Primary Care is Gate Keeper in ACO s

Transcription

1 Shared Savings: Accountable Care Organiza:on and Impact on Quality and Dollars Nancy May, MSN, RN- BC, NEA- BC Baylor ScoP and White Health Central Division Session 114 What is an Accountable Care Organiza:on A partnership among health care providers to coordinate and deliver efficient care for three years Accountable for quality, cost, overall care to Medicare Beneficiaries Must embrace a team based approach for care coordina:on Medicare Shared Savings Program (MSSP) Rewards with incen:ve payments if cost reduced for care delivery is below a specified benchmark What is an ACO? An ACO is an Accountable Care Organiza2on providers (physicians, hospitals, others) working together to manage the health, cost and outcomes of a popula=on of pa=ents Legal structure to disburse incen:ve payments to members within the group Provide care for at least 5000 pa:ents for three years ACO is popula:on health for Medicare Fee- for Service Beneficiaries are assigned to par:cipate from their physician off the assigned TIN through Medicare Pa:ents can opt out of being part of data sharing during data evalua:on Primary Care is Gate Keeper in ACO s Current State of Health Care Fragmented Care Focus on preven:on and wellness Reduc:on of readmissions Reduc:on of hospital acquired condi:ons Reimbursement :ed to Value Based Purchasing Compara:ve effec:veness using EBP guidelines Reduces cost Improves quality and value of care provided Oncologist Chemo Radia:on Breast Surgeon Primary Care Pathologist Radiologist 1

2 History of ScoP and White Healthcare ScoP and White: An integrated healthcare system that is governed as a group prac:ce model Heavy Primary and Internal medicine base Over 100 year history of cost effec:ve care HMO model in the 80 s Owns it s own health plan Covers 29,000 sq miles in Central Texas Serves rural community sehngs at over 80 sites. Over 3 million visits annually ACO Journey ScoP and White merged with Baylor in 10/13 Baylor, Dallas also is part of a different ACO ScoP and White partnered with Walgreens to build their ACO Partnership for the Medicare Shared Savings Program or MSSP. This talk will not include discussion of Pioneer ACO s Who is included? All Medicare Part A & B Pa=ents receiving care from employed S&W physicians under the Clinic TIN (~37,000) Leveraging Exper:se to Improve Outcomes Walgreens Execu:ve speaks Why a partnership for S&W: Baylor ScoM & White and Walgreens can leverage respec=ve areas of exper=se and resources to enhance care delivery and improve outcomes Walgreens Well Network offers: Current and long term strategic partnering opportuni:es Tools for care coordina:on, clinical integra:on, predic:ve modeling Na:onwide, integrated network of health and pharmacy neighborhood loca:ons with convenient access for pa:ents Established pa:ent rela:onships and service exper:se An addi:onal touch point for our pa:ents Support with start- up Interview with thinkprogress.org Jan 11,

3 Why Walgreens? Fortune magazine World's Most Admired Companies (published March 2013) Walgreens ranked No. 5 among food and drugstores and has been listed for the past 20 consecutive years. Fortune magazine 500 Largest U.S.-Based Companies (published May 2013) Walgreens ranked 37th overall in revenue, 3rd among food and drugstores. Fortune magazine Global 500 Largest Companies (published July 2013) Walgreens ranked 120th overall in revenue. Forbes Global 2000 (published April 2012) Walgreens ranked 220th on this list of the 2000 largest public companies worldwide. Why partner with a pharmacy? 32 percent of adverse events leading to hospitalization are due to medications, and only 33 to 50 percent of patients with chronic conditions adhere to their prescribed medication therapies. Data suggests that Medicare beneficiaries with multiple chronic illnesses see on average 13 different physicians, fill 50 prescriptions each year, account for 76 percent of all hospitalizations and are 100 times more likely to have a preventable hospitalization than those with no chronic illnesses. Pharmacists play an important role in achieving desired therapeutic outcomes while promoting cost-effective medication management (Academy of Managed Care Pharmacy, April 2011) 1 4 Why Walgreens? Integra:on with the Medical Community ALTERNATIVE TO BUSY } Open 7 days a week evening, weekend, and holiday coverage PCPs AND OVERBURDENED ER } Walk-in option or access facilitated via online appointment scheduling EASIER AND EARLIER ACCESS TO HEALTHCARE } Encourages preventive care, particularly for those individuals without a PCP and/or in underserved areas } NPs counsel and help patients connect to a medical home approximately 50% of clinic patients do not have a PCP } Refer approximately 10% of our patients (out of scope services) INTEGRATION OF CARE OF PCPs } Copies of record given to all patients } Visit summary sent to PCP, with patient consent, via Efax } Future EMR data transfer Each day 6,000,000 customers 8,117 drugstores All 50 states, District of Columbia, Puerto Rico. GROWING HEALTH } Today: overflow and after hours options for primary care patients, immunizations, and ER SYSTEM AND PHYSICIAN diversion GROUPS AFFILIATIONS } Future: coordinated management of chronic patients and preventable hospital admissions and re-admissions 2012 Walgreen Co. All rights reserved. Confidential and proprietary; should not be re-produced or re-distributed. Opportuni:es Opportuni:es Leverage Walgreens capital and building infrastructure for health and wellness services to support every patients Health screens Hypertension, Foot exam, obesity Medication Management Lab Draws for LDL & HbA1c Group nutritional classes Group DM Management classes Alternative therapies massage, reflexology, yoga Provide all patients convenient tools for self management 3

4 Partnership: Proposed Phases Phase I Selected quality metrics (ACO) Preven:ve Screening & Counseling at Walgreens Immuniza:ons Shared data warehouse Phase II Healthcare Clinics S&W providing oversight Phase III Popula:on health management Transi:on to pay- for- performance model (Affordable Care Act) Ongoing management of chronic illnesses Dr. M. Reis Chairman John Kotlarczyk, Jr. Compliance Director* LEGEND: High- level Organiza:onal Chart: ACO Management Team GOVERNING BODY Physician Group Walgreens Patient Tiffany Berry, M.D. Terry Rascoe, M.D. John David (Jack) Myers, M.D. Michael D. Reis M.D. Michael Averitt, D.O. Justin Johnson Operations Director CMS Mandated* Board of Directors Dr. J. Kang Vice Chairman Frank Koen, RPh Jeff Kang, M.D., MPH Leslie Pafford, PhD., RN, FNP-BC Dr. Jeff Kang Executive Officer* Michael Averitt, D.O. Medical Director* David Ellenbogen Secretary Provided by SW Kenneth Mays Julia Shrabman Finance Director Julia Shrabman Treasurer Provided by WAG Mary Kielty Comm. Director Quality Metrics to Improve On Areas of Focus on Quality Total of 33 Metrics v Pa:ent Caregiver Experience v Care Coordina:on/Pa:ent Safety v Health for Popula:ons v Preven:ve Health v At Risk Popula:ons v Diabetes v CAD Pa:ent Experience Pa:ent/Caregiver Experience CAPHS Timely Care Doctor Communica:on Access to Specialist Ra:ng of Doctor Shared Decision Making Func:onal Status THE FACTS WHO WHAT WHEN WHY HOW Official CMS ACO CAHPS Survey Overview CMS OFFICIAL ACO CAHPS SURVEY CMS Sponsored ACOs - Pioneer and MSSP Press Ganey is administering for Pioneer ACOs, Rand is administering for MSSP ACOs Press Ganey anticipates we will be a certified vendor for MSSP Standard way to measure the patient experience CGCAHPS + Primary Care Themes 6 month retrospective timeframe ü Access to Specialists ü Health Promotion & Education ü Shared Decision-Making ü Care Coordination ü Education about Medication ü Care Coordination ü Stewardship of Patient Resources ü Between Visit Communication ONE time per year: January-March Impacts 25% of their ability to share in savings Pre notification letter, 2 waves of mail, 6 phone attempts, 860 patients contacted Quality Metrics Care Coordina:on/Pa:ent Safety Readmission COPD CHF Integrated EMR Medica:on Reconcilia:on aler discharge from facility Falls Screening $$ This is an additional contract and charge. 4

5 Quality Metrics Quality Metrics Preven:ve Health Influenza Immuniza:on Weight screening Tobacco Assessment/Cessa:on Depression Screening Colorectal Cancer Screening Hypertension Screening Diabetes HbA1C control At Risk Diabetes Popula:on LDL <100 Blood Pressure< 140/80 Tobacco non use ASA use HbA1C (poor control >9) Quality Metrics Hypertension Control Coronary Artery Disease Drug therapy to lower LDL Angiotensin Conver:ng Enzyme ( ACE) Heart Failure Use of Beta Blocker for Lel Ventricular Systolic Dysfunc:on (LVSD) Ischemic Vascular Disease IVD: Complete Lipid Profile with LDL<100 Use of ASA or other an:- thromblic agent Angiotensin Receptor Blocker (ARB) for pa:ents that are diabe:c with LVSD Quality in the ACO?? Project Goal: Triple Aim Improve the health of given popula:on Enhance the pa:ent experience (improved quality, access, and sa:sfac:on) Deliver at a reduced per capita cost Year 1 Quality repor=ng only Year 2 Success in 25/33 measures Year 3 Success in 33/34 measures * If ACO meets Quality Standards, then it is eligible for Shared Savings Closing the Gaps on Metrics Closing the Gap on Metrics ACO will improve patent outcomes & reduce cost by: Maintain pa:ent- centered focus Developing processes to promote evidence- based medicine Promo:ng pa:ent engagement Internally repor:ng on quality and cost Coordina:ng care Step1: Define B S & W ideal process Step 2: Implement B S & W ideal process Step 3: Monitor results, iden:fy and make needed modifica:ons Care Coordina=on/ Pa=ent Safety ACO 9: Chronic Pulmonary Disease or Asthma in Older adults ACO 10: Conges:ve Heart Failure Preven=ve Care ACO 14 Influenza Immuniza:on ACO 15 Pneumonia Vaccina:on ACO 17 Tobacco Screening and Cessa:on Interven:on ACO- 20 Screening Mammography At Risk Popula=on Domain ACO 28 Controlling Hypertension 5

6 Proposed System- wide Work Groups Year 1 (2013) Workgroups Care Process Delivery Work Group End of Life Work Group CHF Work Group COPD Work Group Chair: Dr. Rascoe Lead: Kim Langston Lead: Dr. Erwin Lead: Dr. Barker Mammogram COPD End of Life Care Influenza Pneumonia CHF HTN Tobacco Screening and Cessa:on Approximately 100 Baylor ScoP & White staff members have par:cipated in ACO planning, implementa:on, and work groups Building the Work Groups Charters developed Descrip:on of indicators for 7 metrics with nominator and denominators iden:fied Time line defined Gehng Started Hired Project Manager Care Coordinator Regular Scheduled CommiPee Mee:ngs Strategy team, Quality Team, Nursing Directors, par:cipated in mee:ngs Used SCIO Tool to iden:fy High Risk Pa:ent to tract Pulled list of beneficiary off Medicare Claims data Sent lepers to the beneficiaries on ACO Care Coordinator RN with Ambulatory and previous Case Management background Visited Primary Care and Internal Medicine clinics and obtained hand off informa:on from charge nurse. Started reviewing all data on admissions into hospital to iden:fy ACO pa:ents Role of Care Coordinator Follows up with all high risk pa:ents iden:fied in SCIO that will be discharged to home Coordinates discharge needs: Return to Clinic appointments Coordina:on of DME Set s up Home Care if applicable Reviews medica:on list with pa:ent and family Does Teach Back techniques Preforms Hand Off to clinic nurse 6

7 Follow up Care Clinic Reviews any change in medica:ons and instruc:ons with pa:ent Calls pa:ent biweekly to ensure they are on tract or as needed. Checks admissions daily to ensure pa:ent not admiped. If pa:ent admiped, contact Care Coordinator Gives pa:ent numbers to call if any ques:ons come up. One Year Later Reimbursement or Shared Savings Results for the work Pay for performance How to extrapolate the data PQRS & GPRO Incen:ves Overview of GPRO Group Repor:ng 15 Modules, consis:ng of 22 total measures CMS provides case lists Cases assigned to TIN based on plurality of care and visit charge codes Minimum 411 consecu:ve ranked cases must be submiped for each module (6,165 total cases) 8 week submission period (Feb 15 April 15) Web- based interface developed by CMS for data submission Manual abstrac:on/data entry Electronic Health Record file upload ACO Performance Data GPRO PQRS- ACO Based off claims data pulled from Medicare PQRS Group Repor:ng GPRO annual data pull for incen:ve program Medicare Primary Care Physician is responsible for care coordina:on Insurance Companies Aetna Un:ed Health Well point ACO s are required to report out on 33 Quality metrics GPRO PQRS measures are included within the 33 measures Submission and :melines for ACO GPRO PQRS is the same as non ACO groups 8 weeks submission ( Feb 15- April 15) 7

8 Medicare Shared Savings Program (MSSP) How it Works Yes No Savings of X % Realized Did ACO Meet the 33 Quality Measures? No Shared Savings Medicare spending has increased over the past few years at about 7% PMPY Assume annual spend as $8000/yr for the first ACO year Based on 3 year look back Disperse Savings of X % CMS Receives X% / 2 Yes ACO Receives X% / 2 Did ACO Meet Statistical MSR Hurdle? ACO Partner 1 Receives 50% of (X %/2) operating costs (X% / 2) minus operating costs ACO Partner 2 Receives 50% of (X %/2) operating costs No No Shared Savings As long as opera:ng costs are less than 1% of premium dollars then there will always be shared shavings if ACO meets quality measures and sta:s:cal hurdle. In that first ACO year, na=onal Medicare spending increases 6.0%, ($10,000 $10,600) Our expected spend would then be $ $600 = $8,600 YOU USE THE ABSOLUTE Nat l NUMBER, NOT THE PERCENTAGE If we spend $7900 over the first year We would make the hurdle rate, as we saved more than 2.5% of $8,600 We would save $700 per azributed member If we have 30,000 amributed lives we would receive (before covering startup and opera=ng costs) $21M/2 = $10.5M Shared Savings for Dummies Don t Get Stuck $$$$$$$$$$ Na:onal Medicare Costs S&W Costs hpp:// +on+the+escalator+video+high +resolu:on&form=vire12#view=detail&mid= E724C3EADD29B E724C3EADD29B Year 1 Year 2 Year 3 CMS takes S&W three year average of PMPY costs, applies a hurdle rate (2+%) and then sets benchmark. If ACO PMPY falls under that benchmark, then CMS will distribute half of those shared savings Promotes Integra:on of Care Monthly/Annual payments Incen:ves for Quality(PFP) Establish standard of care for pa:ent popula:on Integrates Services Benefits of ACO Ends fragmented care Ends fee for service Ends excessive u:liza:on Ends lack of medical necessity Contracts services to ACO to treat and referrer to Primary Care Year 1 (2013) Accomplishments Par:al Lis:ng: Ø Successfully created the ACO en:ty, completed all CMS enrollment requirements, and established partnership between S&W and Walgreens Ø Created a data warehouse that successfully receives both claims files from CMS and care data from the medical record Ø Built reports using that data to track progress on quality and stra:fy pa:ent popula:on using risk scores Ø Ini:ated a number of clinical programs, included but not limited to: Complex Case Manager at Memorial Mammo screening and Pneumovax drives Automa:c Pulmonary Appointment Best Prac:ce algorithms and provider educa:on around HTN Improved informa:on for comple:on of advanced direc:ves Stra:fica:on of pa:ent popula:on S&W Pharmacy implemented Bedside Medica:on Delivery at Memorial and is expanding 8

9 Year 2 (2014) Ini:a:ves Ques:ons Par:al Lis:ng: Ø Create a preferred partners list for Post- Acute facili:es based on quality Ø Iden:fy and engage high risk pa:ents using data and risk scores Ø Simplify and clarify the It s Your Choice blue book, improve Advance Direc:ve Planning, and promote beper end- of- life experiences for pa:ents and families Ø Increase medica:on adherence with pharmacy partners Ø Create automa:c follow up appointments and consults for certain high risk pa:ent groups Nancy May, MSN, RN- BC, NEA- BC Baylor ScoP and White Health Central Division 2401 S. 31 st Street Temple, Texas