Advancing Accountable Care

Transcription

1 Advancing Accountable Care April 19, 2012 S. Lawrence Kocot, JD, LLM, MPA Deputy Director, Engelberg Center for Health Care Reform; Senior Counsel, SNR Denton Sean McBride Project Manager, Engelberg Center for Health Care Reform; Project Manager, ACO Learning Network

2 Agenda Overview of national ACO Implementation: growing private and public sector activity Discovering the unicorn: ACO fundamentals Role of Post-Acute Care Providers: Services that Drive Value Implementation through collaboration: Brookings-Dartmouth ACO Learning Network

3 Little formal ACO activity just two years ago {Not exhaustive} Private Sector = Brookings-Dartmouth Public Sector = Medicare Physician Group Practice Demo ; Medicare Health Care Quality Demos

4 Increase in quality scores from baseline to PY5 an average of: 11% points on diabetes measures 12% points on heart failure measures 6% points on coronary artery disease measures 4% points on 9% points on cancer hypertension measures screening measures Four physician groups earned $36.2 million in shared savings in PY5 4 PGP demo informs Medicare accountable care pathway Quality Percentage Shared Savings Payments PY1 PY2 PY3 PY4 PY5 PY1 PY2 PY3 PY4 PY5 Billings 90.91% 97.78% 98.11% 92.45% % $6,689, % 97.78% 92.45% 94.34% 96.23% $3,570,173 $328,798 Dartmouth 9 Everett 86.36% 95.56% 94.34% 94.34% % $129,268 Forsyth % % 96.23% 96.23% % Geisinger 72.73% % % % % $1,950,649 $1,788, % % 98.11% % 98.11% $4,565,32 $5,781,57 $13,816,92 $16,154,24 $15,832,60 Marshfield Middlesex 86.36% 95.56% 92.45% 94.34% % Park Nicollet 95.45% 97.78% % % % $5,673,177 St. John's % % 96.23% 98.11% % $3,143,044 $8,185,757 $2,598, % % 94.34% 96.23% 98.11% $2,758,37 $1,239,29 $2,798,005 $5,222,852 $5,329,967 Michigan 0 4

5 Early private-sector effort: Brookings- Dartmouth ACO pilot sites Payer partners Payer partners Perf. measures Perf. measures B-D Downside risk?* Downside risk?* Other clinical transformation & reform efforts Other clinical transformation & reform efforts Electronic data feeds and dashboards; ambulatory access pilots; CER pilots B-D Yr 1 Homebound program; disease mgmt programs; MD incentives; care reminders B-D Level 6 (of 7) EHR capacity; 3 rd party analytics and HIE platform; medical home TBD IHA Yr 1 EHR deployment in process; patient registries TBD TBD *All pilots plan to introduce downside risk within five years Enterprise-wide EHR; P4P; outcome reporting; physician compensation

6 New momentum from the ACA Passage With the MSSP and ACO Pioneer Model Medicare Shared Savings Program Two tracks offering differing levels of shared savings and risk to ACOs if cost and quality targets are met 33 quality measures spread over four domains Patient/Caregiver Experience; Care Coordination/Patient Safety; Preventive Health; and, At-Risk Populations CMS estimates savings between of $1.3 billion in shared savings payments to ACOs 27 ACOs selected to start in April; over 150 applied to start in July Pioneer ACO Model 32 provider organizations across the country participating in the ACO Pioneer Model, offering accelerated tracks to more financial risk Five different financial models all moving to populationbased payments in year 3 Pioneer Model is meant to inform future changes to the MSSP

7 Commercial insurers also moving to Accountable care arrangements Payers Examples of Accountable Care Initiative Cigna Collaborative Accountable Care Initiatives: Engaged in 22 accountable care programs in 13 states covering more than 270,000 lives with a primary care practice, multi-specialty group and IDS. Cigna hope s to reach 1 million consumers by BCBS of MA AQC: Twelve provider groups are replacing the FFS model with a modified global payment model tied to nationally-endorsed quality metrics. BCBS of MN Aligned Incentive Contracting: Partnering with largest healthcare systems in MN in three contracts that tie provider payments increases to their ability to improve quality and lower costs Blue Shield of California: Participating in three ACOs in Sacramento and San Francisco covering 70,000 lives with two additional collaborations planned. Brookings-Dartmouth ACO Pilot: Working with Tucson Medical Center and the newly created Southern Arizona ACO on a shared savings model. Aetna ACOs: Implemented its ACO model in 36 primary care practices across the nation that focus on realigning incentives through shared savings and employing a care management process. Early Results Downward trends in unnecessary visits and an improving medical cost trend Reductions in readmission rates while the rates for the rest of the network have increased Findings indicate that the cost trend is below the national average while quality has remained high Blue Shield, Catholic Health Care West, and Hill Physicians Group saved $15.5 million last year In progress Net decrease in utilization decreased across the board by 11% - most effective partnerships resulting in a 50% drop. {Not exhaustive}

8 Most states passed or considering passing ACO legislation = passed ACO legislation = actively exploring ACO legislation 12 states passed accountable care legislation in 2011

9 ACO implementation accelerating across the country ACO implementation is now accelerating across the country *Over 200 self-identified ACOs* Private Sector = Brookings-Dartmouth = Premier = CIGNA = AQC (12 organizations in MA) = Other private-sector ACOs Public Sector = Beacon Communities = PGP, MHCQ = Pioneer {Not exhaustive} = MSSP

10 Agenda Overview of national ACO Implementation: growing private and public sector activity Discovering the unicorn: ACO fundamentals Role of Post-Acute Care Providers: Services that Drive Value Implementation through collaboration: Brookings- Dartmouth ACO Learning Network

11 Progression to more accountable payment: Pioneer ACO core payment model Start with shared savings dependent on quality scores Progressively implement a blend of FFS and partial capitation Benchmark based on trend in per capita expenditures for aligned FFS beneficiaries 60% shared risk 70% shared risk 70% shared risk Population-based payment of up to 50% of ACO's expected part A & B revenue Benchmark Actual Expenditure Less a guaranteed discount for Medicare ranging from 3% to 6% based on the ACO's quality score

12 Measuring and supporting better performance Core measures Overview: Easily calculable through administrative data or existing patient survey systems Health IT: Implementable without fully functioning and integrated EHRs (e.g. internal web portals, patient registries) Sample Measures: breast cancer screening, hemoglobin A1c testing in patients with diabetes, patient and care giver experience of care, and total per-capita expenditures Interim process measures Overview: Require clinical data on evidence-based care processes Health IT: Expanded health IT capabilities from investments in electronic data systems and better access to clinical data Sample Measures: drug therapy for lowering LDL cholesterol, beta-blocker therapy for left ventricular systolic dysfunction, and childhood immunization status Longitudinal & Advanced measures Overview: Advanced, patient-reported measures that include functional outcomes and health risk assessment Health IT: Advanced health IT capabilities that likely include an integrated and fully-functioning EHR system Sample Measures: selfreported physical functioning in patients with heart failure, 10-year risk of developing hard CHD, and conditionspecific outcome measures Increasingly Sophisticated Measures Over Time

13 Measuring and supporting better performance Integrated Delivery System Multispecialty Group Practice Physician- Hospital Organization Independent Practice Association Regional Collaborative One or more hospitals & large group of employed physicians Insurance plans (some cases) Aligned financial incentives, advanced health IT, EHRs, & well-coordinated team-based care E.g., Dartmouth Hitchcock Strong physician leadership Contract with multiple health plans Developed mechanisms for coordinated care (sometimes arranged through another partner) E.g., Marshfield Clinic Joint venture between one or more hospitals & physician group Vary from focusing contracting with payers to functioning like multi specialty group practices Many require strong management focused on clinical integration & care management E.g., Tucson Medical Center Small physician practices working together as a corp., partnership, professional corporation or foundation Often contract with health plans in managed care setting Individual practices typically serve non- HMO clients on a standalone basis E.g., Mount Auburn IPA Independent or small providers Leadership may come from providers, medical foundations, nonprofit entities or state government Sometimes in conjunction with health information exchanges or public reporting E.g., NC-CCN

14 Glide path towards payment reforms that reward value

15 Multi-payer efforts critical to successful ACO formation Successful ACOs should build support from private payers, states, and CMS Private Payers ACOs CMS States

16 Insights from a Brookings-Dartmouth ACO Pilot Site And MSSP participant Arizona Connected Care (Tucson, AZ) Commercial Payer-Partner: United Healthcare (Also has applied to the Medicare Shared Savings Program) Legal entity: LLC Governance: Hospital will have 20% representation and physicians will have 80% Payment model: shared savings, no risk in years 1 & 2; transition to risk-bearing in year 3 Patient attribution model: Brookings-Dartmouth prospective method and United Healthcare PCMH Method Performance measures: Brookings-Dartmouth 35 measures of quality and efficiency ACO patient population: 23,000 PPO patients and 8,000 MA beneficiaries ACO physician population: 55 PCPs, 35 specialists Success factors: 1. Capability to care for a population 2. Effective health information technology 3. Performance Measurement Infrastructure 4. Ongoing learning: It s a process not a destination Core challenges: 1. Developing a care management infrastructure 2. Adjusting to a new paradigm for hospital care 3. Overcoming legal barriers 4. Engaging physicians Source: K Carluzzo et al, TMC: A Community Hospital Aligning Stakeholders for Accountable Care, The Commonwealth Fund, January 2012.

17 ACO LN Member Pioneer ACO Implementation Plan Steward Health Care System (MA): Value (quality, access, cost) is the new paradigm Population Identification and Stratification Analyze population to identify patients health status and drive the most appropriate and effective care interventions Deliver Care Interventions Measure & Track Performance Optimize Care & Physician Communication Patient Engagement Evidence based clinical pathways and protocols to define and deliver the most appropriate intervention for all patients based on their identified health status Improve ability to measure population health to the patient level, disease/condition level and physician level IT and communication infrastructure to enable improved care delivery Primary prevention initiatives including cultural compatibility and community education outreach Source: Presentation by Steward Health Care System s Medical Network President, Dr. Mark Girard, to the ACO Learning Network on Jan 2012

18 Key challenges for successful ACO implementation Challenges Potential solutions Required ACO Competencies Aligning multi-payer ACOs with other reform initiatives Catalyzing real leadership from providers & payers Reducing start-up costs Develop a common set of performance measures with a pathway for more sophistication over time Create harmony between other payment and delivery system reforms Commit sufficient leadership support towards shared goals between payers and providers Develop a physician-supported implementation plan to identify costs and quality improvement opportunities Develop common frameworks and contract templates to reduce costs and uncertainty Analyze data to understand organizational performance and develop realistic start-up costs Promote transparency to accelerate learning Governance and leadership focused on the resources and project management required to implement new models of care Health IT that supports measurement for improvement and accountability Care coordination especially for the frail elderly or for those with multiple chronic conditions across clinicians and sites of care Care improvement programs allowing teams comprised of providers to maintain health and prevent costly complications of chronic diseases and major procedures

19 Agenda Overview of national ACO Implementation: growing private and public sector activity Discovering the unicorn: ACO fundamentals Role of Post-Acute Care Providers: Services that Drive Value Implementation through collaboration: Brookings-Dartmouth ACO Learning Network

20 Long-Term Services and Supports: Essential Element of Health Care Reform Large and growing part of health care expenditures Over $200 billion annually (10% of total) Expected to rise, along with doubling of older population in next 30 years Disproportionately affects patients who account for most health care costs and spending growth 80 percent Medicare spending from the 20 percent of beneficiaries with multiple chronic conditions Dual eligible's represent 18% of Medicaid enrollment but account for 46% of total Medicaid spending 1.1 million dual eligible s reside in nursing homes 58% of Medicaid spending on dual eligible s goes to long-term services and supports Disproportionate share of admissions, institutional costs, and other health care costs Reduced payments for hospital readmissions accelerates the need for high-quality post acute care 20

21 Role for Long-Term and Post Acute Care in Accountable Care Improve care coordination across the continuum through improved information sharing Support and participate in HIE s and other data exchanges to improve care coordination across acute and long-term and post acute care settings Compete on value by demonstrating quality and cost of care Demonstrate quality and cost efficiency to acute care providers to compete for preferred referrals by measuring and sharing information on the quality and cost of post acute care Reduce unnecessary readmissions Improve transitions, especially for those with functional impairments, through promising care strategies (Guided Care, PACE, Care Transitions Program, Transitional Care model) Better integrate medical services and social supports Encourage care in lower-cost settings (patient s home) by better integrating ADLs and IADLs, transportation, meals, bathing, and care management with traditional medical services Sustain effective care delivery reforms through simultaneous payment and benefit reforms Engage in new contractual relationships that reimburse based on capitated or episodic rates that help incentivize high-quality care at lower costs 21

22 Agenda Overview of national ACO Implementation: growing private and public sector activity Discovering the unicorn: ACO fundamentals Role of Post-Acute Care Providers: Services that Drive Value Implementation through collaboration: Brookings-Dartmouth ACO Learning Network

23 ACO Learning Network: implementation through collaboration ACO Learning Network Focused on defining core ACO concepts Included webinars, ACO materials, and conference discounts Included the release of our ACO Toolkit Conceptual ACO Learning Network Shared lessons learned from ongoing examples of ACO implementation Identified best practices and strategies from ongoing ACO implementation efforts Provided in-depth analysis of emerging Federal and State regulation ACO Learning Network Focused peer-led work groups on key ACO challenges guided by technical experts and resulting in real actionable ACO implementation tools Continued analysis of emerging Federal and State regulation and National ACO trends Implementation

24 Accountable Care Core Design Elements 1. Overview and Key Principles of ACOs 2. Organization and Governance 3. Accountability for Performance (e.g. patient attribution, payment models, performance measurement) 4. ACO Infrastructure 5. Health Care Delivery Transformations for Achieving High-Value Health Care 6. Legal Issues for ACOs Available at:

25 Overview of the Brookings-Dartmouth ACO Learning Network

26 Clinician-led implementation work groups to address core ACO challenges Implementing Performance Measures Accountable Care Payment Strategies Clinical Transformation High-Risk and Vulnerable Populations Shared learning on how to leverage data collection and acquisition across payers to support both internal feedback to clinicians and external reporting to payers. Shared learning on how to align quality with payment and effectively match payments to staff alignment. From Leadership to Quality Improvement: shared learning on how to engage clinicians in leading quality and process improvement efforts. Shared learning on how to identify and care for high risk and vulnerable populations. Member informed decision-making tools to help ACOs make strategic investments to improve care & lower costs

27 Thank you April 19, 2012 For more information: