Accountable Care Organizations: Implications for CHCs Serving AA&NHOPIs

Transcription

1 Accountable Care Organizations: Implications for CHCs Serving AA&NHOPIs Practice Transformation Webinar Series Webinar 4 April 29, 2015 Moderator: Nina Agbayani, Director of Programs

2 About AAPCHO National association of 35 community health organizations serving Asian Americans, Native Hawaiians, and other Pacific Islanders (AA&NHOPIs). Dedicated to improving the health status and access of these medically underserved communities ACOs: Implica0ons for CHCs Serving AA&NHOPIs 2

3 Practice Transformation Webinar Series To provide latest information on practice transformation Information on quality improvement, meaningful use, accountable care organizations, and patient centered medical homes Impact on community health centers serving Asian Americans, Native Hawaiians and other Pacific Islanders ACOs: Implica0ons for CHCs Serving AA&NHOPIs 3

4 Speaker Ignatius Bau Health Policy Consultant ACOs: Implica0ons for CHCs Serving AA&NHOPIs 4

5 Housekeeping ACOs: Implica0ons for CHCs Serving AA&NHOPIs 5

6 Accountable Care Organiza2ons: Implica0ons for Community Health Centers Serving Asian Americans, Na0ve Hawaiians and Other Pacific Islanders Associa2on of Asian Pacific Community Health Organiza2ons April 29, 2015

7 Outline of Today s Webinar What is an accountable care organiza0on? What are the requirements for the Medicare Shared Savings Program ACOs? What other federal, state, and commerical ACO models are being implemented? What are the implica0ons for CHCs serving AANHOPIs?

8 PATIENT EXPERIENCE OF CARE POPULATION HEALTH REDUCED COST

9

10 Medicare Fee- for- Service Physician Group Prac0ce Demonstra0on Authorized in 2000, began 2005 Was three year demonstra0on, extended to five years Ten large (>200 physicians) medical groups Over 220,000 Medicare beneficiaries S0ll fee- for- service but addi0onal pay- for- performance incen0ves ( shared savings )

11 Medicare Fee- for- Service Physician Group Prac0ce Demonstra0on Shared savings if medical groups met both quality improvement and cost reduc0on goals 32 quality measures (phased in over three years, all outpa0ent measures) Cost reduc0on goals based on past three years of costs (trend- based benchmark, plus na%onal growth rate, risk adjusted)

12 Medicare Fee- for- Service Physician Group Prac0ce Demonstra0on Iden0fy or assign beneficiaries based on where they received plurality of primary care services (beneficiaries retain choice of any fee- for- service providers) Accountable for quality performance for assigned beneficiaries Use total costs (outpa0ent, inpa0ent, all billings) for assigned beneficiaries

13 Medicare Fee- for- Service Physician Group Prac0ce Demonstra0on Pa0ent registries, electronic health records, dashboard reports to providers, health status reports for beneficiaries Increased use of evidence- based guidelines and decision support Developing individual care plans Care coordina0on, disease management, and case management Increased use of nurses on care team and as care managers

14 Medicare Fee- for- Service Physician Group Prac0ce Demonstra0on Mo0va0onal interviewing and educa0on of beneficiaries, pa0ent self- management Medica0on reconcilia0on Coaching at hospital discharge and other transi0ons of care; early/proac0ve physician follow up a^er discharge Home- based monitoring, computerized telephonic monitoring Community- based crisis interven0on services Pallia0ve care

15

16 Medicare Fee- for- Service Physician Group Prac0ce Demonstra0on All ten medical groups met quality goals But only five medical groups met cost reduc0on goals to achieve shared savings Those five medical groups received ~$32 million in shared savings (for the 220,000 Medicare beneficiaries)

17

18 Pa0ent Protec0on and Affordable Care Act

19

20

21

22 POLL QUESTION Are you aware of any Medicare Shared Savings ACOs opera0ng in your service area? YES or NO

23

24 Medicare Shared Savings ACOs Specific governance requirements for ACO (board = 75% par0cipa0ng providers and at least one beneficiary) May need state license(s) to operate as health insurer, contract with health care providers, etc. Must address an0trust and other legal issues in crea0on

25 Medicare Shared Savings ACOs Any Medicare provider can par0cipate in or create an ACO, including FQHCs But assigned/ aligned Medicare beneficiaries based only on primary care physicians in the ACO Each ACO must have at least 5,000 aligned Medicare beneficiaries Funded for a three year program/cycle

26 Medicare Shared Savings ACOs 33 quality measures: pa0ent experience, care coordina0on, pa0ent safety, preventa0ve health and condi0on- specific: diabetes, conges0ve heart failure, coronary artery disease, hypertension, chronic obstruc0ve pulmonary disease, fall risk, osteoporosis, warfarin dosing First year is just pay- for- repor0ng

27 Medicare Shared Savings ACOs Cost benchmark: past three year trend, plus na0onal growth rate, risk adjusted Actual cost based on retrospec0ve alignment of beneficiaries (same method of iden0fying primary care physicians, then pa0ents with plurality of outpa0ent primary care services, then total costs for those beneficiaries)

28 Medicare Shared Savings ACOs Must meet both quality improvement and cost reduc0on goals for shared savings Track 1 One- Sided ACO: no risk of loss in first two years, can share savings up to 7.5% of benchmark; must convert to Track 2 Two- Sided ACO in third year Track 2 Two- Sided ACO: risk of loss all three years - can share savings up to 10% (and risk losses up to 5%)

29 Medicare Shared Savings ACOs First 114 Medicare Shared Savings ACOs (2012) improved quality on 30 of 33 measures 58 achieved shared savings of $315 million More Medicare Shared Savings ACOs start each year; 89 began in January 2015 Now 4.9 million beneficiaries in >330 Medicare Shared Savings ACOs in 47 states, including one all- CHC ACO

30 Medicare Shared Savings ACOs Highly complex to manage/be accountable for assigned beneficiaries who can use any provider ( leakage from ACO) Retrospec0ve assignment, measures, and benchmarks make proac0ve interven0ons challenging Lots of measures, only one year to improve Importance of post- acute and long- term care, and of beneficiary engagement

31

32 Proposed Changes to Medicare Shared Savings ACOs Allow assignment if nurse prac00oner or physician assistant is primary care provider Only 5 ACOs are using Track 2 (with shared losses) so new Track 3 (higher shared savings than Track 1, prospec0ve assignment of beneficiaries) Considering adjustments to benchmarks Beneficiaries must affirma0vely opt- out of sharing data with ACO

33 Pioneer ACOs Authorized by CMS in 2011 Requires even larger number of assigned Medicare beneficiaries (15,000) Two- sided risk for all 3 years, can share savings up to 10% of benchmark In first year, 32 Pioneer ACOs improved quality on 28 of 33 measures Only 11 had $68 million in shared savings Only 23 have con0nued in Pioneer ACO

34 Next Generation ACOs Just announced March to be awarded later in 2015; current Medicare ACOs can apply to switch Beneficiaries can choose assignment (and be paid $50/year by CMS) Some regional adjustments to benchmarks, as well as for already efficient ACOs ACOs can offer enhanced benefits (home visits, telehealth, skilled nursing)

35 Medicaid ACOs State Medicaid programs crea0ng ACO models using Medicaid state plan amendments, 1115 waivers, State Innova0on Model, and other funding Examples: Coordinated Care Organiza0ons in OR, Regional Care Collabora0ve Organiza0ons in CO Ques0ons about appropriate quality measures for Medicaid beneficiaries

36 19 states

37 Commercial (private) ACOs Formed by combina0ons of hospital systems, large physician groups, health plans, large employers (>200 and coun0ng) Rapid growth (with and without health plans) Many different shared savings formulas Challenges in determining total costs of care when not just Medicare Ques0ons about appropriate quality measures for commercial insured

38 POLL QUESTION Are you aware of any other types of ACOs opera0ng in your service area? YES or NO

39 NEWS FLASH: Alternate payment models are a core element of new Medicare physician payment formula

40 What are the implica0ons for CHCs serving AANHOPIs? Context of less uninsured a^er 2014: focus will shi^ from access to improving quality and reducing cost ( value ) More Medicaid and more commercial insured from health insurance marketplaces Think of medical homes and shared risk/ savings as likely models, then requirements, for quality improvement and cost reduc0on in the future

41 What are the implica0ons for CHCs serving AANHOPIs? ACOs are s0ll a grand experiment, and con0nue to evolve May have different names (shared risk/ savings, gain- sharing, value- based payments, alternate payment models) Common elements of combining quality improvement and cost reduc0on S0ll cos0ng more than global capita0on

42

43

44 What are the implica0ons for CHCs serving AANHOPIs? All ACO models built on electronic health records and health informa0on exchange So focus first on EHR adop0on and maintaining eligibility for CMS payments under HITECH Act Meaningful use requirements aligned with both medical homes and ACO requirements

45 What are the implica0ons for CHCs serving AANHOPIs? Then focus on your prac0ce transforma0on/ quality improvement through medical homes (all ACOs are based on primary care) Iden0fy areas for quality improvement Test which quality improvement interven0ons work for your pa0ents Work on increased engagement with both your staff and your pa0ents

46 What are the implica0ons for CHCs serving AANHOPIs? At least 30 CHCs are par0cipa0ng in Medicare ACOs Monitor Medicare and private ACOs opera0ng in your service area Medicaid ACOs might be more relevant, even if not called ACOs Unclear how ACOs can improve care for AANHOPI and dispari0es popula0ons

47 Three AAPCHO members have formed an ACO in Hawaii

48

49 Questions and comments? Final webinar in series: April 29: Culturally and linguistically appropriate services and practice transformation