PIONEER ACO A REVIEW OF THE GRAND EXPERIMENT

Transcription

1 PIONEER ACO A REVIEW OF THE GRAND EXPERIMENT Norris Vivatrat, MD Associate Medical Director Monarch HealthCare 2 Agenda Pioneer ACO basics, performance and challenges Monarch HealthCare Post-acute network ACO next steps and 3-day-rule waiver 1

2 3 Only a third reduced costs 4 Pioneer ACO Basics Launched by CMS Innovation Center, which was formed as part of Patient Protection and Affordable Care Act Began January 1, 2012; a 3-year agreement that can be extended 2 additional years 5 financial models with varying degrees of shared risk Competitive process with only 32 sites selected Dissemination of best practice with other ACOs expected Pioneer ACOs must pass quality gate to be eligible for shared savings 2

3 5 Results at one year 669,000 beneficiaries $87.6 million in savings 2012 All 32 Pioneers improved in quality and satisfaction measures 13 Pioneers qualified for shared savings 25 of 32 Pioneers generated lower readmission rates than benchmark 9 Pioneer ACOs dropping out, 7 to Medicare Shared Savings Program (MSSP), 2 leaving program 6 Why so hard? 3

4 Pioneer ACO Challenges Performance Year 1 Anticipated Challenges Fluid patient alignment No managed care tools (authorizations, referrals, limited network) No prospective payment, and no guarantee of shared savings Provider and patient understanding and engagement Unanticipated Challenges Claims lag and new claims data formats Significant out-of-network utilization 87% of ACO patient encounters were with unaligned physicians Limited capacity to manage out-of-network utilization Patient self-referral rate estimated to be between 60% and 80% Patient identification at point of care Monarch had to invest in new tools to manage the unaligned network 33 Pioneer ACO Quality Domains & Measures CAHPS Survey Measures Timely Care & Service Communication Rating of Doctor ASC Admits Readmissions Fall Prevention Patient/ Caregiver Experience Care Coordination & Patient Safety Preventive Health At-Risk Populations Mammograms Colorectal Cancer Screening Flu Shots Treatment for IVD, HF, Hypertension Diabetes & CAD Composite Measures Year 1 Report Only Year 3 Performance Year 2 Performance 4

5 Population Measures Admissions per thousand (ADK) Bed days per thousand (BDK) Population ADK BDK National Average Medicare FFS California Average Medicare FFS # of admissions or bed days per 1000 members of a given population in a year CA Medicare Advantage Monarch Medicare Advantage CAPG s Elite Groups MA <220 <800 Updated to 2010, from CMS &SDI 2012, Compiled by Managed Care Digest Series Monarch and Pioneer Baselines Level of Care Population ADK BDK ALOS Readmission Rate Acute Skilled Medicare Advantage % ACO % Medicare Advantage % ACO % PY2 population,

6 Monarch and Pioneer Baselines Level of Care Population ADK BDK ALOS Readmission Rate Inpatient Rehab Long term acute Medicare Advantage ACO Medicare Advantage ACO % PY2 population, MONARCH HEALTHCARE Background and Pioneer ACO Performance 6

7 Monarch HealthCare Independent Practice Association (IPA) formed in 1994 as aggregation of three predecessor IPAs 750 PCPs, 1,600 specialists Employed Physician Group, 100 providers Affiliated with Optum Health Collaborative Care along with MHIPA, August Membership 7

8 15 Monarch Pioneer ACO 2013 Alignment 300 PCPs, 50 SCPs 21,856 Beneficiaries Performance Year 1 Results Quality Performance Top performer in several Patient/Care Giver Experience metrics Monarch scored highest in Physician communication with the patient and Patient overall satisfaction with their physician Top performer in several Care Coordination/Patient Safety metrics Monarch scored highest in prevention of admissions for ambulatory sensitive conditions Medical Cost Reduction 2 nd highest performer in the Pioneer program in PY1 Monarch reduced medical cost -5.4% in 2012 from its baseline, while national medical cost grew +1.1% for a comparable population This favorable expense trend was driven by primarily by reductions in hospital and SNF utilization and unit costs 8

9 Key Drivers for Shared Savings 0.0% -0.5% -1.0% -1.5% -2.0% -2.5% -3.0% -3.5% -4.0% -0.7% % Contribution to YOY Change in Medical Cost PY1 ACO Beneficiaries to 2012 Inpatient Physician Outpatient SNF HHA DME Hospice Total -0.6% 0.0% -2.2% 0.1% -0.1% 0.7% -2.8% Actual medical cost declined 2.8% from 2011 to 2012 Driven in large part by lower SNF cost Inpatient and Physician expense both declined YOY Offset in part by increasing ospice expense Key Success Drivers 1. Network Selection Invited a narrow list of top performing physicians (mostly PCPs) to participate in ACO (vs. shotgun approach) 70% of aligned network on common EHR platform 2. Performance-Based Incentives Incentives for PCPs to perform an Annual Wellness Visit, complete a Health Risk Assessment, and perform key health screenings for each attributed patient 3. Targeted Care Management Identification of high risk patients using Optum risk stratification tools and actuarial services Provide access to care navigators, dedicated case managers, home visiting physicians, and personalized pharmacy care 9

10 Developing the Hot List : Multiple Chronic Diseases Across the entire ACO, patients with 2 or more chronic conditions represented 37% of the population and over 85% of medical cost Cumulative Percent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Distribution of Membership, Paid Claims, and Average PBPY Paid Claims, by Count of Chronic Diagnoses $ # of HCCs/Beneficiary Cumulative Percent of Beneficiaries Cumulative Percentage of Total Paid Average Paid (PMPY) $250 $200 $150 $100 $50 Average Paid PBPY ($ Thousands) * Data from Monarch Pioneer ACO 2012 claims experience Key Success Drivers 4. Physician Tools Practice Connect Proprietary point-of-care web interface which displays a summary of a patient s 12-month medical history Highlights significant clinical events such as recent hospitalizations or ER visits Identifies patient diagnoses, recent lab results, and required preventive screenings Annual Senior Health Assessment (ASHA) Document is mostly completed by patient in the form of a pre-exam survey and reviewed by physician with patient during Annual Wellness Visit Addresses comprehensive list of patient screenings required for comprehensive care of a senior and addresses majority of ACO quality metrics 10

11 Go-Forward Strategy Improve specialist engagement Acknowledge specialists as principal care givers and treat them like PCP for chronically ill Identify high performing mini-networks of physicians and experiment with performance-based incentives Promotion of price and quality transparency Publication of specialist clinical outcomes and relative episodic performance to the physician network and to patients Publication of comparative facility and provider cost and quality performance Invest in partnerships with hospitals, post-acute facilities, and ancillary vendors 22 ACO Performance Takeaways Pioneer ACO about innovation, not just savings Anticipated and unanticipated problems Downside risk and significant up-front investment Local market conditions important to chances for success Opportunity to interact with CMS/CMMI 11

12 23 POST-ACUTE NETWORK 24 Post-Acute Network Asks All Monarch Performance and accountability Encourage use of Monarch wrap-around services Data sharing Fair patient selection Specific to ACO Identification at point of care Collaboration on traditional Medicare FFS patients ACO messaging 12

13 Care Management Across the Continuum Care Manager (RN) Primary clinical contact for noncomplex patients in active case management Care Navigator Primary contact for the patient, responsible for triaging care needs, and coordinating services Care Navigator Care Manager Complex Care Complex Care Manager (RN or NP) Primary clinical contact for complex patients in active case management or disease management Primary Physician Patient s principal care giver; May be PCP or specialist depending upon patient disease profile Primary Physician ACO Patient Behav. Health Complex Care Manager, Behavioral Health (LCSW) Conducts special assessments for behavioral health Palliative Care Manager Palliative Care Manager can be engaged by physician, by patient s family, or by patient following consultation Palliative Care Dietician Community Support Community Services Coordinator Coordinates community and social services (transportation, nutritional programs, pharmacy assistance, etc.) Nutritionist / Dietician Develops tailored nutritional plans for patients Additional Patient Support: Pharmacist/Pharm.D. Performs post-discharge med rec telephonically Monarch Medical Directors, Hospitalists, & SNFists Patient Assistance Line - 24/7 telephonic availability 26 Monarch Support to Post-Acute Network Sharing knowledge Facility-specific Unblinded Actionable data Cost information Communication Advocacy with other partners 13

14 27 Right Care at the Right Time: Inpatient Rehab and Long-term Acute Appropriateness Accountability for LOS Discharge planning Communication Outcomes data 28 NEXT STEPS? 14

15 29 3-Day Rule Waiver Current law: Medicare SNF benefit requires a prior inpatient hospital stay of three days or more SNF 3-day rule Pioneer ACOs eligible to apply for waiver of 3-day rule to begin early 2014 Why Pioneer ACOs? Partner SNFs part of application and need to be 3 stars and above in CMS 5-star quality-rating system 30 Opportunities for Waiver Monarch experience with waiver through Medicare Advantage ED transfer, 10% Observa on, 14% Custodial, 2% Clinic, 2% Inpa ent, 72% Potential for hospitalization prevention LOS benefit - 17% of Monarch admits to SNF from inpatient had LOS under 3 days 15

16 31 Discharge Disposition by Admission Source SNF admits from hospital Other, 2% Hospice, 3% Transfer to acute, 14% ALF/B&C, 15% SNF admits from ED or home Other, 3% Hospice, 2% Home, 54% Custodial, 6% Transfer to acute, 15% ALF/B&C, 19% Home, 54% Custodial, 7% 32 ACO Next Steps Potential for new applicants Population-based payment Innovation 3-day waiver??? Building on ACO and MSSP successes 16

17 33 THANK YOU Norris Vivatrat, MD Monarch HealthCare 17