July 30, 2015 Guiding Committee (GC) Meeting. Teleconference/Web Meeting

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1 July 30, 2015 Guiding Committee (GC) Meeting Teleconference/Web Meeting Objectives for the Meeting: Confirm the focus and priorities of next two work groups Identify potential members and collaborators for next two work groups Determine order of roll-out of work groups Obtain input from GC members on stakeholder awareness of payment reform and LAN activities. Welcome and Opening Remarks Co-chairs Mark McClellan and Mark Smith and CAMH Project Leader Anne Gauthier welcomed the members to the third meeting of the Guiding Committee. The co-chairs reviewed the agenda, noting that firming up plans for the next two work groups would be a critical outcome for the meeting. APM Framework and Progress Tracking Work Group: Update The Committee co-chairs introduced Sam Nussbaum, chair of the APM Framework and Progress Tracking Work Group, which is the first work group to be launched. The group s initial call will be July 31 st. As supporting points for his role as chair, they noted his leadership on payment reform more generally as well as his membership on the Guiding Committee. They commented that there is no intention to have all work groups chaired by a Guiding Committee member, but in this case he was considered to be the best candidate to move the APM Framework and Progress Tracking Work Group forward quickly. The work group chair noted that the title was changed from definitions to framework, i.e. the APM Framework and Progress Tracking Work Group. He commented that the thirteen work group members are broadly representative of all the sectors. The first work group call on July 31 will set the stage for their future work. The CMS framework will be presented as a starting point to the discussion, and there will be a round robin opportunity for members to voice their views about work group priorities to help prepare for the in-person meeting August 27 th. Next Two Work Groups At its last meeting, the Committee had identified Accountable Care Organization (ACO) or population based models (the name has not been finalized) and clinical episode models as priorities for future work. The Committee discussed issues related to both potential work groups. The Committee discussed a matrix that showed the technical components for payment 1

2 (i.e. benchmarking/attribution/risk adjustment, performance measurement, patient/consumer engagement, data sharing, best practices) as areas for alignment in each work group. The Committee then discussed the guiding principles that would apply to both of these work groups and other future work groups. The draft principles presented for discussion were: The focus of this work will be on payment not delivery recognizing there is not a definitive line between the two and that the broader LAN will play out these interconnections. The work is about aligning not designing new models from scratch. Inherent in this approach is learning from best payment practices in the field including what did not work and an accelerated pathway to more widespread adoption. Emphasis will be placed on establishing guiding principles and reaching consensus around core components to align and execute upon. The approach taken is not one size fits all but rather tailored to where payer and provider organizations fall along a trajectory. Concrete implementation steps will be directed toward the primary actors with the ability to implement these initiatives such as large payers and providers. A member commented on the goals, saying that various payers are pursuing different approaches. They need to come together around aligned approaches, which means some will have to modify what they are doing now. Another member noted that some organizations and some markets are further along and may have a need for some variation in design more than others. Recommendations for action will be directed toward entities that can implement them. The goal is to enable different types and levels of payers to become aligned. There was consensus that there should be consistency where possible, but various approaches to implementation need to be acknowledged and nuances need to be respected. There were several comments on addressing how APMs can be built to address patient, consumer, and family needs, and not just providers and payers. CAMH staff were directed to revise the principles based on the discussion, so that they could be used for the next meeting and disseminated more broadly to the LAN. Clinical Episodes Payment Work Group The Committee then considered the draft Clinical Episode Work Group goals. The proposed work group proximate goals are: 50% of payment for the first three conditions of focus are paid for in a manner recommended by the work group within two years of finalization. (Note: This may need to vary depending on the episodes chosen.) 5-10 large payers and 5-10 large provider systems use the findings from this process to begin to experiment with a wider variety of episode types within one year of finalization. 2

3 Members of the LAN or other commercial payers agree to require/allow bundled payment for all the care for the episodes identified through this LAN. The members accepted the goals, noting that the work group would need to consider how they would be implemented within the context of clinical episodes. The recommended first three areas of focus include: joint replacement, maternity care, and cancer care. The work group should recommend what services would be included, what data is needed, and what is needed to enable consumer/patient interaction for each of these conditions. The focus should be on key issues where there is the biggest opportunity for change to have an impact on accelerating progress. Members noted that the construct of episodes isn t standardized, so this work group would aim for standard templates for episodes that could be deployed by multiple payers. The Committee discussed four to six week sprints on each area of focus to accomplish the work. There was recognition that this timeline was aggressive, but achievable. The Committee discussed which area should be addressed first. There was widespread support for looking at joint replacement first. The reasons included: it is elective; it emphasizes the importance of patient reported outcomes, such as functional status and pain; there is a good deal of practical experience in bundling joint replacement services to drive better outcomes; and there are functional outcomes assessments that could assure credible measurement. CMS, which has a proposed rule on joint replacement payment out for public comment, would welcome work on this area that could help promote broad alignment, but it was made clear that the work group will not be commenting on that proposal. The Committee agreed that oncology and maternity care are also appropriate clinical episodes for this work group, noting that several health plans have medical oncology bundles that have been tested and evaluated. They agreed that the work group should look at real progress in the field. They also agreed that an iterative, sprint-based approach for the different clinical episodes seemed appropriate, and that the work will vary by clinical area. ACO / Payment Model Work Group The co-chairs reiterated that the aim of this work group is to develop a template that could be applied to accelerate payment changes. This is a particularly broad area broader and maybe more complex than clinical episodes. They noted that ACO is in quotation marks because the name of this work group has not been finalized. Members agreed that the issues and approaches go beyond ACOs. The Committee agreed that the name needs to capture some population-based concept, but distinguish its work from work not relevant to payment reform. The name Population-Based Payment Model Work Group was proposed. The Committee discussed the proposed work group proximate goal. The goal is: 3

4 50% of ACOs and ACO-like organizations implement the recommendations of the component matrix within two years of finalization. A member commented on implement as the work group s proximate goal, saying that technical details may not link to implementation. Plans and delivery systems doing ACOs have concrete issues that accelerate or limit their adoption. It was suggested that this work stream should include a non-technical piece, a business analysis of market drivers--the business constraints and barriers. Next the members reviewed the potential eight to twelve week sprint approach. Members agreed the work group will need to focus quickly on some key components and approach the work in a sequential but coordinated fashion. Some potential areas for the sprints include patient attribution, core quality/performance measures, benchmarking, risk adjustment, risk corridors, and best practices for data sharing (which is critical). It is not clear to what extent the basic features, structures, and templates would apply across the range of population-based payment models; for example, can the same benchmarking apply to all population-based payment models or should there be some variation? Members made additional suggestions about the work, such as looking at how to combine the cost and quality considerations in payment; integrating the two is important from the consumers perspective. The work group should consider the interaction between incentives for clinical episodes and incentives for other models, including population-based models. The work group could also look at various readiness models, competency matrices, assessment tools, and see whether there is agreement on core competencies that are best for alignment. Members discussed the types of people/organizations to be included on the work group or as collaborators. Suggestions included ACOs with experience in social services, patients and patient advocacy groups, and purchasers. The work group should also include a physician-led ACO perspective, not just the hospital-led or payer-led perspective. Next Steps for Forming Work Group #2 The Committee considered which work group should be launched first and what factors should be considered regarding timing (e.g. events, policy development, resources). Members agreed that the ACO/population-based payment work group should be first. The reasoning is that this is the most challenging and critical piece, and a lot of work has already been invested. Also the patient attribution aspect can be worked out, enabling people to begin to think how that might look in implementation. This is a significant need, which can make a difference in other areas too. Members noted that both work groups will benefit from the work of the APM Framework and Progress Tracking Work Group. They also felt that both the episode model and the ACO/population-based payment model need to define the total cost of care, from which operational issues can be defined. 4

5 Communication and Engagement Members discussed the level of awareness and interest in the LAN among stakeholders. They noted that stakeholders are interested in deliverables, which will begin to come out from the work groups in a month or two. They agreed that there was poor awareness among many stakeholders. It s important that members help extend information about the Committee s work, and that they be available to be a sounding board for their colleagues. CAMH staff showed data from the two webinars to date, which showed that over 80% of the audience scored the content on each of the two webinars as 4 or 5 out of 5. Staff are developing additional ideas for improving the webinars and other outreach. The Committee agreed that the LAN needs to get better visibility and participation. Closing Remarks The co-chairs said that the Committee would take these discussions further at its next call on August 14 th. They thanked the members and the staff and adjourned the meeting. 5