Applying ACO Principles to a Pediatric Population UH Rainbow Care Connection: Transforming Pediatric Ambulatory Care with a Physician Extension Team

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1 Applying ACO Principles to a Pediatric Population UH Rainbow Care Connection: Transforming Pediatric Ambulatory Care with a Physician Extension Team Ethan Chernin, MBA Director 1

2 Objectives Understand the underlying principles of accountable care organizations and value-based payment Understand the development of the Physician Extension Team model Likely evolution

3 UH ACO Models University Hospitals Rainbow Care Connection University Hospitals Accountable Care Organization University Hospitals Coordinated Care Organization ACO Type: Pediatric ACO Employee/ Commercial ACO Medicare ACO Attributed Membership: 78,000 53,000 42,000 Payer: Ohio Medicaid Apex / Cigna / United Traditional Medicare Term: July 1, 2012 June 30, 2015 September 2010 / October 1, 2013 / February 1, 2014 July 1, December 31, 2015 Sponsor: Center For Medicare & Medicaid Innovation (CMMI) University Hospitals Executive Leadership/ UHACO Centers For Medicare & Medicaid Services (CMS)

4 Pediatric Accountable Care Organization (ACO) Providers who work together, alongside families, to provide and coordinate services for individuals and collectively take accountability for improving the lives of these children - Ohio Department of Jobs and Family Services (ODJFS)

5 ACO Key Components Accountability Triple Aim Better Health Better Care Lower Cost Risk Upside Downside Rainbow Care Connection 5

6 Value-based Payment Terminology Total cost of care Per member per month (PMPM) Member months - months per year on Medicaid Utilization = visit rate per 1,000 member months Capitation lump sum payment for all costs Bundled Payment lump sum payment for all costs around a defined episode Shared savings -

7 Risk Models

8 Bridging the Transition Transforming Pediatric Care

9 Adult vs. Pediatric ACO Adult (Medicare) ACO PPAC A Defined Based on PCMH Demonstration models Minimum 5,000 patients Waiver for MSSP for fraud and abuse laws Major component disease management / coordination Focus on preventing readmissions Pediatric ACO PPACA not defined, delegated to State Based on PCMH No demonstration models Many needed to evaluate savings No waiver for fraud and abuse laws Only one component disease management / coordination Readmissions less prevalent

10 Population Management - Medicaid Only 2% of Medicaid recipients account for 25% of program s spending

11 Identifying the Targets Children do not get recommended preventive care Cost of care for children rapidly rising 5% of Medicaid enrollees account for 50% of cost 70% ED visits by children on Medicaid are avoidable Poor access for behavioral health services, rising admissions Rising prescription costs 80% of pediatric expense is ambulatory

12 Better Care, Better Health, Lower Cost for Children Where to look? - ED visits - Behavioral health services - Children with complex chronic conditions - Drug expenditure - Quality primary care

13 Community Practices Want to make changes But they don t have Infrastructure Money Time Knowledge No two pediatric practices are alike Change implementation must be flexible Often more than one method is needed Local academic children s hospitals are trusted

14 Providers How likely are you to utilize the following to help guide you through healthcare transformation?

15 Current State of Care Patients Meaningful Care Providers

16 Future State of Care Patients Providers Physician Extension Team

17 Care Provided Current Model 1 Type of Care Interaction Physician Extension Team Model 4 Types of Care Interaction More opportunities to create change

18 Medicaid Plans Patients Physicians Hospital Government Physician Extension Team Better Health Better Care Lower Cost Community Agencies Behavioral Health Agencies

19 Creating the Physician Incentive Plan Align incentive targets with ACO goals Identify and define variables associated with targets (types of patients, type of provider) Determine rationale behind incentive dollar amounts (cost to provider to implement change) Discuss with PCP focus group Finalize definitions and requirements Ensure compliance with laws and regulations No waivers for non-mssp ACOs from fraud & abuse

20 Physician Incentives 1. National quality recommendations 2. Access 3. Care coordination *Made 2 incentive payments to date

21 Health Care Innovation Award University Hospitals was one of 107 recipients from an applicant pool of approximately 3,000 for a Health Care Innovation Award* $12.7 million over 3 years Funding began July 1, 2012 Service delivery began January 1, 2013 The project described is supported by Funding Opportunity Number CMS-1C from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. The data presented has not been audited or verified by CMMI.

22 Program Goals 1. Improve quality of care delivered in primary care practices 2. Improve health and quality of care delivered to children with complex chronic conditions 3. Improve access and functionality of children with behavioral health problems 4. Decrease avoidable ED visits 5. Create a sustainable model

23 Pediatric ACO Programs

24 ACO Structural Programs Provider Network Geographic strategy Broad patient access 8 counties in NE Ohio Urban, suburban, rural FQHC Solo and group Incentive payments Shared Savings Contract with Payers Coordination of opportunities Physicians Patients Quality Shared savings program Population Health & Care Gap Analysis Cost of care Utilization patterns Quality gap targets Rainbow Care Connection 24

25 Provider Network 154 Pediatric Providers 60% UH, 40% Independent 29 Practices 47 Sites ~ 78,000 Medicaid members, 130,000 non Medicaid patients Rainbow Care Connection 25

26 ACO Structural Programs Provider Network Geographic strategy Broad patient access 8 counties in NE Ohio Urban, suburban, rural FQHC Solo and group Incentive payments Shared Savings Contract with Payers Coordination of opportunities Physicians Patients Quality Shared savings program Population Health & Care Gap Analysis Cost of care Utilization patterns Quality gap targets Rainbow Care Connection 26

27 Shared Savings 5 Medicaid managed care plans 2 commercial plans (with adult ACO) Arrangements include dollars earned for: reduced cost (ED and Pharmacy) improved quality

28 ACO Structural Programs Provider Network Geographic strategy Broad patient access 8 counties in NE Ohio Urban, suburban, rural FQHC Solo and group Incentive payments Shared Savings Contract with Payers Coordination of opportunities Physicians Patients Quality Shared savings program Population Health & Care Gap Analysis Cost of care Utilization patterns Quality gap targets Rainbow Care Connection 28

29 Population Health Ohio Medicaid claims data monthly feed Medical Pharmacy Behavioral health costs All claims for the network panel

30 Population Health

31 Clinical Operational Programs Rainbow Care Connection 31

32 Check-up for Quality Year 1 Year 2 Year 3 (proposed) Metric Attainment (to date) Obesity 96% Lead 100% Fluoride Varnish 96% URI 100% Asthma 93% Well Visits 3 6 yrs 93% Preferred Drug List 100% ADHD Pharyngitis Adolescent Vaccines Adolescent Visits yrs Best Value Rx 79% of practices meeting all 7 metric targets

33 Practice-Tailored Facilitation 2,550 Face-to-face contacts 83 Assessment & Observation Visits 188 Education and Feedback Meetings 417 Major chart reviews 1,821 Facilitation visits 41 Training sessions for fluoride varnish 1,146 /phone communications

34 Example - Asthma

35 Clinical Operational Programs Rainbow Care Connection 35

36 Children with Complex 110 patients enrolled Conditions Innovative electronic assessment documentation Telemedicine program connects patient to care team 52% of patients have fewer admissions than compared to baseline* 54% of families reflect increased functionality scores** Over 4,500 touch points with patients and families and 6,900 PCP communications * Patients enrolled > 6 months ** Family Impact Score

37 Clinical Operational Programs Rainbow Care Connection 37

38 Behavioral Health Patients Service Pts. To Date Office-based Assessment 555 Telephone Consultation 32 Resource and Referral Service 1,356 ED SW Crises Intervention 183

39 Patient Functionality* 100% 80% 60% 40% 20% 0% 5% 5% 37% 7% 47% Clinically Significant Deterioration Partial Deterioration No Change Partial Improvement Clinically Significant Improvement 54% with improved functionality scores

40 ED SW Crisis Intervention Rainbow Care Connection 40

41 -25% Cumulative % Admitted

42 Clinical Operational Programs Rainbow Care Connection 42

43 24/7 Three-tiered Medical Team Access

44 The Clear Need Rainbow Care Connection 44

45 UH Rainbow Babies & Children s Hospital HealthSpot Station 45

46 HealthSpot Outcomes 61 patients seen at Friendly Inn 98% patient satisfaction 96% - would return if needed 76% - would have gone to ED/UC if not available

47 Clinical Operational Programs Rainbow Care Connection 47

48 Outreach Example Pediatric Community Health Workers Central Promise Neighborhood (pilot location) Partnership with Sisters of Charity Foundation Developed customized training curriculum Initiated door-to-door outreach campaign

49 Care Connection Program Intervention: 4 or more ED visits/year Real time ED enrollment, education Phone follow-up 1 day, 2, 6, 12 weeks Outcomes: 240 patients enrolled 58% graduation rate

50 ED Recidivism Rate 80% 70% 70% 60% 50% 55% 47% 40% 30% 20% 10% 0% Within 0 3 Months Within 0 6 Months Within 0 9 Months

51 % Decrease ED Medicaid Visits from Prior Year*

52 CareSource 2013 ED PMPM 0.0% 2.0% Q1 Q2 Q3 Q4 4.0% 6.0% 8.0% 10.0% 5.9% 4.2% 8.4% 12.0% 14.0% PMPM = per member per month 11.9%

53 CareSource 2013 ED Utilization 2.0% 0.0% 1.2% Q1 Q2 Q3 Q4 2.0% 4.0% 6.0% 4.5% 3.6% 8.0% 10.0% 8.5% Utilization = visits per 1,000 member months

54 ER Visits per 1000 Comparison Rainbow Care Connection 54

55 Likely Evolution Commercial ACO involvement Payment for specific RCC/PET services Obtain PMPM administration fee Receive greater % of shared savings Move down the risk continuum - capitation

56 Sustainability Timeline Sustainability Funding No Cost Extension Current Shared Savings Additional Innovative Payment Models

57 University Hospitals Rainbow Care Connection Transforming Pediatric Ambulatory Care with a Physician Extension Team

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