Accountable Care Entity. September 11, 2013

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Samantha McDaniel
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1 Accountable Care Entity September 11,

2 Today s Call Explain what an ACE is Why an ACE may make sense Help you Understand the key action steps and capabilities to be successful Interactive Q&A Steve Tutewohl SVP Analytics, Valence Health 20+ years actuarial experience Since 1996, Valence has helped provider organizations, design, develop, implement and manage all forms of riskbased arrangements, especially in Medicaid. 2

Valence Health 20+ years actuarial experience Since 1996, Valence has helped provider

Why Value-Based Care Makes Sense Longitudinal Experience Of Ambulatory Medicare Beneficiaries Assigned To Extended Hospital Medical Staffs (EHMSs) $6,000 42% $5,000 41% 40% $4,000 39% $3,000 38%

3 Why Value-Based Care Makes Sense Longitudinal Experience Of Ambulatory Medicare Beneficiaries Assigned To Extended Hospital Medical Staffs (EHMSs) $6,000 42% $5,000 41% 40% $4,000 39% $3,000 38% $2,000 37% 36% $1,000 35% $- Highest High Middling Low Lowest 34% Spending per Member Quality Index Source: Elliott S. Fisher, Douglas O. Staiger, Julie P.W. Bynum and Daniel J. Gottlieb, (published online December 5, 2006; /hlthaff.26.1.w44). Health Affairs, 26, no.1 (2007):w44-w57. Creating Accountable Care Organizations: The Extended Hospital Medical Staff. Note: Quality Index on graph is average of Quality measures from Exhibit. All four quality compliance measures, essentially delivery of recommended test or care) were averaged to one number. 3

Gottlieb, (published online December 5, 2006; 10.1377/hlthaff.26.1.w44). Health Affairs, 26, no.1 (2007):w44-w57.

4 Medicaid Background By January 1, 2015, 50% of Illinois Medicaid clients are to be enrolled in some form of care coordination system with risk-based payments In addition to existing Managed Care Organizations (MCOs), new models are being developed: Care Coordination Entities (CCEs) for seniors and persons with disabilities CCEs for children with complex needs Managed Care Community Networks (MCCNs) and MCOs for seniors and persons with disabilities ACE: Solicitation was released August 1,

developed: Care Coordination Entities (CCEs) for seniors and persons with disabilities CCEs for children with complex needs

5 What is the ACE Model? An ACE is an organization comprised of and governed by providers An ACE must be an integrated delivery system with sufficient PCPs, specialists, behavioral health, and hospitals. There are maximum travel distances and maximum scheduling wait times to see physicians An ACE must be able to serve a minimum number of lives Cook County 40,000 Lake, Kane, DuPage, Will Counties 20,000 All other counties 10,000 Health IT to coordinate and analyze data is an essential requirement on the ACE ACE model population Children and family members Optional newly eligible adults under ACA Option under state s upcoming mandatory managed care requirement 5

6 Payer cost Fixed costs Variable costs Why Consider the ACE? Protect or enhance market share Easy Glide Path to Risk Refocus mission to population management from acute episodes Advance / accelerate quality initiatives Strengthen relationships with physicians Financially benefit from bending the cost curve Provider Risk Increase control of network usage Build infrastructure for MCO/MCCN Risk in TANF Medicaid population isn t that risky as it is predictable NOT to expect shared savings Government Based 6

accelerate quality initiatives Strengthen relationships with physicians Financially benefit from bending the cost curve

7 The Managed Medicaid Risk Model Predictable margin of -2% to 6% MCCNs and MCOs become valuable assets Plan becomes cash rich due to IBNR States typically see cost savings of.5% to 20%* Cost savings are largely attributable to decreases in inpatient utilization (10-20%) Medicaid Managed Care Cost Savings a Synthesis of 24 Studies, The Lewin Group, revised March

5% to 20%* Cost savings are largely attributable to decreases in inpatient utilization

8 ACE Economics: Shared savings calculation Savings = MCO capitation rate PMPM Measurement Year PMPM Measurement Year PMPM is: FFS costs for covered population Adjusted for relative risk compared to overall population Adjusted for geographic region Excluding claims > $80,000, but including a pooling charge (undefined) Savings are shared 50/50 with the state: 10% of the 50% is automatically given The other 40% based on quality measures (10% for each of four measures) Total shared savings to ACE cannot exceed 5% of target 8

claims > $80,000, but including a pooling charge (undefined) Savings are shared 50/50 with the state: 10% of the 50% is

9 Profit Margin of Provider-Sponsored Plans Plan State Total Driscoll Children s Plan TX -20.5% -9.2% 12.4% -0.2% 6.8% 1.7% Cook Children s Health Plan TX -0.8% -3.8% -10.6% -3.1% 2.8% -2.5% Health Plan of CareOregon OR 5.7% 6.9% 19.5% 7.5% 3.7% 8.5% Children s Mercy s Family Health Partners MO 1.2% 7.8% 12.9% 6.0% 3.1% 7.0% Mdwise IN 0.2% 2.2% 1.5% 1.1% 0.4% 1.2% Texas Children s Health Plan TX 4.9% -1.8% 2.8% 1.9% 7.0% 3.3% Passport Health Plan TX 1.6% 2.0% -1.0% 0.7% 0.6% 0.7% El Paso First Health Plan TX -2.8% 8.5% 9.2% -0.5% 6.4% 4.1% Average -1.3% 1.6% 5.8% 1.7% 3.9% 3.0% Past or Current Valence Client 9

5% Children s Mercy s Family Health Partners MO 1.2% 7.8% 12.9% 6.0% 3.1% 7.0% Mdwise IN 0.2% 2.2% 1.5% 1.1% 0.4% 1.2% Texas Children s Health Plan TX 4.9% -1.

10 Example ACE Performance Urban Hospital with Medicaid representing 50% of revenues Option Metric Baseline 0-18 Months Remain FFS # Medicaid Patients Hospital Revenue Months 37+ Months 50,000 45,000 40,000 40,000 $500m $463m $426m $426m ACE # Medicaid Patients Hospital Revenue ACE Revenue 50,000 55,000 60,000 $488m $499m $522m $81m $89m $97m Assumes 5% decline in annual Medicaid per capita spend for 1 st 2 years 10

40,000 $500m $463m $426m $426m ACE # Medicaid Patients Hospital Revenue ACE Revenue 50,000 55,000 60,000

11 Cap Rate Development State will hire an actuarial firm (currently Milliman) to annually develop the actuarially sound premium rates Rates include the following components Historical medical expense levels Apply expected trend and other adjustments Administration Other pass throughs Profit margin 100% 80% 60% 40% Profit Admin Medical 20% 0% 11

components Historical medical expense levels Apply expected trend and other

12 Cap Rate Development Zero sum game (2% margin will be true over time) Market share will determine how true this cycle plays out Risk adjustment will have some say Bad experience Rates decrease Rates increase Good experience 12

this cycle plays out Risk adjustment will have some say

13 ACE Participation May Make Sense For. Hospital Profile #1 Over 50% of hospital revenue comes from Medicaid Since acute care will be provided largely within their facility the risk is much less Wants to maintain Medicaid market share Wants to be in control of reimbursement and care management Hospital Profile #2 Medicaid represents a small % of revenue for the hospital Hospital would like to dip its toe in the water for value-based reimbursement ACE is an easy path and low risk pilot The infrastructure built for the ACE can be used for larger scale initiatives down the road Wants to improve the quality of care to these patients 13

14 ACE Timeline File Letter of Intent by October 1, 2013 Receive data to develop formal application File formal application by January 3, 2014 ACE s awarded by State Enrollment begins by July 1, 2014 Months 1-18 Months Months 37+ FFS with care coordination fee, with shared savings Prepaid capitation with partial risk ACE must become an MCCN or MCO at this point Shared risk through individual stop-loss or risk corridors Full risk capitation ACE may move to full risk capitation before Month 36 ACE is expected to repay 50% of care coordination fees if exit prior to month 31 14

Prepaid capitation with partial risk ACE must become an MCCN or MCO at this point Shared risk through individual stop-loss or risk corridors Full

15 Sample Project Plan with Milestones RFP Build Network Care Model Organization/Governance Partner for Claims, Member Services & Care Model Prepare for ACE Go-Live Financial Mgmt IT & Implement Care Model Prepare for MCCN Go- Live Implement Claims & Member Services Manage MCCN 15

Model Prepare for ACE Go-Live Financial Mgmt IT & Implement Care

Developing a Path Forward Assessment & Planning LOI and RFP Assess Capabilities, Gap Analysis and Closure Plan Develop Network Governance and Legal Structure

Ongoing cost, risk, and clinical analysis Population Health Take on Risk From monitoring to managing Additional enhancements to care model Incentives internally

16 Developing a Path Forward Assessment & Planning LOI and RFP Assess Capabilities, Gap Analysis and Closure Plan Develop Network Governance and Legal Structure Define Business Case Create Roadmap & Budget Technology, Analytics, and Risk Monitoring Launch Model Technology infrastructure Implement Care Delivery Model Ongoing cost, risk, and clinical analysis Population Health Take on Risk From monitoring to managing Additional enhancements to care model Incentives internally Increased operations (e.g. paying claims) Financial measurement and reporting Further evolve care delivery model Strategic and Tactical Planning Technology & Analytics Services 16

17 What Infrastructure is Required to be Successful Function 0-18 Months Months 37+ Months Shared Savings w/ Care Coordination MCCN or MCO with Shared Risk MCCN or MCO with full risk Marketing X X X Legal & Regulatory X X Risk & Financial Mgmt X X X Claims X X Shared Savings/Bonus/Cap Payment Provider Network Selection/Contracting X X X X X X Out of Network/Wrap Network X X Member Services X X Care Mgmt X X X Quality Measurement/Reporting X X X Clinical Integration X n/a n/a 17

Financial Mgmt X X X Claims X X Shared Savings/Bonus/Cap Payment Provider Network Selection/Contracting X X X X X X Out

work with varying technologies and sources (depending on ACE structure) Cost Capability to work

18 Technology & Analytics Population health infrastructure / technology Quality Clinical Quality Measurement Module Cost and utilization analytics Risk stratification Data collection process to work with varying technologies and sources (depending on ACE structure) Cost Capability to work with / analyze postadjudicated claims Ability to disperse funds within ACE (depending on Structure) 18

19 Key questions to ask Should you pursue at all? Does ACE align with your mission / organization goals? If yes, with whom do you partner? Where are your network holes? What type of Capital Requirements will you need based on assumed lives? What technology is in place, what is required, how will you close gaps? Which expertise and operations do you have internally, which will you build and which will you buy? What is your total downside risk, financially, brand-wise, etc.? 19

What type of Capital Requirements will you need based on assumed lives?

20 Resources and questions Steve Tutewohl, pdf 20

gov/hfs/publicinvolvement/cc/ace/pages/default.aspx http://www2.illinois.

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