Case Study: Population Health Management in Oregon

Transcription

1 Case Study: Population Health Management in Oregon Aaron R. Crane, CEO Propel Health October Copyright Propel Health

2 The mother of all fiscal problems Victor Fuchs, emeritus professor of economics and health research and policy at Stanford University If we solve our health care spending, practically all of our fiscal problems go away And if we don t? Then almost anything else we do will not solve our fiscal problems. James L. Reinertsen, MD (Physician, Health System CEO, Sr Fellow at the Institute for Healthcare Improvement) The principal focus of health policy for the next decade will be cost reduction. 1 Copyright Propel Health

3 Overkill, Atule Gawande, MD 26 tests or treatments scientifically determined to have no benefit or be outright harmful In one year 25-42% of Medicare patients receive at least one of these tests IOM Report that waste accounts for 30% of healthcare spending $750 billion in waste, more than the national budget for K-12 education Source: New Yorker Magazine, 5/5/ Copyright Propel Health

4 Our Statewide Network 3 3 Copyright Propel Health

5 Key market forces uniting the Alliance 2 To maintain and potentially grow share, providers will have to deliver a reliable reduction in trend 4 Population health management capabilities are expensive, and it makes more sense to invest in this together as opposed to many times separately 1 3 Providers who cannot deliver a lower medical trend will likely face a declining share of the market A much lower medical trend is only possible with greater plan / provider alignment and best in class tools for managing utilization 4 Copyright Propel Health

6 The Train has left the station Medicare 30% of our market has already converted into a value based model through Medicare Advantage CMS expects to move 50% of the remaining population by 2018 The effect is compounded by our aging population Medicaid Oregon has embraced a new model of value based care for the vast majority of its Medicaid population ACA initiative to expand this population shifting a large number from the uninsured population in to Medicaid Commercial United Health: We will increase value-based payments by 20% this year to beyond $43 billion, and beyond $65 billion in 2018 Intel: Contract with Kaiser and Providence for 50,0000 lives. 5 Copyright Propel Health

7 Creating Value Will require bringing payment and quality - the two factors of the value equation to the fore and, as in other industries, defining them around the purchaser s needs. -The Healthcare Value Sourcebook, HFMA, Copyright Propel Health

8 What is value based care? The consistent deployment of scarce resources across a larger population to improve quality and lower total cost. Effective risk stratification tool Engage the patient Apply interventions that make a difference Coordinated care team 7 Copyright Propel Health

9 Axioms for a successful business model Downside Risk The level of upside necessary to fund a value-based business is only achievable by also taking downside risk Risk Mgmt Infrastructure In order to manage downside risk, a Value-Based Business must invest in adequate risk management infrastructure Scale Achieving scale helps mitigate volatility and leverage the fixed cost of risk management infrastructure PCP base Scale is driven by the number of participating PCPs, which bring in attributed lives Source: Evolent Heatlh, Copyright Propel Health

10 Path from FFS to Value-Based Care Risk Assumption Integrated Risk Management Functions Unlock value by migrating traditional payer-held functions to health systems Example Drivers Care management Utilization mgmt Risk adjustment Quality Pharmacy Successful Value- Based Care Improved Clinical Decision Making Longer-term change through evolving physician behavior and education Current State Example Drivers Clinical effectiveness initiatives Clinical decision support Physician performance management Source: Evolent Health, 2015 Time 9 Copyright Propel Health

11 Our role Propel Health is a provider-led organization uniquely positioned to align incentives for Oregon providers and payers to improve care quality and patient health. Patients Propel Health brings together key elements of value-based care to advance clinical and business outcomes, including: Care coordination Compliance Data and analytics Payment reform Quality improvement Patient risk assessment Patients Become increasingly engaged in their health Receive more personalized care Providers Empowered to provide timely, coordinated interventions Receive tools, resources, education and incentives Payers Establish partnerships with engaged providers, jointly committing to provide high-quality, costeffective care to patients 10 Copyright Propel Health

12 Value-Based Business Tree Diagram Shared Risk Model Sustainable Model Care is transformed Value is delivered Economically Sustainable Utility Model Network Payer Risk Arrangements Care Product Operating Infrastructure Technology Governance Model Operating board Quality and Care Product Finance and contracting Medicare Commercial Medicaid Care Management Utilization Management Risk Adjustment Central Infrastructure Leadership Risk contracting Technology Analytics Care management Network management Identifi Platform & Data integration Reporting Financial Reward Pharmacy Quality & Star Measures Partner Infrastructure Care management Other? 11 Copyright Propel Health

13 Technology Supporting the Value-Based Business 4 Arm the enterprise with tools to manage clinical and financial outcomes 3 Optimize EMR use to drive better, more efficient care 2 Provide access to an integrated view of data at a deeper and broader level 1 Foundation as an integration engine Source: Evolent Health, Copyright Propel Health

14 Strategic Recipe Achieve Scale (Population) Clinical Product Optimization (Value Metrics) Payer Risk Arrangement (Dollars at Risk) Economic sustainability Physician engagement Care management Utilization management RAF (Medicare Advantage) Pharmacy Quality/Stars Aligned Incentive Delegation of responsibility Achieve Scale 13 Copyright Propel Health

15 Three Drivers Key to Propel Health Success Tactic 1: Scale 14 Copyright Propel Health 1) Rapid expansion of the PCP 2) Signing multiple risk-based payer contracts over the next 15 months Tactic 2: Risk Management Capabilities 1) First focus - Complex and Transition Care 2) Pharmacy and RAF in the short-term 3) Post Acute Care Program MSSP Population 4) Building these capabilities is dependent on the speed at which risk contracts enable those new program offerings to be financially viable Tactic 3: Risk Arrangements 1) Formation of a Finance committee can help Propel Health make a range of key financial and contracting decisions in the coming months 2) Maximizing Propel Health s MA presence, using Medicare FFS as a pipeline for potential captive MA lives, represents significant financial upside

16 Propel Health Value Proposition to Affiliates 1) Provides participants access to new revenue streams that are closer to the premium dollar 2) Redirects incentive money to align physician behaviors to valuebased activity rather than volume-based activity 3) Comprehensive data and analytics capabilities provide a fuller picture of the patient, allowing for improved care through identification of high-value care intervention opportunities 4) Opportunities for governance participation at all levels creates a strong physician voice that can best support patient care 5) Payer relationships create the required funding to put additional care team resources on-the-ground to support existing physician office infrastructure 15 Copyright Propel Health

17 Value by Line of Business Representative economics in Year 3-4 of each deal MA Commercial MSSP Track 3 Starting PMPM $773 $548 $692 Clinical Savings Coding improvement (RAF) 8.5% ($66 PMPM) 12% ($93 PMPM) 6.3% ($34 PMPM) 4.3% ($30 PMPM) 0% 0% Value Drivers RAF, UM, CM CM, UM CM Revenue per Member, PMPM ~$139 ~$18 ~$20 Profit per Member, PMPM ~$88 ~$7 ~$2 # Lives Modeled ~30K ~105K ~98K # Additional Lives in Needed for +$1M in NPV Source: Evolent Health, 2015 ~550 ~6,500 ~23, Copyright Propel Health

18 Propel Health Membership Estimates Health Plan / 3 rd Party Re-seller By Risk Arrangement (Lives, 000s) TBD Utility Model - Other Utility Model - Employee MA Payer Partnerships Commercial PP MSSP 20 TBD TBD Total # PCPs Copyright Propel Health

19 Population Health Transformation Risk Management: Balanced Approach to Growth Fully integrated population health manager Value created accrues predominantly to payer Utilization Mgmt Additional levers Highest value capture Risk Coding Broader Care Mgmt Complex + Transition Care Insufficient approaches to manage total cost of care Fee-for- Service Source: Evolent Health, 2015 Value-Based Contracting Full financial risk 18 Copyright Propel Health

20 Care model transformation Future: Broad Range of Risk Management Capabilities Care Management Utilization Management Risk Adjustment Factor (RAF) Pharmacy Management Quality Measures / Star Ratings Clinical programs: Complex care, transition care, condition care, emergent care Use of payment policy and heath plan levers to avoid spending on low-value care Accurate documentation of members diagnoses and risk level Physician reporting and detailing Formulary design Patient and physician outreach to maximize scores on quality metrics both process and outcome 19 Copyright Propel Health

21 Our initial clinical focus Complex Care Launch Complex Care pilots with by 1/1/16. Complex Care rollout with by 4/1/16. Transition Care Launch Transition Care by 4/1/16. Transition Care rollout by 6/30/16. Identifi Rules Configuration of technology rules engine by 11/30/15. Source: Evolent Health, Copyright Propel Health

22 Preliminary Clinical Savings Projections (% PMPM) Commercial Medicare Advantage MSSP 10% 9% 10% 9% Care Mgmt* Utilization Mgmt 8.4% 8.5% 10% 9% 8% 8% 8% 7% 6% 5% 4% 3% 2% 1% 0% 5.9% 6.0% 4.3% 2.8% 2.8% 1.7% 2.2% 2.5% 1.0% 2.2% 2.5% 3.1% 3.2% 2.7% 1.0% Y1 Y2 Y3 Y4 Y5 Y6 7% 6% 5% 4% 3% 2% 1% 0% 3.3% 3.6% 3.9% 4.2% 4.3% 1.1% 1.1% 3.3% 3.6% 6.1% 4.2% 4.2% 2.2% Y1 Y2 Y3 Y4 Y5 Y6 7% 6% 5% 4% 3% 2% 1% 0% 4.4% 4.8% 4.8% 4.8% 1.2% 2.8% 1.2% 2.8% 4.8% 4.8% 4.8% 4.4% Y1 Y2 Y3 Y4 Y5 Y6 Note: Estimates are shown for a representative MSA. Savings percentages vary 5-10% by MSA based on starting utilization levels Source: Evolent Health. 21 Copyright Propel Health

23 Payer Contracting Process Representative Timeline for Payer Partnership Process Initial Interactions (9-12 months prior to go-live) Initial payer meet and greet Initial payer proposal; sends performance data to provider 9 months prior to go-live Negotiation (4-9 months prior to go-live) Create financial model Red-line initial contract and share with payer Back-and-forth negotiation ending in signed contract 4 months prior to go-live Implementation (0-4 to go-live) Design operating model Receive data, establish feeds Additional go-live prep through working groups to monitor, deliver, and troubleshoot all issues Operational go-live Go-live Date 22 Copyright Propel Health

24 Risk Arrangement Points of Negotiation Key Terms Category Description Terms Included Economic Terms directly driving value of deal to be obtained by payer Shared savings upside % Shared savings downside % Care Coordination Fee Care management reimbursement Quality incentives PAF/RAF assessment form Medical cost target Medical funds Catastrophic claim/member Stop loss protection Reserve fund Medical claims exclusions Quality gate for shared savings Rebasing Savings corridor Shared savings cap Deficit carryover Methodological Terms driving processes by which value is calculated or determined Program changes Risk adjustment Trend Eligibility requirements Referrals Attribution Care coordination fee reconciliation Quality incentive reconciliation Shared savings reconciliation Strategic Terms driving overall legal framework of agreement Non-compete PCPs included Network tiering Term and termination Incentive payment distribution Operational Terms driving provider s ability to generate savings within agreement Delegation of operating responsibilities (eg RAF, UM) Clinical liaison for care management Data and Reporting Feeds from Payer to Provider Data and Reporting Feeds from Provider to Payer 23 Copyright Propel Health

25 Organization Chart Aaron Crane, CEO Erin Jacke, EA Geoff Swanson, MD, CMO Payer Contracting Melissa Davies, Dir of Operations Margerie Reyes, HR Manager Director of Compliance Jennifer Byrne, EA Information Technology Q2 Network Management Director Q1, Analyst Q2, Q3 (2) Amy Speakman, Pharm D. Jackie Motta, RN, Dir Care Advising Care Advisors 1 Q1 2 Q2 1 Q3 Analysts: Chelsea Keating, Jack Phillips, Vacant Q2, Vacant Q3 Communications Gabby Bruya, Vacant Q1 Project Management - Jessica Werhane, Vacant Q1 Finance and Gov t Programs Coordinator Q1 24 Copyright Propel Health

26 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 FTE Growth Copyright Propel Health

27 Key Financial Risks to Pro Forma Slower-than-expected network growth or payer partnership cadence Less attractive payer partnership terms than modeled Executional risk leads to lower clinical savings or RAF value than modeled 26 Copyright Propel Health

28 Pro Forma Sensitivity Analysis Baseline NPV Variable Payer Partnership Terms Care Management Savings Downside Scenario (30% Worse) Upside Scenario (30% Better) RAF Value Membership Utilization Management Savings Source: Evolent Health, $20 $0 $20 $40 $60 $80 $ Copyright Propel Health

29 David a. Burton, MD, HFM Magazine, April 2015 Leaders of health system and payers seem to fall into three camps 1. Strategic thinkers Those who have embraced value-based payment and are fully committed to making the transition 2. Bet hedgers Taking a tactical, defensive approach to dabble in value based payment. Hopeful that the future is still bright for the old model. When they lose money on a shared risk arrangement they threaten to leave 3. Ostriches In denial doing only what is necessary to avoid penalties 28 Copyright Propel Health

30 HFMA Value Project Survey, March 2011 Plans related to investment in population health management capabilities Not planning to invest Planning to invest, but wil wait Planning to invest within 1-2 years Already made a limited investment Already made a significant investment 0% 10% 20% 30% 40% 50% 60% Source: The Healthcare Value Sourcebook, HFMA, Copyright Propel Health

31 Recommended Reading 1. Being Mortal, Atul Gawande,MD 2. Overdiagnosed, Making People Sick in the Pursuit of Health, Dr. H. Gilbert Welch 3. The Healthcare Value Sourcebook, HFMA, 30 Copyright Propel Health

32 Thank YOU!! Any Questions?? Appendix Aaron Crane 31 Copyright Propel Health

33 Definitions Population Health Management - A systematic effort to do four things: Focused on the needs of a defined population Enhance health through disease management and prevention Improve care quality Reduce waste and variation, and eliminate disparities for ethical and economic reasons Value based contracting - Evolution in payment methodology that: Aligns incentives across members, payers, providers and employers Focused on improving clinical outcomes, patient experience and cost efficiency Defines quality and cost outcomes Fosters greater accountability 32 Copyright Propel Health

34 Blueprint Leading Indicators Tracking leading indicators of success will provide guidance to Propel Health s Board on its ability to achieve its long-term goals Scale Risk Management Payer Partnership Terms Illustrative Metrics Actual Projected Employed + affiliated PCPs by EOY # of active conversations with priority primary care clinics # of active conversations with other primary care clinics Lives under risk management Projected # of risk contracts by EOY Commercial clinical savings MSSP clinical savings vs. benchmark MA MLR Key clinical hires in-place [list] Commercial share of savings Medicare Advantage share of savings Share of RAF savings Year of UM operational delegation Sample Scorecard 33 Copyright Propel Health

35 Risk stratification Critical Questions 1. Who are my riskiest patients? 2. Why are they risky? 3. What is the best intervention for them? Source: The Advisory Board Company, Prioritizing the investment plan for population health management, Copyright Propel Health

36 The PCP-Patient relationship Care Management Program Integration Patient Attribution for Risk Contracts PCP-Patient Relationship Downstream Referral Management Longitudinal Patient Management Source: Evolent Health, Copyright Propel Health

37 Ideal Process transition care Last hours Follow-up appt. scheduled Medications reconciled Risk reassessed First 48 hours Home visit if high risk In-home medication reconciliation Day 7, 14, 21 Telephonic follow-up Assess progress toward personal goals Hospital Home Stable Health 4 hours pre-discharge Patient understands red flags and action plan hours Telephonic follow-up (moderate risk patients) First hours Hospitalist & TCA collaborate Transition Care process introduced First 24 hours Confirm receipt of meds Discharge summary to PCP Day 28 Patient moved to Complex Care Quality and satisfaction of transition is assessed Source: Evolent Health, Copyright Propel Health