SOA 2012 Annual Meeting & Exhibit October 14-17, 2012

Transcription

1 SOA 2012 Annual Meeting & Exhibit October 14-17, 2012 Session 152 PD, Actuarial Implications of Accountable Care Organizations & Patient- Centered Medical Homes Moderator: Greger J. Vigen, FSA Presenters: David Anthony Neiman, FSA, MAAA William T. Obrien, FSA, MAAA Primary Competency External Forces & Industry Knowledge

2 Public discussion Tip of the iceberg System Transformation W H O? Payment Transformation $ $ $ $ $ 2012 Annual Mtg - GV 1 Actuarial Role during Extraordinary Times SOA Annual Meeting 2012 Session 152 Business overview before main speakers 2012 Annual Mtg - GV 2 1

3 Your background Major clients Line of business Background on topic Business or personal 2012 Annual Mtg - GV 3 Healthcare the burning issue of our times "Health care costs for American families in 2012 exceed $20,000 for the first time.... single year is equivalent to cost of mid-sized sedan." Milliman.com Gallup Poll - Cost of healthcare Very or Extremely important for 84% of voters 2012 Annual Mtg - GV 4 2

4 Substantial financial potential 2012 Annual Mtg - GV 5 Transformation is certain (Prediction is easy when already underway) 2012 Annual Mtg - GV 6 3

5 Over 250 ACO and hundreds more PCMH 2012 Annual Mtg - GV 7 Actuarial perspective Question 7: How important is it that actuaries provide solutions to the cost and affordability issue in the US? A. Very important B. Somewhat important C. Not very important D. Not important at all 62% 29% 5% 4% Session 24 - Vigen 2 A. B. C. D Annual Mtg - GV 8 4

6 Many actions underway (or being discussed) Payment and system reform workgroup monthly calls Medicaid reform workgroup - bi-monthly calls Research projects (episodes / risk, measurement / applications report, behavior Boot camp Updated Academy ACO paper Multiple webcasts Brookings Dartmouth Provider presentation from major conference 2012 Annual Mtg - GV 9 We will see many changes The forces creating transformation are changing the ways actuaries work Next generation analytic tools New data sources (including clinical and patient data) New actions/solutions supplement traditional solutions (providers have a different toolkit) Other professions entering the financial space New organizations managing risk (provider definition of risk is far different from traditional risks from claims) New organizations creating financial solutions 2012 Annual Mtg - GV 10 5

7 PAYMENT REFORM OVERVIEW A WHAT S HAPPENING? A WHAT DOES IT MEAN? (FROM THE ACTUARY S PERSPECTIVE) Primary Competency: DAVE NEIMAN FSA, MAAA DAVEN@WAKELY.COM FSA (2009), MAAA (2007) 5 Years Health Plan / Integrated Delivery System 5+ Years Consulting Dog Otis (2) Mountain Activities 1

8 Opinions expressed are those of the speaker and do not represent those of the Society of Actuaries, nor of the American Academy of Actuaries, nor of the Actuarial Standards Board, nor of Wakely Consulting Group MOMENTUM Payment and Systems Reform Beyond Politics Separate from Affordable Care Act 2

9 WHAT S HAPPENING? National State Private Payor NATIONAL SCENE $10 Billion Dollars FY2011 FY 2019 Pioneer ACOs / Advanced Payment ACOs State Innovations Model Health Care Innovation Awards Center for Medicare and Medicaid Innovation Dual Eligibles Care Integration Demos Bundled Payments Primary Care Initiative 3

10 STATE INITIATIVES Massachusetts Health Care Reform 2.0 Vermont Blueprint for Health Oregon Medicaid Coordinated Care Organizations MASSACHUSETTS HEALTH CARE REFORM 2.0 Signed into Law August 6 th, 2012 Target Billions in Savings Move to Alternative Payments Increase Transparency Address Market Power Promote Wellness Enact Malpractice Reform Support Health Information Technology 4

11 MASS HCR 2.0 DETAILS Target Growth in Healthcare Costs Limit growth in healthcare spending to rate of growth in Gross State Product for first five years and 0.5% below GSP for five years and target GSP thereafter Mass current GSP is approximately 3.7% and annual health care spending growth has been 6-7% Projected savings equal to $200 Billion over 15 years Alternative Payment Models Requires Government Agencies (eg Connector or MassHealth) to use alternative payment models to achieve savings Provisions for State Certification of ACOs Establishment of Health Policy Commission Set and enforce spending targets Certify new payment methods and care delivery models Conduct Market Studies VERMONT BLUEPRINT FOR HEALTH Transformation into Systematic Approach Payment Reform Phase I Transformation to High Quality Primary Care Phase II Quality Based Payment Reforms Health Information Architecture Coordinated Health Services Measurement & Evaluation Health Learning System Early Indicators / Results Statewide Expansion 5

12 BLUEPRINT PAYMENT REFORM: PHASE I Advanced Primary Care Practices (APCPs) Evaluated against NCQA standards Enhanced payment proportional to NCQA score Payment mandated by Vermont statute Community Health Teams Expand capacity of APCPs by providing access to enhanced services Work closely with or at APCPs 1 CHT worker per 2,000 APCP members No cost sharing and payments mandated by statute Community Health Team Extenders Support targeted sub-populations Self-Management Support Document Individual Goals Health Coaches Healthier Living Workshops VERMONT BLUEPRINT FOR HEALTH Level of Need: uity and Complexity Ac Advanced Primary Care Practice Health Maintenance Prevention Access Communication Self-Management Support Guideline Based Care Coordinate Referrals Coordinate Assessments Panel Management Community Health Teams Support Patients & Families Support Practices Coordinate Care Coordinate Services Referrals & Transitions Case Management Self Management Support Counseling Population Management Specialized & Targeted Services Specialty Care Advanced Assessments Advanced Care Management Social Services Economic Services Community Programs Self Management Support Public Health Programs 6

13 OREGON MEDICAID CCO S MHOs & DCOs MCOs Providers CCO Oregon Health Authority PRIVATE PAYOR INITIATIVES HealthPartners Total Cost of Care BCBS of Massachusetts Alternative Quality Contract BCBS of Michigan Physician Group Incentive Program CareFirst BCBS Humana WellPoint Patient-Centered Medical Home Program Commercial ACO Pilot with Norton Healthcare Patient-Centered Pilots 7

14 HEALTHPARTNERS TCOC MEASUREMENT Population-Based, Person-Centered Measurement Total Cost Index Measures change in claim costs per member per month Risk adjusted to capture changes in population illness burden Total Resource Use Index Measures efficiency of resource use in treating conditions Risk adjusted to capture changes in population illness burden Use Total Care Relative Resource Values (TCRRVs) Relative Payment systems are created independently (eg MSDRGs, APCs & RVUs) TCRRVs measure relative resource use across all types of medical services, procedures and places of service HEALTHPARNTERS TCOC CONSIDERATIONS Data Sources Risk Adjustment Member Attribution Peer Grouping Benchmarks / Targets Claim Truncation Population-Specific ifi Adjustments t 8

15 HEALTHPARTNERS TCOC CONCLUSIONS Independent Study Findings of HealthPartners Risk-Adjusted Costs 17% lower than Regional and Minnesota costs 8 percent lower than National costs Lower utilization per 1,000 metrics TCOC measures can be part of a provider contracting strategy including: Quality Metrics Patient Experience Measurement TCOC measures can be used as an ACO evaluation tool TCOC Methodology is Publicly Available WHAT DOES IT MEAN? Potential Implications to an Actuary Contractual Payment Model Cost & Quality Measurement Savings Estimates / Return on Investment Evaluation of Potential Partners Mergers & Acquisitions / Joint Ventures Solvency & Capital Requirements 9

16 CONTRACTUAL MODEL CONSIDERATIONS General Payment Model Options Global Capitation Shared Savings Incentives Payment Model Considerations Period of Time Benchmark / Targets One or Two Sided Risk Phase-In of Payment Model Enterprise Wide Management of Contractual Arrangements HEALTH PLAN CONTRACTING SIMPLE EXAMPLE Five Provider Groups support Health Plan Benchmark is set to market average growth in claim costs Each has a one-sided shared savings arrangement 50% of savings above 1% relative to benchmark are returned to provider group Base Year Measurement Year Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Total Member Months Claim Costs 1 Member Months Claim Trend Shared Costs 1 Savings Payment SSP Adj Claim Costs 1 15,000 $ ,500 $ % $0.00 $ ,000 $ ,000 $ % $8.04 $ ,000 $ ,500 $ % $1.93 $ ,000 $ ,000 $ % $0.00 $ ,000 $ ,000 $ % $2.25 $ ,000 $ ,000 $ % $2.46 $ per member per month claim costs risk and benefit adjusted 10

17 COST MEASUREMENT CONSIDERATIONS Define Costs Define Members Minimum Enrollment Attribution Logic Individual Claims Truncation Trend Attachment Point Risk Adjustment Model Choice Calibration to Other Contractual Parameters Provider Coding Patterns SAVINGS CALCULATION CONSIDERATIONS Where is the Organization today? Level of current medical management / care coordination Do ocomparative paa eanalytics ay csexist? Information Technology Infrastructure Culture for Change Where does the Organization want to go? What changes are included in the plan? Has the organization set targets or goals? How long will the Organization take to get there? What are the up-front costs? When will savings from the initiatives materialize? Will there be savings off-sets? 11

18 CHANGE & TRANSFORMATION Getting over a painful experience is much like crossing monkey bars. You have to let go at some point in order to move forward. -C.S. Lewis RESOURCES Center for Medicare and Medicaid Innovation Massachusetts Health Care Reform Vermont Blueprint for Health Oregon Medicaid CCOs HealthPartners Total Cost of Care BlueCross BlueShield of Massachusetts Alternative Quality Payment BlueCross BlueShield of Michigan PGIP CareFirst BlueCross BlueShield PCMH Humana Norton ACO WellPoint PCMH Pilots 12

19 Actuarial Implications of ACOs / PCMHs Presented to SOA Annual Meeting October, 2012 Presented by Bill O Brien, FSA, MAAA Consulting Actuary Milliman Houston, TX (832) Session 152 Agenda SOA Research Project on Accountable Care Organizations What s Driving ACOs? Strategy, Strategy, Strategy Physician Group Practices Hospital Systems Preserving FFS Revenues alongside ACOs Which way will the balance tip? 2 1

20 SOA Research Launched April, 2012 Multiple Milliman offices participating Goal: To develop tools and methods to assist ACOs achieve and measure financial success Take episode of care analytics to next level Risk adjusted costs and utilization by service type 3 SOA Research Approach: Risk adjust Episode of Care cost and utilization experience High-cost or avoidable service utilization Total costs by major service type (IP, OP, Pharma, Physic) Develop a financial model to estimate potential savings within Episode types, as ACO care efficiency improves; Reflect variation due to population size Develop methods for evaluating ACO results based on annual claims data. 4 2

21 ACO Episode Risk-Adjustment Study Aggregate Costs by Episode Type Entire 3 Million Population DRAFT Episodes per Thousand Normalized Allowed Episode Type: Member per Year Cost per Episode PMPM Asthma 41.0 $ 1,104.0 $ 3.52 Cerebral Vascular Disease 3.0 $ 8,059.0 $ 1.88 Chronic Obstructive Pulmonary Disease 6.0 $ 2,384.0 $ 1.11 Congestive Heart Failure 2.0 $ 6,103.0 $ 0.95 Diabetes 40.0 $ 2,391.0 $ 7.44 Hyperlipidemia 68.0 $ $ 2.92 Hypertension $ $ 7.27 Ischemic Heart Disease 13.0 $ 8,742.0 $ 8.84 Joint Degeneration, localized - back 33.0 $ 3,715.0 $ 9.54 Pregnancy with Delivery 13.0 $ 12,798.0 $ Risk Adjusted Episodes $ 2,191.1 $ SOA Research Utilization Metrics for Risk Adjustment Medical/Surgical Hospital inpatient admissions Avoidable Emergency Room Visits Advance Imaging Services (CT, MRI, PET Scans) Physician Office Visits (Primary & Specialty) 6 3

22 SOA Research Cost per Episode Metrics for Risk Adjustment Total All Services Inpatient Costs Outpatient Costs Physician/Other Costs Pharmacy Costs 7 Episode: Ischemic Heart Disease Service Type Utilization per Thousand Episodes Normalized Allowed Cost per Unit within Episode Cost Per Episode Raw Units Risk Adj Days/Unit Days Unit per Day Raw Risk Adj Inpatient Med/Surg Admissions XX XX X X $X $X X Other Inpatient X X X $X $X X Total Inpatient X X X $X $X $XX $XX Outpatient Avoidable ER Visits XX XX $XX $XX Advanced Imaging XX XX $XX $XX ER - Urgent X X X OP Surgery X X X Radiology - General X X X Pathology X X X Therapies X X X Other Outpatient X Total Outpatient $XX $XX Professional/Other Office Visits XX XX X X ER Visits X X X Consults X X X Inpatient Surgery X X X Outpatient Surgery X X X Inpatient Visits X X X Preventive Services X X X Pathology X X X Radiology X X X Physical Therapy X X X Cardiovascular X X X Durable Medical Equip X X X Home Health X X X Other Pro/Other X Total Pro/Other $XX $XX Pharmacy Branded Drugs X X X X X X Non-Branded Drugs X X X X X X Total Pharmacy X X X X X $XX $XX Total Total All Services $XX $XX 8 4

23 Episode: Ischemic Heart Disease Population Full Market Scan Sample Service Type Measure Unit Mean Percentiles - Raw Data (No Risk Adjustment) Raw/ Risk Adjusted 25th 50th 75th 90th 95th 99th Inpatient Med/Surg Admissions per Thousand Episodes Total Inpatient Costs Cost per Episode Outpatient Avoidable ER Visits per Thousand Episodes Advanced Imaging Total Outpatient per Thousand Episodes Cost per Episode Professional/Other Office Visits per Thousand Episodes Total Pro/Other Cost per Episode Pharmacy Branded Drugs Percentage Non-Branded Drugs Total Pharmacy Percentage Cost per Episode Total Total All Services Cost per Episode 9 What s driving ACOs? Accountable Care Act CMS Shared Savings Program (MSSP) CMMI Pioneer ACO Pursued mainly by physician group practices Overall shift from FFS to Value/Population-based payments that include adjustments for Quality Outcomes Bundled Payments Gain Sharing Arrangements Capitations 10 5

24 Differing Incentives: Hospitals vs. Physicians One Party s Savings = Another s lost Revenue Physicians Physicians primary driver of savings from hospitals Little lost revenue until near well managed New Revenue Stream opportunity Hospital savings Can be used to finance practice improvements in efficiency CMS offering partial up-front payments for small, rural practices Vast Majority of MSSPs are physician organizations Options that offer upside risk only 11 Differing Incentives: Hospitals vs. Physicians One Party s Savings = Another s lost Revenue Hospitals Most early Savings come from reduced hospital revenues Creates conflicting incentives for FFS vs. Population-based Consensus Change is happening now and accelerating into 2014 Hospitals would need >75% of savings to replace lost margin contributions from eliminated services There is no status quo option FFS may soon be a casualty of high costs, reform Dangers: Moving too quickly before fixed costs are reduced Moving too slowly and being shut out of ACO networks, payers Physicians create an ACO and cut out the hospital 12 6

25 Differing Incentives: Hospitals vs. Physicians Hospital Responses Buying strategic physician practices Primary Care, Hospital-based physicians Medicare Reimbursement opportunities (e.g. Oncology) Partnering/Merging with other hospital systems Everyone is talking to Everyone Bundled Services or Capitations Controlling the revenue Requires discounting current and future services Starting an HMO Insert themselves higher in the revenue stream HMO margins offset some lost Hospital profits 13 Initial Population Targets Hospital system employee health plan Generally self funded; Savings (mostly) accrue to system Medicare Advantage Product simplicity Large portion of patient populations High potential for savings Medicaid Savings offset low unit reimbursements Commercial & ASO/TPA Revenue to cover administrative costs of other products Preparation for exchanges 14 7

26 Balancing Act FFS payments still dominant Optimistically, may be 50% at-risk in 2-3 years Some services, specialties don t bundle easily Many providers not pursuing risk strategies preserve FFS Spillover Effect Improved Efficiency = Services eliminated = Poor FFS performance Physician Compensation Must promote/reward conflicting goals Reduced costs per episode of care Increased quality and outcome measures Increased patient services volume (FFS) 15 QUESTIONS AND DISCUSSION 16 8