Using the MSSP ACO Model as a Pathway Towards Risk Contracting

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1 Using the MSSP ACO Model as a Pathway Towards Risk Contracting Hymin Zucker MD, CMO & Amy Holm, MHA Triple Aim Development Group November 12 th 13 th 2015 Extinction/Volume Evolution/Value 1 Disclaimer: This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Every reasonable effort has been made to assure the accuracy of the information within these pages. The Triple Aim Development Group makes no representation, warranty, or guarantee that this presentation information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide

2 As of Today: What is the opportunity? FFS is over, embrace the value based payment model MIPPA act of 2008 PPACA 2010 Recent NEJM article: setting value based payment goals written by Secretary Burwell 30% of Medicare payment will be via alternative models by 2016, 50% by 2018 No better way to learn the new payment system than being in an ACO Alternative Payment Models (ACOs, bundled payments, etc.) Alternative Payment Models FFS Other VBP Programs FFS Other VBP Programs 3 3 What is the Value Based Payment Modifier (VM)? Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS) VM assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule The Grading System For CY 2015, CMS will apply the VM to groups of physicians with 100 or more eligible professionals (EPs) For CY 2016, CMS will apply the VM to groups of physicians with 10 or more EPs Phase-in to be completed for all physicians by 2017 Implementation of the VM is based on participation in Physician Quality Reporting System ( PQRS) or GPRO for Physicians in ACOs 30% of FFS will be under some value based payment by 2016 and 90% by

3 Value Based Payment Replaces FFS Each group receives two composite scores (quality of care; cost of care), based on the group s standardized performance (e.g., how far away from the national mean). Group cost measures are adjusted for specialty composition of the group This approach identifies statistically significant outliers and assigns them to their respective cost and quality tiers. Low Cost Average Cost High Cost High Quality +9.0% +2.0% 0.0% Average Quality +2.0% 0.0% 2.0% Low Quality 0.0% 2.0% 9.0% 55 CMS Innovations Portfolio: Testing New Models to Improve Quality Accountable Care Organizations ACOs Medicare Shared Savings Program (Center for Medicare) Pioneer ACO Model Advance Payment ACO Model Comprehensive ESRD Care Initiative Primary Care Transformation Comprehensive Primary Care Initiative (CPC) Multi Payer advanced Primary Care Practice (MAPCP) Demonstration Federal Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Independence at Home Demonstration Graduate Nurse Education Demonstration Bundled Payment for Care Improvement Model 1: Retrospective Acute Care Model 2: Retrospective Acute Care Episode & Post Acute Model 3: Retrospective Post Acute Care Model 4: Prospective Acute Care Capacity to Spread Innovation Partnership for Patients Community Based Care Transitions Million Hearts Health Care Innovation Awards State Innovation Models Initiative Initiatives Focused on Medicaid Population Medicaid Emergency Psychiatric Demonstration Medicaid Incentives for Prevention of Chronic Disease Strong start initiative Medicare Medicaid Enrollees Financial Alignment Initiative Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents 66 3

4 The QRUR (Quality and Resource Use Report) All physicians are being measured as of September 2014 Improve quality and efficiency of medical care via meaningful, actionable, and fair ways to measure physician performance Began under MIPPA of 2008 Includes Hospital based charges to encourage alignment among all aspects of patient care 7 PGP Cost and Expense Findings Directed Care Influenced Care Contributed Care $9,339 annual cost of care $10,901 annual cost of care $15,566 annual cost of care CMS 2010 Average Risk adjusted patient data Conclusion: Increased primary care involvement impacts overall costs the PCP centric solution 8 8 4

5 PCP Centric Solution Starts with a Belief! If you believe in something, BELIEVE in it all the way Walt Disney 9 9 What you Do Not Need Years of managed care experience Experience in pay for performance Experience in PCMH Expertise in medical informatics What you Do Need Belief that a primary care physician can make the difference Understanding that fee for service has evolved to highlight value based payment Change starts at the PCP/patient office visit

6 The PCP Environment: Moving towards full risk contracting The traditional Physician group practices Hospital owned PCPs Independent Primary care provider What is Risk Contracting? Accepting a fixed payment for the delivery of all healthcare services for a given population Assuming a population can spend below previous years benchmark Examples of Risk Contracts: ACO track 3 Bundled payment

7 Risk Contracting Requires the ability to sort population data to define Risk Readiness 1.Beneficiary Retention 2.Patient Access 3.Workflow/Office Operations 4.Quality/Outcomes 5.Cost and Utilization Management 6.Patient Experience/Engagement Risk Contracting Readiness/Population health Model Moving from Episodic care to population health Population health model starts with policies and programs derived to address the six categories required to manage healthcare risk Must be universally accepted and applied Must be sustainable is population health.html

8 How can we Prepare? A) Organize and become a MSSP ACO B) Understand the rules required to practice accountable care C) Define the purpose and set goals to change the culture of the primary care physician environment What is the Solution? Getting physicians to change practice culture by using a proactive approach Don t rush into IT/Population registry/integration They get better all the time Your needs may change in a matter of months It takes 90 days to get your data Ensure the proactive process that supports the ACO are firmly in place first

9 17 Proactive or Reactive Approach Proactive approach incorporates policies, procedures, principles and standardization of processes. Reactive approach analyzes what has already occurred and results in process changes

10 What Approach do we Take? Day 1 initiative to incorporate a handful of proactive processes and programs at the physician patient level Lay the groundwork for the subsequent use of big data analysis and integrative health information exchange systems Proactive Approach 1.Survey for Risk Readiness 2.Introduce population health dynamics A.Beneficiary Retention B.Appropriate Access C.ER reduction program D.Readmission reduction E.Transition of care 3.Expectations for expense reduction

11 Proactive Set Expectations Do you think you can reduce 5% 10% savings? Retain your patients: What percent of Beneficiaries should be retained? Part A Inpatient SNF HHA Hospice Institutional Outpatients Part B Workflow Assessment of Risk Readiness Survey the primary care provider offices for existing ACO practice patterns of patient retention, access, office operations, patient engagement, quality and outcomes, part A components, part B components, utilization, and IT

12 Survey Results at Start 40% 80% 40% Of PCPs didn t know what an ACO was Of PCPs did not educate their staff on ACO material Of PCPs have answering machines directing patients to the ER if there is an emergency 60% Of PCPs work 4 days a week Survey Results After Impact 40% increased same day appointments 45% improved their current oncall process 45% have a relationship with hospitals and SNF Schedule subsequent appointments, work 5d/week Have PCP answer phone during non office hours notify pcp when patients are in ER/hospital/SNF Decreased ER visits, increased patient retention, increased quality metrics, increase CAHPS scores

13 Establish Key Performance Measures These performance measures support the triple aim and are attainable by primary care physician efforts Beneficiary Retention >70% Beneficiary Access to Care >70% Emergency Utilization <500/1000 Readmissions for 30, 90, and 180 days <50% Transitions of Care PCP office visit post discharge from hospital and SNF >70% Per member per month (PMPM) cost reductions over time Quality of care metrics Annual Wellness Visits >70% Proactive Strategy to Rank Physicians By using the key performance measures, administration can create competition for recognition Team A: helping the ACO by having relative improvement in performance Team B: No change in relative improvement, therefore, not helping or hurting the ACO Team C: hurting the ACO by having relative worsening of performance No TIN gets left Behind rule

14 Reawakening the Student Within Example: Beneficiary Retention 15% 10% 5% 0% Physician Group F depicts a 15% improvement in beneficiary retention from the previous year to the current year 5% 10% 15% A B C D E F Accountable Care Organization Administration Creation of Value To obtain appropriate leadership and know how to effectuate change Identify barriers to achieving improvements in orchestrating network wide solutions To obtain the appropriate analytic tools to create physician specific actionable reports To provide the appropriate guidance to improve performance (tactics to improve)

15 Beneficiary Retention > 70% Increases the continuously assigned beneficiaries Actuarially supported to improve chances of obtaining shared savings Metric of excellence for any payer/plan Required metric for risk readiness 100% 70% 50% Q1 Q2 Q3 Q4 29 Review of Lost Patient and New Patient Lists Lost Patients: conduct root cause analysis on a sample of patients with appropriate interoffice connections Lost via join MA plan Lost via plurality Lost via no office visit New Patients: ensure subsequent office visits are scheduled 30 15

16 Beneficiary Access to Care Quarterly > 70% 67% of beneficiaries have chronic care dx Chronic care patients recommended 4 visits per year plus one wellness visit All other beneficiaries are recommended to have 2 visits per year inclusive of a wellness visit Subsequent visits scheduled routinely All no shows and cancellations are rescheduled Metric of risk readiness 31 Emergency Room Utilization < 500/1000 Reduction in ER use results in reductions in Part A and Part B Root cause analysis of ER utilization: No urgent office visit access After hour on call issues Ineffective resolution of prior office visit treatment Insufficient office hours Metric of risk readiness 32 16

17 Post Acute Transition of Care > 70% Establish an ACO wide expectation Hospital will provide ADT feeds in a timely manner PCP will forward all pertinent health information Discharge should have a scheduled appointment with PCP within 7days Decrease in Readmission Day intervals 33 PMPY Costs Tracking over time Breakdown of TIN expense quarterly for Part A, Part B, and Total (A +B) Analytics of part A Hospital SNF HHA Hospice Institutional outpatient Analytics of part B Results highly dependent on proactive process in place 34 17

18 Quality: Group Practice Reporting Option (GPRO) Metric of Annual Wellness Visits 11/33 quality measures are included Is immediately reimbursable Measure of PCP participation Cannot score favorable in GPRO without Need > 70% performance Metric of risk readiness 35 Wellness Visit Quality Measures Preventive Health Domain Influenza Pneumococcal Adult weight screen and f/u Tobacco use and intervention Depression screening Colorectal cancer screening Mammography screening Care coordination domain Screening for fall risk At risk population domain Diabetes composite (aspirin use) Ischemic vascular disease (use aspirin and other antithrombotic)

19 Taking on Risk Assuming responsibility of delivering healthcare across a population 1. 70% of beneficiaries are retained 12months 2. 70% of discrete patients receive office visits quarterly 3. ER admissions approach 500/ Transitions of care performed post acute hospital visit 70% of the time day readmission for chronic disease are < 50% 6. Annual Wellness Visits performed > 70% Foundation for ACO success and assumption of risk 37 THANK YOU! Call Hymin Zucker MD, CMO Triple Aim Development Group at