Pathways for Physician Success in Accountable Care Organizations and Healthcare Payment Reform

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1 Pathways for Physician Success in Accountable Care Organizations and Healthcare Payment Reform Harold D. Miller Executive Director Center for Healthcare Quality and Payment Reform April 8, 2011

2 What is an Accountable Care Organization? 2

3 The Official Definition What is an Accountable Care Organization? A group of providers who are accountable for the quality, cost, and overall care of patients Section 3022, Patient Protection and Affordable Care Act 3

4 The Real Definition What is an Accountable Care Organization? A group of providers who can figure out how to save money in health care 4

5 How Will ACOs Generate All These Savings? Financial Risk Patients ACO ( the Black Box ) Lower Costs Organizational Structure 5

6 What s In That Black Box Can t Be Good For Consumers, Can It? Financial Risk Patients ACO RATIONING ( the Black Box ) Lower Costs Organizational Structure 6

7 Early Successes Need to Assure That Savings Rationing Patients REDUCING COSTS WITHOUT RATIONING Lower Costs 7

8 Reducing Costs Without Rationing: Can It Be Done?? 8

9 Reducing Costs Without Rationing: Prevention and Wellness Healthy Consumer Continued Health Preventable Condition 9

10 Reducing Costs Without Rationing: Avoiding Hospitalizations Healthy Consumer Continued Health Preventable Condition No Hospitalization Acute Care Episode 10

11 Reducing Costs Without Rationing: Efficient, Successful Treatment Healthy Consumer Continued Health Preventable Condition No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 11

12 Reducing Costs Without Rationing: Healthy Consumer Is Also Quality Improvement! Continued Health Preventable Condition Better Outcomes/Higher Quality No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 12

13 Who Should Be Accountable For Achieving Higher Value Care? Health Plans? Hospitals? 13

14 Physicians are at the Core of Accountable Care Healthy Consumer Continued Health Preventable Condition PRIMARY CARE + SPECIALISTS No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 14

15 Current Payment Systems Reward Bad Outcomes, Not Better Health Healthy Consumer Continued Health $ Preventable Condition No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 15

16 Are There Better Ways to Pay for Health Care? Healthy Consumer $? Continued Health Preventable Condition No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 16

17 Episode Payments to Reward Value Within Episodes Healthy Consumer Continued Health Preventable Condition $A Single Payment For All Care Needed From All Providers in the Episode, With a Warranty For Complications No Hospitalization Acute Care Episode Episode Payment Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 17

18 Yes, a Health Care Provider Can Offer a Warranty Geisinger Health System ProvenCare SM A single payment for an ENTIRE 90 day period including: ALL related pre-admission care ALL inpatient physician and hospital services ALL related post-acute care ALL care for any related complications or readmissions Types of conditions/treatments currently offered: Cardiac Bypass Surgery Cardiac Stents Cataract Surgery Total Hip Replacement Bariatric Surgery Perinatal Care Low Back Pain Treatment of Chronic Kidney Disease 18

19 Payment + Process Improvement = Better Outcomes, Lower Costs 19

20 It Can Be Done By Physicians, Not Just Health Systems In 1987, an orthopedic surgeon in Lansing, MI and the local hospital, Ingham Medical Center, offered: a fixed total price for surgical services for shoulder and knee problems a warranty for any subsequent services needed for a two-year period, including repeat visits, imaging, rehospitalization and additional surgery Results: Health insurer paid 40% less than otherwise Surgeon received over 80% more in payment than otherwise Hospital received 13% more than otherwise, despite fewer rehospitalizations Method: Reducing unnecessary auxiliary services such as radiography and physical therapy Reducing the length of stay in the hospital Reducing complications and readmissions. Johnson LL, Becker RL. An alternative health-care reimbursement system application of arthroscopy and financial warranty: results of a two-year pilot study. Arthroscopy Aug;10(4):

21 The Weakness of Episode Payment Healthy Consumer Continued Health Preventable Condition How do you prevent unnecessary episodes of care? (e.g., preventable hospitalizations for chronic disease, overuse of cardiac surgery, back surgery, etc.) No Hospitalization Acute Care Episode Episode Payment Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 21

22 Comprehensive Care Payments To Avoid Episodes Healthy Consumer $ A Single Payment For All Care Needed For A Condition Continued Health Preventable Condition Comprehensive Care Payment or Global Payment No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 22

23 Isn t This Capitation? No It s Different CAPITATION (WORST VERSIONS) No Additional Revenue for Taking Sicker Patients COMPREHENSIVE CARE PAYMENT Payment Levels Adjusted Based on Patient Conditions Providers Lose Money On Unusually Expensive Cases Providers Are Paid Regardless of the Quality of Care Provider Makes More Money If Patients Stay Well Flexibility to Deliver Highest-Value Services Limits on Total Risk Providers Accept for Unpredictable Events Bonuses/Penalties Based on Quality Measurement Provider Makes More Money If Patients Stay Well Flexibility to Deliver Highest-Value Services 23

24 Example: BCBS Massachusetts Alternative Quality Contract Single payment for all costs of care for a population of patients Adjusted up/down annually based on severity of patient conditions Initial payment set based on past expenditures, not arbitrary estimates Provides flexibility to pay for new/different services Bonus paid for high quality care Five-year contract Savings for payer achieved by controlling increases in costs Allows provider to reap returns on investment in preventive care, infrastructure Broad participation 14 physician groups/health systems participating with over 400,000 patients, including one primary care IPA with 72 physicians Positive first-year results Higher ambulatory care quality than non-aqc practices, better patient outcomes, lower readmission rates and ER utilization 24

25 Payment Reform Allows Pursuing a Different Triple Aim Better Care for Patients (Win) Lower Costs for Purchasers/Payers (Win) Equal or Better Margins for Providers (Win) 25

26 A Deeper Dive into Episode Payments and Implications Healthy Consumer Continued Health $ Preventable Condition No Hospitalization Acute Care Episode Episode Payment Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 26

27 Episode Payment = Bundling + Warranty Bundling: Making a single payment to two or more providers who are currently paid separately e.g., services of both a hospital and a physician e.g., both hospital and post-acute care services Warranty: Not charging/being paid more for costs of treating hospital-acquired infections, problems caused by errors, etc. 27

28 How Can Physicians, Hospitals, and Payers Benefit from Bundling? 28

29 Example: Reducing Cost of Joint Replacement COST TYPE TODAY Physician Fee $ 1,500 Device Cost $ 7,500 Other Hospital Cost $ 6,750 Hosp. Margin (5%) $ 750 Total Hospital Pmt $15,000 Total Cost to Payer $16,500 29

30 Physicians Could Help Hospitals Reduce Cost of Medical Devices COST TYPE TODAY CHANGE Physician Fee $ 1,500 Device Cost $ 7,500-33% ($2,500) Other Hospital Cost $ 6,750 Hosp. Margin (5%) $ 750 Total Hospital Pmt $15,000 Total Cost to Payer $16,500 30

31 Today: All Savings Goes to the Hospital, No Reward for Physician COST TYPE TODAY CHANGE SPLIT Physician Fee $ 1, % Device Cost $ 7,500-33% ($2,500) Other Hospital Cost $ 6,750 Hosp. Margin $ % ($2500) Total Hospital Pmt $15,000 Total Cost to Payer $16,500-0% 31

32 Bundling Allows Savings Split Among Physicians, Hospitals, Payers COST TYPE TODAY CHANGE SPLIT Physician Fee $ 1, % ($750) Device Cost $ 7,500-33% ($2,500) Other Hospital Cost $ 6,750 Hosp. Margin $ % ($750) Total Hospital Pmt $15,000 Total Cost to Payer $16,500-6% ($1000) 32

33 So Joint Replacement is Cheaper But More Profitable COST TYPE TODAY CHANGE SPLIT NEW Physician Fee $ 1, % ($750) $ 2,250 Device Cost $ 7,500-33% ($2,500) $ 5,000 Other Hospital Cost $ 6,750 $ 6,750 Hosp. Margin $ % ($750) $ 1,500 Total Hospital Pmt $15,000 $13,250 Total Cost to Payer $16,500-6% ($1000) $15,500 33

34 Won t Bundling Encourage More Procedures? 34

35 The Same Procedure, But For A Full Population of Patients COST TYPE TODAY 200 Cases Physician Fee $ 1,500 $300,000 Device Cost $ 7,500 Other Hospital Cost $ 6,750 Hosp. Margin $ 750 $150,000 Total Hospital Pmt $15,000 Total Cost to Payer $16,500 $3,300,000 35

36 What If There is Evidence of Overutilization? COST TYPE TODAY 200 Cases Physician Fee $ 1,500 $300,000 Device Cost $ 7,500 Other Hospital Cost $ 6,750 Hosp. Margin $ 750 $150,000 Total Hospital Pmt $15,000 Local study finds that 25% of procedures are unnecessary or can be avoided through medical management Total Cost to Payer $16,500 $3,300,000 36

37 Appropriateness Guidelines Alone Can Hurt Both Hospitals & Physicians COST TYPE TODAY 200 Cases TODAY 150 Cases Chg Physician Fee $ 1,500 $300,000 $ 1,500 $225,000-25% Device Cost $ 7,500 $ 7,500 Other Hospital Cost $ 6,750 $ 6,750 Hosp. Margin $ 750 $150,000 $ 750 $112,500-25% Total Hospital Pmt $15,000 $15,000 Total Cost to Payer $16,500 $3,300,000 $16,500 $2,475,000-25% 37

38 Bundling+Appropriateness Guidelines Can Reduce Costs w/o Financial Harm COST TYPE TODAY 200 Cases NEW 150 Cases Chg Physician Fee $ 1,500 $300,000 $ 2,250 $337, % Device Cost $ 7,500 $ 5,000 Other Hospital Cost $ 6,750 $ 6,750 Hosp. Margin $ 750 $150,000 $ 1,500 $225, % Total Hospital Pmt $15,000 $13,250 Total Cost to Payer $16,500 $3,300,000 $15,500 $2,325,000-30% 38

39 How Can Physicians, Hospitals, and Payers Benefit from Warranties? 39

40 Prices for Warrantied Care Will Likely Be Higher 40

41 Prices for Warrantied Care Will Likely Be Higher Q: Why should we pay more to get good-quality care?? A: In most industries, warrantied products cost more, but they re desirable because TOTAL spending on the product (repairs & replacement) is lower than without the warranty 41

42 Prices for Warrantied Care May Be Higher, But Spending Lower Q: Why should we pay more to get good-quality care?? A: In most industries, warrantied products cost more, but they re desirable because TOTAL spending on the product (repairs & replacement) is lower than without the warranty In healthcare, a DRG with a warranty would need to have a higher payment rate than the equivalent non-warrantied DRG, but the higher price would be offset by fewer DRGs w/ complications, outlier payments, and readmissions 42

43 Example: Procedure Where Physician & Hospital are Paid $10,000 Today Cost of Procedure $10,000 43

44 Cost of Procedure Actual Average Payment for Procedure is Higher Added Cost of Infection Rate of Infections Average Total Cost $10,000 $20,000 5% $11,000 44

45 Starting Point for Warranty Price: Actual Current Average Payment Cost of Procedure Added Cost of Infection Rate of Infections Average Total Cost Price Charged Change in Net Revenue $10,000 $20,000 5% $11,000 $11,000 $0 45

46 Limited Warranty Gives Financial Cost of Procedure Incentive to Improve Quality Added Cost of Infection Rate of Infections Average Total Cost Price Charged Change in Net Revenue $10,000 $20,000 5% $11,000 $11,000 $0 $10,000 $20,000 4% $10,800 $11,000 $200 Reducing Adverse Events...Reduces Costs... Improves The Bottom Line 46

47 Higher-Quality Provider Can Charge Less, Attract More Patients Cost of Procedure Added Cost of Infection Rate of Infections Average Total Cost Price Charged Change in Net Revenue $10,000 $20,000 5% $11,000 $11,000 $0 $10,000 $20,000 4% $10,800 $11,000 $200 $10,000 $20,000 4% $10,800 $10,800 $0 Enables Lower Prices 47

48 Cost of Procedure A Virtuous Cycle of Quality Improvement & Cost Reduction Added Cost of Infection Rate of Infections Average Total Cost Price Charged Change in Net Revenue $10,000 $20,000 5% $11,000 $11,000 $0 $10,000 $20,000 4% $10,800 $11,000 $200 $10,000 $20,000 4% $10,800 $10,800 $0 $10,000 $20,000 3% $10,600 $10,800 $200 Reducing Adverse Events...Reduces Costs... Improves The Bottom Line 48

49 Cost of Procedure Win-Win-Win for Patients, Payers, and Providers Added Cost of Infection Rate of Infections Average Total Cost Price Charged Change in Net Revenue $10,000 $20,000 5% $11,000 $11,000 $0 $10,000 $20,000 4% $10,800 $11,000 $200 $10,000 $20,000 4% $10,800 $10,800 $0 $10,000 $20,000 3% $10,600 $10,800 $200 $10,000 $20,000 3% $10,600 $10,600 $0 $10,000 $20,000 0% $10,000 $10,600 $600 Quality is Better......Cost is Lower......Providers More Profitable 49

50 In Contrast, Non-Payment for Infections Creates Financial Losses Cost of Procedure Added Cost of Infection Rate of Infections Average Total Cost Amount Paid Change in Net Revenue $10,000 $20,000 5% $11,000 $11,000 $0 $10,000 $20,000 5% $11,000 $10,000 -$1,000 $10,000 $20,000 3% $10,600 $10,000 -$600 $10,000 $20,000 0% $10,000 $10,000 $0 Non- Payment for Infections Causes Losses While Improving 50

51 Not Just Better Acute Care, But Reducing the Need for It Healthy Consumer Continued Health Preventable Condition No Hospitalization Acute Care Episode Efficient Successful Outcome High-Cost Successful Outcome Complications, Infections, Readmissions 51

52 Utah Oregon Hawaii Wyoming Washington Idaho Arizona Minnesota Nevada Alaska Colorado Vermont New Mexico California Delaware Nebraska Florida Wisconsin Virginia Iowa Maine New Hampshire Maryland Montana North Dakota Georgia Connecticut South Carolina North Carolina South Dakota Kansas Michigan Pennsylvania Indiana Texas Missouri Oklahoma DC Massachusetts New York New Jersey Illinois Tennessee Ohio Alabama Arkansas Mississippi Kentucky Rhode Island West Virginia Louisiana Hospitalizations per 100,000 Beneficaries Significant Opportunity to Reduce Hospitalizations in Missouri 10,000 Rate of Hospitalizations for Ambulatory Care Sensitive Conditions, 2009 (Medicare Beneficiaries) 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,

53 Examples: Significant Reduction in Rate of Hospitalizations Possible 40% reduction in hospital admissions, 41% reduction in ER visits for exacerbations of COPD using in-home & phone patient education by nurses or respiratory therapists J. Bourbeau, M. Julien, et al, Reduction of Hospital Utilization in Patients with Chronic Obstructive Pulmonary Disease: A Disease-Specific Self-Management Intervention, Archives of Internal Medicine 163(5), % reduction in hospitalizations for CHF patients using homebased telemonitoring M.E. Cordisco, A. Benjaminovitz, et al, Use of Telemonitoring to Decrease the Rate of Hospitalization in Patients With Severe Congestive Heart Failure, American Journal of Cardiology 84(7), % reduction in hospital admissions, 21% reduction in ER visits through self-management education M.A. Gadoury, K. Schwartzman, et al, Self-Management Reduces Both Short- and Long-Term Hospitalisation in COPD, European Respiratory Journal 26(5),

54 We Don t Pay for the Things That Will Prevent Overutilization CURRENT PAYMENT SYSTEMS Health Insurance Plan $ $ $ Physician Practice Office Visits Phone Calls Nurse Care Mgr No payment for services that can prevent utilization... ER Visits Avoidable Lab Work/ Imaging Avoidable Hospital Stay Avoidable...No penalty or reward for high utilization elsewhere 54

55 Global Payment Can Solve That, But It s a Big Jump from FFS FULL COMP. CARE/GLOBAL PAYMENT Health Insurance Plan Condition- Adjusted Per Person Payment $ Physician Practice/ ACO $ Office Visits Phone Calls Nurse Care Mgr ER Visits Avoidable Lab Work/ Imaging Avoidable Hospital Stay Avoidable Flexibility and accountability for a condition-adjusted budget covering all services 55

56 What Might a Transitional Payment System Look Like? CURRENT PAYMENT SYSTEMS Health Insurance Plan $ $ $ Office Visits ER Visits Hospital Stay Physician Practice Phone Calls Nurse Care Mgr Avoidable Lab Work/ Imaging Avoidable Avoidable 56

57 Typical Medical Home Solution : Pay More for Physician Services (TYPICAL) MEDICAL HOME PROGRAM Health Insurance Plan $ $ $ Physician Practice Higher payment for primary care... Office Visits Monthly Care Mgt Payment Phone Calls RN Care Mgr $ ER Visits Avoidable Lab Work/ Imaging Avoidable Hospital Stay Avoidable 57

58 Weakness: More $ for Physicians, But Any Savings Elsewhere? (TYPICAL) MEDICAL HOME PROGRAM Health Insurance Plan $ $ $ Physician Practice Higher payment for primary care... Office Visits Monthly Care Mgt Payment Phone Calls RN Care Mgr $ ER Visits Avoidable Lab Work/ Imaging Avoidable Hospital Stay Avoidable...But no commitment to reduce utilization elsewhere 58

59 Is Shared Savings the Answer? SHARED SAVINGS MODEL Health Insurance Plan $ $ $...Returned to physician practice after savings determined... Physician Practice $ Office Visits Phone Calls Nurse Care Mgr...but no upfront $ for better care ER Visits Avoidable Lab Work/ Imaging Avoidable Hospital Stay Avoidable Portion of savings from reduced spending in other areas... 59

60 Weaknesses of Shared Savings Provides no upfront money to enable physician practices to hire nurse care managers, install IT, etc.; additional funds, if any, come years after the care changes are made Requires TOTAL costs to go down in order for the physician practice to receive ANY increase in payment, even if the practice can t control all costs Gives more rewards to the poor performers who improve than the providers who ve done well all along The underlying fee for service incentives continue; losing less (via shared savings) is still losing compared to FFS I.e., it s not really true payment reform 60

61 Better Approach: Simulate Flexibility & Incentives of Global Payment CARE MGT PAYMENT + UTILIZATION P4P Health Insurance Plan $ $ $ Physician Practice $ $ $ More $ for PCP Office Visits Monthly Care Mgt Payment Phone Calls RN Care Mgr $ ER Visits Avoidable Lab Work/ Imaging Avoidable P4P Bonus/Penalty Based on Utilization Hospital Stay Avoidable Targets for Reduction In Utilization 61

62 Example: Washington State Medical Home Pilot Program Payers will pay the Primary Care Practice an upfront PMPM Care Management Payment for all patients ($2.50 first year, $2.00 future years) Practice agrees to reduce rate of non-urgent ER visits and ambulatory care-sensitive hospital admissions by amounts which will generate savings for payers at least equal to the Care Management Payment (targets are practice specific) If a practice reduces ER visits and hospitalizations by more than the target amount, the payer shares 50% of the net savings (gross savings minus the PMPM) with the practice If a practice fails to meet its ER/hospitalization targets, the practice pays a penalty via a reduction in its FFS conversion factor equivalent to up to 50% of Care Management Payment 62

63 Example: A Hypothetical Underpaid PCP Practice PRIMARY CARE PRACTICE PCPs 4 ER Visits/ Patients/Physician 2,000 % Preventable 40% PMPY Primary Care Cost $140 Per ER Visit $1,000 Annual Revenue $1,120,000 ER Visit Cost to Payer $640,000 Overhead Costs $400,000 Physician Salary $180,000 Cost of Nurse Practitioner $80,000 Reduction in Prev. ER Visits 40% Other Costs $10,000 Savings $256,000 Total Costs $90,000 Upfront Payment $90,000 Payment to Practice $90,000 Net Savings to Payer $166,000 Share of Savings $83,000 Share to Practice 50% New Physician Salary $200,750 Net Savings to Payer $83,000 Increase in Phys. Salary 12% % Savings to Payer 13% 63

64 Many Patients Are Going to ER Due to Difficulty Seeing PCPs PRIMARY CARE PRACTICE HEALTH PLAN ER EXPENSES PCPs 4 ER Visits/ Patients/Physician 2,000 % Preventable 40% PMPY Primary Care Cost $140 Per ER Visit $1,000 Annual Revenue $1,120,000 ER Visit Cost to Payer $640,000 Overhead Costs $400,000 Physician Salary $180,000 Cost of Nurse Practitioner $80,000 Reduction in Prev. ER Visits 40% Other Costs $10,000 Savings $256,000 Total Costs $90,000 Upfront Payment $90,000 Payment to Practice $90,000 Net Savings to Payer $166,000 Share of Savings $83,000 Share to Practice 50% New Physician Salary $200,750 Net Savings to Payer $83,000 Increase in Phys. Salary 12% % Savings to Payer 13% 64

65 PCPs Could Reduce ER Expenses With Right Resources PRIMARY CARE PRACTICE HEALTH PLAN ER EXPENSES PCPs 4 ER Visits/ Patients/Physician 2,000 % Preventable 40% PMPY Primary Care Cost $140 Per ER Visit $1,000 Annual Revenue $1,120,000 ER Visit Cost to Payer $640,000 Overhead Costs $400,000 Physician Salary $180,000 Cost of Nurse Practitioner $80,000 Reduction in Prev. ER Visits 40% Other Costs $10,000 Savings $256,000 Total Costs $90,000 Upfront Payment $90,000 Payment to Practice $90,000 Net Savings to Payer $166,000 Share of Savings $83,000 Share to Practice 50% New Physician Salary $200,750 Net Savings to Payer $83,000 Increase in Phys. Salary 12% % Savings to Payer 13% 65

66 Upfront Money Could Enable PCPs to Change, If Willing PRIMARY CARE PRACTICE HEALTH PLAN ER EXPENSES PCPs 4 ER Visits/ Patients/Physician 2,000 % Preventable 40% PMPY Primary Care Cost $140 Per ER Visit $1,000 Annual Revenue $1,120,000 ER Visit Cost to Payer $640,000 Overhead Costs $400,000 Physician Salary $180,000 Cost of Nurse Practitioner $80,000 Reduction in Prev. ER Visits 40% Other Costs $10,000 Savings $256,000 Total Costs $90,000 Upfront Payment $90,000 Payment to Practice $90,000 Net Savings to Payer $166,000 Share of Savings $83,000 Share to Practice 50% New Physician Salary $200,750 Net Savings to Payer $83,000 Increase in Phys. Salary 12% % Savings to Payer 13% 66

67 Win-Win-Win for PCPs, Patients, & Premiums PRIMARY CARE PRACTICE HEALTH PLAN ER EXPENSES PCPs 4 ER Visits/ Patients/Physician 2,000 % Preventable 40% PMPY Primary Care Cost $140 Per ER Visit $1,000 Annual Revenue $1,120,000 ER Visit Cost to Payer $640,000 Overhead Costs $400,000 Physician Salary $180,000 Cost of Nurse Practitioner $80,000 Reduction in Prev. ER Visits 40% Other Costs $10,000 Savings $256,000 Total Costs $90,000 Upfront Payment $90,000 Payment to Practice $90,000 Net Savings to Payer $166,000 Share of Savings $83,000 Share to Practice 50% New Physician Salary $200,750 Net Savings to Payer $83,000 Increase in Phys. Salary 12% % Savings to Payer 13% 67

68 Win-Win-Win for PCPs, Patients, & Premiums PRIMARY CARE PRACTICE HEALTH PLAN ER EXPENSES PCPs 4 ER Visits/ Patients/Physician 2,000 % Preventable 40% PMPY Primary Care Cost $140 Per ER Visit $1,000 Annual Revenue $1,120,000 ER Visit Cost to Payer $640,000 Overhead Costs $400,000 Physician Salary $180,000 Cost of Nurse Practitioner $80,000 Reduction in Prev. ER Visits 40% Other Costs $10,000 Savings $256,000 Total Costs $90,000 Upfront Payment $90,000 Payment to Practice $90,000 Net Savings to Payer $166,000 Share of Savings $83,000 Share to Practice 50% New Physician Salary $200,750 Net Savings to Payer $83,000 Increase in Phys. Salary 12% % Savings to Payer 13% 68

69 But Upfront Payment Reform is Needed to Allow Care to Be Changed PRIMARY CARE PRACTICE HEALTH PLAN ER EXPENSES PCPs 4 ER Visits/ Patients/Physician 2,000 % Preventable 40% PMPY Primary Care Cost $140 Per ER Visit $1,000 Annual Revenue $1,120,000 ER Visit Cost to Payer $640,000 Overhead Costs $400,000 Physician Salary $180,000 Cost of Nurse Practitioner $80,000 Reduction in Prev. ER Visits 40% Other Costs $10,000 Savings $256,000 Total Costs $90,000 Upfront Payment $90,000 Payment to Practice $90,000 Net Savings to Payer $166,000 Share of Savings $83,000 Share to Practice 50% New Physician Salary $200,750 Net Savings to Payer $83,000 Increase in Phys. Salary 12% % Savings to Payer 13% 69

70 Wouldn t the ACO Shared Savings Model Achieve the Same Goal? 70

71 Same PCP Practice as Before... Year 0 Year 1 Year 2 Year 3 Total Yrs 1-3 PCP Revenues $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Shared Savings $128,000 $128,000 $256,000 Total $1,120,000 $1,120,000 $1,248,000 $1,248,000 $3,616,000 Expenses $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Care Mgt $0 $90,000 $90,000 $90,000 $270,000 Total $1,120,000 $1,210,000 $1,210,000 $1,210,000 $3,630,000 Net Revenue $0 -$90,000 $38,000 $38,000 -$14,000 Margin 0.0% -7.4% 3.1% 3.1% -0.4% Payer PCP Costs $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 ER Costs $640,000 $384,000 $384,000 $384,000 $1,152,000 50% Shared Savings $128,000 $128,000 Total $1,760,000 $1,504,000 $1,504,000 $1,504,000 $4,512,000 Savings From Year 0 $0 $256,000 $256,000 $256,000 $768,000 % Savings 15% 15% 15% 15% 71

72 Simple Model: Payer Spending Limited to PCPs & Prev. ER Visits Year 0 Year 1 Year 2 Year 3 Total Yrs 1-3 PCP Revenues $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Shared Savings $128,000 $128,000 $256,000 Total $1,120,000 $1,120,000 $1,248,000 $1,248,000 $3,616,000 Expenses $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Care Mgt $0 $90,000 $90,000 $90,000 $270,000 Total $1,120,000 $1,210,000 $1,210,000 $1,210,000 $3,630,000 Net Revenue $0 -$90,000 $38,000 $38,000 -$14,000 Margin 0.0% -7.4% 3.1% 3.1% -0.4% Payer PCP Costs $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 ER Costs $640,000 $384,000 $384,000 $384,000 $1,152,000 50% Shared Savings $128,000 $128,000 Total $1,760,000 $1,504,000 $1,504,000 $1,504,000 $4,512,000 Savings From Year 0 $0 $256,000 $256,000 $256,000 $768,000 % Savings 15% 15% 15% 15% 72

73 PCP Invests in Year 1, Payer Reaps Benefit, PCP Loses Year 0 Year 1 Year 2 Year 3 Total Yrs 1-3 PCP Revenues $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Shared Savings $128,000 $128,000 $256,000 Total $1,120,000 $1,120,000 $1,248,000 $1,248,000 $3,616,000 Expenses $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 PCP Invests in Care Mgt $0 $90,000 $90,000 $90,000 $270,000 Better Care Mgt Total $1,120,000 $1,210,000 $1,210,000 $1,210,000 $3,630,000 Net Revenue $0 -$90,000 $38,000 $38,000 -$14,000 Margin 0.0% -7.4% 3.1% 3.1% -0.4% Payer PCP Costs $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 ER Costs $640,000 $384,000 $384,000 $384,000 $1,152,000 50% Shared Savings $128,000 $128,000 Total $1,760,000 $1,504,000 $1,504,000 $1,504,000 $4,512,000 Savings From Year 0 $0 $256,000 $256,000 $256,000 $768,000 % Savings 15% 15% 15% 15% 73

74 PCP Invests in Year 1, Payer Reaps Benefit, PCP Loses Year 0 Year 1 Year 2 Year 3 Total Yrs 1-3 PCP Revenues $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 No New Revenues Shared Savings $128,000 for PCP $128,000 in Year 1 $256,000 Total $1,120,000 $1,120,000 $1,248,000 $1,248,000 $3,616,000 Expenses $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 PCP Invests in Care Mgt $0 $90,000 $90,000 $90,000 $270,000 Better Care Mgt Total $1,120,000 $1,210,000 $1,210,000 $1,210,000 $3,630,000 Net Revenue $0 -$90,000 $38,000 Negative $38,000 Margin -$14,000 Margin 0.0% -7.4% for 3.1% PCP in Year 3.1% 1-0.4% Payer PCP Costs $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 ER Costs $640,000 $384,000 $384,000 $384,000 $1,152,000 50% Shared Savings $128,000 $128,000 Total $1,760,000 $1,504,000 $1,504,000 $1,504,000 $4,512,000 Payer Benefits if Savings From Year 0 $0 $256,000 $256,000 $256,000 $768,000 PCP is Successful % Savings 15% 15% 15% 15% 74

75 PCP Gets More Revenue in Year 2, But Not Enough to Cover Year 1 Loss Year 0 Year 1 Year 2 Year 3 Total Yrs 1-3 PCP Revenues $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Shared Savings Shared Savings $128,000 $128,000 Paid in Year $256,000 2 Total $1,120,000 $1,120,000 $1,248,000 $1,248,000 $3,616,000 Expenses $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Care Mgt $0 $90,000 $90,000 $90,000 $270,000 Total $1,120,000 $1,210,000 $1,210,000 $1,210,000 $3,630,000 Positive Margin Net Revenue $0 -$90,000 $38,000 $38,000 -$14,000 But < Year 1 Loss Margin 0.0% -7.4% 3.1% 3.1% -0.4% Payer PCP Costs $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 ER Costs $640,000 $384,000 $384,000 $384,000 $1,152,000 50% Shared Savings $128,000 $128,000 Total $1,760,000 $1,504,000 $1,504,000 $1,504,000 $4,512,000 Payer Still Savings From Year 0 $0 $256,000 $256,000 $256,000 $768,000 Benefits % Savings 15% 15% 15% 15% 75

76 PCP Still Worse Off After 3 Years, Payer Saves Significantly Year 0 Year 1 Year 2 Year 3 Total Yrs 1-3 PCP Revenues $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Shared Savings $128,000 $128,000 $256,000 Total $1,120,000 $1,120,000 $1,248,000 $1,248,000 $3,616,000 Expenses $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 Care Mgt $0 $90,000 $90,000 $90,000 $270,000 Total $1,120,000 $1,210,000 $1,210,000 $1,210,000 $3,630,000 Net Revenue $0 -$90,000 $38,000 $38,000 -$14,000 Margin 0.0% -7.4% 3.1% 3.1% -0.4% Payer PCP Costs $1,120,000 $1,120,000 $1,120,000 $1,120,000 $3,360,000 ER Costs $640,000 $384,000 $384,000 $384,000 $1,152,000 50% Shared Savings $128,000 $128,000 Total $1,760,000 $1,504,000 $1,504,000 $1,504,000 $4,512,000 Savings From Year 0 $0 $256,000 $256,000 $256,000 $768,000 % Savings 15% 15% 15% 15% Net Loser For PCP Win for Payer 76

77 Not Just PCPs, But The Medical Neighborhood, Too Resources & Incentives for More Coordinated Care FFS Payment Based on Volume, Procedures, & Office Visits Primary Care Medical Home (Non-Primary Care) Specialists PATIENT 77

78 Pay Both PCPs & Specialists for Outcomes & Coordination Resources & Incentives for More Coordinated Care Payment for Consultation w/ PCP; Outcomes-Based Payment Primary Care Medical Home (Non-Primary Care) Specialists PATIENT 78

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