Population Health: Tales from the Front

Transcription

1 Population Health: Tales from the Front Integrated Design and Case Study from Northwest Arkansas Objectives Discuss current Population Health trends and approaches in the market Determine the strategies and capabilities needed to enter into value-based care model Define the foundational elements of a Clinically Integrated Network (CIN) Identify real-time learnings for individual CIN design and operations 2015 Valence Health. All rights reserved. 2 1

2 Hospital-Physician Alignment Is More of an Imperative Than it has Ever Been Factors Driving Physician-Hospital Alignment Administrative burdens IT capability build Unpredictable compensation Leadership opportunities Reimbursement decline Population health Value-based payment Onset of healthcare consumerism Contracting capabilities Quality of care improvements Narrow networks Ambulatory competition Cost control Leakage Valence Perspective 1 Tighter physician alignment gives both physicians and hospitals more opportunities for surviving in the new value-based world to come 2 Each market will have its own unique set of value propositions that will inform the right approach 3 Organizations that are thoughtful and deliberate in their approach to physician alignment, and who offer multiple options for alignment, will be the winners 2015 Valence Health. All rights reserved. 3 What is Value-Based or Accountable Care? Value-Based Care = (Access + Quality = Outcomes ) Cost Financial Opportunity & Incentive Alignment P4P PCMH SAVINGS BUNDLED PAYMENTS RISK CAPITATION FULL RISK PROVIDER- SPONSORED HEALTH PLANS VALUE-BASED DELIVERY SPECTRUM 2015 Valence Health. All rights reserved. 4 2

3 Continued Growth Year Over Year of ACOs Rapid Growth of ACOs Year Over Year 1 # of Payors Participating in ACOs Q Q Q Q Q Q Q Q Q Q # of Lives (in Millions) Covered in ACOs ) Leavitt Partners Center for Accountable Care Intelligence, Valence Health. All rights reserved. 5 Value-based Payments Will Double by 2018, Creating a $300 Billion Payment Shift Payors are quickly shifting from fee-for-service payment arrangements Multiple value-based payment models are being deployed, from capitation to payfor-performance Provider organizations ability to develop diversified revenue sources, including various value-based terms, is key to long-term sustainability Commercial payers will move away from FFS only contracts over next 5 years (Percent of Overall Payment Mix) Medicare will increase use of alternative payment models between (Percent of Overall Payment Mix) 24% decrease in FFS only % ($150B) increase in alternative payments FFS P4P Bundled Global Payment Capitation Other Source: McKesson The State of Value-Based Reimbursement and the Transition from Volume to Value in Valence Health Analysis. FFS only FFS Linked to Quality Alternative Payment Models Source: Triple Tree, The Far Reaching Impacts of Medicare s Shift to Alternative Payment Models. February Valence Health. All rights reserved. 6 3

4 How is Value-based Care Today Different than the 90s? 1990 s Today Lack of Shared Incentives Aligned Incentives Lack of Physician Voice Physician-led and Physician-driven Effort Fragmented Structure Limiting access dictated margin success. Coordination Powered by Technology Today, quality gates help determine margin 1) Deloitte Center for Health Solutions. Physician-hospital employment: This time it s different ) PwC Health Research Institute. From courtship to marriage: A two part series on physician-hospital alignment Valence Health. All rights reserved. 7 Physician Alignment: Required in the Transition To Value-based Care Key Market Forces Consolidation and integration Physician alignment Innovative care delivery Value-based care maturity Recent Trends Regional networks, increasing competition Smaller systems and physicians developing their own networks; partnering with existing networks Physician groups leading effort on clinical quality, cost efficiencies, and access Physician network performance a leading strategy; large networks begin to cull lower performers Disruptive innovators are entrenched Creative solutions to reach patients better and improve quality and lower cost of care Networks offering health plans, direct to employer contracts and/or accepting risk Payors looking to expand plans tied to ACOs, increase narrow networks and reduce FFS reimbursements Strategic Implications for Health Systems and their Physicians 1 Physician integration will provide more opportunities for surviving in the valuebased world 2 Option(s) should provide differentiation and competitive advantage 3 Potential partners must address current needs and be aligned on future goals 4 Formal Integration will serve as the vehicle to align payor contracts with care delivery models 2015 Valence Health. All rights reserved. 8 4

5 The Measurement of Success Is Evolving From Fee For Service To Value-Based Care Market Share Adjusted Admissions Market Share Covered lives (attributed or capitated) Quality Process measures Quality Outcome measures Physician Alignment Medical staff Physician Alignment Participating Physicians Patient Acquisition Emergency Department (ED) Patient Acquisition Patient Outreach Care Manageme nt Case management Care Manageme nt Cross-continuum care coordination Provider Incentives Relative Value Units (RVU) Provider Incentives Quality/Cost 2015 Valence Health. All rights reserved. 9 Three Key Measures Achieve Significant ROI in Both VBC and FFS Worlds Increasing Market Share Reducing Network Leakage Optimizing Risk Coding Percent of your network s share of total dollars in your primary service area Incremental care your network would provide if your patient sought all of his/her care within your network Providers code using Hierarchical Condition Category (HCC) to more completely capture disease burden managed High Risk Medium Medium / High Risk Briefly Intense Medium/Low Low Risk 2015 Valence Health. All rights reserved. 10 5

6 What We Are Seeing in the Market Model Trends Clinically Integrated Networks ACOs and Full Risk Contracts Major momentum in many/most markets Drivers differentby market type Some cross-system collaborations Some IPA/Physician lead models, but mostly hospital / system supported Commercial and Medicare ~50/50 Latest batch of MSSP about to be released to applicants Data reporting/sharing often still problematic Seeing selected expansion of full-risk contracts some provider inspired Medicaid risk contracts in some states Rapid Growth of ACOs Year Over Year Q Q Q Q Q Provider- Sponsored Plans Bundled Payments PCMH Some marquis growth (Sutter, NSLIJ) and smaller players (CHOMP, Florida Hospital, solutions ABCO says 1 in 5 systems to be payors by 2018 Focused around cardio, ortho and birth episodes/procedures Medicare Comprehensive Care for Joint Replacement CCJR ~5000 accredited sites New growth has slowed Funding from commercial payors may be focused elsewhere Number of ACOs by Referral Region 1 1) Leavitt Partners Center for Accountable Care Intelligence, Valence Health. All rights reserved. 11 Gathering Early Market Intelligence Provides a Sound Basis for Developing Value-Based Options Population Assessment Understand the population composition and analyze future trends Key Components of Strategic Intelligence Development + Market Profile and Competitive Position Identify value-based trends, key competitors, and employer activity + Payor Assessment Discern payor valuedrivers and contracting trends + Physician Landscape Pinpoint key opportunities for alignment What is the current distribution of lives across payor segments, and how does that population grow / decline over time? What is the approximate PMPM by population segment? What is the number of addressable lives and the related spend? What is the current state of risk-based activity in the primary service area? What are competitors in the region doing with regards to value-based care contracting and physician alignment? What are the opportunities for Direct-to-Employer valuebased contracting? Who are the top payors in the primary service area, and what is their current market share of lives? What products have they introduced in recent years, and what are the future trends? What are the existing primary care and specialist physician groups and related health system alliances? What is the concentration of physician group practices in the community, size of those practices, and appetite for value-based care? A comprehensive market assessment provides the necessary fact base to begin understanding the viable options for value-based care delivery in the market 2015 Valence Health. All rights reserved. 12 6

7 A Gap Analysis is Important to Understand Organizational Readiness for the Different Models of Value-based Care Dimension Components Rating Organizational Alignment Payor Contracting Executive alignment and capacity Integrated clinical and leadership forums Operational infrastructure Staff support and capacity Tools and resources to support decision-making Rate target development Contract negotiation and enforcement Reserves & Reinsurance Funds flow model and cross-network distribution ability Claims receipt and processing within and out of network Organizational readiness for each dimension has been evaluated relative to the requirements for management of shared risk Data, Analytics & Technology Care Model Provider Alignment and & Network Use of common technology platforms Cost of care and utilizationdata Quality measurement Population health management Risk stratification Predictive modeling Claims processing Data governance Development and use of clinical protocols Care coordination program and resources PCMH functionality, care gaps Care team, physician, and patient engagement Utilization and referral management High risk and population-specific programs Networks: Primary care and Specialist, post-acute, other Physician leadership and governance Access and capacity Membership/ participation criteria Value-based incentive program Network performance and remediation process Rating System No capabilities built; no planned adoption Beginning to build capabilities; planning for adoption Building capabilities; beginning to adopt Capabilities in place; partial adoption All necessary capabilities built and fully adopted 2015 Valence Health. All rights reserved. 13 Risk Level & Required Provider Capabilities for Accountable Care Increasing Assumption of Risk Requires More Resources Capabilities No Risk (P4P) Shared Savings Shared Risk Full Risk Care Management Quality Reporting Clinical Integration Risk and Financial Management Incentive Program Provider Network Management Technology and Analytics Member Services Not Required Partial or Begin to Implement Required 2015 Valence Health. All rights reserved. 14 7

8 Shared Savings is No Risk, but Often No Savings for the Long Term P 4 P PCMH SAVINGS BUNDLED PAYMENTS RISK CAPITATION FULL RISK HEALTH PLANS Prior Baseline Costs Year 1 Savings Shared Savings Budgeted dollars Upside only Premium is reset based on medical expenses Re-baseline Cost Year 2 Savings Re-baseline Cost What have you done for me lately? Year 3 Savings? 2015 Valence Health. All rights reserved. 15 Bundled Payments Allow for Defined Areas of Risk P 4 P PCMH SAVINGS BUNDLED PAYMENTS RISK CAPITATION FULL RISK HEALTH PLANS Degree of Risk A single payment to cover all services from multiple providers involved in a care episode Single provider s technical risk Multiple Providers technical risk Multiple providers technical AND probability risk DRGs Episode-Based Global Cap 2015 Valence Health. All rights reserved. 16 8

9 In a Shared Risk Agreement, the Payor and Provider Share the Savings or Loss P 4 P PCMH SAVINGS BUNDLED PAYMENTS RISK CAPITATION FULL RISK HEALTH PLANS $ Illustrative Shared Risk Agreement with Savings $ Illustrative Shared Risk Agreement with Loss TIME TIME Provider savings Payor savings Provider loss Payor loss Arrangement based upon agreed upon budget Could be a percentage of premium or a set amount Premium is reset based on medical expenses Upside and down-side risk: Provider and payor share savings/loss 2015 Valence Health. All rights reserved. 17 Full-Risk Arrangement Structure P 4 P PCMH SAVINGS BUNDLED PAYMENTS RISK CAPITATION FULL RISK HEALTH PLANS Payor A Payor B Payor n Variable Capitation Negotiated, riskadjusted PMPM payment for defined populations Fee for Service Payments ACO/CIN Credentialing Care Management Utilization Management Disease Mgmt Quality Measures Data Analytics Quality Incentive Payments Member A Member B Member C Member D Non- Network Providers Network Members or Participants 2015 Valence Health. All rights reserved. 18 9

10 Provider-Sponsored Health Plans Offer Greatest Value Opportunity P 4 P PCMH SAVINGS BUNDLED PAYMENTS RISK CAPITATION FULL RISK HEALTH PLANS Greater impact on Mission, more people insured Able to impact premiums Control network development and usage Access to data Run health plan as you see fit Able to control provider rates Closer to the first dollar Ability to Impact legislation/benefit design Likely over 100 plans in operations today 2015 Valence Health. All rights reserved. 19 Clinical Integration is a Contracting Strategy in Itself but Also Builds Foundational Capability for Risk P 4 P PCMH SAVINGS BUNDLED PAYMENTS RISK CAPITATION FULL RISK HEALTH PLANS Formal program between health system and defined private physicians Designed to improve quality and cost Allows some benefit distribution back to the physicians No downside financial risk First step in shifting from a volumebased focus to a value-based focus Still subject to FTC/OIG scrutiny on market share Crawl Walk Run Agree to guidelines - EBM Gather, standardize, analyze data FFS Contracting (Commercial) Measure Results Enforce Performance Distribute Incentives Population Health Mgt Reduce Clinical Variation Change Behavior Focus on Patient-engaged Teams 2015 Valence Health. All rights reserved

11 What Is a Clinically Integrated Network (CIN)? A Clinically Integrated Network (CIN) is a selective partnership of physicians, led by physicians, collaborating with hospitals to deliver evidence-based care to improve quality and demonstrate value to the market. Participation & Collaboration Payors and Employers Contracts $ CIN Entity Participation & Collaboration Physicians Private physicians maintain independence Lead and govern the CIN entity Improve quality of care delivered Opportunity for enhanced reimbursement by demonstrating quality Private Practice Physicians Distribution $ $ of Funds Health System(s) and Employed Physicians Health System(s) Align independent and employed physicians Opportunity for enhanced reimbursement by demonstrating quality Improve hospital-physician relations 2015 Valence Health. All rights reserved. 21 Clinical Integration is a Defined Program by the FTC to Allow Joint Contracting Without Financial Risk The Building Blocks of Clinical Integration Enhanced Accountability Quality Data Aggregation and Reporting Engaged Provider Network Performance Measurement and Incentives Evidence- Based Best Practice Utilization Legal Entity and Governance Structure Clinical Integration is an active and ongoing program to evaluate and modify practice patterns by the network s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. -Federal Trade Commission (FTC) Definition 2015 Valence Health. All rights reserved

12 To Remain Viable Long-term, a CIN Must Be Designed to Deliver Value to All Involved Stakeholders Member Physicians CIN Success will require: Consistent and ongoing leadership commitment through the full implementation of the clinically integrated network Collaboration and coordination across the health system Physician engagement and contribution Speed to market Hospitals Payors / Employers 2015 Valence Health. All rights reserved. 23 Quality and Cost Are the Top Concerns for Payors and Patients Hospitals and Employed Physicians + Independent Physicians Clinically Integrated Model of Governance and Org Structure Commercial Payors Government Payors Employers and Narrow Networks Improved Quality and Support through Collaboration, Metrics, and Analytics 2015 Valence Health. All rights reserved

13 At the Core of Clinical Integration is the Ability to Capture, Aggregate, and Act on Clinical Information Network Development Stakeholder Engagement Value Proposition Participation Criteria Physician Leadership Incentive Design IT Infrastructure and Capability EMR & EHR Clinical and Financial Patient Engagement Tools Integration with existing systems Cross-continuum Coordination Strong Primary Care Communication Referral Management Population-Based Programs Shift to Ambulatory Management Transitions of Care Organizational Structure & Planning Payor Contracting Strategy Physician Governance Committees and Decision-Making Financial Structure Organizational Incentive Alignment Analytics Clinical Metrics & Results Cost Analytics Standard vs. Ad-hoc Reporting Risk Identification Regulatory vs. Operational Collaboration Platform Common Protocols Physician-Guided Quality Best Practice Dissemination Clinical Metric Selection Peer Review; Transparency Build Network Culture 2015 Valence Health. All rights reserved. 25 Clinical Integration Provides Significant Benefits to Physician Practices Who Value Their Independence Value Proposition Better balance physician vs. payor control Empower physician decision-making in the broader system Opportunity to be rewarded for delivering higher quality care and lowering costs; Doing the right thing Enhance communication and joint accountability - "Doctors talking to doctors" Support private practice model and physician autonomy Ability to manage risk and manage population health to be successful in value-based environment Maintain patient volumes Share evidence-based best practices across care settings to facilitate population health management Buffer against uncertainty and changes in healthcare industry Enable efficiencies of physicians time through standardized and coordinated processes Improve access to and use of IT and data analytics Create infrastructure and data transparency to better compete in the market Priority* High High High High High Med-High Med-High Medium Medium Medium Medium Medium 2015 Valence Health. All rights reserved

14 Key Factors Necessary for Successful Implementation Critical Success Factors for Value-Based Care Strong physician leadership and governance encompassing multiple constituencies with well defined participation criteria A value-based focus with transparent, aligned financial incentives tied to quality and efficiency measures Significant investment in technology focused on the creation of a patientcentric, comprehensive view of clinical data across all providers Standard quality measures and custom metrics based on targeted populations and data availability Blend of individual and group accountability through alignment of incentives: economic rewards, remediation efforts, and enforcement standards 2015 Valence Health. All rights reserved. 27 Geographic Integration is an Important Component of Delivering Value to the Market 2 Markets 1 CIN Future Opportunities for Collaboration and Integration? Benefits of Integration More physicians in the CIN through integration equals more lives Identification and implementation of best practices and processes Enhanced collaboration and collegiality from physicians and subject matter experts Value Greater number of attributed lives enhances the attractiveness of the CIN to both payors and employers and increases opportunity for value-based reimbursement Improved ability to consistently deliver high-quality, coordinated care to patients while optimizing efficiency of practice operations Healthy environment to not only solve problems, but proactively identify potential issues and/or develop new solutions to enhance ambulatory, inpatient and post-acute care delivery 2015 Valence Health. All rights reserved

15 An Organic Change in Ownership for CI Collaboration is Important to Optimize the Network Evolution Expectations Learning Engaging Owning Disparate Physician Groups * 0-3 months Understanding clinical integration and value-based care Aligning on common purpose and vision Initial participation in process CI Design Team * 3-6 months Increased participation in meetings Enlightened input into decisions Engaging peers in dialogue about the network * 6+ months Leading, Collaborative Network Proactive voice in governance and decisionmaking Leading network strategy Growing strategic operations 2015 Valence Health. All rights reserved. 29 The Relationship Between the Physicians and the Hospital Member Will Ultimately Lead to the Success of the CIN Relationship Factors 1 Previous History 2 Current Relationship 3 Community Primary Care 4 Community Specialists Hospital initiatives that went poorly Former leadership Misalignment of values and trust Political concerns Ongoing initiatives Current leadership Communication Level of collaboration Future potential Inpatient vs. outpatient needs Technology support Relationship with employed doctors Access Inpatient vs. outpatient needs Referrals Relationship with employed doctors In order to mitigate potential barriers, the CIN must incorporate fundamental elements: Value Propositions Transparency Voice in the design Collaborative CIN Design Value Added Services 2015 Valence Health. All rights reserved

16 Best Practices and Lessons Learned Should Inform the CIN s Communications and Design Strategy Plan, Plan, Plan Have a well-defined communications timetable Assign ownership and identify key communicators from the beginning Establish the foundation for success Varied, Yet Consistent Use various media to get the message across Decide early on consistent core messages to permeate all communications Tailor message and media to your target audience Collaborate Across the Team Share the production of communications with the rest of the project team Be Willing to Adjust Your Strategy It s Never Too Early! Review effectiveness of communications regularly Engaging stakeholders early starts to build interest and trust in the CIN Extract learnings from target audience feedback Hospital executive leadership and community leadership must be champions for the CIN 2015 Valence Health. All rights reserved. 31 Real Time Learnings Can be an Effective Tool in Your Design Process Successful CIN Implementation Perceived need by the community and the hospital Physician led design and implementation Collaboration with the Hospital Trust and transparency with the Hospital Meaningful Value Propositions Adequate resources for design and implementation Communicate, communicate, communicate Questions for Michael on from the community perspective? Questions for Rick from a national perspective? 2015 Valence Health. All rights reserved

17 Thank You for Your Time Today For additional questions and comments, please contact Rick Bobos at vquest Medical Cost & Utilization Risk Adjustment Vision Clinical Integration Quality Measures Population Health for Multi-TIN Settings Registries Population Health Management Solutions Health Plan Services Claims Processing Premium Billing Provider Portal Member Portal Care Manager Case Management Care Coordination Patient Outreach 2015 Valence Health. All rights reserved