ACO FINANCIAL AND STRATEGIC ANALYSIS

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1 ACO FINANCIAL AND STRATEGIC ANALYSIS 2012 SPRING MANAGED CARE FORUM The American Association of Integrated Healthcare Delivery Systems John Harris Principal DGA Partners (610) ext 231

2 Agenda > Strategic context for ACOs > How ACOs work under the final rule o Key regulatory considerations and implications > Financial analysis o Illustrative financial model > Strategic considerations 2

3 ACO Financial and Strategic Analysis STRATEGIC CONTEXT FOR ACOs 3

4 STRATEGIC CONTEXT FOR ACOs What is an ACO? An ACO is an entity that is clinically and fiscally accountable for the entire continuum of care that a given population of patients may need. Partners In Health > Medicare Shared Savings Program in PPACA for Medicare Parts A and B > CMS triple aim of better care, better health, and lower per capita cost 4

5 STRATEGIC CONTEXT FOR ACOs Final rule improved the ACO opportunity in several ways > Less risk > More generous sharing > Easier quality standards > Prospective identification of beneficiaries > Advance payment option for some physicians 5

6 STRATEGIC CONTEXT FOR ACOs ACOs are one tool that Medicare is looking towards to slow spending growth > Potential Medicare initiatives have varying cost impact and require varying degrees of population health management Potential to save taxpayer funds Lower rates in FFS Medicare Bundled Payments Value Based Payments ACOs Premium Support Medicare Advantage Need for providers to manage population health 6

7 STRATEGIC CONTEXT FOR ACOs Commercial payers are also finding new ways to reward quality and cost accountability > Pay-for-performance > Tiered or narrow networks > Care coordination payments > Patient-centered medical home > Shared risk contracting Health Insurance Exchanges may increase pressure to manage cost 7

8 STRATEGIC CONTEXT FOR ACOs Transition to new model may involve multiple contracting approaches Care Delivery Model Contracting Method Potential Population Served ACO Traditional Medicare Accountable Care Model P4P Contracting Risk Sharing/ Narrow Network Direct Contracting Full or Shared Risk Contracting Commercial Payers Commercial Payers on Insurance Exchange Hospital s Employees Self-insured Employers Medicare Advantage Commercial Payers 8

9 STRATEGIC CONTEXT FOR ACOs Current state of health reform what happens if health reform is upheld or overturned? > Supreme Court > 2012 Election 9

10 ACO Financial and Strategic Analysis HOW ACOs WORK UNDER THE FINAL RULE 10

11 HOW ACOS WORK Eligible entities Professionals in group practice Networks of individual practices (e.g., IPA) Hospitals and professionals in partnership (e.g., PHO) Hospitals with employed professionals *Under the final rule, FQHCs, RHCs and CAHs billing under method II may form independent ACOs, if they meet eligibility requirements, and may also be ACO participants in ACOs formed by other entities. FQHCs and RHCs 11

12 HOW ACOS WORK Costs tracked across all providers ACO Entities Other Medicare Providers Hospital A PCPs Specialists ASC Specialists Other Hospital B Home Health > No gatekeeper/pre-authorization requirements > Costs are tracked no matter where care is received o All services are paid at Medicare provider rates o All Part A and B costs are accrued on the ACO s tally, less IME and DSH payments ACO Total Expenses 12

13 HOW ACOS WORK Track 1 - optimistic scenario 2% - 3.9% Minimum Savings Rate Benchmark Spending Savings for Sharing CMS/ACO Spending ($) Actual Spending Savings are shared from the first dollar if Minimum Savings Rate (MSR) is exceeded Savings are adjusted by quality scores Year 13

14 HOW ACOS WORK To succeed, an ACO must: > Achieve sufficient scale > Make a significant effort in care management/information technology > Generate savings > Meet quality scores > Backfill volume by growing market share o Or reduce someone else s volume, not yours 14

15 HOW ACOS WORK Medicare ACO application timeline Contract Start Date Notice of Intent Due Applications Accepted Applications Approval or Denial Decision April 1, 2012 January 6, 2012 December 1, 2011 January 20, 2012 March 16, 2012 July 1, 2012 February 17, 2012 March 1 30, 2012 May 31, 2012 January 1, 2013 June 15, 2012 August 1 30, 2012 Fall

16 HOW ACOS WORK Final regs: more attractive Area Key Change Implication Quality > 33 measures instead of 65 measures > Lower reporting burden > Easier to generate shared savings EHR Data Antitrust > Use of EHRs is now a quality measure, not a requirement > Data shared unless patients opt-out > ACOs will receive more frequent, quarterly aggregate cost reports for assigned beneficiaries > No requirement for mandatory review > ACOs not meeting EHR measure may still achieve shared savings > Better information about key patient groups for care management/quality improvement efforts > Lower start-up costs > More providers may qualify 16

17 HOW ACOS WORK More changes in final regulations Area Key Change Implication Beneficiary Assignment Eligible Entities Financial > Beneficiaries are assigned to an ACO on a prospective basis, with year-end reconciliation > Some assignment to ACOs by specialist if no PCP > Broadened participation to include: Federally Qualified Health Centers and Rural Health Centers > Sharing on the first dollar of savings > No requirement to take on risk in the first three years > ACO can proactively contact members and manage population health > The likelihood of more physician interest in ACO concept > There are likely to be more ACO entrants > Greater reward for achieving cost savings > There are likely to be more ACO entrants 17

18 HOW ACOS WORK 33 quality measures, including EHR Individual Health Population Health Patient/ Care Giver Experience Care Coordination Preventive Health At Risk Population 7 measures (Scored as 2 measures) 6 measures (Scored as 6 measures) 8 measures (Scored as 8 measures) 12 measures (Scored as 7 measures) Transitions - 2 Diabetes - 6 Patient Safety - 4 Hypertension - 1 Ischemic Vascular Disease - 2 Heart Failure - 1 Coronary Artery Disease

19 HOW ACOS WORK Legal considerations > Antitrust o Rule of Reason treatment in final rule o Safety zone established for ACOs with less that 30% market share of the primary service areas in each service > Fraud and abuse o 5 waivers to Stark, AKS, and CMP > ACO pre-participation waiver, ACO participation waiver, Patient incentive waiver, Shared savings distribution waiver, Compliance with Stark law waiver o Must have documentation and board approvals o Possible public disclosure requirements 19

20 HOW ACOS WORK How are physicians responding? > Renewed interest among PCPs > Specialists are still concerned o Fear losing volume o Not a very lucrative joint venture > ACOs require much working capital o Advanced Payment Model may help physician groups with less than $50 million in revenue 20

21 HOW ACOS WORK 32 organizations have been selected as a Pioneer ACO across 18 states Source: CMS.gov State No. of ACOs California 6 Massachusetts 5 Michigan 3 Minnesota 2 Texas 2 Wisconsin 2 New York 1 New Mexico 1 Illinois 1 Vermont 1 Nevada 1 Colorado 1 Pennsylvania 1 Florida 1 Indiana 1 Iowa 1 Arizona 1 Maine Midwest Northeast South West

22 HOW ACOS WORK Pioneer ACOs Name of ACO Name of ACO Allina Hospitals & Clinics Michigan Pioneer ACO Atrius Health Monarch Healthcare Banner Health Network Mount Auburn Cambridge IPA Bellin-Theadacare Healthcare Partners North Texas ACO Beth Israel Deaconess Physician Organization OSF Healthcare System Bronx Accountable Healthcare Network Park Nicollet Health Service Brown & Toland Physicians Partners Healthcare Dartmouth-Hitchcock ACO Physicians Health Partners Eastern Maine Healthcare System Presbyterian Healthcare Services Fairview Health Systems Primecare Medical Network Franciscan Alliance Renaissance Medical Management Company Genesys PHO Seton Health Alliance Healthcare Partners Medical Group Sharp Healthcare System Healthare Partners of Nevada Steward Health Care System Heritage California ACO TriHealth, Inc JSA Medical Group (Health Partners) Source: CMS.gov 22

23 HOW ACOS WORK 27 MSSP ACOs begun in April 2012 > Predominantly physician driven 19 of 27 > 90 percent of applicants were approved > 10,000 physicians involved (1.4% of all U.S. Physicians) > 10 hospitals involved (0.2% of all U.S. Hospitals) > Five of 27 will receive Advance Payments 23

24 HOW ACOS WORK MSSP ACOs are concentrated in the Northeast and South State N/O ACOs New York 4 North Carolina 3 New Jersey 3 Florida 3 California 2 Texas 2 Georgia 2 Massachusetts 2 Pennsylvania 1 Kentucky 1 Hew Hampshire 1 Wisconsin 1 Arizona 1 Mississippi Midwest Northeast South West Source: CMS.gov 24

25 HOW ACOS WORK Standard ACOs Name of ACO Members Name of ACO Members ACC of Texas, Inc. 70,000 ACC of Coastal Georgia, LLC 8,000 Atlantic ACO, LLC 50,000 AppleCare Medical ACO, LLC 8,000 CIPA Western NY IPA d/b/a Catholic Medical Partners 31,000 Primary Parnters, LLC 7,500 Optimus Healthcare Partners, Inc 29,000 Arizona Connected Care, LLC 7,500 Florida Physician Trust, LLC 16,500 ACC of the Mississippi Gulf Coast, LLC 7,000 Premier ACO Physician Network 12,500 ACC of Mount Kisco, LLC 6,200 Chinese Community ACO 12,000 Jackson Purchase Medical Associates, PSC 6,000 Coastal Carolina Quality Care, Inc. 11,000 RGV ACO Health Providers, LLC 6,000 Hackensack Physician-Hospital Alliance ACO, LLC 11,000 Jordan Community ACO 6,000 ACC of Eastern North Carolina, LLC 10,000 North Country ACO 6,000 ACC of Southeast Wisconsin, LLC 10,000 ACC of the North Country, LLC 5,300 Crystal Run Healthcare ACO, LLC 10,000 ACC of Caldwell County, LLC 5,000 West Florida ACO, LLC 10,000 Physicins of Cape Cod ACO 5,000 ACC of Greater Athens Georgia, LLC 8, ,000 > The top four ACOs represent 48% of the members > Nine are joint ventures with Collaborative Health Systems Source: CMS.gov 25

26 HOW ACOS WORK July 1 Applicant Pool > 150 applicants for July (5 times as many as April) > 50 (1/3) of July applicants seek Advance Payments 26

27 HOW ACOS WORK Almost 200 ACOs may be accountable for 2.9 million Medicare beneficiaries Accountable Care Organizations Traditional Pioneer ACO April 1 July 1 (estimated) Total Number of ACOs Number of Beneficiaries 725, ,000 1,750,000 2,850,000 % of Phyician-only 34% 70% tbd Number of Physicians n/a 10,000 tbd Average Beneficiary ACO 22,700 14,000 14,000 15,500 Number of Hospitals n/a

28 HOW ACOS WORK ACOs would still represent a small proportion of all Medicare beneficiaries Medicare Beneficiaries Traditional Medicare Pioneer ACOs Traditional ACOs: April 1, 2012 Traditional ACOs: July 1, 2012 (estimated) Medicare Advantage But the impact could be significant in specific markets 28

29 ACO Financial and Strategic Analysis FINANCIAL ANALYSIS 29

30 FINANCIAL ANALYSIS Two tracks are available in the final Medicare ACO regulations Track One Upside only All 3 Years Shift to Track 2 (Risk) if Renew Track Two Upside and Downside Risk All 3 Years Must Convince CMS You Are Ready for Risk 30

31 FINANCIAL ANALYSIS Track 1 - Optimistic Scenario 2% - 3.9% Minimum Savings Rate Benchmark Spending Savings for Sharing CMS/ACO Spending ($) Actual Spending Savings are shared from the first dollar if Minimum Savings Rate (MSR) is exceeded Savings are adjusted by quality scores Year 31

32 FINANCIAL ANALYSIS Track 1 - Pessimistic Scenario Spending ($) Actual Spending Losses accrue to CMS Benchmark Spending Losses are not shared with ACO Year 32

33 FINANCIAL ANALYSIS ACOs that take on risk have opportunity for a greater portion of shared savings Minimum Savings or Loss Rate Track 1 Track 2 2% to 3.9% of benchmark, depending on ACO size 2% of benchmark Shared Savings or Losses First dollar savings First dollar savings Sharing Rate 50% 60% Shared Savings Cap 10% of benchmark 15% of benchmark Minimum Loss Rate N/A 2% of benchmark Shared Losses N/A First dollar losses Shared Losses Rate N/A 1 minus sharing rate Shared Losses Cap N/A 5% in Year 1 7.5% in Year 2 10% in Year 3 33

34 FINANCIAL ANALYSIS Medicare Payments by Service Category Medicare Payments by Service Category Other, 15% Home Health, Hospice, SNF, 17% Hospital, 48% Physician, 20% > About half of all Medicare medical expenses are for hospital care 1 > Of this hospital care, researchers have estimated that approximately 64% is provided at the hospital at the center of a local delivery system 2 1. Health Affairs, Creating Accountable Care Organizations: The Extended Hospital Medical Staff; December 5, A Data Book: Healthcare Spending and the Medicare Program, Medicare Payment Advisory Commission, June

35 FINANCIAL ANALYSIS ACOs must reduce costs over historical benchmarks for shared savings eligibility; managing utilization offers opportunity to reduce costs Discharges per 1,000 Medicare Enrollees National Utilization Rates per 1,000 Medicare Enrollees 10th 20th 30th 40th 50th 60th 70th 80th 90th Percentile of Hospital Service Areas > Areas with low utilization rates may have more difficulty generating savings 35

36 FINANCIAL ANALYSIS The net impact of a Medicare ACO on a hospital depends more on market share than on shared savings > Due to high fixed costs at hospitals, reduced utilization as a result of ACO efforts will have a significant financial effect > Increasing the hospital s share of ACO admissions can offset utilization rate reductions o More PCPs attracted to ACO model of care o Splitters decide to use hospital more due to better patient experience o May reduce leakage as patients prefer better coordinated care 36

37 FINANCIAL ANALYSIS Long range opportunity is limited > A bar will be raised with each renewal > ACO sponsors must have an exit plan 37

38 ACO Financial and Strategic Analysis ILLUSTRATIVE FINANCIAL MODEL 38

39 ILLUSTRATIVE FINANCIAL MODEL Assumptions > 30,000-member ACO, starting July 2012 > Track 1 (avoid taking risk on first agreement period) > 50/50 divide between physician participants and a hospital partner > IP utilization could be decreased by 10% over the contract period > Meets Minimum Savings Rate (MSR) for CMS shared savings > ACO would achieve strong quality reporting (90%) 39

40 ILLUSTRATIVE FINANCIAL MODEL Three-step ACO Impact Assessment CMS Calculation of ACO Shared Savings ACO Revenue Statement Net Impact on Hospital Revenue Statement Revenue Revenue = Medicare Benchmark Spending for ACO Population Shared Savings Patient Services + Share of ACO Surplus/Deficit Expense Expense = Total Spending for ACO Population (Hospital/ Physician/ Other) ACO Operations Hospital Operations Surplus / Deficit Shared Savings $ ACO Surplus/Deficit $ Hospital Surplus/Deficit CMS Physicians 40

41 ILLUSTRATIVE FINANCIAL MODEL Assess the impact of CMS s calculation of ACO Shared Savings CMS Calculation of ACO Shared Savings ACO Revenue Statement Net Impact on Hospital Revenue Statement Revenue Revenue = Medicare Benchmark Spending for ACO Population Shared Savings Patient Services + Share of ACO Surplus/Deficit Expense Expense = Total Spending for ACO Population (Hospital/ Physician/ Other) ACO Operations Hospital Operations Surplus / Deficit $ Shared Savings ACO Surplus/Deficit Hospital Surplus/Deficit $ CMS Physicians 41

42 ILLUSTRATIVE FINANCIAL MODEL To calculate the CMS Shared Savings, you first need to understand the benchmark expenditures Benchmark Expenditures (millions) Average Annual Medicare Payment per Beneficiary $ 8,400 $ 8,600 $ 8,900 $ 9,200 ACO Members 30,000 30,000 30,000 30,000 Benchmark Expenditures (millions) $ 126 $ 259 $ 267 $ 275 $ 927 I Amount for 2012 represents only six months of benchmark expenditures, given the ACO's July 2012 start CMS calculation of Shared Savings: Revenue > With a 30,000 member ACO, the benchmark expenditures equal over $250 million annually 42

43 ILLUSTRATIVE FINANCIAL MODEL CMS calculation of Shared Savings: Expense One way for an ACO to generate savings is through reduced inpatient utilization as a result of increased care coordination Savings Generated by ACO Current Target Change Admissions / 1, (35) ACO Members 30,000 30,000 Inpatient Admissions for ACO 10,380 9,342 (1,038) Average Medicare Payment/Admission $ 11,206 $ 11,206 ACO Pmt to Hospitals (millions) $ $ $ (11.6) 43

44 ILLUSTRATIVE FINANCIAL MODEL CMS calculation of Shared Savings: Surplus/deficit By reducing the volume of inpatient admissions, a surplus is created Reduction in Admissions and Savings Generated by ACO (millions) Reduction in Inpatient Admissions 5.0% 7.5% 10.0% 10.0% Estimated Savings Generated by ACO 1 $ 2.7 $ 8.2 $ 11.3 $ 11.6 $ The ACO starts in July 2012; 2012 therefore represents just six months of shared savings generated. The ACO's results for 2012 will be summed with those of 2013, so that the first performance period represents the ACO's first 18 months. > Savings generated by the ACO total $34 million over the 3.5-year contract period 44

45 ILLUSTRATIVE FINANCIAL MODEL Assess factors determining the ACO revenue statement CMS Calculation of ACO Shared Savings ACO Revenue Statement Net Impact on Hospital Revenue Statement Revenue Revenue = Medicare Benchmark Spending for ACO Population Shared Savings Patient Services + Share of ACO Surplus/Deficit Expense Surplus / Deficit Expense = Total Spending for ACO Population (Hospital/ Physician/ Other) Shared Savings $ ACO Operations ACO Surplus/Deficit $ Hospital Operations Hospital Surplus/Deficit CMS Physicians 45

46 ILLUSTRATIVE FINANCIAL MODEL ACO Revenue Statement: Revenue Estimated Shared Savings to the ACO is $17 million ($13.5 million after quality adjustment) Shared Savings to ACO (millions) Estimated Savings Generated by ACO $ 2.7 $ 8.2 $ 11.3 $ 11.6 $ 33.8 Sharing Rate 50% 50% 50% 50% Estimated Shared Savings to ACO - before Quality Adjustment $ 1.3 $ 4.1 $ 5.6 $ 5.8 $ 16.9 Estimated Quality Score 90% 90% 75% 75% Estimated Shared Savings to ACO - after Quality Adjustment $ 1.2 $ 3.7 $ 4.2 $ 4.4 $ 13.5 > CMS would benefit by saving about $20 million on this 30,000-member ACO, or about $680 per member 46

47 ILLUSTRATIVE FINANCIAL MODEL Operating expenses required to ensure an ACO s success can be significant ACO Revenue Statement: Expense Startup Costs $ 250,000 $ - $ - $ - Ongoing Staffing Costs 796,000 1,640,000 1,690,000 1,740,000 Overhead 199, , , ,000 IT Expense 625, , , ,000 Incentive Payments to Physicians 300, , , ,000 Legal/Consulting/Other 175,000 50,000 50,000 50,000 Total ACO Operating Costs $ 2,345,000 $ 2,550,000 $ 2,612,000 $ 2,675,000 > Estimates of ACO operating costs vary significantly, and can depend on other initiatives already underway (e.g., EHR) 47

48 ILLUSTRATIVE FINANCIAL MODEL Under this scenario, the ACO generates a surplus in most years ACO Revenue Statement: Surplus/deficit ACO Revenue Statement (millions) Revenue (Shared Savings) $ 1.2 $ 3.7 $ 4.2 $ 4.4 $ 13.5 Operating Expenses ACO Net Income $ (1.1) $ 1.1 $ 1.6 $ 1.7 $ 3.3 > Physician-only ACOs realize these gains, if they can reduce utilization as estimated 48

49 ILLUSTRATIVE FINANCIAL MODEL Step 3: Does the hospital lose more in volume than it gains in shared savings? CMS Calculation of ACO Shared Savings ACO Revenue Statement Net Impact on Hospital Revenue Statement Revenue Revenue = Medicare Benchmark Spending for ACO Population Shared Savings Patient Services + Share of ACO Surplus/Deficit Expense Expense = Total Spending for ACO Population (Hospital/ Physician/ Other) ACO Operations Hospital Operations Surplus / Deficit Shared Savings $ ACO Surplus/Deficit $ Hospital Surplus/Deficit CMS Physicians 49

50 ILLUSTRATIVE FINANCIAL MODEL If the hospital increases its market share from ACO member admissions, reduced utilization can be offset Net Impact on Hospital Revenue: Revenue ACO Impact on Hospital Admissions and Revenue Current Under ACO Change Inpatient p Admissions p for ACO Members 10,380 9,342 (1,038) Admissions 70% 77% ACO Member Admissions at Sponsor Hospital 7,266 7,231 (35) Average Medicare Payment per Admission $11,206 $11,206 Hospital Revenue for ACO Member Admissions (millions) $81.4 $81.0 ($0.4) 50

51 ILLUSTRATIVE FINANCIAL MODEL Net Impact on Hospital Revenue: Surplus/deficit After splitting savings with physicians, the hospital can break even if gained market share Overall Hospital Impact (millions) Close-Out Close-Out Impact on Hospital Operating Income ($0.5) ($0.4) ($0.5) ($0.2) N/A ($1.6) Hospital Share of Savings $0.0 $0.0 $0.0 $0.0 $1.7 $1.7 Net Impact on Hospital ($0.5) ($0.4) ($0.5) ($0.2) $1.7 $0.0 Note: The hospital share of savings is generated from 50% of the ACO Shared Savings ($3.3 million) Hospital Share of Savings from ACO +$1.7 million Impact on Hospital Operating Income ($1.6 million) Net Impact on Hospital $0.00 Numbers may not tie due to rounding 51

52 ACO Financial and Strategic Analysis STRATEGIC CONSIDERATIONS 52

53 STRATEGIC CONSIDERATIONS ACOs raise several strategic questions > Do we want to be an ACO? > Would it help us transition to new revenue models? > What is our long-term strategy? > How would an ACO support other strategies? > Should we pursue commercial ACO contracts? > What would it take to get ready? > Can we succeed on our own, or should we partner? > What are our competitors planning? > What are local physicians planning/seeking? > Could we gain market share, or would we lose utilization anyway 53

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