ACO Impact on Vermont Health Care Delivery J. Churchill Hindes, PhD Joyce Gallimore, MPH, CPHQ Amy Cooper, Georgia J. Maheras, Esq.

Transcription

1 ACO Impact on Vermont Health Care Delivery J. Churchill Hindes, PhD Joyce Gallimore, MPH, CPHQ Amy Cooper, Georgia J. Maheras, Esq. September 9, 2014

2 J. Churchill Hindes PhD Chief Operating Officer, OneCare Vermont ACO Vice President for Accountable Care, Fletcher Allen Health Care Clinical Associate Professor of Medicine, University of Vermont

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4 Vermont ACO s are different Across the nation, ACO s are essentially business arrangements between groups of providers and a payer, often Medicare. Providers see primary value in ACO as a way to maybe make some extra money. In Vermont, the ACO s are also business arrangements between groups of providers and multiple payers, that began with Medicare. Providers also see ACO as a way to maybe make some extra money AND, the ACO s (particularly OneCare) are key, high profile leaders for statewide health care payment reform and system reform private provider led efforts that complement public sector led initiatives 4

5 ACO s as a platform for reform ACO s are a Health Care Reform Trifecta Broad network of providers Voluntarily bound together through contract agreements Committed to better understand their community status & needs Willing to try and incorporate new ideas into daily practice Collaborating with insurers (Medicare, Medicaid, Blue s, MVP ) Striving to achieve slower cost growth (While improving clinical quality and patient satisfaction) Willing to be paid differently Willing to accept more financial risks

6 Vermont ACO Roles Legislators Regulators Payers ACO s Physicians Hospitals Other Providers Provider-Led, Population-Based Coordination, Alignment, and Support Forum for Delivery System Design/Optimization Payment Reform Leadership Revenue Model Design Incentive Programs Care Management Design and Support Primary Care/PCMH Alignment HIE Facilitation Population-Based Clinical and Analytic Systems Quality Measurement

7 OneCare Vermont Statewide ACO Provider Network Both Academic Medical Centers (Fletcher Allen and Dartmouth) Every hospital in the state 400+ Primary Care clinicians 90% are Blueprint PCMH practices Majority of Specialist MDs in Vermont 3 Federally Qualified Health Centers 5 Rural Health Clinics Statewide VNA, SNF and Mental Health and Substance Abuse organizations 100,000 attributed beneficiaries 7 Hospitals with Employed Attributing Physicians Significant Attribution from Community Physicians Links to ACOs in New Hampshire, upstate New York and Maine

8 Data Money OneCare: Network strategy Attributing Participants Non- Attributing Participants Non- Attributing Collaborators Parents Statewide Hospitals and Physicians Sub-Acute Providers Large Spend High Impact Providers Small Spend High Impact Providers Other Fletcher Allen Health Care/UVM College of Medicine $ Hospital, Clinics and Faculty Practice Plan $ Dartmouth Hitchcock/Geisel School of Medicine $ Hospital, Clinics and Faculty Practice Plan $ Regional and Community Hospitals Hospital employed physicians and practices FQHCs and Rural Health Clinics Community physician practices Skilled Nursing Facilities $ Home Health and Hospice Agencies $ Designated Community Mental Health Agencies $ Long-term supports and services providers $ Area Agencies on Aging # Youth Services Providers # Housing agencies and authorities Special Education Schools Parent Child Centers Vermont Ethics Network # etc. # Medicare, Commercial and Medicaid (Phase I) Medicaid (Phase II) None 8

9 OneCare: Governance & Leadership Founder s Seats Provider Participant Seats Consumer Seats

10 OneCare: Clinical Leadership & Direction

11 Simply said VITL and OneCare VITL s success is vital to OneCare s success ACOs add great value by accessing the power of linked clinical and financial data CMS, DVHA and Blue Cross provide the financial/claims data to our analytics team VITL is the primary conduit used by ACO providers to make the clinical data available VITL knows more about where clinical data is and how to access it than anyone in Vermont

12 Vital VITL: Population-Based Informatics

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14 What could happen next? ACO transitional name, lasting idea? Another buzz phrase will come along CMS is already tweaking its accountable care programs Clinically integrated networks should be here for a long time Shared responsibility for quality and cost of care should continue Accountability for specific populations wellbeing should also Broadened, more inclusive care relationships should prevail Shared Savings is a transitional concept More substantive payment reforms are inevitable The volume to value transition is real and lasting Todays ACOs may be good means to position for further changes 14

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17 AMY COOPER, MBA EXECUTIVE DIRECTOR, HEALTHFIRST INC EXECUTIVE DIRECTOR, ACCT. CARE COALITION OF THE GREEN MOUNTAINS (ACCGM) 17

18 Healthfirst ACOs Governance Structure ACCGM Medicare ACO, VCP Commercial ACO ACO Management Committee Quality Improvement Committee Clinical Implementation Committee Joe Haddock MD - Chair Thomas Chittenden Health Center Peter Gunther MD Good Health PC Paul Reiss MD Evergreen Family Health Eileen Fuller MD Middlebury Family Health Sean Uiterwyk MD White River Family Health Brad Freisen MD Pediatric Medicine PLC Steffen Hillemann MD Champlain Valley Cardiovascular Associates Amy Cooper Executive Director Healthfirst The Honorable Madeleine M Kunin Medicare Beneficiary Commercial Consumer Beneficiary - TBD Paul Reiss MD Medical Director Evergreen Family Health Chris Meriam MD Green Mountain Orthopedic Surgery Pam Dawson MD Thomas Chittenden Health Center Chris Hebert MD Michael Johnson MD Evergreen Family Health Mark Pitcher MD Good Health PC Gamal Eltabbakh MD Lake Champlain Gynecologic Oncology Deanne Haag MD MouseTrap Pediatrics Jill McKenzie RN BSN CCM Clinical Manager Cheryl McCafferty Practice Manager Thomas Chittenden Health Center Jennifer McGinn Practice Manager Good Health PC Stacy Ladd Practice Manager Middlebury Family Health LeAnn Runne Practice Manager Alderbrook Family Health Roseann Sbarra Practice Manager Evergreen Family Health Consumer Advisory Board TBD 18

19 ACCGM Overview Accountable Care Coalition of the Green Mountains Joint venture with Collaborative Health Systems (a division of Universal American) First ACO in Vermont, joined MSSP in July Independent Primary Care Practices 35 physicians 7,466 Medicare Beneficiaries as of Q1 19

20 CHS Partnership CHS has invested significantly to support ACO Efforts across the country, with 35 ACO partners as of Jan 2014 NAACOS survey of 70 MSSP ACOs estimated each ACO will need $3.5-$4M in capital for first 2 years before meaningful savings are generated CHS leverages technology and infrastructure investments across the entire network to offer care management and data analytics platforms to each ACO partner and lower expenses per ACO 20

21 VCP Overview Vermont Collaborative Physicians LLC Participating in VT State Commercial ACO Pilot starting in Independent Primary Care and Pediatrics Practices throughout the state 68 Physicians Attribution 7,200 as of 6/2014 (BCBS only) 21

22 ACCGM Beneficiary Demographics & Estimated Annualized Expenditures Trailing 12 months Q % 95% 6,568 Beneficiaries $51M Annual Spend $1.52 $3.34 ESRD 90% % $6.93 Aged/dual 80% 75% 70% Disabled 65% 60% 5,423 $39.54 Aged/non-dual 55% 50% ACO Population Est Annual Spend ($M) 22 Source: CHS Analysis of a rolling 12 months worth of CMS Claims through April 2014 with dates of service through Feb Aged = Medicare beneficiaries over 65 yrs of age. Aged duals = Medicare beneficiaries over 65 yrs. of age who are also eligible for Medicaid. ESRD = patients over or under 65 yrs with End Stage Renal Disease. Disabled = patients over or under 65 yrs with a disability as defined per Section 223 of Social Security Act.

23 ACCGM 2014: Three Areas of Focus to Focus on Wellness Achieve Savings Chronic Disease Management Transition of Care Coordination Programs: Annual Wellness Visit Campaign Programs: CHF Program PCP referrals to care coordinators Programs: Home Health Pilot Clinical Manager + 2 Care Coordinators monitoring hospital and ER census, f/up with pts in hospital & immediately after discharge 23

24 ACCGM Wellness Program Medicare Annual Wellness Visits Completed by Quarter + 35% Q1 Q2 Q3 Q4 24

25 CHS MSSP ACOs Performance on Ambulatory Care Sensitive Conditions: Admits Per Thousand Diabetes mellitus with complications Asthma Urinary tract infections Pneumonia (except that caused by tuberculosis or sexually transmitted disease) Chronic obstructive pulmonary disease and bronchiectasis Congestive heart failure Total 6 A Best #1 Top 10 ACOs A #2 or #3 ACCGM A A A A A Avg of 31 ACOs A A Average

26 HF Experiences to Date Attribution issues result in failure to attribute new patients, and falling off of healthiest patients who seek care infrequently MSSP benchmarking provides less opportunity to health systems who are already highly functional, efficient and cost conscious VT commercial SSP benchmarks are based on health insurance premiums, creating same targets for all providers. Efficient networks are potentially rewarded, and can do even better with improvements. Medicaid SSP, using the MSSP type benchmark would also disadvantage efficient networks, and with a difficult population to manage, substantial upfront, non-reimbursed resources would be needed. Unrealistic for a physician driven network. Substantial learning has been facilitated by the ACO model: physicians working together and better understanding the process of care. Improvement opportunities are greatest in transitions of care, communication, improving efficient use of sub acute and home care. 26

27 JOYCE GALLIMORE, MPH, CPHQ DIRECTOR, COMMUNITY HEALTH PAYMENT SYSTEMS COMMUNITY HEALTH ACCOUNTABLE CARE, LLC

28 Overview What s in a name? Who do we serve? What are CHAC s priorities? CHAC s governing board & process CHAC s values in action: Committee work HIE outlook and opportunities 28

29 CHAC: Statewide Access Community Health Accountable Care, LLC (CHAC) is statewide, primary care centric Vermont ACO based on the Patient Centered Medical Home model of care. CHAC is comprised of 9 Federally Qualified Health Centers (FQHCs), Bi- State Primary Care Association and diverse network providers. CHAC has a Management Services Agreement with Bi-State. 29

30 CHAC Population Served Attributed Lives % Product Attributed Lives # Medicare 5,980 Medicaid 22,000 Commercial 8,900 24% 16% 60% Medicare Medicaid Commercial 30

31 CHAC s Priorities Compliance with federal and State Programs Collaborate in VHCIP workgroups * Establish Board * Implement Committees Identify opportunities through data analysis Care management Consumer feedback & communication Establish data analytics platform 31

32 Managing Our Business 32

33 CHAC Governing Board 33

34 34 Standards for Primary Care Standard (Must meet or exceed or have approved, documented plan) Electronic Health Record Plan to have a fully implemented certified, EHR System by end of 2014 Year 1 Year 2 Achievement of appropriate Meaningful Use stage PCMH Recognition NCQA Level 1 NCQA Level 2 (in Year 2 or at next scheduled recertification) Quality Improvement Permanent QI staff Documented quality plan Integration with non-primary Care Able to integrate with SAFTINet Participation in State infrastructure Able to receive and use any information from non-pcp participants Ability to integrate data to SAFTINet (or develop workaround for CQM reporting) Meets all State standards Shared infrastructure HIE Blueprint/DocSite Permanent QI staff Approved quality plan aligned with ACO goals Able to receive and use any information from non-pcp participants (no change) Fully integrated with SAFTINet Meets all State standards Shared infrastructure HIE Blueprint/DocSite

35 Clinical Areas of Focus Evidence Based Interventions: COPD, CHF, Falls Risk Care Management Modeling Provider Engagement Quality Benchmarking 35

36 HIE Outlook FQHCs partnering with VITL for EHR Implementation and interface development Enthusiastic about data mart/data repository VHIE high potential with Event Notification System Challenges: Part 2 regulations create challenges CHAC Seeking low-cost analytics option to use VHIE data 36

37 Evolving HIE Environment VITL s leadership will be crucial to attaining a working public infrastructure Data Repository/Data Marts POSSIBLE FUTURE PUBLIC INFRASTUCTURE ACO Gateway ENS FUNDED FUTURE Evolving technologies UNDISCOVERED POTENTIAL 37

38 CHAC: Strengths and Challenges Strengths Primary Care Centric Model Location: Essential Access Collaboration Among FQHCs Collaborative engagement with Diverse Community Providers Challenges Launched three payers in Year 1 No Shared HIT / Analytics Platform Not-yet fully staffed 38

39 Contact Amy Cooper Joyce M. Gallimore ext. 222 Churchill Hindes Georgia Maheras

40 BACKGROUND 40

41 What do we mean by payment reform The ultimate objective of any payment reform is to motivate behavioral change that leads to lower costs, better care coordination, and better quality. Cutler, David M., Ph.D., and Ghosh, Kaushik, Ph.D. (March 22, 2012) The Potential for Cost Savings through Bundled Episode Payments, N Engl J Med 2012; 366: DOI: /NEJMp

42 What would constitute success? A health information technology and health information exchange system that works, that providers use, and that produces analytics to support the best care management possible. A system of care management that is agreed to by all payers and providers that: utilizes Blueprint and Community Health Team infrastructure to the greatest extent possible fills gaps the Blueprint or other care models do not address eliminates duplication of effort creates clear protocols for providers reduces confusion and improves the care experience for patients follows best practices A predominance of payment models that reward better value. 42

43 Adoption of alternatives to FFS require a better organized system with more sophisticated capture and use of performance data and metrics Better Organized System FFS More Sophisticated Quality Measurement Systems Global Payments Bundled Payments

44 Medicaid s payment reform strategies under the VHCIP aim to: 1) Shared Savings ACO Program 2) Episodes of Care Program 3) Pay-for- Performance (P4P) Program Align and continue to support care transformation by participation in the Blueprint for Health, Enhanced Primary Care Program, Medicaid Health Home s and other ongoing related work Incent care delivery transformation and better organization of the health system through a focus on value instead of volume Incent use of data, analytics and quality reporting to improve care delivery and succeed under value-based payment systems Work with all stakeholders to ensure broad participation and support Work with other payers to mirror programs to increase the magnitude of rewards and limit administrative burden Allow for incremental independent study of feasibility and implications of adoption of alternative payment models across more organized provider groups and across types of services

45 Vermont Health Care Innovation Project (VHCIP)

46 Complementary Models ACO SSP System-wide performance Wide range of providers across specialty types and sites of care Total resource use and quality for attributed population across all providers who provide care Focus on collaboration and use of data to inform better care delivery and experience of care Leads to more organized system of care EOC Performance related to treatment of specific condition Providers specifically accountable for care of a particular condition Resource use and quality of treatment of a condition for sub-set of population Focus on collaboration and use of data related to treatment of specific condition Leads to more organized system of care P4P Individual /Practice/Site of Care performance Providers accountable for population they serve Resource use and quality of treatment under their individual control Focus on individual performance and how to use data for internal quality improvement 46

47 Multi-Payer Shared Savings ACO Program A performance-based contract between a payer and provider organization that sets forth a valuebased program to govern the determination of sharing of savings between the parties Fund%20Report/2012/Aug/1618_Forster_accountable_care_strat egies_premier.pdf