Accountable Care Models: Where We ve Been, Where We Are Going

Transcription

1 Accountable Care Models: Where We ve Been, Where We Are Going

2 Outline for Discussion September 2014 CMS ACO Report: Good, bad, and/or ugly? Depends who you believe. CMS Proposed Changes: Real changes to help improve performance or too little too late? Connecting the dots of Accountable Care: For all the time/money ey spent on ACOs, and other Accountable Care models, are we connecting the dots on cost, return, and value? Are all these things aligning (the infrastructure, the requirements to manage/comply, the quality and performance metrics, the payor incentive/rewards) 2

3 ACOs Today 3

4 ACOs Defined History & Evolution: The Dartmouth Atlas Project: Underscored broad geographic variations in cost and quality across healthcare markets. Medicare Payment Advisory Commission i (MedPAC): Formalized the concept and featured its in June 2009 report to Congress during the development of healthcare reform. CMS finalized rules for participation in the Medicare ACO program on 10/20/11. Also referred to as Medicare Shared Savings Program (MSSP) In Chicago and other markets, PHOs/IPAs serve as a logical lstarting ti point for building an ACO (care management, risk sharing, claims analysis, patient engagement, etc). 4

5 ACOs Defined The ACO Model: ACOs encompass a broad array of providers: Physicians and clinicians (primary care focused but specialists play an important role as do mid-level providers) Hospitals Pharmacies SNFs/LTCs The ACO incentivizes i i and rewards reductions in costs and dimprovement in patient outcomes using various metrics to measure success. ACOs may choose to participate in one of two tracks: Track 1: One sided (upside risk/shared savings only) Track 2: Two sided d (upside and downside risk, shared savings and losses) Agreement period is 3 years; all ACOs that continue after the first three-year agreement must move to the two-sided model. 5

6 Accountable Care Organizations (ACOs) Quality Domain Number of Measures Data Source Patient/Care Giver Experience 7 total measures Patient Survey Care Coordination/Patient 6 total measures Claims Safety Preventive Health 8 total measures GPRO Web Interface At-Risk Populations 12 total measures GPRO Web Interface Diabetes 6 measures GRPO Web Interface Heart Failure 1 measure GPRO Web Interface Coronary Artery Disease 2 measures GPRO Web Interface Hypertension 1 measure GPRO Web Interface Ischemic Vascular Disease 2 measures GPRO Web Interface 33 total measures 6

7 Accountable Care Organizations (ACOs) Source: CMS.gov 7

8 ACO Results (CMS Fact Sheet 9/16/14) Last year, the ACOs had higher quality and better patient experience than published benchmarks. This year, the ACOs improved significantly for almost all of the quality and patient experience measures demonstrating that these organizations improve care. ACOs in the Pioneer ACO Model and Medicare Shared Shavings Program (Shared Savings Program) also generated over $372 million in total program savings for Medicare ACOs. At the same time, ACOs qualified for shared savings payments of $445 million. The encouraging news comes from preliminary quality and financial results from the second year of performance for 23 Pioneer ACOs and the first year of performance for 220 Shared Savings Program ACOs. 8

9 ACO Results (CMS Fact Sheet 9/16/14) Medicare Shared Savings Program Performance Year 1 Results: 53 Shared Savings Program ACOs held spending $652 million below their targets and earned performance payments of more than $300 million as their share of program savings. One ACO in Track 2 overspent its target by $10 million and owed shared losses of $4 million. The Medicare Trust Funds will save about $345 million, including repayment of losses for one Track 2 ACO. An additional 52 ACOs reduced health costs compared to their benchmark, but did not qualify for shared savings, as they did not meet the minimum savings threshold. Shared Savings Program ACOs improved on 30 of 33 quality measures. Quality improvement was shown in such measures as patients ratings of clinicians communication, beneficiaries rating of their doctor, health promotion and education, screening for tobacco use and cessation, and screening for high blood pressure. Shared Savings Program ACOs achieved higher average performance rates on 17 of the 22 Group Practice Reporting Option Web Interface measures reported by other Medicare FFS providers reporting through this system. In 2013 alone, over 125,000 eligible professionals who were ACO providers or suppliers qualified for their incentive payments for reporting their quality of care through the Physician Quality Reporting System (PQRS) These providers will also avoid the PQRS payment adjustment in 2015 because they demonstrated the ability to report quality measures through their ACO. 9

10 Pioneer ACOs (CMS Fact Sheet 9/16/14) Pioneer ACOs showed improvements in three key areas: Financial: During the second performance year, Pioneer ACOs generated estimated total model savings of over $96 million and at the same time qualified for shared savings payments of $68 million. They saved the Medicare Trust Fund approximately $41 million. The total model savings and other financial results are subject to revision. Pioneer ACOs achieved lower per capita growth in spending for the Medicare program at 1.4 percent, which is about 0.45 percent lower than Medicare fee-for-service. Eleven Pioneer ACOs earned shared savings, 3 generated shared losses, and 3 elected to defer reconciliation until after the completion of performance year three. Quality of Care and Patient Experience: The mean quality score among Pioneer ACOs increased by 19 percent, from 71.8 percent in 2012 to 85.2 percent in The organizations showed improvements in 28 of the 33 quality measures and experienced average improvements of 14.8 percent across all quality measures. These measures included screening for future fall risk, screening for tobacco use and cessation, patient t experience in health promotion and education, and controlling high h blood pressure. The Pioneer ACOs improved the average performance score for patient and caregiver experience in 6 out of 7 measures. These results suggest that Medicare beneficiaries who obtain care from a provider participating in Pioneer ACOs report a positive patient and caregiver experience. 10

11 Others Don t Paint Such a Rosy Picture Initial Problems with ACOs: Start Up Costs and Cash hflow: Average $2M start up costs Because of the slow build on return/lag on reconciliations, the average ACO will have to assume 3 years of operational costs before ($3.5M average) before it will see any cash flow from shared savings. Operational Problems: Big problem in accessing CMS data/learning to use it Difficulty in meeting implementation schedules Slow/costly IT implemenatation Lack of skill sets among staff/leaders Translating Data into Actionable Information for Caregivers Enrollee Attribution and Compliance Challenges 11

12 Others Don t Paint Such a Rosy Picture NAACOs: Only 53 of the 220 ACO/MSSPs will receive payment and recoup some of their investment. (NAACOs estimates that $1B have been spent, only $373M in returns). 167 ACOs will receive not return on their investment. The Pioneer ACO program isn t working: 10 have exited since the program began. The providers in the Pioneer program, chosen because of their relative maturity and presumed ability to handle risk, have not benefited from the program in the way they'd hoped. Example: Sharp HealthCare/San Diego recently dropped out of the Pioneer program: In its third-quarter financial report Sharp leaders noted that they were at risk for making a big payment to Medicare, despite the fact that they had cut readmission rates. Sharp execs said the deal wasn't working out because CMS was setting standards on a national level rather than adapting to the markets in which it operated. Underscores a big problem with the core intent of ACOs: If even a high performer like Sharp risks having to pay millions back to Medicare, there's something seriously wrong here. 12

13 Others Don t Paint Such a Rosy Picture NAACOs: Only 53 of the 220 ACO/MSSPs will receive payment and recoup some of their investment. (NAACOs estimates that $1B have been spent, only $373M in returns). 167 ACOs will receive not return on their investment. The Pioneer ACO program isn t working: 10 have exited since the program began. The providers in the Pioneer program, chosen because of their relative maturity and presumed ability to handle risk, have not benefited from the program in the way they'd hoped. Example: Sharp HealthCare/San Diego recently dropped out of the Pioneer program: In its third-quarter financial report Sharp leaders noted that they were at risk for making a big payment to Medicare, despite the fact that they had cut readmission rates. Sharp execs said the deal wasn't working out because CMS was setting standards on a national level rather than adapting to the markets in which it operated. Underscores a big problem with the core intent of ACOs: If even a high performer like Sharp risks having to pay millions back to Medicare, there's something seriously wrong here. 13

14 Proposed Changes to ACOs Additional Quality Improvement Reward: Revising quality scoring strategy to recognize and reward ACOs that make year-to-year improvements in quality performance scores on individual measures by adding a quality improvement measure that adds bonus points to each of the four quality measure domains based on improvement. Revisions to Quality Measure Benchmarks: In response to feedback regarding topped out measures, modifying benchmarking methodology to use flat percentages to establish the benchmark for a measure when the national FFS data results in the 90th percentile being greater than or equal to 95 percent. Modifications to the Quality Measures that Make Up the Quality Reporting Standard: Revisions i to reflect up-to-date clinical i l guidelines and practice, reduce duplicative i measures, increase focus on claims-based outcome measures, and reduce ACO reporting burden. The proposed changes increase the number of measures calculated through claims and decrease the number of measures reported by the ACO through the GPRO Web Interface. The total number of quality measures for quality reporting would increase from 33 to 37 measures under this proposal. Specifically, new measures would be added to focus on avoidable admissions for patients with multiple chronic conditions, heart failure and diabetes; depression remission; all cause readmissions to a skilled nursing facility; and stewardship of patient resources; the existing composite measures for diabetes and coronary artery disease would also be updated. 14

15 Proposed Changes to ACOs Additionally, CMS is seeking public comment on future quality measures for consideration that address the following areas: Gaps in measures and additional specific measures Measures for retirement (e.g., topped out measures) Caregiver experience of care Alignment with the Value-Based Payment Modified ( VBM) Assess care in the frail elderly population Utilization Health outcomes Public health 15

16 Proposed Changes to ACOs Additionally, NAACOs proposes discussion on these changes: Change the way patients are attributed to the ACO and bring stability to the population the ACO is serving Strengthen the relationship of the Medicare Beneficiary with their ACO physician Improving the formula for risk-adjusting and setting the savings targets Account for the fact that in some communities the costs of care are well below the national average, and for them, it is even more difficult to achieve savings Improve the clinical and claims data ACOs receive to improve care Recognize that quality of care varies from community to community and allow regional differences and allow ACOs to receive savings/rewards if their overall quality of care is improved year over year 16

17 Moving from Volume to Value 17

18 Payment Reform in PPACA Drives Accountable Care Payment Models in PPACA: Reimbursement Highlights: Payment changes to support Patient Centered Medical Home and Accountable Care models Episode of care payments to improve quality and reduce the costs of major acute care Comprehensive care or global payments to improve the quality and reduce the cost of the full range of healthcare services for a population of patients Paying More for Certain Services (preventive, primary care) Paying Based on Quality of Services (process, outcome) Combining Separate Services into a Single Payment (episodic treatment payments, global payments) Making Payment Dependent on the Cost of Services Delivered by other Providers (resource use-based, shared savings/gain sharing) Paying to Support Specific Provider Structures, Systems, Locations (HIT/EMR/registry/etc, care coordination systems, geographic shortages) 18

19 How is Accountable Care Affecting Medicine? i Processes to support metrics: PQRS, Core Measures, CI, ACO, ACE Alignment of care givers, technology, care pathways, payor/provider efforts Accountable Care models (government, commercial c models) Physician and Patient Communication Infrastructure needs 19

20 PPACA: Blurring Traditional Roles Payor and Cap Providers Compete and Collaborate Shared-Savings Model: ACO Providers enter Payor space, and vice versa Episodic Bundling Hospital-Physician Bundling Pay for Performance 20

21 Accountable Care Overview Medicare s Movement Toward Value Spiraling costs have led the Center for Medicare and Medicaid Innovation (CMMI) to propose various payment reforms, including: ACOs Patient Centered Medical Homes Bundled Payments for Care Improvement Initiative (BPCII) Source: Congressional Budget Office Source: Congressional Budget Office 21

22 Accountable Care Models Accountable Care Organizations (ACOs) Clinically Integrated Networks (CINs) Accountable Care Entities (ACEs) Patient t Centered Medical Homes (PCMHs) Bundled Payments Global Payments However defined, Accountable Care is dependent immediately upon Clinical Integration and Physician Alignment; and later upon Patient Engagement and Payor Partnerships 22

23 Building an ACO or Accountable Care Models Physician engagement g and leadership Hospital commitment Seek excellence in vendor partners Network contracting Payor engagement Take the time to educate physicians and office staff on Program Requirements and using the tools, or they won t! 23

24 The Increased Importance of Payor Strategyt Patient Segment Today s Benefit &Contract Tomorrow s Benefit &Contract Uninsured No Coverage, Self-Pay Medicaid, Public Exchange, Medicaid HMO, Co-Ops Public Aid Medicaid, Medicaid, Medicaid HMO (ABD, MMAI, TANFF, D-SNP) Medicaid, HIX Plan, Co-Ops, Medicaid HMO (ABD, MMAI, TANFF, D-SNP) Commercial HMO, PPO, POS HMO, PPO, POS, HIX Plan, Co-Ops, Commercial Contracts, HX Contracts, Employer Contracts, Broad and Narrow Networks Medicare Medicare, Medicare Advantage Medicare, Medicare Advantage, Broad and Narrow Networks Demands on payor contracting and revenue cycle management increase exponentially. 24

25 Insurer Product Expansion What does it mean for healthcare providers? Increased complexity & need to manage payor mix Current -Simple Future More Complex BCBS Other Comercial BCBS Other Commercial Medicare Medicaid Medicare Medicare Advantage Medicaid Managed Medicaid Medicare Dual Eligible State Exchange BCBS State Exchange Oh Other Commercial 25

26 Commercial Payor ACO Models Most commercial payors moving to: BCBS Accountable Care Contract: Additional reimbursements for Quality (Quality, Cost, Admin Compliance, Patient Satisfaction) Offering providers online access to data (claims data, patient registries) Future rate increases dependent upon provider performance (cost, quality, service metrics) Narrow networks Global Risk Expansion into Medicare, Medicaid, id Individual/Insurance id Exchange products Rules: Clinically Integrated, EMRenabled, provide evening, weekend hours, utilize hospitalists, submit claims data for all patients, quarterly reporting Total Episodic Care Management Formulary compliance/e-prescribing Referral re-direction (Blue Distinction, preferred OP Ancillary) Utilize BCBSIL-provided reporting tool and/or other means to identify gaps in care Conduct Patient Outreach for identified populations Reward: If you manage trend you share in savings 26

27 Payors Driving Consumerism and Value in Benefit Plans, Education How are consumers defining value, and who teaches them? Increased product offerings: More choices are related to plan design, access, costs (narrow networks, tiered co-pays) Transparency : An effort to get patients to shop for services (costs/rates, quality metrics, administrative measures): Is the data any good? Is cost defined as rates, charges or some ill-defined hybrid? Patients/consumers have varying (and ever changing) definitions of value: Is expensive high quality? Is low cost low quality? Are they able to understand these metrics and will they make decisions with little/potential inaccurate information? When you do outreach to fill their gaps in care, is that perceived as quality or intrusive? i 27

28 Summary & Conclusion: Future State t Core Competencies 1. Build or Buy Now: Scale, Brand, Physician Leadership, Strategy 2. Payor Contracting and Relationship Management (including the ability to contract for services provided on a performance basis (quality, cost; process/outcome) 3. Patient-centric and population-based p care management (vertical and horizontal care management) 4. Ability to track and report outcomes and quality (and hold your own against insurers who have different data) 5. Direct to consumer marketing and enrollment 6. Capital requirements (including insurer risk reserve requirements) 7. Strong yet adaptable infrastructure 8. Connectivity via technology 9. Physician Engagement 10. Patient Engagement 28

29 Summary & Conclusion: Positioning i for Success Know what types of networks/health systems and payor contracts initiatives that are out there that affect your organization. Understand how your organization can participate in these initiatives to support all of the above (across all flavors of Population Health -preventive, chronic care, surgical care, gaps in care) Know your metrics and how your organizations tracks and reports (process, outcome, quality, cost, patient satisfaction) or how someone else tracks/reports your performance (payors, consumer websites) Know/manage your payor contracts and your referral relationships What kind of infrastructure do you need to to manage this environment? (i.e., Patient Registries, MAs, additional admin staff) Project the additional potential revenues and expenses your organization has or will incur as a result of marketplace activities, opportunities and threats Assess how your organization works with referring physicians and affiliated hospitals to improve quality and lower cost (i.e., Clinical Integration Programs, ACOs, ACEs, Medical Home models); your performance can affect their performance and reimbursement/incentives Think about how payors and health h insurance options are changing how you engage your patient population in population health management (i.e., outreach/gaps in care, preventive, follow-up) 29

30 Summary & Conclusion: Have A Strategy t Strategy: Understand the world we are entering as partly ACA and partly the Wild West. We understand some of each, and some of it makes no sense. Plan accordingly. Networks: Participate in payor and provider networks aligned with your referral base. Know that sometimes what is important to you is not important to your referral base, and vice versa (i.e., Medicaid, Exchange patients). Infrastructure: Invest in the infrastructure to be able to manage a rapidly growing and diverse Payor Contract Portfolio and Patient Base, driven by VBP and Consumerism. Volumes: Assume an influx of new patients to the system; but utilization of services will likely drop. Assume less payment per service, with a greater portion of revenue will come from patients (not payors). Communication: Go above and beyond to communicate to referring physicians and your entire patient base. This drives the Patient Satisfaction scores the most. Go Big: Assess opportunities to create a bigger organization to leverage expense base, technology, revenue levers and market share. 30