The Journey to Population Health Management: A Capability Framework and Assessment for Accountable Care

Transcription

1 The Journey to Population Health Management: A Capability Framework and Assessment for Accountable Care DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Thinking Broadly: Best Practices from 100 Accountable Care Readiness Assessments Joe Damore, FACHE Vice President, Premier Healthcare Alliance February, 2012

3 Roadmap for Today s Discussion Review of Reform/Accountable Care Premier s ACO Model/Collaborative Premier s AC Experience/Lesson s Learned 2

4 Life is not about waiting for the storm to pass, it s about learning to dance in the rain - Anonymous

5 Implications for the U.S Total Federal Spending for Medicare & Medicaid Under Assumptions About the Health Cost Growth Differential Differential of: 2.5 Percentage Points 1 Percentage Point Zero Actual Projection Tax rates 2050: 10% 26% 25% 66% 35% 92% % of GDP

6 A Strategic Perspective of Healthcare Reform Track 1 Track 2 Cuts to Existing FFS System Market basket reductions DSH cuts Nonpayment for anything preventable or unnecessary Disrupt Existing System Bundled Payments Innovation Center Demonstrations ACOs 5

7 History does not repeat itself but it does rhyme. Mark Twain 6

8 What is Different? Capitation (1990s) vs. ACOs (2010s) HMOs/Capitation Insurance industry driven Insurance risk Shifts risk to PCPs Measures quality Enrollment/gate keeper/lock-in Wellness care Fragmented delivery system Plans have the population based data Accountable Care Provider driven Performance risk Shifts reward and/or risk to aligned, integrated system Pays for quality Attribution/primary care/medical home Patient engagement/disease management High value delivery system Providers have the population based data 7

9 Ten Percent of Hospital Medicare Revenue at Risk by 2017 Value Based Purchasing Readmissions and hospital acquired conditions penalties Inpatient Quality reporting participation incentive program Meaningful Use incentive payments Source: AHA

10 Medicare Cost Variance (per capita) $5,400 $7,800 $16,000 9

11 Charles H. Mayo The past 50 years have been marked by advances in the science of medicine. The next 50 will be marked by improvements in the organization and teamwork of how health care is delivered. January,

12 Accountable Care Organization An Accountable Care Organization (ACO) is a network of physicians and other health care providers who are willing to work together and accept responsibility to improve quality and reduce the costs of health care services for a defined population. 11

13 ACO Information Technology Needs Hospital EMR (including CPOE) Physician Office EMR Health Information Exchange (HIE) or Integration Engine to connect the Continuum of Care Population Health Data Management System Robust Business Intelligence / Predictive Analytics Platform Consumer Health Platform/Portal 12

14 Accountable Care Market Segments Employee Health Plan Self-funded Employers Private Health Plans Medicaid Program Medicare Program Uninsured Retail Health Insurance 13

15 From Fee for Service to Accountable Care Current FFS System What are the underpinning building blocks? Accountable Care Accountable Care Core Components People Centered Foundation Health Home High Value Network Population Health Data Management ACO Leadership Payer Partnerships Foundational Philosophy: Triple Aim/ Measurement /

16 The Evolution of Payment Models to Accountable Care Fee-for-service Value Based Purchasing Care Management Bundled Payment/Episode of Care Shared Savings (no downside risk) Shared Savings with downside (limited) risk Partial or Full Capitation The Road to Accountable Care

17 Expending ACO Shared Savings Model ACO Launched Projected Spending Target Spending Shared Savings Actual Spending Year Source: Lewis, Julie. What Could be Next for Health Reform? The Debate In Washington Presentation. The Dartmouth Institute for Health Policy & Clinical Practice

18 Medicare Shared Savings Program Final Rule CMS issues Final ACO Rules (October, 2011) OIG Issues draft waiver rules for Anti-Kickback (Stark) FTC/DOJ releases draft Antitrust Safe Harbor Rules IRS issues draft Tax exempt rules for NP ACO s 17 CMMI Pilot Program rules (Bundled payment, etc.)

19 CMS Next Steps Two Year Renewal of All 10 PGP Demonstration Sites (Initiated in 2006) CMMI Pioneer Program (32 sites) Other CMMI Pilot Programs Bundled payments, etc. Implementation of CMS ACO/MSSP State Medicaid Reform 18

20 CMS Demonstration Projects Partnership for Patients This public-private partnership is designed to test care models to reduce hospital-acquired conditions and improve transitions in care. Bundled Payments for Care Improvement The Bundled Payments for Care Improvement initiative seeks to improve patient care by paying providers for episodes of care. Three models involve a retrospective bundled payment arrangement, and one model would pay providers prospectively. Comprehensive Primary Care Initiative This initiative will help primary care practices deliver higher quality, more coordinated and patientcentered care in a handful of selected markets. Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration This demonstration evaluates the impact of advanced primary care practice on improving care, focusing on prevention, and reducing healthcare costs among Medicare beneficiaries served by FQHCs. Health Care Innovation Challenge Will award up $1 billion in grants to applicants who will implement the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and CHIP. 19 Medicare Shared Savings Program for ACOs The Medicare Shared Savings Program (MSSP) will allow providers who voluntarily agree to work together to coordinate care for patients and who meet certain quality standards to share in any savings they achieve for the Medicare program. Advance Payment ACO Model The Advanced Payment model will provide additional support to physician-owned and rural providers participating in the MSSP who also would benefit from additional start-up resources to build the necessary infrastructure. Pioneer ACO Model The Pioneer model is an initiative complementary to the MSSP designed for organizations with experience providing integrated care across settings. Financial Models to Support State Efforts to Integrate Care for Medicare-Medicaid Enrollees This initiative will test two models a capitated model and a managed fee-for-service model -- for States to better align the financing of the Medicare and Medicaid programs and integrate the continuum of care services and supports for Medicare-Medicaid enrollees.

21 Accountable Care Organization Model A group of providers willing and capable of accepting accountability for the total cost and quality of care for a defined population. Payor Partners Insurers Employers States CMS Core Components People Centered Foundation Health Home High-Value Network Population Health Data Management ACO Leadership Payor Partnerships 20

22 Building Blocks for Integrated Care Payor Partnerships 21 Primary Care Physicians Populations and People Health Homes Clinical Integration Care Physician- Hospital Integration Population Health Manageme nt Continuum of Leadership and Culture EHR and HIEs Specialty Care Physicians Measuremen t

23 Building Blocks for Integrated Care 22 # Building Block 1 Define targeted population(s) and assess people s needs, risks and costs 2 Develop and implement leadership structures and cultural alignment 3 Create measurement capacity to evaluate and model transformation impact 4 Recruit and engage primary care physicians to serve targeted population(s) 5 Establish physician-hospital integration to form authentic partnerships 6 Engage philosophically aligned and high value specialty care physicians 7 Build primary care health homes to coordinate care and support people 8 Engage a wide range of services across the continuum of care 9 Integrate EHR and HIE solutions to enable sharing of electronic health data 10 Forge clinical integration in care delivery processes across the continuum 11 Build and implement population health management capabilities 12 Develop payor partnerships on a foundation of shared benefit and value

24 Definition of Success Improving Triple Aim Population Outcomes 23

25 Approach to Assessment Pre-Assessment Operational Survey Capabilities Framework Scoring Market Research On-Site Readiness Assessment Introductory Discussion and ACO Readiness Overview Organizational Discussion Interviews to Verify Capabilities Framework Scoring Initial Readiness Assessment Report Out Qualitative Quantitative Post-Site Visit Premier to finalize and submit Readiness Assessment [2-3 Weeks] Premier to be available for follow up discussion / presentation via conference call 24

26 Readiness Assessments Qualitative Assessment Summary of key findings from a set of key open ended questions asked of a C- level representative (CEO, COO, CMO, CNO, etc.), assessing their: Market Environment Organization Readiness Strategic Commitment Clinical Integration Quantitative Assessment Spider chart of assessment result for each of the 6 components Drivers for ACO development -- top Priority Operating Activities for: Readiness to negotiate contract with a Payor as an ACO (private or public) ACO impact on the Triple Aim objectives High level qualitative summary of Readiness Assessment scoring results Attachment to report Readiness Assessment tool with scoring results 25

27 Qualitative Assessment A summary of key findings based on qualitative responses and market research: Market environment Organization readiness Strategic commitment Clinical integration Supporting documentation: 26 Operational survey responses CMS Hospital Compare including HCAHPS Dartmouth Atlas Data for Medicare American Hospital Directory data RWJF s County Health Rankings

28 The Capabilities Framework 27

29 Two Collaborative Tracks Implementation Collaborative Readiness Collaborative Early ACO implementation Pursue CMS/national payor contracts Build out core Accountable Care capabilities Tool kits, best practices Benchmark against peers Accelerate learning and population management capabilities Prominent national leadership Enhance selected Accountable Care Capabilities Maximize learning and shared lessons Stay abreast of ACO development Opportunity to access collaborative for limited tool kits Gap analysis to pinpoint focus areas Learn about population management Preparation for local leadership as ACO moves forward 28

30 Readiness Collaborative Members 29 As of 10/05/2011 NJ DE MD WA IL WI LA AR MO IA MN KS NE SD ND MT WY CO NM ID UT AZ NV CA OR MA RI CT SC NC VA W V PA VT NH ME FL GA AL MS TN KY MI OH IN DC MO NY TX OK

31 Implementation Collaborative Members As of 10/25/ NJ DE MD WA IL WI L A AR MO MN KS NE SD ND MT WY NM ID UT NV OR MA RI CT SC NC VA WV PA VT NH ME GA AL MS KY MI OH IN DC MO NY TX OK IA FL TN CA CO AZ HI

32 Partnership for Care Transformation Baseline Assessment Implementation Collaborative Overall Assessment* Readiness Collaborative Overall Assessment** *Data from 24 markets **Data from 51 assessments Blue = High Green = Average Red = Low 31

33 Areas of Per Capita Cost Reduction Chronic disease management across the continuum in the six major disease areas (asthma, diabetes, CHF, COPD, hypertension, and chronic depression) Health Home (Patient Centered Medical Home) Palliative/End of life care Reduced utilization of expensive diagnostics Pharmaceutical use/costs (e.g., use of generics) Replacement of more expensive location of care with less expensive location (e.g., family practice office vs. ER).

34 33 Gaps and Top Priorities To Meet MSSP Based Upon ~95 Accountable Care Assessments Broad and robust primary care network Physician alignment Health Home (Patient Centered Medical Home) Clinical Integration model Care management EMR/HIT & informatics Payor alignment with care management Leadership, culture and transformation Payor Partners Insurers CMS Employers

35 Lessons Learned Environmental Assessment Start with environmental assessment Review available comparable data(external) Quality (HQID / QUEST / CMS / HCAHPS / Other) Cost / Payment (CMS) Population Data / Cost, Utilization Dartmouth Atlas Perform cultural assessment (internal) 34

36 Lessons Learned Primary Care Network Health (Medical) Home Physician-Hospital Partnership Physician Relations / Engagement Physician Leadership Roles / Development Primary Care and Specialists Clinical Integration Alternative Models 35

37 Lessons Learned Clinical Integration Joint venture structure (mission, goals, etc.) Creates interdependence/cooperation to control cost/ensure quality Ongoing program evaluates/modifies practice (EBM) patterns Mechanism (pathways/care management) to monitor/control utilization/quality of services Selectively choose partners who further efficiencies Prioritize significant capital investment (IT) to realize efficiencies Focus first on integrating actionable information as opposed to full integration of all information Joint payor contracting 36

38 Lessons Learned Information Technology Assessment of existing IT infrastructure Development of ACO IT Plan Implementation of Hospital EMR (including CPOE) Physician Office EMR alternatives Integrating the Hospital and Physician Office EMR Integration Engine or HIE? Population Measurement Health Data System Business Intelligence / Predictive Analytics Quality Measurement System (across the Continuum) Cost Measurement across the continuum Consumer Health Platform development 37

39 Lessons Learned High Value Network Development Owning vs. Contracting People Centeredness Coordinated Care Management Electronic Health Record (across the continuum) 38

40 Lessons Learned Education/ Cultural Transformation Accountable / Integrated Care Concepts (educate) Hospital vs. Population-Centric Physician-centric Culture Balance between Specialty and Primary Care 39

41 Lessons Learned Payor Partnerships Which population segments are we going to target? What are the prevalent risk factors in any given population? Is there a match with your capabilities? What role should the payor play (care management, etc.)? What criteria should we use to evaluate potential payor partners? What are the important areas in contracting with a payor? Transparency Timely and comprehensive data Shared savings Care management role 40

42 Top Priorities & Member Gaps to Meet MSSP Based Upon over 80 Accountable Care Assessments Broad and Robust Primary Care Network Health Home (Patient Centered Medical Home) Physician Alignment Clinical Integration Model Care Management Program EMR/IT Payor Alignment with Care Management Leadership, Culture and Transformation 41

43 How To Get Started Public Hospital System Redesign employee health plan Enhance / expand Medicaid health plan Implement care management for uninsured Build EMR Across the Continuum Midwest Regional Hospital System Redesign employee health plan Focus on private payors Two health home pilot locations Develop bundled payment program for large commercial insurer and private pay Build EMR Across the Continuum 42

44 Why is Accountable Care Difficult for Hospitals? Episodic Treatment vs. Population Health Payment reinforces acute care Specialty dominated physician leadership Key Core Competencies (care management, integrating care, etc.) Continuum of Care develop/experience Senior Executives experience-acute care 43

45 What s Next? CMS MSSP/ACO Final Rules Released (10/20/11) Innovation Center Pilots (Pioneer, Bundled payment) State Medicaid Reform (NJ, FL, AL, MI, OH, etc.) 2012 Election Medicaid expansion/funding issues? Accountable Care? Medicare voucher program? Independent Payment Advisory Board (IPAB) Judicial Issue 44

46 Things do not get better by being left alone Winston Churchill 45

47 Summary and Questions What is the future of Integrated/Accountable Care in the commercial sector? How will states reform Medicaid programs to address budget challenges? How will the federal and state governments be able to fund the uninsured in 2014? Will the CMS ACO final rules be attractive for many hospitals/integrated systems? How will the Supreme Court Decision and the 2012 elections impact Health Reform? Will physician-hospital integration continue on the current growth trend? What role will commercial health plans try to play in the AC world?

48 47 Th e pu b crawl t o capitat ion.

49 THANK YOU Questions? 48