ACO s as Private Label Insurance Products

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1 ACO s as Private Label Insurance Products Creating Value for Plan Sponsors Continuing Education: November 19, 2013 Clarence Williams Vice President Client Strategy Accountable Care Solutions

2 Today s discussion Welcome and introductions Shift from Volume to Value Learning's from successful ACO s Value for all stakeholders What about employers? Productizing ACO s What s next? Q & A 2

3 Quick definition: Accountable Care Organization An Accountable Care Organization (ACO) is a providerbased organization willing to take responsibility for managing the health of a defined population Improve efficiency Improve satisfaction External ACO goals Improve quality 3

4 Changing the reimbursement focus Volume Provider revenues contingent on volume of care provided Encourages additional capacity and unnecessary care Denied claims, unreimbursed admissions and other penalties as payers manage utilization Payers and providers as adversaries Value Re-aligned financial incentives create diversified revenue sources Improved cost structures and efficiency lower overhead and increase profitability Quality improvement increases performance-based reimbursement and patient outcomes Aligned incentives to provide appropriate and evidence-based care in the best setting Reimbursement focused on paying doctors to keep our members healthy, not just when they are sick

5 Value Based Care is coming

6 A shift is underway from volume to value

7 A Transformational Model More than 250 providers have partnered to form ACO s, which together will serve more than 4 million Medicare beneficiaries These transformational models are no longer isolated pilots, they are becoming the face of American Medicine. - Kathleen Sebelius, Health & Human Services Secretary

8 Early ACO entrants were hospital-led, but Physician-led ACOs now outpace them Providers, particularly independent practice associations, have surpassed hospital systems as the most common sponsoring entity among all 428 ACOs. 200 ACOs by Sponsoring Entity Physician Groups Hospital Systems Insurers 0 5 Community-based Orgs. Q Q Q Q Q Q Q Q Q Q Q Q Jan 2013 Muhlestein, D. (2013, February 19). Continued Growth of Public And Private Accountable Care Organizations. Retrieved March 18, 2013, from Health Affairs Blog:

9 Studies validate that patient-centered care increases value State Cost Improvement Quality Improvement Florida Michigan 40% fewer inpatient days 37% lower ER visits 18% lower total costs 10% lower adult ER visits 17% lower ambulatory care sensitive inpatient admissions Increased primary care visits by 250% 60% better access to care Minnesota New Jersey North Carolina Ohio Rhode Island Texas 39% lower ER visits 24% lower inpatient admissions Reduced PMPM costs by 10% 26% lower ER visits 21% lower inpatient admissions 52% fewer visits to specialists 70% fewer visits to ER Medicaid saved $900 million in 3 years 34% decrease in ER visits 17-33% lower costs among PCMH members 23% lower readmission rates $1.2 million in estimated cost savings Reduced appointment wait time from 26 days to 1 day 31% increase in ability to self-manage blood sugar 24% increase in LDL screening Medicaid: 21% increase in asthma staging 112% increase in flu inoculations 22% decrease in patients with uncontrolled blood pressure 44% increase in quality scores for family/children s health 35% increase for women s care Results compiled by the Patient-Centered Primary Care Collaborative at: Benefits of Implementing the Primary Care Patient-Centered Medical Home. PCPCC

10 Successful Programs Call for Analysis Pilot/Demonstration Population Overall Cost Savings PMPM Reported / Calculated Assumed Gross CDPHP New York Phase 1 Results: March 2011 Commercial, Medicare Advantage, Medicaid Managed Care $32 PMPM reported $32.00 Group Health Cooperative of Puget Sound All $10 PMPM reported; $71 per $10.00 patient 3 Community Care of North Carolina Medicaid $516 per patient $43.00 Colorado Medicaid and SCHIP Medicaid + CHP 22% 2 ; $169-$530 per patient 3 $14.08 to $41.17 Intermountain Healthcare Med Group Chronic Disease $640 per patient $1,650 per highest risk $53.33 to $ MeritCare: BCBS N Dakota Diabetes $530 per patient $41.17 Vermont BluePrint Health Commercial, Medicare Advantage, Medicaid $215 per patient $17.92

11 A Transformational Model

12 All stakeholders win with value-based care A solution to reduce cost, improve care quality, and the patient experience has key benefits for all major stakeholders in the health system. Provider What About Employers? Payer Patient Reimbursement incentives aligned with efficient, quality care based on measures and patient satisfaction Technology enhancement supporting care coordination? Cost savings Sustainable solution Improved quality Enhanced wellness and care management Competitive billing rates Enhanced patient experience Lower out-of-pocket costs Quality-based, coordinated care Tools to support a healthy lifestyle

13 All stakeholders win with value-based care MSSP Example: Track 1 - No Downside Risk A. Benchmark and Savings Part A & B Annual Medical Cost Benchmark per Patient $8,160 Portland Medical Cost Savings Achieved 7.0% Shareable Savings $571 Provider Reimbursement incentives aligned with efficient, quality care based on measures and patient satisfaction Technology enhancement supporting care coordination B. Savings Split and Quality Score Adjustment CMS Shared Savings Split - Track One 50.0% Quality Score Adjustment 90.0% Quality Adjusted Sharable Savings Split 45.0% C. Physician Organization Shared Savings Split Sharable Savings $571 Quality Adjusted Sharable Savings Split 45.0% Physician Organization Shared Savings Split $257 D. Shared Savings per PCP Total Patients per Doctor 2500 % Medicare Fee-for-Service Patients 16% % Attributed to Doctor based on CMS logic 50% Medicare Beneficiaries per PCP 200 Physician Organization Shared Savings per Patient $257 Total Annual Revenue per PCP $51,408 $3.08m in new revenue to ACO (Assumes 60PCP s in ACO)

14 All stakeholders win with value-based care A solution to reduce cost, improve care quality, and the patient experience has key benefits for all major stakeholders in the health system. Provider Payer Patient Reimbursement incentives aligned with efficient, quality care based on measures and patient satisfaction Technology enhancement supporting care coordination Cost savings Sustainable solution Improved quality Enhanced wellness and care management Competitive billing rates Enhanced patient experience Lower out-of-pocket costs Quality-based, coordinated care Tools to support a healthy lifestyle

15 Accountable care improves upon the traditional health system Traditional Health Care Accountable Care Patient fills out multiple paper forms with the same information Incomplete or lost information leads to duplicate tests As data are limited, doctor can t compare clinical information Patients seek care only when they are already sick Limited ability to improve quality Provider payments contingent on service volume Information is all in one record; no need to fill out multiple forms Entire care team has access to the same information Patient data are analyzed and presented with treatments based on best practices At-risk patients are identified early and treated before crises occur Better care management decisions Provider payments are aligned with for improvement of quality, clinical efficiencies and total cost of care 15

16 All stakeholders win with value-based care A solution to reduce cost, improve care quality, and the patient experience has key benefits for all major stakeholders in the health system. Provider Payer Patient Reimbursement incentives aligned with efficient, quality care based on measures and patient satisfaction Technology enhancement supporting care coordination Cost savings Sustainable solution Improved quality Enhanced wellness and care management Competitive billing rates Enhanced patient experience Lower out-of-pocket costs Quality-based, coordinated care Tools to support a healthy lifestyle

17 Savings more competitive product invaluable learning's from successful PCMHs/ ACOs CareFirst BCBS 1 (Maryland) Horizon BCBS 2 (New Jersey) BCBS Michigan 3 (Michigan) Membership: 1 million Plan type: All plans Intervention: member data; performance-based contract; local care managers Two Year Results: 2.7% reduction in costs in 2012 compared to 1.5% in 2011 (first year of the program) $98 million in savings in $60 million increase over previous year ($38 million in 2011) ~66% of providers qualified for shared savings Qualifying providers had 4.7% lower costs than expected (4.2% in 2011) Quality scores increased 9.3% from 2011 to 2012 PCP participation rose from 2,200 nurses and physicians in 2011 to 3,600 today Membership: 154,000 Plan type: Commercial and Medicare Advantage Intervention: member data; performance-based contract; embedded care managers Results: 10% lower PMPM costs 26% fewer ED visits 25% fewer hospital readmissions 21% fewer inpatient admissions; 5% increase in use of generic prescriptions Improved clinical quality in diabetes and preventive screenings. Membership: 1.5 million Plan type: All plans Intervention: member data; coordinated care; increased FFS and/or partial PCMH implementation reimbursement Results: $155 million in prevented claims costs from $26.37 lower PMPM costs 3.5% higher quality measure 5.1% higher preventative care measure 1. CareFirst Blue Cross Blue Shield. (2013, June 6). Patient-Centered Medical Home Program Trims Expected Health Care Costs by $98 million in Second Year. 2. Patel, B. (2012, September). Horizon s Patient-Centered Medical Home Program Shows Practices Need Much More Than Payment Changes To Transform. Health Affairs, p BCBS Michigan Press Release (2013, July 8) Blue Cross Blue Shield of Michigan saves an estimated $155 million over three years from Patient-Centered Medical Home program.

18 All stakeholders win with value-based care A solution to reduce cost, improve care quality, and the patient experience has key benefits for all major stakeholders in the health system. Provider What About Employers? Payer Patient Reimbursement incentives aligned with efficient, quality care based on measures and patient satisfaction Technology enhancement supporting care coordination? Cost savings Sustainable solution Improved quality Enhanced wellness and care management Competitive billing rates Enhanced patient experience Lower out-of-pocket costs Quality-based, coordinated care Tools to support a healthy lifestyle

19 ACO s Creating Value For Plan Sponsors

20 Accountable Care Organizations Differ from Traditional Models: Moving from patient treatment to population health management Three transformational goals make the difference: Improve patient health at a lower cost strategic financial incentives drive the insurance carrier and the provider system to work in collaboration to improve quality while controlling costs. Doctors use technology to help patients make informed health care decisions technology that provides the right information at the right time to make the best possible decisions. Exceed expectations health care is coordinated, measured and constantly working to improve health outcomes and deliver an exceptional member experience. 20

21 Healthcare is evolving ACO Plan Design Collaboration PCMH Patient centered medical home Physician focused ACO Attribution Usually hospital system-wide collaboration Savings based on quality and efficiency 3-tier plan design Savings based on price reduction, quality and efficiency Early stage Savings based on quality and efficiency 21

22 Creating Value for Plan Sponsors 22

23 The best way to capitalize on a value-based relationship with a healthcare provider is to productize it. ACO Specific Product designed to achieve 5% to 15% savings Plan Design Employees access care from ACO doctors who are rewarded for improved quality and lower costs Unit Cost Discounts ACOs agree to market-leading fee discounts in exchange for more ACO Plan patients Cost Efficiencies Advanced technology and new care management reduces waste, identifies gaps in care, and improves the patient experience 23

24 Creating Value for Plan Sponsors Illustrative example showing average monthly medical costs for each member $450 $400 $350 $378 Without ACO $408 With ACO $364 $441 $389 $1,600 savings per member over 3 years $340 $ $38 savings $44 savings $52 savings 8 to 15% medical cost savings in first year Reduced trend maintained through ACO care model 24

25 One insurer s ACO-specific products charge premiums 5 percent to 12 percent below the market Dynamics / Challenges / Requirements Close collaboration with high-quality providers required Marketing ACO specific products means choosing partners Different approach historical focus on network breadth, not quality or value Need health system partners for ACO products around the country Challenging dynamics with multiple ACO products/partners in a market Very different relationship Health plans must share data with providers Provide advanced risk assessment & performance management tools Support clinical transformation and organizational change. That would be compelling even with a no-name network but these products are supported by top provider brands in their markets Source: Oliver Wyman Client Briefing TURNING AN ACO INTO AN INSURANCE PRODUCT, October

26 Case Study: Banner Health Accountable Care Goals Enhance strategic relationships with employers and health plans Create quality and efficiency through population management Strategy Drive and leverage clinical integration processes Launch commercial product for individuals, small group, public & labor and other targeted self insured customers Deploy entire Payer/Insurer Partner s technology stack and care management support to achieve PMPM savings targets Improve management of Medicaid beneficiaries through home health model Collaborate with Insurance Partner to market directly to employers and grow membership in their accountable care organization Model: Branded Network and Accountable Care Headquartered in Phoenix, AZ with 23 facilities across 7 states More than 36,000 employees and 9,000 physicians Nationally recognized for technology and patient safety efforts Charter member of the Premier ACO collaborative

27 Creating Value for Plan Sponsors Source: OliverWyman.com

28 ACOs & the expanding value-based network Over 250 active ACO negotiations covering 60% of U.S. population Key CT DE DC MA MD NJ Contracted ACOs Primary Care Medical Homes (PCMH) Medicare Collaborations ACOs in Negotiation Other Value-based contracts (Institutes of Excellence and Quality, Hospital/Specialty P4P, Bundled Payments, Performance Network, etc.) 28

29 All stakeholders win with value-based care A solution to reduce cost, improve care quality, and the patient experience has key benefits for all major stakeholders in the health system. Provider Payer Patient Reimbursement incentives aligned with efficient, quality care based on measures and patient satisfaction Technology enhancement supporting care coordination Cost savings Sustainable solution Improved quality Enhanced wellness and care management Competitive billing rates Enhanced patient experience Lower out-of-pocket costs Quality-based, coordinated care Tools to support a healthy lifestyle

30 All stakeholders win with value-based care A solution to reduce cost, improve care quality, and the patient experience has key benefits for all major stakeholders in the health system. Provider Payer Patient Employer Reimbursement incentives aligned with efficient, quality care based on measures and patient satisfaction Technology enhancement supporting care coordination Cost savings Sustainable solution Improved quality Enhanced wellness and care management Competitive billing rates Enhanced patient experience Lower out-of-pocket costs Quality-based, coordinated care Tools to support a healthy lifestyle Cost savings Sustainable solution Improved quality Enhanced wellness and care management Ability to work in partnership with health systems for plan design

31 Everyone Wins With A Better Model Better health 0.9% 1.6% reduction in hospital admissions 28% 64% patients reaching goals for blood pressure and cholesterol levels 1 Better care 0.5% 1.2% increase in PCP visits 2% 5% reduction in hospital readmissions Better cost 3.9% 4.5% clinical efficiencies 5.3 % 6.0% reduction in radiology utilization 8% 15% expected medical cost savings* Medical results above are generated by the Pioneer Medicare population from Banner Health Network. 1 Payer-Provider Collaboration in Accountable Care Reduced Use and Improved Quality in Maine Medicare Advantage Plan, Aetna and NovaHealth, Health Affairs, Volume 31, Number 9, September *Actual costs will vary. 31

32 Payer-Provider Collaboration Journey Ahead Payer-owned Providers Providerowned Plans Now Co-Branded Products ACO PCMH Then HMO Capitation PPO Insurance

33 Questions?

34 Thank you Clarence Williams Vice President Client

35 Common features of successful programs 1 2 Care Managers Some embedded some included in community health teams Care coordination function is essential to driving medical home success which requires dedicated resources Data-Driven Analytics Accessible data to manage performance and track patients Population based decision making with predictive modeling Ensure achievement of clinical goals for patients Expanded Access 3 4 Round-the-clock access to a health provider to reduce ED use Direct communication between care coordinator and patient Technology member portals Incentive Payments Motivate behavior change among providers Reward physicians and providers who demonstrate consistent and successful application of the medical home features Source: Health Affairs: Driving Quality Gains and Cost Savings Through Adoption of Medical Homes

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