Integrated Care and the Future of the Kidney Disease Reimbursement
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1 Integrated Care and the Future of the Kidney Disease Reimbursement Mark Caputo Executive Vice President & Managing Partner Joint Ventures September 28, 2012 (c) Copyright 16/10/2012
2 Integrated Care Q: What is Integrated Care? A: Innovative Reimbursement Systems Reward investments in Part B (outpatient care) with Part A savings (reduced hospitalizations) Shared Savings Shared Risk and Savings Global Capitation Page 2
3 Integrated Care Innovative Reimbursement Examples: Demonstration Project ( ) Aetna & Commercial Payers today MA Plans ACOs Medicare & beyond: The Future of ESRD reimbursement Page 3
4 FMC Demonstration Project Time Frame: Size: 2000 patients (full 5-years) Partners: 134 Nephrologists Clinics: 194 FMC Dialysis Clinics Page 4
5 FHP Demo Is a Proven Model of Success Significant Savings and Improved Health Outcomes Improved health outcomes and cost savings of $3,618 PPPY vs. FFS Medicare Adjusted 1 year Mortality Adjusted 2 year Mortality Patients Hospitalized All Causes 2 year Patients Hospitalized CVD 2 year FHP Demo Medicare FFS (Case Mix Adjusted) % FHP Improvement 9.3% 14.6% 36% 19.9% 26.1% 24% 60.5% 76.1% 20% 59.7% 75.2% 21% All results were adjusted for demographics and co morbidities Source: Arbor Research : ESRD Demonstration Disease Management Demonstration Evaluation from , the First Three Years of a Five Year Demonstration, December 8, Page 5
6 Demonstration Project -- Economic Impact Nephrology Practice Economics Continued Fee For Service payments $25 PMPM reimbursement Shared Savings participation Practice Example: $1 Million in incremental revenue over 4 year period Page 6
7 CMS Innovation Center (CMMI) CMS Renal Integrated Care Pilot (expected 2013) FMC and DVA submitted joint renal integrated care proposal to CMMI in 2011 Bring integrated care to broader ESRD population based on lessons learned in ESRD demonstration project Shared savings model Path to a new permanent payment model Building on a proven model of success from the ESRD Demonstration Project, We will contract with CMS for the entire continuum of care for ESRD patients Page 7
8 Significant Savings Achieved in FHP ESRD Demonstration 2008 Per Patient Per Year (PPPY) Part A Part B Total Medicare Dialysis (Baseline) 1 $29,208 $41,738 $70,946 FHP Medicare ESRD Demonstration 2 $25,706 $41,622 $67,328 FHP Savings $3,618 % of Baseline 5.1% $3,618 X 100,000 Beneficiaries = $3.6 billion in potential 10 year savings 1 CMS ( and USRDS ( 2 ESRD Demonstration Evaluation Report: Page 8
9 Dialysis Industry Economics Patients Industry Profit Page 9
10 Aetna CKD Management Project Turnkey solution for Aetna - CKD Stages ESRD (incident patients) Builds on success of CMS ESRD Demo Physicians participate in monthly PMPM Comprehensive patient-centric intensive care management program for Aetna CKD and ESRD patients Page 10
11 Aetna CKD Program 1H 2012 Results 1000 Aetna patients identified and referred 45 ESRD starts 35 ESRD starts in FMC/Liberty/RAI clinics Nephrology Practice Economics Continued Fee For Service payments $25 PMPM reimbursement Future Shared Savings program participation (negotiations continuing with Aetna) Page 11
12 Aetna CKD Program 1H 2012 Summary Improved Referral Flow Doubled our rate of capture from Aetna Improved nephrology practice reimbursement $25 PMPM Improved Commercial Mix Improved Dialysis Joint Ventures growth, outcomes and performance Page 12
13 Major Payer Examples 2012 Payer A 1000 ESRD patients 6000 CKD patients Wants exclusive nephrology/dialysis network with shared risk Payer B Insures 20% of the state population Can now steer patients Wants shared savings program Wants broad kidney disease partnership Shift in Payer Dynamic Negotiation is no longer about dialysis rates, but rather a percentage of the global dialysis premium. Page 13
14 What Is an ACO? An Accountable Care Organization is a group of physicians and providers taking cost and quality accountability for their patient population ACOs that: + = Improve outcomes and Reduce costs will Share in savings Reward investments in Part B (outpatient care) with Part A savings (reduced hospitalizations) Page 14
15 Are All ACOs the Same? No ACOs mean different things to different people. Medicare Commercial Size Minimum of 5,000 patients Any Payor Medicare Commercial insurers Economic Model Traditional ACO Only share savings Less upside Pioneer ACO Share savings and costs Greater upside PFP, Shared Savings, Capitation Requires Physician Exclusivity Yes No Flexible Terms No Yes Physicians need to understand what kind of ACO they are dealing with. Page 15
16 When Are ACOs Coming? They are already here Medicare ACOs 32 Pioneer ACOs (December 2011) 116 Medicare Shared Savings Program (Traditional ACOs) 27 ACOs (April 2012) 89 ACOs (July 2012) Commercial ACOs Page 16
17 What Do Medicare ACOs Look Like? Primary Care Is at the Hub Hub and Spoke Model PCP at the hub coordinates care among satellite specialists Page 17
18 Challenges for Nephrologists in Medicare ACOs Joining an ACO Can Be an Exclusive Proposition 2 step process to assign patients to an ACO Step 1 Patient is assigned to their PCP s ACO Step 2 If patient does not have a PCP but receives plurality of primary care from a given specialist, patient is assigned to that specialist s ACO But any physician practice with patients assigned to an ACO must be exclusive to that ACO Because many nephrologists provide primary care services, they can be the basis for assignment of a patient to a Medicare ACO As a result, the entire practice can be forced into exclusive relationship with an ACO even if only one patient from the practice is assigned This applies to Medicare ACOs only Primary Care defined as services identified by the following HCPCS codes: , , through 99350, G0402, G0438, G0439. Page 18
19 Solution: Sub-ACO Model Instead of tying themselves to only one ACO X Nephrologists can partner with Fresenius Renal ACO to avoid exclusivity and work with multiple ACOs. Nephrologists can: Expand referral base Expand market reach Page 19
20 Fresenius Model Expands Practice Opportunity By working together with you and multiple ACOs Renal Sub-ACO will be your partner Page 20
21 Sub-ACO Model Can Apply Across Payor Types Physician Provider Payor Medicare ACOs Practice Group Renal ACO Pioneer ACOS Commercial ACOs Working together, nephrologists and Fresenius can bring the promise of integrated care to any payor s renal population Page 21
22 Improved care coordination during transition periods can reduce cost and improve outcomes Late Stage CKD egfr <15 ml/min Incident ESRD Smoother Transition into Dialysis (>30% mortality) Prevalent ESRD Prepare for Dialysis (50% crash into dialysis) Manage Comorbidities (55% potentially avoidable hospitalizations) Page 22
23 Innovative Programs Innovative Programs for Integrated Care Renal Care Coordinators (RCC) Case Manager placed in the nephrology practice Cost shared 50/50 with FMC and Practice Eye-popping preliminary results: Improved access rates Reduced Missed Treatments Reduced hospitalization Reduced mortality Page 23
24 Innovative Programs Innovative Programs for Integrated Care Renal Inpatient Care Management (RICM) Goal: To improve patient outcomes and length of stay (LOS) efficiency while optimizing care coordination and a smooth transition from inpatient to outpatient care. Preliminary Results: Reduced Length of Stay Reduced Missed Treatments Cost Savings Page 24
25 Integrated Care Keys to Success: Engaged Physician Partners designing and leading innovative programs Expertise in negotiating and managing risk Expertise in managing full continuum of care Sophisticated I.T. Systems Financial capability to assume risk (i.e. multi-billion dollar balance sheet) Broad geographic network coverage Page 25
26 The Path Forward Principles of a Renal Care Partnership We believe that engaged and empowered physician partners create an enduring competitive advantage We have a voice. Absent our voice, others will decide our fate. As leaders in our system of care, we share responsibility for the outcomes of all the patients in the system, regardless of whether we were personally involved in their care. Let s design the system together Page 26
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