ACO Contractual Arrangements in California s Commercial PPO Market

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1 Issue Brief No. 17 May 2015 ACO Contractual Arrangements in California s Commercial PPO Market Thomas R. Williams, Dr.PH, Vice President and General Manager, Accountable Care, Stanford Health Care; Former President and CEO, The presence of many sophisticated physician organizations in California with decades of HMO managed care experience suggests an environment conducive to ACO PPO arrangements. Nonetheless, ACO PPO contracts to date are still best characterized as works in progress. INTRODUCTION Despite the challenges experienced in early pilot studies, expectations remain high that Accountable Care Organizations (ACOs) can serve as catalysts to help fix the U.S. health care system. 1 This optimism is based on a key premise of the ACO concept: that truly integrated provider organizations are best positioned to efficiently manage both the health care needs and costs of patient populations, moderating the upward trend in insurance premiums. However, experience suggests that effective integration extends well beyond the legal formation of an ACO; it requires the alignment of interests among the providers within it and between the ACO and its health plan partners. Meaningful alignment between the ACO and health plan presents challenges for both including patient attribution, data exchange, risk sharing arrangements and unclear responsibilities for care management. Many of these issues are addressed by contractual arrangements between the ACO and health plan, offering practical insights into the evolving inter-organizational relationships. This Issue Brief examines these contractual arrangements within commercial PPO markets in California. ACOs ENTER THE COMMERCIAL MARKET The ACO concept took flight nationally when the Centers for Medicare & Medicaid Services (CMS) launched the Pioneer ACO and Medicare Shared Savings Program (MSSP) pilots in January Applying some of the principles of HMO population management, these programs attempt to use ACOs to manage beneficiaries in Medicare s traditional fee-for-service program. Key elements include: attributing traditional Medicare beneficiaries to an ACO with the expectation that it will coordinate and manage their care, and implementing shared savings and risk arrangements with ACOs, using incentive Published by 2015 All rights reserved ABOUT THIS ISSUE BRIEF This Issue Brief examines these contractual arrangements within commercial PPO markets in California. Related Issue Briefs address other aspects of ACOs emerging in the state, including: A Large Community Health Center Adapts to a Changing Insurance Market, by Jill Yegian, Ph.D Accountable Care in California: Imperatives and Challenges of Physician-Hospital Alignment, by James C. Robinson, Ph.D, and Referral Management and Disease Management in California s Accountable Care Organizations, by James C. Robinson, Ph.D. Background on the underlying case study and descriptions of the physician organizations included are in the Appendix. 1

2 payments and downside risk based upon their performance managing the total cost and quality of care. As these Medicare ACO pilots launched, commercial health plans also began to encourage the development of ACOs for their fee-for-service PPO populations. In California, this began in 2011 with a Brookings/Dartmouth sponsored initiative between Anthem and several large provider organizations. 2 There were significant challenges in applying attribution methods and care management to a commercial PPO population in this early effort, but the parties persisted and Anthem recently announced a joint savings of $4.7 million with HealthCare Partners, one of the ACOs participating in this pilot. Subsequently, Anthem and other national insurers including Aetna, CIGNA and UnitedHealthcare began experimenting with ACO contracts for extensive PPO memberships in California. Blue Shield of California has focused primarily on engaging ACOs in its HMO products; it recently announced plans to have 20 ACOs throughout the state by 2015 and is currently involved in at least one ACO PPO initiative. These initiatives, structured within contractual arrangements between the ACO and health plan, generally include: a total cost of care budget based on historical claims experience for the PPO population attributed to the ACO, and a variety of measures for quality, patient satisfaction and other factors in conjunction with a total cost of care budget target; in most cases, if the total cost budget is exceeded, there is no reward, even if performance in other areas is high. Although ACOs incurred administrative costs to comply with contractual requirements, there was no downside risk for them in these arrangements. Health plans delegated certain aspects of care management to the ACOs and typically paid them to provide these functions. The plans also provided comprehensive data support including predictive analytics and reporting. PPO MARKET DYNAMICS IN CALIFORNIA HMO enrollment in California is 43.6 percent of the total insurance market, much higher than the nationwide rate of 23.5 percent. Conversely, PPO enrollment in California is relatively lower than the rest of the nation. However, the commercial PPO market in California recently began to grow, due to: competitive premiums compared to HMOs, primarily driven by the cost advantages of high-deductible benefit designs, and exemptions from the federal premium tax and mandated essential health benefits imposed by the Affordable Care Act (ACA) for self-insured plans, which are typically PPO benefit plans. HMO enrollment in California is 43.6 percent of the total insurance market, much higher than the nationwide rate of 23.5 percent. The most popular benefit plans offered by Covered California, the state health insurance exchange, require real time tracking of claims to determine when a deductible is met. Furthermore, premiums for health plans offered in Covered California must be retroactively adjusted based on the risk profile of enrolled members. Detailed claims information is required in both of these situations, which has been difficult to administer in capitated HMO plans. Therefore, HMO offerings on Covered California have been limited and PPO enrollment has grown proportionally larger. The Kaiser Foundation Health Plan has been able to offer and administer high-deductible HMO plans and maintain enrollment in the face of these market dynamics, but other commercial health plans that rely on capitated networks of medical groups and Individual Practice Associations (IPAs) have suffered HMO enrollment losses from about 5.5 million HMO enrollees in 2008 to fewer than 4 million in CURRENT ACO PPO CONTRACTS IN CALIFORNIA The estimated number of health plans, ACOs and enrolled members participating in ACO PPO contracts and product offerings has been growing in California, as reflected in Table 1. Health plans and ACOs in this study reported mixed success with ACO PPO contracts. All shared the view that applying ACOs to commercial PPO populations was still in an early, experimental stage. Health plans have responded by adjusting some contract terms or requirements. For example, one health plan indicated it will announce a significant reduction in the number of performance measures required beginning in 2016 in response 2

3 Table 1: ACO PPO Contracts and Enrolled Members in Select Health Plans and Physician Organizations in California Year (Projected) Health Plans with ACO PPO Contracts ACO PPO Contracts* * Some ACOS have multiple contracts. Data compiled from interviews conducted with case study participants in June-September to concerns expressed by ACOs that too many measures are required. Health plans in this study were generally optimistic that the ACO PPO model would continue to grow, with enrollment predicted to reach about 800,000 in California in However, ACOs were more restrained in their support and enthusiasm, indicating that the additional investments to manage these populations offset the care management fees and shared savings they might receive. They were also concerned about the sustainability of early shared savings payments and the challenge of managing different contractual requirements among the health plans especially the varying performance metrics and approaches to care management. PATIENT ATTRIBUTION Models for attributing patients to ACOs were described as health plan driven, and based upon identifying patients who receive a significant proportion of their care from ACO physicians, with emphasis on care by primary care physicians. None of the ACOs studied were able to negotiate the attribution model; however, they were able to determine which physicians would be included in the model and ACO network. Three of the ACOs in the study noted their approach to defining commercial ACO networks was influenced by their Medicare Pioneer ACO experience. Brown & Toland and Monarch HealthCare reported using a parsimonious approach to selecting the primary care physicians in their network restricting the selection to medical group physicians and preferred IPA network primary PPO Enrollees Attributed to ACOs 100, , , ,000 care physicians with the strongest relationships defined by larger patient volumes, shared electronic medical records and exclusive IPA relationships. While this yielded a lower number of attributed patients, it enhanced the ability to manage their care. HealthCare Partners decided to include all of its employed clinicians and many of its IPA physicians in its Medicare ACO network to optimize patient membership and benefit from economies of scale. This strategy was challenged by the characteristics of the attributed membership, with a disproportionate share of dual eligible patients (eligible for both Medicare and Medicaid) and high risk conditions (such as malignancy) compared to the reference population. HealthCare Partners also had greater difficulty in influencing the referral pattern of its IPA physicians as compared to employed physicians. For this and other reasons, the organization chose to leave the Medicare Pioneer ACO program and transition to the MSSP. Another challenge was that the commercial PPO attribution logic used by the health plans does not attribute patients to an ACO if they have not seen a primary care physician within a designated period. However, these patients remain in the comparison group used to calculate ACO shared savings. Therefore, ACOs expressed the belief that the comparison group enjoys a more favorable experience, making it difficult for ACOs to demonstrate and achieve shared savings targets. The majority of health plans in the study identified a minimum threshold of 5,000 attributed patients as a basic requirement for participating in ACO PPO contracts, which presents particular problems in sparsely populated rural areas. To address this, Anthem developed geographic ACOs in two rural areas. In this model, patients are attributed to individual primary care physicians, but because of relatively small samples, the results are pooled across a defined geographic area when measuring results. PERFORMANCE MEASUREMENT ACO PPO contracts measure the ACO s quality, resource use and total cost of care, but with significant variation in the types and numbers of measures. The ACOs attempted to work with the health plans to align their measure sets, without much traction. One health plan used 110 measures, although not all were tied to compensation. Another concentrated its measures on several important chronic conditions measuring quality, utilization and total 3

4 ACOs described the cascade of measures with significant variation in types and numbers by contract as overwhelming. cost of care for each condition. ACOs described the cascade of measures as overwhelming. Brown & Toland reported dealing with this challenge by annually prioritizing a subset of measures that present the most opportunity thereby concentrating improvement efforts. The ACOs and health plans expressed confidence that applying performance metrics at the ACO level would yield improvements. Early results appear to support this, with health plans reporting some level of quality improvement across all participating ACOs during the first contract year, even if no significant cost savings were realized. DATA SHARING Data sharing to support ACO PPO contracts was described as primarily unilateral, with data flowing from the health plan to the ACO. The ACOs involved in this case study were generally complimentary of the data the health plans provided, although they expressed concern it was not yet adequately real time. CIGNA received especially favorable comments about its data sharing and reporting capabilities, which proved very useful to its ACOs. The health plans also provided ACOs with predictive modeling analytics identifying patients experiencing high utilization, co-morbidities and those likely to experience high utilization soon. ACOs reported sharing these reports with physicians who applied their own assessment of such patients, indicating which were the most likely to benefit from case management or other programs. Brown & Toland and HealthCare Partners both reported using this process, which one medical director described as Physician Directed Predictive Modeling. One area of data sharing that was a shortfall for most health plans was real time reporting of emergency department and inpatient utilization. This was particularly true when the ACO had not established an effective working relationship with its hospital partners or did not employ hospitalists. INCENTIVE/SHARED SAVINGS PAYMENTS Reimbursement for physician services provided within the ACO PPO was based on traditional fee-for-service arrangements, and health plans did not require the ACOs to discount fees. A total cost of care budget was typically set by the health plan for an annual performance year and a shared savings incentive formula established, with upside sharing by the plan with the ACO. In some cases, the ACO had to pass through a quality gate or achieve a minimum threshold target to become eligible for shared savings. Generally, total cost of care budgets were established for an ACO using prior baseline costs for that ACO and its attributed population with or without an adjustment for inflation. Health plans used two basic methodologies to determine shared savings: comparing results against either the prior year experience of the ACO or the regional market. The regional market comparison proved problematic for at least one ACO that reported attracting higher maternity risk than the regional population, resulting in no shared savings. In addition to the shared savings incentives, most health plans paid a per patient case management fee for patients attributed to the ACO. UnitedHealthcare, a later entrant to the ACO PPO market in California, was still considering its approach to paying any patient management fee at the time of the study.the amount of the fee paid varied by plan. CIGNA established its fee to fund one case manager for every 10,000 attributed patients; ACOs could either hire new staff or assign existing staff to provide case management. ACOs completing one or two annual performance contract years reported mixed results. Fees typically covered most case management activities, but not the full range of data diving and subsequent communications and interactions with physicians and patients. Where the ACO received a year-end shared savings payment, it generally compensated for the additional administrative costs incurred; however, the ACOs in the study reported about breakeven results across their portfolio of ACO PPO contracts. CARE MANAGEMENT During the past decade, physician organizations in California have complained about the division of care management responsibilities between health plans and providers. This issue arose primarily in HMO contracts in which physician organizations were paid capitation for professional services and provided upside shared savings for efficient inpatient use. Despite these incentives, health 4

5 With the introduction of ACO PPO contracts, efforts have been made to better align both financial incentives and care management responsibilities between the health plan and ACO. plans often engaged in care management that duplicated and overlapped similar activities being handled by the physician organizations. Historically, these physician organizations did not have financial incentives to manage PPO populations; therefore, health plans have typically managed care of acute and chronically ill PPO patients. With the introduction of ACO PPO contracts, efforts have been made to better align both financial incentives and care management responsibilities between the health plan and ACO. In return for the patient management fee paid to the ACO, it must designate staff to manage the particular health plan s PPO patients and work closely with its medical management staff. Anthem s Enhanced Care Coordination program was described as the most highly developed, providing the greatest oversight of the care management process with specific toolkits for physicians and patients. This program targets health plan members with multiple chronic conditions using a health team composed of a physician, registered nurse and other practitioners as needed. Anthem also provides ACO staff lists of patients, along with a defined protocol for contacting them. ACOs described confusion caused by the different health plan approaches and requirements for handling care management, which weakened their ability to provide the most effective care management services. The ACOs also reported achieving savings for PPO patients by more effective care direction. This involved encouraging the ACO primary care physicians to refer patients to specialists within the ACO specialty network. This had a dual advantage: specialists were paid at lower contracted fees and members paid lower copayments and coinsurance amounts to in-network PPO specialists and ancillary providers. LOOKING FORWARD The presence of many sophisticated physician organizations in California with decades of HMO managed care experience suggests an environment conducive to successful ACO PPO arrangements. Nonetheless, the ACO PPO contracts implemented to date are still best characterized as works in progress. California health plans are more optimistic about the early results than their contracted ACOs that are struggling to manage the plans different contractual requirements. The ACOs have found it challenging to engage their network physicians and patients in care management within the looser construct of a PPO benefit design. An important lesson the ACOs learned is the need to rely on their most engaged primary care physicians, with whom they have the greatest influence. The number of ACOs and patients involved in ACO PPO contracts in California and nationally continues to grow at a steady pace. This suggests sufficient momentum to push health plans and ACOs through the thorny details necessary to achieve the goals of improving quality and moderating upward cost trends. Notes 1. Debra Ness and William Kramer, The First Year Pioneer ACO Results: Predictable Bumps in the Road, July 25, 2013: healthaffairs.org/blog/2013/07/25/the-first-year-pioneer-acoresults-predictable-bumps-in-the-road/. Lawrence Kocot, Ross White, Pratyusha Katikaneni and Mark B. McClellan, A More Complete Picture of Pioneer ACO Results, July 25, 2013: David Muhlestein, Medicare ACOs: Mixed Initial Results and Cautious Optimism February 4, 2014: 2. Josette N. Gbemudu, et al., Healthcare Partners: Building on a Foundation of Global Risk Management to Achieve Accountable Care, The Commonwealth Fund, January 2012: commonwealthfund.org/publications/case-studies/2012/jan/ healthcare-partners. 3. Jill M. Yegian and Thomas R. Williams, Status, Challenges and Opportunities of the Delegated Model in California, Cal. J. Pol. & Pol y, Vol. 6, Issue 2 (April 2014): item/3gn7q6x9#. Acknowledgments This project was supported by a grant from the Robert Wood Johnson Foundation. The author would like to thank the Foundation, the ACO Case Study Team and all of the health plans and physician organizations that contributed their valuable time and insights to this Issue Brief. 5

6 Appendix Background and Methodology ABOUT THIS STUDY This Issue Brief and three others draw upon information from a case study conducted by the Integrated Healthcare Association (IHA) and researchers from the University of California at Berkeley, School of Public Health. Support for the two-year study, which was launched in April 2013, was provided by a grant from the Robert Wood Johnson Foundation and focused exclusively on the California market. The research team conducted two rounds of structured interviews in 2013 and 2014 with five prominent Accountable Care Organizations (ACOs). It also undertook two rounds of interviews with health plan executives responsible for ACO strategy and contracting at five health plans in California: Aetna, Anthem, Blue Shield of California, CIGNA and UnitedHealthcare. PHYSICIAN ORGANIZATIONS INCLUDED This study focused on five physician organizations each distinct in scale, geography, structure and ownership ties to hospitals. All are deeply engaged in ACO initiatives, defined broadly as including payment methods linked to the total cost of patient care. Some have new ACO contracts with Medicare and private insurers, while others are focused on capitation payment from Medicare Advantage, commercial HMO and managed Medicaid plans. AltaMed Health Services was founded more than 40 years ago as a grant-funded free clinic serving the Latino population in Los Angeles. It is the largest independent Federally Qualified Health Center in the U.S., delivering more than 930,000 annual patient visits to 180,000 patients through 43 sites in Los Angeles and Orange Counties. The majority of AltaMed s patients 85,000 are Managed Medi-Cal enrollees, but it serves an additional 11,500 through Medi-Cal fee-for-service contracts. In addition, 26,000 patients are covered through commercial HMO and PPO contracts, and 5,000 are Medicare patients. AltaMed provides care through staff-model clinics with an IPA that supplements the clinic staff with community physicians. It offers primary medical care, dental care and senior long-term care services. Brown & Toland Physicians is an Independent Practice Association (IPA) founded in 1992 in San Francisco, with a recent expansion into the East Bay market. Its 1,500 physicians care for more than 34,000 Medicare patients including 16,000 through Medicare Advantage and 18,000 through its Pioneer ACO contract. It also serves 100,000 commercial HMO patients through capitation contracts; 175,000 commercial PPO patients; and 2,700 Medicaid managed care enrollees. Brown & Toland partners with several hospitals in the area, including Sutter, where many admits come from California Pacific Medical Center and Alta Bates Summit Medical Center. It also partners with other area hospitals including Dignity Health, the University of California, San Francisco and the Alameda Health System. HealthCare Partners, a division of DaVita HealthCare Partners, manages and operates HealthCare Partners Medical Group in California along with organizations in Arizona, Colorado, Florida, Nevada and New Mexico. In California, HealthCare Partners serves 175,000 Medicare patients, including 125,000 through Medicare Advantage, and the remainder through its Medicare Shared Savings Program (MSSP) ACO and the Medicare fee-for-service program. It also serves 100,000 commercial PPO patients, 400,000 commercially insured HMO patients and 117,000 Medi-Cal managed care and feefor-service patients. For HMO and Medicare Advantage patients, HealthCare Partners is paid capitation for the full range of physician and hospital services. HealthCare Partners contracts with nearly 50 hospitals in Southern California. Monarch HealthCare is an IPA that includes 640 primary care physicians throughout Orange County. It serves 61,000 Medicare patients, of which 38,000 come through Medicare Advantage plans and 23,000 through its Pioneer ACO contract, plus 61,500 Medi-Cal patients through the CalOptima managed care program and 92,000 commercially insured HMO and PPO patients, combined. It is owned by Optum, Inc., a subsidiary of the UnitedHealth Group that also has an affiliation with the UnitedHealthcare insurance plan. Monarch does not have an ownership association with any hospital 6

7 Patient Enrollment at a Glance Physician organization HMO commercial PPO Medicare Advantage Medicare Medicare FFS Managed Medi-Cal Medicaid Medi-Cal FFS AltaMed Health Services 23,000 3,000 2,500 2,500 85,000 11,500 Brown & Toland 100, ,000 16,000 18,000 2,700 0 HealthCare Partners 400, , ,000 50, ,000 5,000 Monarch HealthCare 89,500 2,500 38,100 22,800 61,500 0 St. Joseph Heritage 151, ,000 33,000 38,000 3,500 5,500 *Enrollment as of August 2014 system, but admits patients to all the major facilities in Orange County and Los Angeles. Through Optum, it is also involved with payment and organizational initiatives for a larger set of medical groups across the nation. St. Joseph Heritage Medical Group is the physician organization affiliated with the St. Joseph Hoag Health alliance in Orange County. It contains both integrated medical groups and IPAs around the four major St. Joseph Hoag facilities in the county, as well as smaller initiatives at hospitals it owns in northern California. It serves 33,000 Medicare Advantage enrollees; 151,500 commercial HMO enrollees; 3,500 Medi-Cal managed care enrollees; and 5,500 Medi-Cal fee-for-service patients. In addition, it serves 38,000 Medicare fee-for-service and 111,000 commercial PPO enrollees; these are not covered by ACO contracts and their care continues to be reimbursed on a fee-for-service basis. Together, St. Joseph Hoag hospitals and the Heritage physician groups represent the vertically integrated physician-hospital organization, contracting as a single unit with health insurers. RESEARCH TEAM MEMBERS The research team was comprised of: Thomas R. Williams, Dr.PH Vice President and General Manager of Accountable Care at Stanford Health Care; Former President and CEO at the Integrated Healthcare Association James C. Robinson, Ph.D Leonard D. Schaeffer Professor of Health Economics at the University of California at Berkeley School of Public Health and Director of the Berkeley Center for Health Technology Jill Yegian, Ph.D Senior Vice President, Programs and Policy at the Kimberly MacPherson, MPH, MBA MPH Program Director, Health Policy and Management at the University of California at Berkeley School of Public Health and Co-Director of the Berkeley Center for Health Technology, and Kelly Miller Project Manager at the Integrated Healthcare Association. ISSUE BRIEFS PRODUCED This Issue Brief focuses on findings related to four physician organizations: Brown & Toland Physicians, HealthCare Partners, Monarch HealthCare and St. Joseph Heritage Medical Group. A fifth, AltaMed, was also included in the study, but because of its unique structure as a community clinic, the results are addressed more specifically in a separate Issue Brief: A Large Community Health Center Adapts to a Changing Insurance Market, by Jill Yegian, Ph.D. Additional Issue Briefs stemming from this study address other aspects of ACOs emerging in the state, including: Accountable Care in California: Imperatives and Challenges of Physician-Hospital Alignment, by James C. Robinson, Ph.D, and Referral Management and Disease Management in California s Accountable Care Organizations, by James C. Robinson, Ph.D. 7

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