Lessons Learned from Multiple Structural ACO Models. Brown & Toland Physicians Overview

Transcription

1 Lessons Learned from Multiple Structural ACO Models A Conversation with Brown & Toland Physicians 2014 CAPG Annual Healthcare Conference June 5, 2014 Stephanie Mamane, Director, PPO & ACO Claire Shoen, Vice President, Network Management and Product Development Andrew Snyder, MD, Chief Medical Officer (moderator) Marcus Zachary, DO, Medical Director, ACO 1 Brown & Toland Physicians Overview Multi-specialty, clinically integrated, 100% Physician-owned IPA formed in 1992 Provides comprehensive administrative, group contracting, practice management and clinical management services Represents over 525 primary care physicians and over 1200 specialists across the San Francisco Bay Area Headquartered in San Francisco, network coverage in five counties, 250 employees Multiple hospital partners Led to HMO Patient Volume 1992 Leader of Care Coordination Contracting 300,000 for various products Led to PPO 1999 Leader in Clinical Integration Contracting Commercial HMO Leading in ACO Led to ACO Medicare Advantage 2010 Development contracting PPO 2013 Accountable Care 2.0 Knox Keene Medi-Cal Managed Care Total Cost of ACO Future Leader in Population Health Care 2 1

2 Awards & Accolades Elite Status-- CAPG standards of excellence program Selected as 1 of 32 Pioneer ACOs by CMS, 3 rd top performer after year 1 Named Top Performing Physician Group in 2012 by the Integrated Healthcare Association (IHA) in its annual California Pay for Performance (P4P) initiative Various quality based health plan awards (Blue Shield of California, Anthem Blue Cross, Health Net) PBHG Blue Ribbon Award winner for three years for quality, cost, data and partnering Employer awards, including Bay Area Best Places to Work (2010, SF Business Times) Multiple marketing and advertising awards, including BTP s member newsletter 3 The Pace of Change 4 2

3 The Pace of Change 5 Brown & Toland s Current Total Cost of Care Landscape ACO Description Patients 2014 Growth City and County of San Francisco CCSF employees and retirees enrolled in Blue Shield HMO 18,759 Pioneer Medicare ACO Traditional Medicare FFS patients who were aligned by CMS to a B&T Pioneer physician 17,000 PPO ACO (currently 2 commercial plans) PPO patients aligned to B&T physicians. TCC Model. Data by reports and raw data provided. 18,500 32,500 (2 additional Plans) Knox Keene (Full Risk) Restricted Knox Keene Keene License as BTHS to assume Full clinical financial risk ,000 Hospital Shared Risk HMO patients with which the Hospital entered into Capitation with a BTP Management QIP 7,000 Total: 62, ,

4 Topics for Today s Conversation Engagement g Interventions and Outcomes Lessons Learned 7 Engagement Stating the Obvious 8 4

5 Engagement at many levels IPA & Physicians Employer IPA Coordination Health Plan Member Hospital Care Coordination Physician Patient Engagement Engagement Population Health Practice Quality Management/ Improvement MSO Services Data & Analytics 9 Critical Engagement - Where to Start Strengths, experience and capabilities of each partner must be recognized to foster integration, accountability and success Governance and Leadership Employer, Member & Physician i Engagement Population Health Management How do we partner to better achieve integration? What gaps and redundancies currently exist and how do we address these? How are our stakeholders impacted (employer, patients, members, physicians, care providers, project resources)? Care Measurement Data Delivery & Tracking Exchange CRITICAL QUESTIONS THAT NEED TO BE ADDRESSED TO BUILD INTEGRATION How do we redesign the care delivery and care transition processes to be proactive and efficient both horizontally (coordination of activities at the same stage of delivery) and vertically (coordination of care at different stages)? How do we collectively engage to drive desired outcomes? How do we communicate internally and externally? What are each organization s capability strengths and how do we collectively leverage? What are the challenges of implementing clinical change? 10 5

6 5/28/2014 Health Plan Engagement Relationship realignment from necessary competitors to meaningful collaborators Use process of data refinement as vehicle for transparency, shared truths, aligned expectations, and partnership accountability This group activity requires feeding, watering and time to grow. Plan early tactics, resource allocation and performance metrics accordingly. Waves of activities (vs. tsunami) highly recommended Health Plans have excellent Project Management Resources to supplement your internal resources take advantage of them Quality improvement initiatives can decrease costs in one area and increase cost in another, be mindful of that result at the onset 11 Health Plan Engagement Lessons Learned Meet early and often Define, Measure, Scope, Execute, Measure, Tweak, Measure, Repeat. Identify goals based on agreed upon data and establish measurable interventions This work will identify silos inside all partnership organizations In holding partners accountable, be kind and constructive in your criticism as you will be receiving your own fair share Keep track of anecdotal stories of how interventions improved quality of care for individual patients this helps all participants when the going gets tough Celebrate successes it will help for the next wave of work Each party with skin in the game needs a financial win 12 6

7 5/28/2014 Provider Engagement Keep expectations low and requests to providers focused Be very specific regarding patients criteria/measurement agree on what you re going to measure and how to get physician to buy in MUST get clinical information Ask for their help Face to face meetings to educate the provider about all the services available and who you are looking for Give them easy way to contact you Train the whole team to always loop back with the provider Its not about the short term but the long term 13 Provider Engagement Future State Providers identify patients for us and task care management via the enterprise platform (self sustaining referrals) Quarterly rounds with engaged providers to both report out and reload Integrated pods/teams will include referral nurse, clinical nurse, physician service reps, social worker The elusive Scalable PCMH 14 7

8 5/28/2014 Patient Engagement Some organizations cold calling works but not ours Attribution isn t precise so verifying provider-patientpatient can be challenge Senior and commercial tactics are different for communication Tool kit needs to be broad (low tech still works great) No data is accurate and perfectly real-time learn to apologize gracefully to providers and patients 15 Hospital Partner Engagement Tactics are dependent on Population Captive or attributed Risk Population acuity mix Incentives - Upside, Downside, Realistic Targets Financial alignment understood by all parties Unaligned objectives and unsupported financial incentives quickly surface Different levels of engagement for different ACO models Inpatient requires hospital partner buy-in FFS, Capitated Risk, or DRG incentives and management differs Outpatient requires physician channeling 16 8

9 5/28/2014 Employer Engagement Employers can add tremendous value to program dynamics Identify employer objectives and health conditions Bus Drivers with low back pain/return to work After Hours Access Transitions of Care Improvement Opportunities Employer resources to reinforce messages Educated employer is an empowered employer Wellness initiatives Benefit plan development Market purchasing power 17 Internal Engagement Exec ACO Leadership Committee (Strategic) ACO Subcommittees (Tactical) Operations ACO Committee 18 9

10 Interventions and Outcomes 19 Interventions Across the Continuum of Care: Build with Caution - Different populations will have different needs Awareness creating early engagement Wellness making prevention easy Access increasing access to care Chronic Mgmt regaining optimal health ED Mgmt directing patients to appropriate care Inpatient coordination of patient Outpatient continuation of care Orientation to PCP B&T screening member letter programs Member Dedicated communication/ member postcards on access engagement alternatives team Leverage Plan Wellness program Gaps in Care quality program B&T Dedicated Nurse Advice Line PCP outgoing messages updated with after hours information Assistance with postdischarge appointments Expansion of after hours availability to create the After Hours Network Leveraging B&T s Patient Centered Medical Home Generic vs Brand Utilization Management and targeted outreach Stratification of highest risk members via Predictive Modeling Tools Management of high risk medications within senior population High touch, integrated complex case management program Referrals from Care Transitions Manager into complex case management program ED discharge instructions & PCP follow up for nonemergent care Cross organizational access to traditionally proprietary medical record systems (MIDAS & Ibex, Epic, and AllScripts) Quarterly distribution of Access & ED utilization data for all PCPs; Transparency Urgent Care access and education Coordinated discharge planning/ transition of care, & IDT rounding Dedicated Hospitalist Program Advanced Illness and End of Life Programs Manage elective inductions SNF model of care Post discharge appts. for high risk patients Reengineering hospital discharge process ED Care Managers to prevent avoidable admissions Personalized Care Plan, including discharge instructions, shared with PCP Transition of Care Calls; Transitional Clinic POLST, Palliative, and Compassionate Care programs Scope of Practice for PCPs to standardize best practices across all B&T practices Home Visits Program Behavioral Health Integration Dedicated Pharmacist & Medication Management Strategy 20 10

11 Coordinated Care across the Continuum 1% Catastrophic Illness 4% 5+ Conditions 20% 2 4 Chronics 25% 1 Chronic Condition 15% At Risk 35% No Ongoing Physical Health Needs Social Risk Clinical Risk Behavioral Risk 2014 Physicians Brown & Toland Physicians 21 Interventions Patient Identification is Key Non-HMO population: you re not going to find these patients on a capitation list or with an ID card that is stamped ACO anywhere on it Program identifier loaded in Physician EHR Flag added to Hospital admitting software IPA Case Manager embedded in Emergency Department Bi-lateral view-only access into partners clinical documentation systems Physician Signature On-File with IPA for Orders New provider resource tool development 22 11

12 CCSF ACO Results Show Positive Impact on Key p y Metrics Brown & Toland CCSF Commercial ACO Utilization Dashboard Last date of service month Oct-12 Last paid month Dec-12 Note: Reporting Dates based on admission dates, not discharge or paid dates Brown & Toland CCSF ACO Inpatient Utilization, Rolling 12 Months of Data Brown & Toland CCSF ACO ER Visits/K Rolling 12 Months of Data Brown & Toland CCSF ACO Admits/K Target Admits/K Brown & Toland CCSF ACO Days/K Target Days/K Brown & Toland CCSF ACO ER Visits/K, Total Target ER/K Admits/K Days/K ER Visits/K Brown & Toland CCSF ACO Membership&Mean DxCG Concurrent Risk Score Brown & Toland CCSF ACO Generic Rx Rates Rolling 12 Months of Data Membership Mean DxCG Concurrent Risk Score Brown & Toland CCSF ACO Generic Rx Rate Target Generic % 21, % % Membership 20, Risk Score Generic Prescribing Rate 75.2% 72.8% % , % 23 Pioneer ACO & Knox-Keene Admits/1000 Medicare Advantage Plan Full Risk 24 12

13 Commercial PPO Early Results Program measures our cost trend over performance time compared to market cost trend Early indicators showed our OP Facility costs much higher than market Through various interventions focused on OP Ancillary and ED avoidance, increased use of After-Hours practices, our costs went down -7.7% over course of performance year. Market trend for OP Facility was -0.5% By contrast, IP Facility costs skyrocketed - our trend increased by over 15%. Due to unexpected increase in maternity on small population. 25 Lessons Learned 26 13

14 Lessons Across the Spectrum Attribution and Analysis of population must be understood before the contract is signed Commercial Payers each have their own unique model Less or different PPO data HMO Attribution and data acquisition easier, Often lack accountable PCP (PPO), previously unmanaged Open network (PPO) Quality programs, targets, and relative value vary considerably across Plans Commercial Populations are different than Senior Different disease burden (ex. IP drivers) Different high cost utilization patterns Different cost drivers 27 Lessons Across the Spectrum HMO UM Management Prior Authorization Referral Management Evidence based concurrent reviews Utilization, Care and Pharmacy Management Upfront cap augments infrastructure Sicker, 5% = 50%, better data, better analytics PPO Pharmacy & Radiology Steerage OON repatriation Lack of concurrent review opportunity Steerage as main driver More difficult to resource Healthier, limited savings 28 14

15 Engagement Lessons Health Plan Engagement Must share data, resources, and work collaboratively. I ll show you mine if you show me yours Provider Engagement Analytics will never substitute for the physician s perspective (you cannot bypass the physician) Patient Engagement Not one size fits all. Seniors will fill out surveys. Commercial patients receptive to phone calls. But warm outreach better than cold Hospital Partnerships Things had to get bad before they got good. Must have trust to succeed and dthat ttakes time and effort Employer Relations For the best results, employer must be engaged. Help us help you Internal Stakeholders You cannot communicate too much or too often 29 Clinical and Analytical Lessons Multidisciplinary coordination may be underestimated Engage g hospitalists early and often Have a SNFist strategy for Seniors Creativity counts: build from managed care experience, look for new solutions to old problems Do assessment in planning phase Understand your population and levers you have access to before jumping in Accurate and timely data trump all 30 15

16 Operational Lessons You ve seen one ACO, you ve seen one ACO Time and resource commitments (many meetings x many health plans = calendar madness) Internal Governance Oversight of program differences, relative value, and programmatic approaches Focus, focus, focus need to have, not nice to have Reality is that these populations are not all alike so identify market leverage and environmental leakage 31 Financial Lessons Each ACO has very different potential ROIs - multivariate Prioritize the early financial wins to fund future program development Value of Quality improvement measures are the trigger of success Upfront costs and ROI be realistic! Payout upfront necessary because of delay / timing of shared savings must fund start up costs Confidential / For Internal Use Only / 2013 Brown & Toland Physicians 32 16

17 Financial Lessons Investment required long before return horizon. External upfront funding from plan often is recovered before shared savings thresholds are met. Identify your home runs early on (i.e. Admits, ED, ancillary steerage) Invest for the future, not single project 33 Final Thoughts, please remember. ACO - Marathon, not a sprint Data must be customizable and integratable at the same time Complementary to provider and managed care workflows and processes Plan, measure, find programmatic overlap Long term sustainability beyond low hanging fruit? Physician groups can lead this change it is individual patient management that becomes the sustainable advantage ACO s are a journey worth taking 34 17

18 Thank you! Q&A 35 18