician members 17k covered lives

- First Clinical Transformation

Workgroup (CTW) convened to address clinical variation

- Nemours pediatric specialists joined (100+ providers)

- Network adequacy software adopted

- New contracts: United Medicare Advantage (UMA)

1k Physician members 27k covered lives

- Partnership with Baptist Health’s Social Responsibility department established to address social determinants of health

- Data analytics focus shift to population health

- New contract: Medicare Shared Savings Program (MSSP) Track 1

1.1k Physician members 62k covered lives

People Process Technology Value-based Contract

2019 2020 2021 2022

- End-of-life focus added to care coordination strategy

- Senior population health strategy evaluation

- Online application process/management system launched for provider applicants and members - BPP Bulletin launched: monthly email update for providers

- Data analytics platform optimized to design robust physician dashboards

1.1k Physician members 69k covered lives

- Accurate diagnosis documentation strategy initiated

- Home-based care coordination strategy implemented

- Analytics platform migrated from IBM Explorys to Cerner HealtheIntent

- New contract: Bundled Payments for Care Improvement Advanced

1.1k Physician members 75k covered lives

- HealtheIntent go-live for BPP quality metrics

Home-based model of care significantly expanded Onboarded physician to lead ambulatory palliative care initiative

1.1k Physician members 86k covered lives

- Population health transformation team established

- Care coordination team shifted to regional model of care

- Remote monitoring strategy implemented for patients with diabetes and hypertension

- Health system migration to Epic Onboarded physician to lead Senior Strategy initiative

1.1k Physician members 88k covered lives

Physical Presence 5 Counties

87,526

BPP Covered Lives* (2022)

*Includes covered lives from the following value-based agreements: Medicare Shared Savings Program, United Medicare Advantage, Baptist Health Employee Health Plan, Aetna Whole Health, and myBlue.

6 Hospitals (5 Adult and 1 Children’s)

5 Value-Based Contracts

6 Preferred Home Health Care Partners

≈ 9k Patients enrolled in care coordination annually (2020-2022)

11

Preferred Skilled Nursing Facility (SNF) Partners

2020

$37.2M

2021

$40.8M Total Savings**

9 Enhanced Home Support Models (EHSM)

**Total Savings is the overall amount saved by the payer and BPP. Shared Savings is the amount of savings that is dispersed to BPP prior to any distribution to the health system, physicians, or administration fees. Exception: Baptist Health Employee Health Plan (distribution to the health system has already occurred in reported number). Total Savings amount includes Bundled Payments for Care Improvement Advanced.

Clinically Integrated Network

1,152 Physician members (Oct. 2022)

BPP combines independent and employed physicians and the resources of Baptist Health into a clinically and financially aligned partnership designed to deliver outstanding care and improve outcomes while reducing inefficiencies and their associated costs. This network is BPP’s Clinically Integrated Network (CIN) with a focus to provide the right care at the right time.

962 957

480 195

190 672 83

Primary care physicians (16% of total physician members) Specialists (84% of total physician members)

Employed (42% of total physician members)

Independent (58% of total physician members)

Adult (83% of total physician members)

Pediatrics (17% of total physician members)

Physician groups

The CIN includes 83 physician groups, representing many essential specialties. The below list includes adult specialties represented in the CIN with more than 10 physicians. Additionally, there are 40 adult specialties in BPP that includes less than 10 physicians.

Adult specialties with more than 10 physicians:

• Anatomic Pathology & Clinical Pathology

• Anesthesiology

• Cardiothoracic & Vascular Surgery

• Cardiology & Cardiovascular Disease

• Diagnostic Radiology

• Emergency Medicine

• Endocrinology

• Gastroenterology

On July 30, 2022, Baptist Health made the system-wide transition from multiple disparate electronic health record (EHR) systems to one system, Epic. The Epic system strengthens Baptist Health’s technology and supports long-term growth. The system helps integrate and standardize workflows and has also improved BPP’s ability to coordinate care.

How has Epic helped BPP?

Epic offers providers and care team members interoperability, or the ability to share records within Baptist and with other health systems that also use Epic as their EHR. This feature is specifically helpful in preventing avoidable admissions and readmissions. Communication between patient care settings is straightforward with the use of in-basket messaging; care coordinators can communicate with physicians using a centralized workflow.

Epic offers an enhanced level of transparency for BPP’s care coordination team as they monitor patient care and utilization from the ambulatory setting. Compass Rose,

Epic’s application for comprehensive care coordination incorporates programs, targets, and patient outreach into one arena. By leveraging assessments and flowsheets, care coordinators and social workers can track patient outcomes over time to better understand the impact of interventions. Care plans contain evidence-based practice for specific conditions powered by Elsevier, a peer-reviewed journal that develops patient education materials. Providers can review and close care gaps directly from the patient’s storyboard.

Additionally, data from Epic flows directly into HealtheIntent, BPP’s population health quality data management platform, which allows providers to view their personal valuebased quality metric data. In the future, we plan to build Epic tags so patients who are included in a value-based care arrangement, can be quickly identified by providers and care team members.

Post Live and Optimization

8.1.22 –9.30.22

Data Analytics

The Population Health Analytics team maintains and utilizes a variety of solutions to create dashboards and reports for multiple stakeholders across the CIN and health system. The team aggregates, analyzes and interprets results from multiple data sources to help identify best practices, ideal outcomes, and program opportunities.

The Population Health Analytics team has a strong focus on accurate, real-time data access for physicians, care team members,

and administration. During the past two years, the analytics team led the successful launch of HealtheIntent, a quality portal, with an access link embedded in Epic for providers, care team members, and administration to view near real-time BPP quality metric data and patient details. Additionally, the team created 24/7 access to the BPP citizenship metric performance dashboard within the Baptist physician’s portal for providers and practice administrators to review at their convenience.

Analytic Strategies

• Identify high-risk, high-cost patients

• Design provider engagement reporting

• Understand care gap patterns

• Evaluate care programs

• Group Performance Reporting Option (GPRO) – CMS submission

• Accurate documentation and diagnostic coding (ADDC)/Hierarchical Condition Categories (HCCs)

• Financial modeling for BPP shared savings distribution

• Evaluation of network sufficiency and optimization

To meet the care needs of the increasing patient population, the Ambulatory Care Coordination team now provides care for patients at home.The team comprises more than 50 team members who have recently been divided into eight regional, multidisciplinary teams with representatives from nursing, social work, health coaching, and respiratory therapy. With additional support from care coordinator assistants and intake specialists, they provide telephonic, virtual, and in-home visits to high-risk and rising-risk patients with multiple comorbidities.

Regional teams coordinate care for patients along the care continuum, including: patients discharged from the hospital, patients in skilled nursing facilities, assisted living facilities and longterm care, and patients in their home environments. Team members work at the top of their licenses, reference data to risk stratify patients and allocate resources appropriately.

Baptist Health’s recent transition to Epic allows for seamless coordination of care across the continuum, in addition to communication with Baptist Physician Enterprise providers, all of whom document in Epic.

Care Coordination Strategies

26

Nurse Care Coordinators

12 Care Coordinator Assistants and Intake Coordinators

10 Social Workers

Multidisciplinary Team-Based Approach

Care Coordination across the Continuum

3 Health Coaches

Data-Informed, Risk Stratification, Resource Allocation

Serious Illness Management and Advocacy (SIMA)

1 Clinical Educator

Goals of Care and Advance Care Planning

Social Determinants of Health and Health Equity

1 Diabetes Educator

Care Coordination: Serious Illness Management & Advocacy

The Serious Illness Management and Advocacy (SIMA) model is a population health initiative focused on complex chronic illness. It is an episodic, home-based, and interdisciplinary care model dedicated to optimize current and future clinical planning. SIMA integrates the paradigm of care coordination and the traditional roles of palliative medicine including symptom management and goals of care. BPP RN care coordinators and social workers form the foundation of SIMA bolstered by a strong interdisciplinary team of Pharmacy, Spiritual Care, and AgeWell HouseCalls.

Key Pillars of SIMA

Using empathetic communication, data gathering and resource management, SIMA targets four consultation outcomes: establishing the active plan of care and ensuring elements of the plan are in place such as medications and appointments; understanding the patient’s goals of care; developing a preparedness plan for anticipated decline; and identifying drivers of utilization or decreasing quality of life. Once identified, interventions can be targeted medically, pharmaceutically, psychosocially, and/or spiritually to improve patient wellbeing and prevent unwarranted utilization.

1 2 3 4 5 6

Function

Function is a key clinical marker for prognostication, an important component of populationhealth planning, maximizing clinical wellbeing.

Symptom

Assessment and Management

Addressing and managing symptoms to increase quality of life and decrease tertiary utilization.

Resource Optimization

Standardizing internal and external resource allocation and follow-through.

Goals of Care

Establishing patient directives to honor their health care objectives and best understand potential incongruencies between patient and provider expectations.

Utilization Prevention

Ensuring that the care plan is implemented as directed by the provider. This includes follow-ups and medication management targeting SDoH to impact reversible factors that drive utilization.

Preparedness Planning

Including advance care planning, discussions for potential placement needs, and discussions of next steps in case of clinical decline.

Despite receiving in-home nursing assistance and monthly home visits from a nurse practitioner, Evelyn Lammert still needed high-level clinical assistance in managing her husband’s medically complex conditions, which included home infusion therapy.

Over the past year, her husband, Bruce, was hospitalized with complications related to chemotherapy and radiation treatment for metastatic prostate cancer. A cystectomy was also planned but delayed due to persisting osteomyelitis.

Thankfully, their first Serious Illness Management and Advocacy (SIMA) home visit was scheduled for the day after the postponement. Their distress was evident. Shawna Watson, MSN, RN, CCRN, Bruce’s SIMA RN care coordinator, took the lead in helping plan their next steps.

Along with ensuring the delivery of medications for the unexpected continuation of in-home antibiotics, Shawna addressed their apprehension, completed a medication review, and helped Eleanor prioritize her questions for Bruce’s nurse navigators at

Care Coordination: Patient Experience

Baptist MD Anderson Cancer Center. Shawna also scheduled an appointment to complete advance care planning documents with the couple.

Evelyn had a clear understanding that she had unfettered access to her “go-to” SIMA nurse for any questions. After their second in-home visit, the couple expressed their gratitude for the many resources provided by the SIMA program.

Bruce underwent surgery six weeks later. Shawna continued to follow-up to assist with medication reconciliation, relieve anxiety and cope with related lifestyle changes.

Bruce is expected to recover and is looking forward to getting back on his motorcycle. Added Shawna,”I’m grateful that our regional RN care coordinator recognized Bruce’s elevated risk and highly stressed status and referred him to our program.”

Clinical Transformation Workgroups

Clinical Transformation Workgroups (CTWs) are physician-led and bring together interdisciplinary subject matter experts from across the care continuum to enhance the quality of care for patients. Participating physicians are incentivized by receiving an educational credit counting toward their overall BPP citizenship requirement. The

governance structure of these workgroups allow quick turnaround times in response to identified opportunities.

Reducing unwarranted clinical variation continues to stand as a pillar of BPP’s population health strategy. The era of COVID-19 transformed the way the CTWs

Diabetes Ilene Levenson, MD

COPD Jim Clower, MD

Post-Acute Kerry Maher, MD

ESRD Craig Shapiro, MD

HF, HTN, Lipids Russell Stapleton, MD Coding Howard Rodenberg, MD

COVID-19 Ted Glasser, MD

ACP Liz McCullough, MD

develop and implement consensus-based clinical guidelines. Historically, CTWs targeted patients with high-cost, high-risk disease states who are cared for in the ambulatory setting. In our post-COVID-19 health care landscape, CTWs now also create guidelines that focus on care in the home setting through enhanced home support models (EHSMs).

Clinical Transformation Workgroups

In 2021 and 2022, CTWs concentrated their efforts on developing EHSMs for seven bundles, contributing to a reduction in overall SNF utilization. The below timeline includes a comprehensive list of CTWs by topic and the respective physician chair.

2021 2022

Long COVID Shalika Katugaha, MD HF EHSM Russell Stapleton, MD

COPD EHSM Jim Clower, MD

TAVR EHSM Ruby Satpathy, MD

Sepsis EHSM Ted Glasser, MD Alison Bartfield, MD

UTI EHSM Shalika Katugaha, MD

Influenza EHSM Shalika Katugaha, MD

Spinal Fusion EHSM Edward Saleh, PA

Annual Wellness Visits Virginia Hosang, MS, BSN

AMI EHSM Russell Stapleton, MD

Enhanced Home Support Models

By the end of 2022, BPP implemented nine Enhanced Home Support Models with the support of Baptist Primary Care, multiple specialty service lines, Baptist Home Health Care by BAYADA, clinical informatics, and BPP care coordination. These innovative models of care have substantially evolved since its first protocol for COVID-19. EHSMs aim to reduce utilization of hospital, emergency department, and skilled nursing facility services by safely managing patients in the home setting.

A physician can order the EHSM standing orders for patients who meet qualifying criteria, which depends on the protocol details. For example, a patient with heart failure (HF) can be referred to the HF EHSM from primary care, the emergency department, or the inpatient setting. On the contrary, a patient with sepsis may only be referred to the Sepsis EHSM by a hospitalist in the inpatient setting as this protocol is intended for patients who had a hospitalization for an episode of sepsis.

The success of the EHSMs can be attributed to Baptist Health’s post-acute preferred provider network, or PPN. The PPN is a network of home health agencies and SNFs specializing in post-acute care who work closely with Baptist Health to provide safe, high-quality care. To date, there are six home health care agencies and 11 skilled nursing facilities in the PPN. Success can also be attributed to the inpatient care coordination team who ensure that our patients transition to the most appropriate next site of care, in addition to physicians who refer patients to these home-based models.

Patient Experience

Enhanced Home Support Models

Joan Kavanaugh takes medicine twice a day for atrial fibrillation (AFib). As a component of her clinical care plan, the 86-year-old monitors her blood pressure and pulse. When a recent reading detected tachycardia, Joan’s daughter, Mary, immediately became concerned.

“My mother was not acting quite right, so I called her Baptist Health care coordinator right away,” Mary said.

Kathleen Ostynski, BSN, RN, an ambulatory care coordinator with Baptist Physician

Partners, made a quick assessment of the situation over the phone.

Following a focal neurologic and respiratory survey, she determined Joan displayed neither dysarthria or dyspnea. She and Joan’s daughter developed a quick action plan that included:

• Calling 911 so emergency medical technicians could further assess Joan to determine if she needed additional medical attention

• Purchasing a pulse oximeter at their nearest drug store to more reliably track her heart rate

• Scheduling a home visit by Baptist Home Health Care by BAYADA

During the home health visit, the nurse, Sharon, determined Joan’s vital signs were normal. She didn’t need further medical evaluation at the Emergency Room.

“The home health nurse had a great bedside manner and really put my mother and me at ease,” said Mary. “We couldn’t speak more highly of her and the enhanced home support we experienced.”

Accurate Documentation and Diagnostic Coding

The Accurate Documentation and Diagnostic Coding (ADDC) team ensures that all key stakeholders are aligned and are working in a unified manner to enhance capture of the high-quality patient care we provide. The ADDC team collaborates with ambulatory providers to identify and communicate best practices and opportunities regarding documentation guidelines and coding requirements. The team’s goal is to improve the overall quality and completeness of patient medical records.

At the end of 2022, Baptist Health signed an agreement with Stanson Health to integrate the Stanson HCC Solution within the Epic workflow for Baptist Physician Enterprise physicians, for patients attributed to BPP. This solution, which is scheduled for mid-2023 implementation, provides real-time alerts for treating physicians at the point of care. Alerts

identify and suggest a hierarchical condition category (HCC) codes based on existing documentation within the patient’s chart. The treating physician then has the opportunity to document the monitoring, evaluation, assessment, or treatment of the suspect condition in their progress note and add the code to the claim record; or to decline to add the code, as they deem appropriate. The goal of HCC documentation is to capture the patient’s actual clinical picture, including disease severity and associated risk, and then assign an appropriate HCC code.

Payers use HCC codes submitted to them on claims to determine applicable benchmark costs under shared savings arrangements. Accurate documentation and coding efforts are critical factors driving performance in value-based care models.

Population Health Transformation

The Population Health Transformation team serves as the bridge between BPP and CIN physician members to ensure value-based contracting goals are communicated and achieved. The team references reports generated by the Population Health Analytics Team to identify and share successes and opportunities with physicians and clinic team members to improve quality goals. Areas of focus include quality care gaps, accurate documentation, annual wellness visits, and avoidable utilization. The team also identifies and shares cross-continuum opportunities related to the BPCI Advanced.

BPP Initiatives

a. Quality

b. Patient Satisfaction

c. Accurate Documentation

Primary Care Physicians

a. Care Gaps

b. Office Workflows

c. Epic

Quality Spotlight

Each month, the Population Health Transformation Team spotlights one valuebased quality measure. Spotlights include contract-specific quality measures, in addition to BPP-specific quality measures to ensure alignment of clinical care with BPP’s overall quality strategy. Monthly meetings with primary care stakeholders ensure consistency and long-term success.

Quality Improvement

In addition to stakeholder alignment, the team collaborates with stakeholders from across the health system to improve upon operational- and documentation-specific processes. Examples include accessing and interpreting data in HealtheIntent, documenting care gaps in Epic, and scheduling patients for annual wellness visits.

Population Health Transformation Team

Bundled Payments for Care Improvement Advanced

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) model, also referred to as bundles, is a two-sided, value-based incentive program managed by CMS. Baptist Health has participated in this model since 2020 as it rewards efficient, high-quality care and supports enhanced care coordination. Under the BPCI Advanced model, Baptist Health is responsible for the total cost of care for patients in certain defined episodes. Savings are generated if the total cost for an episode is less than the benchmark cost for the episode; losses are generated if total costs exceed the benchmark episode cost. Savings and losses are adjusted based on quality scores. BPP manages quality and costs for patients in the BPCI Advanced model.

A BPCI Advanced clinical episode is triggered either at the start of an inpatient admission (Anchor Stay) to an acute care hospital or at the start of an outpatient procedure (Anchor Procedure). Inpatient admissions that qualify as an anchor stay are identified by Medicare Severity-Diagnosis Related Group (MS-DRGs) codes, while outpatient procedures that qualify as an Anchor Procedure are identified by Healthcare Common Procedure Coding System (HCPCS) codes. These codes are rolled up into eight different clinical episode service line groups (CESLGs) that model participants elect to partake in. The Clinical Episode length is the Anchor Stay plus 90 days following the day of discharge, or the Anchor Procedure plus 90 days following the day of completion of the outpatient procedure. Clinical episodes include all services that overlap the Clinical Episode window, with some exclusions.

Baptist Health participates in this program at the hospital level. Baptist Jacksonville, Baptist South and Baptist Clay all participate

in eight CESLGs as one entity under the Baptist Jacksonville CMS Certification Number (CCN). Baptist Beaches participates in five CESLGs.

BPP utilizes the Committee to Operationalize Medicare Value-Based Programs (COMVP) to engage specialist physicians under bundles. COMVP focuses on reducing 90-day hospital readmissions, decreasing SNF utilization, and optimizing care for patients who are at end of life. This committee also serves as a platform for feedback on home-based programs to further prevent avoidable acute and post-acute utilization.

Care Coordination Strategy: CarePort CarePort Connect, a care coordination solution that connects Baptist Health hospitals to SNFs, went live in November 2022, replacing Signify Health’s Episode Connect. This solution displays real-time data on patient transitions and allows for effective care coordination decisions. It provides timely information on where patients currently are and their clinical status after they are discharged from the hospital. This solution is integrated with more than 95% of

SNF electronic health records. This fosters a timely, collaborative relationship with them to optimize utilization. CarePort Connect is a critical solution in our overall BPCI Advanced strategy.

The Baptist Physician Partners ACO achieved its third consecutive year of top-ranking results in both clinical performance and health care savings for Northeast Florida’s Medicare population. With a strong focus on quality through the Medicare Shared Savings Program (MSSP), the ACO lowered the expected cost of care by nearly $34 million for more than 40,000 Medicare beneficiaries in 2021. Over the last four years, BPP has improved health outcomes and reduced health care spending by more than $75 million. The overarching goal of the ACO is to deliver high-quality, appropriate care across all settings at the lowest possible cost.

These accomplishments of the ACO under MSSP serve as a milestone for value-based care; however, improvements to our overall quality score, specifically patient experience, are a focus for 2023 and beyond. Additional opportunities include addressing prescription medication discussions and cost, result follow-ups, fall risk assessments, depression screenings and follow-ups, and tobacco screening and cessation intervention.

Clinical success is attributed to physician collaboration across the ACO, care coordinator support for high-risk patients, reducing unnecessary hospital admissions and readmissions, and implementing enhanced

MSSP Final Performance Feedback

home support models that allow patients to recover at home. From 2020-2022, the care coordination team coordinated care for nearly 9,000 Medicare beneficiaries annually. BPP continues to participate in Premier’s Population Health Management Collaborative (PHMC), which coordinates a group of ACOs to share knowledge, data and expertise on program performance. The PHMC includes 66 ACOs across 34 states. Through these efforts, BPP achieved the following results compared to the average of ACOs in the Premier PHMC in 2021:

• Hospitalizations were 16.5% lower

• Prevented nine fewer admissions per 1,000 Medicare beneficiaries

• Transitioned 11 fewer Medicare beneficiaries per 1,000 to skilled nursing facilities. Among beneficiaries who transitioned to a SNF, their average length of stay was four days shorter.

BPP intends to participate in MSSP for the foreseeable future.

MSSP Membership

*The final settlement statement is used for 2018-2021 member person years. Membership is preliminary for 2022 (as of February 2023).

United Medicare Advantage

BPP has demonstrated success in the United Medicare Advantage (UMA) agreement since the first year shared savings was achieved in 2019. UMA is BPP’s only Medicare Advantage valuebased product and is a one-sided risk agreement. This means that BPP shares in generated savings but is not responsible for the repayment of any losses incurred. UMA has seen steady growth in membership, up 46% since its inception. Our focus to date continues with quality. United Healthcare calculates an overall quality star rating that is used to determine the percentage of shared savings for which BPP is eligible.

UMA Quality Star Ratings

Quality star ratings include:

• Preventative screenings (breast cancer, colorectal cancer, and eye exams for patients with diabetes)

• Medication adherence for diabetes, cholesterol, and hypertension medications

• Statin therapy for patients with diabetes and patients with cardiovascular disease

• Patient experience

United Medicare Advantage

United Healthcare also holds us accountable to maintain a benefit-cost ratio (BCR) which is the ratio of total medical costs to revenue received by United for the UMA members attributed to BPP. The BCR must be below and the quality star rating must be above their respective targets to achieve shared savings. Moving forward, we will reinforce the importance of quality measures, with a heightened focus on medication adherence and patient experience, which together make up over two-thirds of our UMA quality score.

Employee Health Plan

The Baptist Health Employee Health Plan (EHP) is BPP’s first value-based contract and continues to be administered by Florida Blue. Our quality ratings in this agreement have continuously satisfied contract requirements, earning us shared savings from 2019 through 2021. BPP leans heavily on the commercial care coordination team, comprising health coaches and a certified diabetes educator. In 2022, the team coached 72 plan members with diabetes and 88% saw an improvement in their A1c value. Although shared savings was achieved in 2021, the amount was significantly lower than in previous years due to 2020 being a benchmark year. In calendar year 2020, utilization was significantly lower than prior years due to the COVID-19 pandemic.

EHP Membership

$22.0K

EHP Total and Shared Savings

Average enrolled members: All members who enrolled in the plan

BPP EHP Members: Members who established care with a Baptist Primary Care Provider $11.0K

BPP continues to partner with Aetna under a shared savings only, value-based agreement for their Aetna Whole Health product. It is a lower cost, narrow network, commercial alternative that Aetna offers to employee groups, both fully insured and self-funded. Although the Aetna Whole Health relationship has existed since 2018, enrollment in the product remains consistently low and BPP has yet to achieve shared savings. Achievement of quality targets remains challenging, mainly due to random variability of quality scores driven by low enrollment. However, BPP stabilized per member, per month medical costs.

To increase enrollment and obtain a statistically significant membership base, BPP agreed to allow Aetna to offer the product with an out-of-network option beginning in 2022. BPP and Aetna expect the out-of-network product benefit will attract more members to the product and Aetna/CVS is also offering Aetna Whole Health as a health plan benefit under their employee health plan. BPP anticipates that any increased enrollment due to this change will not be fully experienced until calendar year 2023, since the change occurred after the open enrollment window closed for 2022. BPP remains engaged with Aetna to support the broader Baptist/Aetna business relationship and to gain experience managing a younger, commercial population outside the Baptist Health Employee Health Plan.

Risk Score

.87% Current

.81%

-6.2% Medical Services

-1.4% Medical & Pharmacy Services

Aetna Whole Health Membership

Commencing in January 2021 and continuing throughout calendar year 2022, BPP participated in a value-based, shared savings agreement with Florida Blue for their myBlue HMO line of products sold to residents of Clay, Duval, and Nassau counties via the health care exchange. MyBlue products are heavily subsidized commercial HMO health plans, sold to individuals and families on the health care exchange, sometimes referred to as Obamacare.

BPP entered into this value-based agreement to increase the quality of care and improve the total cost for members attributed to Baptist Primary Care physicians. Prior to the existence of this agreement, BPP physicians and community physicians participated in a provider network for myBlue that did not include a value-based component. The BPP value-based agreement did not alter the existing network agreements, and many are still in place today.

After two full contract years, BPP chose not to participate in the myBlue value-based agreement for a third year and terminated the agreement at the end of 2022. MyBlue provided a valuable opportunity for BPP to apply its population health initiatives to a non-Medicare, health care exchangebased population. However, the myBlue population required significantly greater resources to realize quality and total cost targets when compared to BPP’s Medicarebased beneficiaries. Additionally, monthto-month total medical costs were highly variable, which made it extremely difficult to determine which initiatives were successfully impacting shared savings. Despite these circumstances, BPP consistently met peerbased quality targets set by Florida Blue.

HealthPlace on Demand

Baptist Health launched HealthPlace on Demand in March 2020, an online, 24/7 virtual visit service powered by Telescope Health. In addition to offering this service to all Baptist Health patients, members of Baptist Health’s Employee Health Plan are eligible to use the service and qualify for a discounted copayment.

Baptist Health’s partnership with Telescope Health also allows the implementation of pilot programs to address specific needs across the health system. Telescope Health serves as a stop-gap for Original Medical beneficiaries who are discharged from Baptist Medical Center Beaches and included in the BPCI Advanced model; beneficiaries without an assigned Baptist Primary Care physician who experience barriers to follow-up care qualify for a virtual visit.

Virtual visits also benefit qualifying patients in the post-acute setting. Among BPP’s preferred network of home health care agencies and skilled nursing facilities, Telescope Health virtual visits are leveraged to help prevent patients from visiting the emergency department, ultimately preventing avoidable readmissions.

Patients can download the app at baptisthealthplace.com and have access to 24/7 virtual care.

Social Determinants of Health

Social Determinants of Health in Epic

Tobacco Use

Dec. 6, 2022: High Risk

Alcohol Use

Dec. 6, 2022: Heavy Drinker

Financial Resource Strain

Dec. 6, 2022: Low Risk

Housing Stability

Dec. 6, 2022: Unknown

Physical Activity

Dec. 6, 2022: Sufficiently Active

Transportation Needs

Dec. 6, 2022: No

Transportations Needs

Social Connections

Dec. 6, 2022: Moderately Isolated

Intimate Partner Violence

Dec. 6, 2022: Not At Risk

Depression

Nov. 29, 2022: At Risk

Stress

Dec. 6, 2022: Not At Risk

Food Insecurity

Dec. 6, 2022: Unknown

The BPP Social Services team expanded from three members in 2020 to 11 members in 2022 to support the increased number of patients with complex needs. The team offers services in multiple locations, including medical offices, patient’s homes, and facilities. Social workers complete comprehensive biopsychosocial assessments to identify factors impacting a person’s overall health and well-being. They also leverage a person-in-environment perspective, looking at the environmental contexts in which that person lives and acts, to uncover the dynamics affecting a person’s life.

Social Determinants of Health (SDoH) barriers contribute to a portion of our patient’s identified needs. Since transitioning to Epic, the Social Services team utilizes the SDoH Wheel to track these factors over time. This allows all care team members to easily view and provide a more holistic perspective when developing a care plan. The graphic in the left column is an example of how SDoH needs are represented in Epic.

In addition to collaborating with Baptist Health’s Social Responsibility team, the Social Services team utilizes FindHelp to identify and refer resources to patients. This tool is a closed-loop community-based organization (CBO) referral platform embedded in Epic. It identifies CBOs that provide services specific to a patient’s need. Referrals can be tracked and analyzed to determine specific needs for different areas in our community and highlight opportunities for partnerships.

The Social Services team continues to receive referrals for patients or caregivers needing assistance navigating the complex process of receiving long-term home and community-based services. To help meet this need, BPP has a strategic partnership with Aging True. Over the course of the past three years, this partnership has evolved to become an invaluable resource for patients and caregivers. Aging True provides in-home, nonskilled support services while patients wait for activation of long-term care services. BPP’s partnership with Aging True allows patients and families to age at home. This tailored program, along with other communitybased resources, is critical in supporting patients and caregivers through their health care journey.

The Social Determinants of Health Wheel in Epic tracks barriers for patients over time.

Patient Experience

Ever since her husband of more than 50 years died a few years ago, Geraldine Jones has had trouble paying for her monthly prescriptions.

After a BPP nurse care coordinator referred the 81-year-old widow to Yessica Marshall, LCSW, a BPP social worker, Geraldine was connected to patient assistance programs that helped defer the cost of her brand-name medications.

But Geraldine’s problems didn’t stop there. She confided to her social worker that she was experiencing depression due to limited family support and had become fearful of leaving her home, following numerous fainting spells.

In addition, Geraldine had stopped preparing her own meals because she could no longer stand for extended periods of time and was fearful of falling in her bathroom and shower, as it was not equipped with any safety assistance devices.

Yessica immediately referred Geraldine to a local non-profit, Aging True, which has helped thousands of seniors in the Jacksonville community with the assistance they need to live independently.

Aging True completed a safety evaluation of Geraldine’s home. They added special grab

bars and other modifications to her bathroom and provided an in-home aide twice a week. The aide accompanies Geraldine on short walks to encourage mobilization and increase her opportunities for socialization. Aging True also coordinated the delivery of hot meals through Meals on Wheels.

Geraldine also receives telehealth counseling services from Aging True to help her navigate changes in her mental health.

SNF at Home

The Skilled Nursing Facility (SNF) at Home model is a pilot initiative in partnership with River Garden Senior Services and Baptist Home Health Care by BAYADA. Both are members of Baptist Health’s postacute preferred provider network. This interdisciplinary, collaborative model of care aims to reduce the SNF length of stay by transitioning patients home with home health care services as soon as the patient is ready.

This model leans heavily on rehabilitative services and the patient’s level of function throughout the recovery process. Welldefined inclusion criteria helps foster positive outcomes by focusing on the patient’s prior

history, safety protocols, and communication of expectations with the patient and primary care provider. The pilot went live in December 2021 and has cared for 20 patients through December 2022. This model’s readmission rate is 10% and fosters a halo effect for our Medicare value-based agreements.

Reasons to Heal at Home

• Decreased infections

• Decreased falls

• Decreased confusion

Baptist Medical Center

Skilled Nursing Facility

Nationally, Medicare-eligible lives are growing at a rate of 10,000/day. Over the next four years, forecasts predict an estimated 20% increase in our local senior demographic. Baptist Health’s Senior Strategy serves this population, supports providers caring for this generational shift, and maintains competitiveness in the health care marketplace.

As a clinical strategy, it is a coordinated system-spanning infrastructure to support senior wellness, maximize senior function, augment provider resources, and mitigate risk. Patients often share common physical, emotional, and psychosocial concerns

that can be magnified by the loss of independence and the unknowns of chronic disease. These factors often lead to decisionmaking in times of medical crisis. The Senior Strategy builds upon multi-faceted resources including discussions of preparedness planning and goals to optimize care and more thoughtfully engage appropriate clinical transitions.

As a contract strategy, it stands at the intersection of our population health clinical strategy. Our goal is to maximize quality and reduce redundancy to lower health care costs and our mission to remain viable as a health care leader in the community.

Geripsychiatry

Integration with Baptist Behavioral Health

Rehabilitation

Standardized assessment models for cognitive testing, teaching, and function

Serious Illness Management and Advocacy (SIMA)

Chronic disease management model

Pharmacy

Support for complex medication management and harm reduction

Home-Based Models of Care

Enhanced home support models, SNF at Home, and HouseCalls

AgeWell

Clinic-based, longitudinal care for chronic, critically ill patients

Looking Toward the Future

Home-Based Models

Expansion of Enhanced Home Support Models, Serious Illness Management and Advocacy program, and SNF at Home

Patient Experience

Develop a standardized and scalable model to enhance patient experience across all primary care offices

Accurate Documentation

Streamline accurate documentation and coding workflows for providers within Epic in partnership with Stanson

Population Health Analytics

Multi-source performance measurements (claims and EMR) and data

BPP Provider Bridge

A multidimensional model to impact provider performance, access and satisfaction

Practice Transformation

Communicating data and BPP mission to the providers

Medical Director of Senior Strategy

Physician-facing for quality measure guidance and engagement

Physician Lead, ACO Strategy

Physician-facing support for subjective concerns impacting provider satisfaction and patient access

Alison Bartfield, MD

Alison Bartfield, MD, is the medical director for the Baptist Health Senior Strategy. She has practiced as a hospital-based internal medicine physician since 1998 and has been a practicing hospitalist with Baptist Health since 2002. During her tenure, Dr. Bartfield founded the Baptist Beaches hospitalist team, and has served as the lead physician for the Baptist South hospitalist team and the Medical Director for Baptist Home Health Care.

Dr. Bartfield has been a dedicated champion for patient safety initiatives throughout her career. She founded the Quality Management Committee at Baptist Beaches and co-founded the Health Connections program (currently HouseCalls) at Baptist Health.

Dr. Bartfield has dedicated 10 years to the Patient Safety Institute at MagMutual Insurance and served on the Board of Directors for the last three years. Most recently, she served as chair of both the Practice Performance Committee and the Department of Medicine at Baptist South, and co-chair of the Sepsis Clinical Transformation Workgroup.

Dr. Bartfield currently leads the health system’s Senior Strategy to align BPP’s contracting strategy with clinical strategy across the care continuum. She partners with Baptist Health physicians to enhance value, grow the number of covered lives, and increase access.

Liz McCullough, MD

Liz McCullough, MD, is the physician lead for the ambulatory palliative care and ACO strategy. She is an internal medicine physician with subspecialty training and practice in palliative medicine. She has 30 years of experience in diverse fields, including finance and research.

Following training, she worked for the Program of All-Inclusive Care for the Elderly (PACE) in Portland, Oregon. In 2013, Dr. McCullough joined Baptist Health as a palliative medicine partner serving the inpatient population. At the request of BPP, she chaired the Advance Care Planning Clinical Transformation Workgroup and built strong interdisciplinary inpatient and ambulatory partnerships that address multidimensional obstacles. This work ultimately led to the implementation of a referral-based system-wide advance care planning model.

In 2020, Dr. McCullough joined BPP as the Physician Lead of Ambulatory Palliative Care. She is developing an ambulatory palliative medicine model that includes engaging traditional palliative medicine roles, comprehensive care coordination, and functional assessments to develop concrete goal-directed outcomes impacting both patient quality of life and avoidable health care utilization. This model is the ongoing work of 2023. In addition to her role in ambulatory palliative care, Dr. McCullough is collaborating with Dr. Bartfield and Mary Leen to partner with BPE as we develop clinical strategies to align with ACO contracting strategies.

Board of Managers and Committee Members

CIN Board of Managers

Officers

Ilene Levenson, MD, Chair

Kenneth Mayer, MD, Vice Chair

Allison Bartfield, MD

Pat Calhoun, MD

Thomas Connolly, MD

Marsha Donaldson

Kyle Etzkorn, MD

Catherine Graham

Edward Gorak, DO

Cam Greene, MD

Timothy Groover, MD

Mark Laborde

Mary Leen, DNP

Michael Mayo, DHA

Matt Rill, MD

Craig Shapiro, MD

Keith Tickell

Matt Zuino

ACO Board of Managers

Officers

Ilene Levenson, MD

Paul Dillahunt, MD

Marsha Donaldson

Kyle Etzkorn, MD

Ted Glasser, MD

Catherine Graham

Timothy Groover, MD

Joel Schrank, MD

David Sutton, MD

Keith Tickell

COMMITTEE MEMBERS

Finance and Contracting

Michael Erhard, MD, Chair

Philip Boyce

Todd Braddock, DO

Benjamin Ernst, DO

Joseph Greenhaw, MD

Timothy Groover, MD

Mark Laborde

Roger Miller, MD

Pam Rama, MD

Matthew Rill, MD

Brad Talley, MD

Sofija Rak, MD

Samuel Velez, MD

Membership and Quality

Richard Picerno, MD, Chair

Deborah Abram, MD

Patricia Calhoun, MD

Perry Carlos, DO

Hiram Carrasquillo, MD

Catherine Graham

Glenn Martin, MD

Bill Putnam, MD

Jeffrey Smowton, MD

George Woodward, DO

Matt Zuino

Clinical Transformation Council

Ed Gorak, DO, Chair

Kate Barrier, MD

Jim Clower, MD

Lysette Cournoyer

Tammy Daniel, DNP

Timothy Groover, MD

Miriam Halimi, DNP

Stacey Johnston, MD (Voting Ex-Officio Member)

Shalika Katugaha, MD

Mary Leen, DNP

Ken Mayer, MD

Savita Pai, MD

Matt Rill, MD

Craig Shapiro, MD

Mark Stich, DO

Information Technology

Tito Balbino, Chair

Deborah Abram, MD

Patricia Calhoun, MD

Kevin Comar, MD

Jennifer Fulton, MD

Niraj Gusani, MD

Terry Hayes, MD

Irene Louh, MD

Ken Mayer, MD

Sara Meinke

Aaron Miri

Jason Ross

David Sutton, MD

Asad Tariq, MD

Pediatric Clinical Transformation Council

Thomas Connolly, MD, Chair

Deborah Abram, MD

Bethany Atkins, MD

Michael Aubin

Scott Baity

Philip Boyce

Barry Brennan, MD

Jerry Bridgham, MD

Kim Dal Porto, MD

Michael Erhard, MD

Timothy Groover, MD

Gary Josephson, MD

Kevin Kasych, MD

Ken Mayer, MD

Matt Paton, MD

Robert Paton, MD

Anthony Pohlgeers, MD

Shiree Sauer, MD

Stephen Silberman, MD

James Waler, MD

Matt Zuino

Administration

Mary Leen, DNP, Vice president

Alison Bartfield, MD

Shauna Davis

Sidney Lynch

Liz McCullough, MD

Care Coordination

(Assistants, Intake Specialists, and Health Coaches)

Danielle Leen, Manager

Tashemah Aaron

Candace Adams

Brittany Bozeman

Anna Chmielewski

Candi Clymer

Kim Edwards

Nina Maldosevic

Nate Morales

Vera Mungin

Erica Page

Tamara Philips

Michele Sinclair

Angie Smith

Cathy Warren

Melissa Whitney

Baptist Physician Partners Team Members

Care Coordinators

(Nurses)

Katie Kiley, Director

Tameko Jones, Clincial Educator

Alysia Agnew

Jessie Bourquin

Tina Crooks

Amanda Francisco

Sherri Fussell

Mary Jane Gemoto

Deloris Hathcock

Marie Hilario

Lynn Howard

Ashley Hughes

Vanetta Jackson

Leatha Kirkland

Cathy Leen

Teresita Lelina

Ashley Malone

Rebecca Mayes

Dana Moser

Kathleen Ostynski

Wendy Pope

Phinely Popera

Barbara Quinn

Marian Raftis

Ruby Rupac

Shawna Watson

Brenna Waxman

Rochelle Wigley

Alina Wilford

Lisa Wolfson

Data Analytics

Lysette Cournoyer, Director

Jeff Daniel

Aditya Goli

James Hirmann

Christopher Hulsey

Jean Lovelace

Documentation and Coding

Larry Wilson, Manager

Population Health Transformation

David Dekevich, Manager

Paul Apple

Natasha Joshua

Quality Outcomes

Nichole Hodge

Social Services

Blair Sisisky, Manager

Yessica Marshall, Team Leader

Sheronda Allen

Teshira Brooks

Hannah Crowe

Caitlin Dilley

Courtney Edmund

Kimberlee Flores

Tiffany Lynch

Laura Mccaslin

Katie Parker

Breonna Reese

Wade Wolosencuk

Sarah Young-Veiga

Physician Network

Practice Name

Amelia Anesthesia, PL

Anthony Capasso, MD

Baptist AgeWell Center for Senior Health

Baptist Behavioral Health

Baptist Endocrinology

Baptist ENT Specialists

Baptist Heart Specialists

Baptist Infectious Diseases

Baptist Lyerly Neurosurgery

Baptist MD Anderson Cancer Center

Baptist Neurology

Baptist Pediatrics

Baptist Primary Care

Baptist Pulmonary Specialists

Baptist Rheumatology

Baptist Specialty Physicians

Baptist Urology

Beaches Facial Plastic & Nasal Surgery Center

Beaches OBGYN

Borland Groover Clinic

Bowden Eye & Associates

Brooks Rehabilitation Medical Group

Brown Fertility

Bruce S. West, MD

Cardiothoracic & Vascular Surgical Associates, PA

Carithers Pediatric Group

Ceron Pediatrics and Integrative Medicine

Clinic for Kidney Diseases

Ellison Vein Institute

Emergency Resources Group

FABEN Obstetrics & Gynecology

Family Allergy & Asthma Consultants

First Coast Allergy and Asthma

First Coast Urogynecology

Florida Center for Infectious Diseases

Florida Institute for Reproductive Medicine

Futch Podiatry

Garcia and Associates OBGYN

Harris Foot and Ankle

Hospital Specialists, PA

Internal Medical Group

Jacksonville Hearing & Balance Institute

Jacksonville Hospitalists

Jacksonville Kidney Center

Jacksonville Nephrology

Jacksonville OB/GYN, LLC

Jacksonville Orthopaedic Institute

Jacksonville Pediatrics

Jacksonville Skin Cancer Specialists

Jacksonville Sleep Center

John P. Kartsonis MD, PA

Kidney Clinic of Jacksonville

Leder Retina & Uveitis Specialist

Lem Turner Family Medical Care

Levenson Eye Associates

Mandarin Pediatrics

MBB Radiology

McIver Urological Clinic Division

Millennium Physician Group

Mosolf Pediatrics

Nemours Children’s Specialty Care

Nemours Specialty Care Jacksonville

Nephrology Associates of Northeast Florida

Nephrology Consultants of Jacksonville

North Florida Gynecology Specialists

Northeast Florida Lung Clinic

North Florida Surgeons

Northeast Florida Endocrine & Diabetes Association

Orange Park Pediatrics

Pediatric Associates of Julington Creek

Podiatry Associates of Florida

Regional Obstetric Consultants

Respiratory Critical Care & Sleep Medicine Associates

Sepa Labs

SRB OGBYN

St. John’s Pediatrics

Total Dermatology Care Center

Trogolo Obstetrics And Gynecology

U.S. Anesthesia Partners of Florida

William J. Namen, DPM, PA

Womens Care Florida

Yash P. Sangwan, MD, PA

Ilene Levenson, MD, who served as the chair of both the CIN and ACO board of managers since January 2020, retired in January 2023. BPP is grateful for Dr. Levenson’s dedication and devoted leadership to BPP over the years. At this time, we are pleased to welcome Craig Shapiro, MD, MBA, FASN as the new chair of both the CIN and ACO board of managers effective March 2023.

Ilene Levenson, MD

Dr. Levenson is a respected partner who truly immersed herself in advancing BPP’s population health journey. She went beyond expectations to advance the Baptist Health’s value-based care strategy and played a key role in building bridges between BPP and member physicians. She is a board-certified internal medicine physician who has practiced in Jacksonville since 1989. While practicing at Baptist Health, she served as the chair of the BPP Clinical Transformation Council and spearheaded the initiative to reduce unwarranted clinical variation, which is foundational for success in value-based agreements. Dr. Levenson led the BPP Clinical Transformation Workgroup which developed BPP’s first consensus-based guideline, addressing the treatment of diabetes. BPP’s recent work and accomplishments presented in this value report occurred under her leadership.

Dr. Levenson has accepted the invitation to serve as a Baptist Health Trustee. In this new role, we look forward to her continued contributions and advancing the quality of care Baptist Health provides. Thank you, Dr. Levenson. BPP wishes you all the best in your retirement and future endeavors.

Craig Shapiro, MD, MBA, FASN

Dr. Shapiro is a board-certified nephrologist with over 23 years of experience. He is in private practice with Nephrology Associates of Northeast Florida. Dr. Shapiro is a past chief of staff of Baptist Jacksonville and he currently serves as a voting physician manager on BPP’s CIN board of managers. Dr. Shapiro chairs BPP’s End-Stage Renal Disease Clinical Transformation Work Group and he also serves on BPP’s Clinical Transformation Council. Dr. Shapiro has extensive experience leading patient safety initiatives and collaborating with primary care physicians to care for patients. Welcome Dr. Shapiro, we look forward to your leadership!

Baptist Physician Partners

841 Prudential Drive

Suite 1450

Jacksonville, FL 32207

Phone: 904.202.6BPP (6277)

FAX: 904.391.5321

Email: bpp@bmcjax.com

baptistphysicianpartners.com