Wellmark s ACO Model and the Value Index Score. Tom Newton, Vice President Network Engagement

Transcription

1 Wellmark s ACO Model and the Value Index Score Tom Newton, Vice President Network Engagement

2 Wellmark s ACO Shared Savings Model 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 2

3 What is an ACO? ACO Definition A local provider or group of providers that assume accountability for the quality and cost of care delivered to a defined population. If you ve seen one ACO You ve seen one ACO. The Wellmark model varies from other Blues plan models, other commercial models, and the Medicare model. Details of the Wellmark ACO Model No change to existing payment methods places accountability to manage the care and budget of a specific population Effective primary care is at the core Requires member attribution to a primary care physician Works best with health care organizations that have a significant number of members Multi-year agreement Total cost of care agreement Shared savings/losses Quality targets and incentives Risk adjustment 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 3

4 What a Wellmark ACO is not An ACO is not a Product existing Wellmark products remain in place An ACO is not an Organization Wellmark is not entering the health care delivery market An ACO does not change existing payment methods it is a separate Agreement with a Shared Savings/Losses payment method in addition to fee for service payment 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 4

5 Wellmark ACO Components Category Fully Insured Two Targets Value Index Score Potentially Preventable Events (PPEs) Clinical Risk Groups (CRGs) Description Initially, ACOs were responsible for fully insured members only Select self-funded members will be added in 2015 The model measures performance against a target Consumer Price Index Target Wellmark Trend Target Single composite score measuring 5 domains Claims-based measurement of population outcomes Influenced by provider intervention and supported by external evidence PPEs are imbedded in the Value Index Score Indicate an improvement opportunity in health care delivery Unique risk adjustment approach that incorporates the whole person rather than disease states More than 1,000 CRGs aggregated into nine health statuses 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 5

6 Three Performance Measures for an ACO 1. Quality trigger on Shared savings/losses 1. Consumer Price Index Target 2. Wellmark Trend Target 0 7/11 10/11 1/12 4/12 7/12 10/12 1/13 4/13 7/13 10/13 Best Practice (20% of shared savings) Network (15% of shared savings) Baseline (10% of shared savings) 3. Quality incentive payment 1. ACO compared to network 2. ACO compared to baseline 3. ACO compared to best practice 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 6

7 The Wellmark ACO : Attribution IDENTIFYING A POPULATION 1. Members that choose a PCP through enrollment are attributed to that PCP Attribution is a monthly process using standard claims data 2. Members that have not chosen a PCP are attributed to the PCP that provided the majority of that member s office-based E&M services over the past 12 months. (Any ties work through three additional tiebreaking steps) The process is driven by member choice members are attributed to a provider they select or go to most often 3. Members that remain unattributed repeat the process with 24 months of claims data 4. Members are aligned to an ACO if their attributed PCP is participating with an ACO. 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 7

8 Real-time tools Real-Time Tools Definition Web-based analytics provided to the ACO by Wellmark What tools are provided ACO Payment Manual VIS Business Rules Performance dashboards Reports and data including but not limited to: Financial Population Preventable Events Quality Data refreshed monthly 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 8

9 The Value Index Score 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 9

10 Value Index Score SM Development Principles Meaningful to Wellmark customers and members Population, not disease centric Outcome-based Claims-based Measures are risk adjusted Influenced by provider intervention Supported by external evidence of the measures Use valid building blocks reasonably free from upcoding Transparency Supportive of the Triple Aim s principles: Health, Cost, and Experience 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 10

11 Measuring ACO Quality The Value Index Score (VIS) Developed for Wellmark by Treo Solutions, the Value Index Score (VIS) is a single score that quantifies the quality of care like a Consumer Reports for health care value. Comprised of 14 quality measures categorized in five domains The measures look at the way a PCP cares for all patients regardless of their health status Many measures are drawn from the National Committee for Quality Assurance (NCQA) which publishes the Healthcare Effectiveness Data and Information Set (HEDIS) VIS is a critical component of ACO performance serving as a trigger to shared savings and determining the ACO quality incentive bonus 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 11

12 Value Index Scores (VIS) VIS is calculated with two types of performance rates Percentage completion (e.g., percent of well child visits completed among eligible children) Percentage difference from expected (e.g., percentage difference in readmission rate from expected readmission rate) A Z-Score is used to convert the measures so they are on the same scale If a Z-Score has a value of 0 is positive is negative is equal to +1 is equal to -1 it is equal to the network mean it is above the network mean it is below the network mean it is one standard deviation above the mean it is one standard deviation below the mean A Z-Score is converted to percentile for ease in communicating 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 12

13 The Value Index Score (VIS) VIS The VIS is an aggregate score that accounts for each measure in all six domains DOMAIN DOMAIN DOMAIN DOM Primaryand Secondary Prevention Chronic and Follow Up Care AIN DOMAIN Population Health Status Continuity of Care Tertiary Prevention MEASURES MEASURES MEASURES MEASURES MEASURES Breast Cancer Screening Risk- adjusted percent difference in Potentially Preventable Readmissions Percent difference of Attributed Members who do not acquire chronic conditions, risk- adjusted Percent of Attributed Members who are non- users, not riskadjusted Risk-adjusted percent difference in Potentially Preventable Admissions Colorectal Screening Percent of Attributed Members with hospital discharge with provider office visit equal to or less than 30 days post discharge Percent difference of Attributed Members with chronic conditions that do not increase in severity, riskadjusted Percent of Attributed with PCP visit, not riskadjusted Risk-adjusted percent difference in Potentially Preventable Emergency Department Visits Percent of Attributed Members birth to 15 months who had the recommended number of well-child visits with a PCP Percent of Attributed Members with chronic disease (Clinical Risk Categories 50, 60, 70) with 3 or more provider visits Percent of Attributed Members with continuity of care, risk- adjusted Percent of Attributed Members 3-6 years of age who had the recommended number of well-child visits with a PCP 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue 13 Shield

14 The Value Index Score Primary and Secondary Prevention Domain For early detection and prevention of disease The four measures are percent completion: Breast Cancer Screening Colorectal Cancer Screening Well-child visits birth to 15 months Well-child visits 3 to 6 years of age 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 14

15 The Value Index Score Chronic and Follow- Up Care Domain Provision of posthospital care and engagement with attributed members who have chronic conditions There are three measures: Risk-adjusted percent difference in Potentially Preventable Readmissions (PPR) Percent of attributed members with hospital discharge with a provider office visit within 30 days post discharge Percent of attributed members with a chronic disease with at least three provider visits 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 15

16 The Value Index Score Continuity of Care Domain Measures how well the physicians engage and manage their patients There are three measures for the concentration and consistency of physician visits: Percentage of attributed members with at least one physician visit, not risk adjusted Percentage of attributed members with PCP visits, not risk adjusted Average attributed member continuity of care score, risk adjusted 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 16

17 The Value Index Score Tertiary Prevention Domain Measures the effectiveness of a provider in addressing acutely ill patients to manage their care in the most appropriate setting There are two measures for the physician s performance on minimizing risk for attributed members experiencing episodes of illness: Percent difference in Potentially Preventable Admissions, risk adjusted Percent difference in Potentially Preventable Emergency Department Visits, risk-adjusted 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 17

18 The Value Index Score Population Health Status Domain This is an indicator of whether the chronic member population maintains or becomes sicker There are two measures for the health status change of the physician s attributed members with chronic conditions: Percent difference of attributed members who acquire additional chronic conditions, riskadjusted Percent difference of attributed members with chronic conditions that increase in severity, riskadjusted 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 18

19 The Value Index Score Member Experience Patient experience has an impact on clinical outcomes the better the experience, the better the health outcomes Member Experience: Not included today, but important to the overall Value. Simplified CAHPS (Consumer Assessment of Healthcare Provider & Systems) measures related to perception of member self-efficacy and relationship with and access to a PCP: 1. How confident are you that you can control and manage most of your health problems? (Patient Confidence) 2. Do you have one person you think of as your personal doctor or nurse? (Continuity of Care) 3. When you visit your doctor s office, how often is it well organized, efficient, and does not waste your time? (Office Efficiency) 4. How easy is it for you to get medical care when you need it? (Access to Care) 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 19

20 Network VIS Performance Prior to the 2012 ACO start, the Network VIS was trending down at -0.12% At the end of the first ACO Performance Year, the Network VIS Performance was trending positive at 0.69% Measure 2012 Target 2012 Performance % Difference Potentially Preventable Admissions 0.8% 11.5% 10.7% Well Child Visits % 70.2% 7.4% Potentially Preventable Readmissions 1.1% 7.4% 6.3% Well Child Visits Infant 62.4% 67.3% 5.0% Physician Visit 92.0% 94.6% 2.6% Severity Jumpers 15.5% 17.0% 1.5% 30-Day Discharge Follow-Up 66.2% 67.0% 0.8% PCP Visit 87.3% 87.6% 0.3% Potentially Preventable ED Visits 0.1% 0.2% 0.1% Status Jumpers -5.4% -5.3% 0.1% 3 Chronic Care Visits 84.6% 84.5% 0.0% Colorectal Cancer Screening 11.4% 11.2% -0.2% Breast Cancer Screening 54.6% 54.4% -0.2% Continuity of Care 0.1% -2.1% -2.2% 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 20

21 Wellmark Accountable Care Organizations (ACOs) Family Health Care of Siouxland (Year 1) Genesis (Year 3) Currently working with 10 health systems in Iowa in 8 ACO arrangements McFarland Clinic (Year 1) Mercy Cedar Rapids / The University of Iowa (Year 2) Mercy Des Moines/ Mercy North Iowa (Year 3) The Iowa Clinic (Year 1) Unity Point Health (Year 3) Wheaton-Franciscan (Year 2) Year 3 = 2012 Start Date Year 2 = 2013 Start Date Year 1 = 2014 Start Date Highlighted Counties = ACO-defined Service Areas 9/24/2014 Confidential and Proprietary Wellmark Blue Cross and Blue Shield 21

22 An Independent Licensee of the Blue Cross and Blue Shield Association