David Swieskowski, MD, MBA President Mercy ACO

Transcription

1 David Swieskowski, MD, MBA President Mercy ACO

2 Mercy ACO Today 58 Primary Care & Specialty Participant Organizations Mercy Affiliated & Independent Organizations 1,000+ Providers (Physicians & Mid-Levels) 175 Provider sites in 30 of Iowa 99 Counties Nearly every specialty within the Central Iowa CIN. Primary Care Specialist Rural Health Center Medical Center Critical Access

3 Why Do We Want a Statewide ACO Scale IT, Management staff, Marketing Avoid duplication of work Guidelines, metrics, compliance programs Shared population health management approaches Access to wider range of clinical expertise Statistical and actuarial stability Reduce clinical and financial variation MSSP Savings Threshold 5,000 lives requires 3.9% savings 60,000 lives requires 2.0% savings Better ability to market our Network Go to market under our name rather than an insurance company name Match our competitors marketplace presence

4 Mercy ACO LLC organized in Feb to meet CMS ACO rules for the purpose of: Achieving the triple aim goals of Better Health, better care, lower cost Creating an environment to optimize the opportunity for providers to achieve the goals Data Systems, Care Management, Quality Improvement, and a Clinically Integrated Network Assuming of risk for a defined population Contract to reward the value produced 4

5 Degree of Complexity Shifting Risk to Providers High Insurance product Global capitation Partial Capitation Shared Savings / Losses Bundled episodes (pre- and post-care included) Bundled episodes (inpatient only) P4P programs Inpatient case rates (DRGs) Low Fee for service Scope of Risk High

6 Annual %age Increase When Providers Do the Hard Work of Decreasing Costs & as Margins are Compressed a Value Gap is Created All the Savings / Value, Accrues to Payers and Purchasers Unless We Are in Shared Savings or Other Risk Arrangement $ savings Bending trend to meet CPI creates $300 million to $400 million in annual value capture opportunity in the DM market in future years. Government, insurance companies, individuals, employers and integrated networks will compete to capture the value. Time Introduction of ACO Care Management & Other Efforts to Increase Value There is a significant first mover advantage. By contracting for risk, and driving down the cost of care below trend, MHN can capture disproportionate share in the shift to value. 6

7 Value Based Agreements Over 100,000 lives in 2014 Commercial Shared Savings ACO Start Date: April 2012 Covered Lives 2013: 23,306 Covered Lives 2014: 40,000 (est.) Agreement : Shared Savings Medicare Shared Savings ACO Start Date: July 2012 Covered Lives 2013: 22,380 Covered Lives 2014: 45,000 (est.) Agreement: Shared Savings Employer Sponsored Program Start Date: January 2013 Covered Lives: 10,465 Agreement: Self-funded Insurance Medicare Advantage Product Start Date: January 2013 Covered Lives 2014: 500 (est.) Agreement: Narrow Panel Product Percent of Premium Insurance Exchange Product Start Date: January 2014 Covered Lives: 4,500 (est.) Agreement: Tiered Panel Product Medicaid Expansion ACO Start Date: January 2014 Covered Lives: 8,000 (est.) Agreement: FFS with P4P

8 How Is This Different From an HMO? ACO Patients are free to self refer Sophisticated risk adjustment Want the sickest patients Data Warehouses and metrics HMO Primary care must authorize referrals Risk adjustment only by age and sex Want the healthiest patients Rudimentary data 8

9 Mercy ACO Care Delivery Vision 9 Manage patients as populations and individuals Planned patient visits Measure population based outcomes like % with BP controlled IT systems AEHR, Disease registries, Care management software Engage patients with Health Coaches Identify those most likely to benefit Coordinate care Communication and sharing information Plan transitions Continuous Quality Improvement Measurement and reduction in variation Access to care Develop models to be reimbursed for value, not just volume P4P, Shared savings, Capitation

10 How This Reduces the Cost of Care Relatively low cost care delivery system changes can improve the health of patients Health coaching Coordination of care Reduction in variation Improving the health of patients will reduce Hospitalizations ED use Drug costs Denying needed care would NOT be effective 10

11 Projected ACO Savings in Year 2 Based on: 30% reduction in ED visits* 12% reduction in Admissions** 30% increase in Primary Care visits Projected Yearly ACO Savings Total Savings % Shared ACO Yield Medicare $ 8,487,600 50% $ 4,243,800 Wellmark $ 2,634,444 70% $ 1,844,111 Total $ 6,087,911 * California MA plans showed a median reduction of 30% in ED visits & 12% in admits -America s Health Insurance Plans, center for policy and Research (2009) ** Geisinger showed a 18% reduction in admissions -American Journal of Managed Care August

12 390 Hospitalizations - Utilization Per 1k Person Yrs 16.8% hospitalizations CY13 Q1 claims data missing 2 weeks of run-out 250 BY 09 BY 10 BY 11 CY12 Q3 CY12 Q4 CY13 Q1 CY13 Q2 CY13 Q3

13 ACO Measures Required by CMS Full specifications found at: Payment/sharedsavingsprogram/Downloads/ACO_QualityMeasures.pdf CMS requires ACOs to report on 33 measures Patient experience - 7 measures CAHPS: Access, Communication, SDM, functional status, Health promotion & education, overall rating Care Coordination 6 measures Readmission rates, Admit rate for COPD and HF, fall risk assessment, EHR use, Med Rec. Population Health 20 measures Immunizations Pneumococcal & flu Screening for weight, tobacco, depression, BP Screening for colon & breast cancer Diabetes HgA1c, Lipids, BP, ASA use, tobacco non-use CV BP, Lipids, ASA, Drug Rx (B-blocker, ACEI, Lipid Rx)

14 Wellmark Value Index Score Baseline VIS Measure/Domain Mercy ACO Percentile DSM Percentile MNI Percentile Total VIS Blend 55.8% 55.4% 56.5% Shared Savings Trigger 54.8% 54.7% 55.1% Breast Cancer Screening 41.3% 36.5% 61.0% Colorectal Cancer Screening 54.2% 55.7% 49.7% Six Well Child Visits Birth to 15 Months 71.0% 76.7% 52.3% Yearly Well Child Visits 3-6 Years of Age 50.4% 52.1% 41.4% Primary & Secondary Domain 49.2% 48.3% 53.1% Potentially Preventable Readmissions 38.1% 37.6% 39.2% Provider visit with 30 Days of Hospital Discharge 45.8% 40.8% 59.4% 3 Chronic Care Visits in the last year 59.1% 63.9% 42.2% Chronic & Follow Up Care Domain 57.7% 58.3% 55.0% Potentially Preventable Admissions 34.1% 34.7% 32.3% Potentially Preventable ED Visits 53.6% 61.6% 30.8% Tertiary Prevention Domain 52.3% 59.5% 31.7% Patients with at least one PCP Visit in the last year 46.2% 41.9% 59.2% Patients with at least one Physician Visit in the last year 46.1% 45.3% 48.9% Continuity of Care Measure 45.7% 38.6% 70.0% Continuity of Care Domain 41.2% 35.3% 64.6% CRG Severity Jumper 49.6% 46.7% 59.8% CRG Status Jumper 51.1% 49.9% 55.8% Health Status Domain 52.6% 50.4% 57.9%

15 ACO Challenge Reduce Utilization & Cost Improve Quality Metrics As defined by payers Improve Patient satisfaction

16 Data is Essential for Population Heath Need a list of the patients in the population Outcomes for key measures to know who is not meeting goals You can t Manage what you don t measure Need feedback to know if your interventions are effective Frequency of feedback sets the improvement cycle time Performance reports to engage the organization No physicians want to be at the bottom Data needs to be near real time for patient management and QI 16

17 McKesson Data Warehouse: Robust Data Acquisition Reports: 1. % BP Control 2. Due for visit 3. High ED visits 4. Variation in cost 5. Pharmacy use 6. Predict high risk 7. Episode groups 8. Outflow

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19 Disease Registry for Quality Reporting Provider reporting: Hierarchical and drill down to the detail Interactive filters allow configuration: By provider, group, organization, payer, registry, measure, compliance status Practice Group Quality Compliance Report Organization Registry Care Guideline No. of Eligible Patients Process Process % Num ber and Percentage of Patients Meeting Guidelines Process Network % Overall * Overall * % Overall* Network % MDSM Hypertension Hypertension Controlling High Blood Pressure 38,595 36, % 84.7% 26, % 61.5% 19

20 Quality Reporting, Jan Diabetes Registry Diabetes Care Guideline BP Control less than 140 over 90 for Diabetes Daily Aspirin Use for Diabetes and IVD Dilated Eye Exam for Diabetes HbA1c Control less than 8 LDL-C Control less than 100 Nephropathy Assessment Tobacco Non Use No. of Number and Percentage of Patients Meeting Eligible Process Overall* Patients Process Overall Overall Process Network Network % * * % % % 15,045 11, % 75.1% 8, % 56.5% 3, % 19.7% % 15,045 1, % 7.7% 1,291 15,045 11, % 73.9% 6, % 15,045 10, % 66.0% 4, % 26.0% 15,045 9, % 64.8% 9, % 64.8% 15,045 1, % 16.6% % 8.6% 7.7% 38.7% 6.5% 6.6%

21 Patient Stratification and Segmentation: Everything Must Change But Not for Every Patient Focus on the Highest Cost Chronic Patients Clinical Risk Group Distinct Members Plan Distribution Cost to Plan PMPM 10 - Healthy 7, % $ Delivery w-out Other Significant Illness % $ Evidence of Significant Chronic or Acute Diagnosis without Other Significant Illness % $ History Of Significant Acute Disease % $ Evidence of Significant Chronic or Acute Diagnosis with History of Significant Acute Illness % $ Single Minor Chronic 2, % $ Multiple Minor Chronic % $ Single Dominant or Moderate Chronic 3, % $ Pairs - Multiple Dominant and/or Moderate Chronic 3, % $ Triples - Multiple Dominant Chronic % $ 2, Malignancies - Metastatic, Complicated or Dominant % $ 3, Catastrophic % $ 6, Total Number - Average Cost 23,000 $ Aggregate $ 109,967,794

22 Stratification of Patients by Risk is Essential 10% of the Population Accounts for 68% of All Health Care Costs Mean Annual Percent of Percent of Total Per Person Population Health Care Expenses Cost Advanced Illnesses Multiple Chronic Conditions 1% 9% 29% $101,000 At Risk 20% 39% $ 15,000 70% 21% $ 3,700 Stable 11% $ 580 National Sample of 21 Million Americans Between 2003 and Source: Truven Health Analytics, Market Scan, 2012

23 Mercy Care Management Model Triple Aim Goals pursued through a comprehensive care model Better Care / Patient Experience Data Management Population-Based Care Extensivist Clinic Primary Care Transformation Disease Management Care Transitions Hospitalists 23 Lower Costs Reducing Variation Palliative, Post-Acute Healthier Communities

24 Primary Care Transformation Improves Population Health 1. Greater Access to needed services 2. Greater focus on prevention 3. Early management of health problems 4. Cumulative effect of the main primary care delivery characteristics Care focused on the whole person leads to better outcomes than care focused on a disease or organ 5. Coordination of care Avoid duplication and low value care 6. Team Based Care Self Management support Health coaches 24

25 Health Coaches Currently staffed at 1 per 2000 ACO patients 25 Self-Management Support Health Behavior change and Motivational interviewing Start with the patients goals not our clinical goals Connection to community resources Coordination of care Closing the loop on referrals and transitions Review population data for opportunities Shared decision making Distribution and decision aids and f/u Quality Improvement Point person for introduction of new care processes High Risk Patient case manager Proactive follow up Care access point direct phone &

26 Transition Coach Currently staffed at 3 FTEs See ACO patients while in the hospital Teaches warning symptoms and what to do if they occur Assesses medication issues Facilitate the transition back to the medical home Makes appointment for joint F/U with doctor and coach Encourages patient to bring all meds to the visit Tracks the patient until seen back in the medical home Communicates discharge info to the medical home Health Coach Collaborates with the hospital care team on high utilizing patients Office coach makes weekly calls for 4 weeks 26

27 Mercy ACO CMS Readmit Rate 8.2% hospital re-admits Day All Cause Readmission Per 1k Discharges CY13 Q1 claims data missing 2 weeks of run-out BY 09 BY 10 BY 11 CY12 Q3 CY12 Q4 CY13 Q1 CY13 Q2 CY13 Q3

28 Disease Case Management Most commonly done for Heart Failure, COPD, Diabetes Care guideline standards by disease Proactive outreach between visits Tele-monitoring Protocols for intervention based on symptoms Immediate intervention if needed Multiple Chronic Diseases This is the most common high risk presentation Common factors across all chronic diseases are more significant than disease specific factors Treatment plan adherence, depression, mental status, functional status, social issues 28

29 Systems of Care Metrics measure how a system performs more than an individual physicians Deming 85/15 rule Primary care metrics measure office site processes more than physicians Systems require standard processes If every does it their own way you have no process and can not do process improvement Measure & monitor the process output Provide resources for process improvement

30 Process Example: Health Coaches Using Disease Registries and Protocols to Improve BP Control Process: Use registry to identify patients without BP control and not seen in 30 days Coaches contact the patient to come in for follow up Motivational interviewing about Medication Adherance & life style Provider visit if BP not controlled after 3 months 90% 80% 70% 60% 50% 40% 51% 76.24% N= 20, % N= 5,000+ Percent of Hypertensive Adults with Controlled BP 30% 20% 10% 30 0% U.S. Ave. MCI All MCI on P4P

31 Access to Care is a Key System Issue Mammogram rates Overdue patients were called to schedule exam No progress until the scheduling process was simplified Colon Cancer Screening Overdue patients were called to schedule colonoscopy No progress until more GI Drs. Hired ED visit rates go down with improved primary care access

32 Patient Compliance Every population of patients has some who do not adhere to recommendations This is built into the baseline measurements This is an opportunity for Systems & Providers who make compliance their issue Start by addressing patient goals rather than clinician goals Understand patient values and preferences Most patients have a reason they are not adhering Health Coaches can be very helpful

33 33 Customer Relationship Management (CRM) Software Allows the ACO to know and track the patient and their health relationships across the continuum Tracks patients goals and preferences Links patients to community resources Consolidates community resources into a dynamic electronic guide Ratings to develop preferred resources Highlights non-clinical barriers and needs that impact health, cost and risk for providers Embeds care management work flow into an electronic format Standardize care management work Assigns tasks and prioritizes work lists Library of work documents and patient handouts Tracks productivity

34 Employee Care Management In place for Mercy Des Moines Employees Coaching based on risk assessments Patients with chronic disease: diabetes, heart failure Provided in physician offices not over the phone Registry tracking and follow up (population based care) Cancer screening immunizations Chronic disease standards Wellness Programs Smoking cessation Weight loss Nutritional Counseling Exercise Health behavior change counseling 34

35 Results Through Sept Quality Cost / Savings Contract Year: PY2 (2013) 0.11 Overall VIS 0.06 Share Savings VIS ($6.59) PMPM $3.0M VIS & Savings Contract Year: PY1 ( ) 8.2% hosp. re-admits 16.8% hospitalizations 4.8% Cost Savings $8.8M * 50% = $4.4M Contract Year: PY1 (2013) 4.5 Star Plan 10.8% hosp. re-admits 16.1% ED Visits 71.22% MLR (85% Target) $400K incentive 2.0% PMPY (5% Target) $533K incentive $225K Mgmt. fee

36 $8,500 $8,400 $8,300 $8,200 $8,100 $8,000 $7,900 $7,800 $7,700 $7,600 $7,500 7, Total Expenditures Per Medicare Beneficiary 8, , , , , CY13 Q1 claims data missing 2 weeks of run-out 8, , BY 09 BY 10 BY 11 CY12 Q3 CY12 Q4 CY13 Q1 CY13 Q2 CY13 Q3

37 Go to Market Strategy Mercy Health Network Statewide CIN Trinity Health Livonia, MI Accountable Care Shared Services Mercy Health Network MHN CIN Performance Standards Provider Network Support Shared Infrastructure Contracted Services with Members / Others Catholic Health Initiatives Englewood, CO Go to Market Strategies / Product Offerings Mercy- Sioux City CIN Mercy Dubuque CIN Mercy North Iowa CIN Mercy Clinton CIN Mercy Central Iowa CIN Other Future CINs 37

38 Physician Compact Mercy ACO Providers Commit to: 1. Share data including clinical data from your EHR and billing data from the claims you submit. The data will be used to create performance measures which will be shared transparently. 2. Provide timely and effective communication with clinical and administrative colleagues within the Clinically Integrated Network. 3. Support physician colleague leaders in their efforts and support the development of future physician leaders. 4. Recognize the authority of the CIN physician committees to set common goals for quality, utilization, and patient satisfaction. 5. Work with the CIN staff and programs to review and use data to achieve the triple aim of improved health, improved care and, lower costs for the communities we serve. 6. Improve access for patients in need of services.

39 Physician Compact Mercy ACO Commits to: 1. Employ fair process and transparency when making decisions that impact patients, physicians, and practices. 2. Provide feedback on practice utilization patterns based on reliable data, and ensure that performance-based metrics are aligned with stated goals. 3. Create an environment improve patient outcomes by providing IT systems, health coaches, care models, education, scorecards, and process improvement. 4. Develop appropriate financial recognition for those who engage in CIN activities. 5. Collaborate with physicians to achieve the ACO Mission: to improve health, improve care, and lower costs for the communities we serve.

40 Mercy ACO Vision Shared savings is not the end game Stepping stone to assuming risk The only way to reduce cost is to have healthier patients Volume based system penalizes you for healthy patients We must learn to capture the value we create Covered lives will be the measure of growth not hospital admissions ACOs align the reimbursement system with our mission and values Better Health instead of more services

41 Appendix

42 The Clinically Integrated Network Providers who join agree to work collaboratively to improve the health of the patients they serve CIN functions: Create a high degree of interdependence and cooperation among the physicians Evaluates the care provided by the CIN Creates programs to modify practice patterns to control costs an ensure quality Holds providers accountable Legal structure to accept and distribute funds to align incentives 42

43 CHI Trinity / CHE Mercy ACO Governance Structure Mercy ACO Data Commitee MHN BOD Mercy ACO BOD Mercy ACO CI Workgroup MHN CEO Council Mercy ACO Contracting & Finance committee Mercy ACO Care Mgmt Committee Central IA Chapter CIN Governance North IA Chapter CIN Governance Sioux City Chapter CIN Governance Dubuque Chapter CIN Governance Clinton Chapter CIN Governance Quality / PI Committee Quality / PI Committee Quality / PI Committee Quality / PI Committee Quality / PI Committee

44 Mercy ACO / MHN Management Structure CHI Iowa MHN BOD CHE / Trinity MHN CEO MHN ACO President MHN CAH Exec Mercy Des Moines President MHN Management Council Mercy North Iowa President Mercy Sioux City President Mercy Dubuque President Mercy Clinton President MMC Exec leadership team MNI Exec leadership team MHN ACO Leadership MHN ACO Clinical Integration Workgroup Local CIN Governance Leadership Local CIN Governance Leadership MHN ACO Staff CIN Quality / Care Mgmt Staff CIN Quality / Care Mgmt Staff Local CIN is responsible for local CI work: Quality across the continuum of the local market Care Management in the local market Local Network development and maintenance PI to help providers meet goals MHN CIN is responsible for: Statewide guidelines and care models Coach Training and standards Data management Performance monitoring Setting metrics and goals Contracting

45 UIHA Structural Overview Critical Access Hospitals Ability to become affiliates of the Non-Profit Membership Organization Mercy Health Network University of Iowa Health Alliance (Non-Profit LLC) Mercy Cedar Rapids Genesis Health System Membership Agreement UI Health Care Significant Physician Organization(s) Other Institutional Members Network Board Member Sub-Agreements Primary Care Network Care Delivery Management Insurance Initiatives/ Relationships Iowa HIE/ Data Solution Home Care Medicare ACO Shared Services Integrate Ancillary Services Clinical Services Ambulatory Facilities New Technology/ Innovation Required Sub-Agreements : -All members fund and work together on these initiatives - A priority focus for early evolution of the Alliance Optional Sub-Agreements : -Any two (or more) members can participate in these initiatives to build further value Three community systems were working together on population health and a commonly funded HIE data solution. University of Iowa Health Care was working separately on strategic positioning in its market and saw a need to align. The four parties came together and negotiated a corporate Membership Agreement to form an alliance. The Agreement defined how the parties would work together as a Network Board and established that members would enter into sub-agreements of two types: (1) Required and (2) Optional. Members built within the Agreement the ability to grow by adding other members over time. The Alliance also has the ability to establish affiliate relationships with Critical Access Hospitals as appropriate

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47 USA Health Care Spending is not Performance-Based Healthcare Spending per Capita vs. Life Expectancy in OEC Countries Japan USA Turkey Data Source: OECD

48 Future Revenue Sources $110 $100 $90 $80 Driven by Volume Not Price Per Unit $ $70 CF indexed to Health Ins Premiums: Up 178% $60 $50 $40 $30 CF Adjusted for Inflation: Up 33% $36.69 CMS RVU CF: Down 7% $51.40 $

49 Chapter Flow of Shared Savings Funds Mercy ACO Shared Savings and Quality Revenue 20% Shared Risk Pool Allocated by percent of ACO attributed lives 80% Performance Pool Allocated by performance on quality and cost metrics 30% subject to Shared Savings Quality Light- Switch 70% flows directly to Chapter based on individual provider PMPM performance Chapter Distribution Pool