Commercial ACOs: Trials and Tribulations

Transcription

1 Commercial ACOs: Trials and Tribulations June 12, 2015 Agenda: John Jenrette, MD, CEO, Sharp Community Medical Group Moderator Nancy Greenstreet, MD, Medical Director, Physicians Medical Group of Santa Cruz County Blue Shield ACO Stacey Hrountas, CEO, Sharp Rees-Stealy Medical Group Aetna ACO Richard Fish, CEO, Brown & Toland Physicians Cigna ACO Kooros Samadzadeh, DO, Medical Director, SeaView IPA Anthem ACO CO ACO Annual Master

2 Physicians Medical Group of Santa Cruz Nancy Greenstreet, MD Medical Director Reviewing Blue Shield Commercial ACO Physicians Medical Group of Santa Cruz Physicians Medical Group of Santa Cruz Santa Cruz Co. pop. 270,000 Independent Physicians Association (IPA) 250+ independent physicians network 20,000 HMO members 6 Commercial health plans 4 Medicare Advantage plans CO ACO Annual Master CO ACO Annual Master

3 BSC HMO/PMGSC/Dignity Health ACO Blue Shield of California Physicians Medical Group of Santa Cruz Dignity Health Dominican Hospital BS ACO collaboration almost 3 years All Blue Shield HMO members in the ACO Platform for change CO ACO Annual Master Financial Model Traditional HMO delegated contract Coordinated care - members assigned to PCP ACO agreement on top of HMO contract Upside and downside risk with limits Based on total cost of care Cost trend proposed for 2015 set at 3.6% Net experience closer to 4.5% Evolving goals, evolving parameters CO ACO Annual Master CO ACO Annual Master

4 Financial Incentives Aligned Dom Hospital has greater % risk than PMG SC Inpatient and Acute Rehab services at DH Local SNF services PMG SC has greater % risk than Dom Hospital Other hospital in Santa Cruz County Professional fees PMG SC and Dom Hospital have equal risk Out of area referred & emergencies Ambulatory Surgery Centers CO ACO Annual Master ACO Product Current BSC HMO ACO not a product, transparent to members Trio, BSC product, introduced 1/01/2015 Initially has 15K lives CO ACO Annual Master CO ACO Annual Master

5 ACO Collaboration Forum to discuss platform for change with BSC, Dominican Hospital, PMGSC Work group, Clinical group, Leadership group Bed Days, LOS, Readmissions, ED Intercept ED Usage Generic prescribing Care Coordination PMGSC Complex Case Management PMG Hospital Nurse Case Management Chronic disease management Diabetes CO ACO Annual Master Data Sharing BS provides rolling 12-mo data each month Data sharing not available prior to ACO Analyst/actuary available for review, drill down, provides comparisons & perspective Data from claims potentially evolving to more real time data Start with financial data, drill down to clinical drivers Actionable patient profiles - Diabetes, opioid overuse, readmissions, polypharmacy CO ACO Annual Master CO ACO Annual Master

6 Outcomes 1 st year - more opportunity for savings ED usage rate stabilized, 1-2 day stays 2nd year more challenging to identify savings opportunities Declining population = more data variability Areas for moving from traditional silos to collaboration Discharge planning, Home Health, Hospitalist incentives CO ACO Annual Master Thank You Thank you to our partners! Blue Shield of California Dignity Health/Dominican Hospital PMG Santa Cruz Physicians PMG SC Blue Shield Members PMG SC Administrative Staff CO ACO Annual Master CO ACO Annual Master

7 Sharp Rees-Stealy Medical Group Stacey Hrountas Chief Executive Officer Reviewing Aetna Commercial ACO Sharp HealthCare s Integrated Delivery System Largest health care system in San Diego with highest market share 2 affiliated medical groups: Sharp Community Medical Group and Sharp Rees Stealy Medical Group 4acute care hospitals 3 specialty hospitals Malcolm Baldrige National Quality Award Recipient, 2007 Largest private employer in San Diego 17,000 employees 2,600 affiliated physicians 2,300 volunteers Not for profit organization serving 3 million residents of San Diego County CO ACO Annual Master

8 Sharp Medical Groups SRS Multi-Specialty Medical Group Model SCMG IPA Model Total Physicians ,335 Nurse Practitioners/Physician Assts Commercial and Senior HMO Enrollees 177, , ,354 Anthem & Aetna Attributed Commercial ACO 20,326 15,656 35,982 members Locations 21 >250 Employees 2, ,265 Patient Mix (HMO/FFS) 70/30 60/40 First Capitated Contract Sharp ACO Collaborations Commercial PPO Patients SCMG SRSMG SHC Commercial PPO Patients SCMG and SRSMG hold separate agreements Effective Date August 1, 2013 Effective Date January 1, 2011 CO ACO Annual Master

9 Aetna/Sharp ACO Financial Model Shared savings Product and Attribution models have upside and downside opportunity Surplus is generated if: Product: Medical costs are lower than target Attribution: ACO trends is lower than market Quality gates Quality gate based on 6 Clinical Performance Measures (Aetna national adjusted numbers) Care Coordination Fees Payments included in any upside/downside calculations Top 5 Drivers of Performance surgical bed days/admits avoidable ER CT/MRI per 1,000 OP surgery steerage OP lab steerage Alignment of Population Attribution Retrospective look back for visits with a PCP in the last 12 months Excludes certain visits Future or Current Product Members in Product will be enrolled, no PCP selection required ACO to attribute Product members using its own processes Plan outreach to members ACO aligned members Non ACO aligned members Member engagement Product benefit design encourages network affiliation Delegation of CM and DM (not current state) CO ACO Annual Master

10 Delegated Activities Care coordination activities Robust reports No delegation currently Care management Collaborative process with inpatient/outpatient hand offs Disease management Seeking delegation for some programs Program design Balance of delegation with risk Data Topics Timeliness, actionable Slow start to get data into Sharp system Reports Plan reports continue to improve Clinical decision support tools Many steps to aggregate patient data Early outcomes Fully insured at surplus Self insured mixed results CO ACO Annual Master

11 Brown & Toland Physicians Richard Fish Chief Executive Officer Reviewing Cigna Commercial ACO Brown & Toland Physicians Providers in Independent Physician s Association Founded in 1992 Physician owned Serves over 300,000 patients in 5 San Francisco Bay Area Counties 500+ PCP s, Specialists ACO Population over 100,000 patients Senior Medicare Pioneer ACO 20,000 Commercial Cigna PPO 16,000 Aetna PPO 14,000 Blue Shield HMO 18,000 Blue Shield PPO 6,500 Anthem PPO - 26,000 CO ACO Annual Master

12 Cigna PPO ACO Financial Model Shared Savings Model Upside Risk only Based on Total Medical Cost Trend vs. Market Trend Quality gates Consolidated quality results for 60 measures compared to market trend, rather than benchmarked Shared savings adjusted based on ability to meet or exceed market quality trend Care Coordination Fees Pmpm amount provided to fund embedded care coordinator Care Coordination fees are adjusted annually based on Shared Savings Fees are included in the Total Cost of Care calculation Drivers of Performance Focus on Efficiency and Quality Metrics ER Visits, Ambulatory Surgery, Hi-Tech Radiology and Preferred, high quality, efficient Providers 60 evidence-based medicine measures trimmed down to 14 measures Program Highlights Clinical Management Collaboration Care Coordination Brown & Toland and Cigna Clinical Care Managers meet weekly for high-risk case review Monthly Operations meetings strengthen relationship Quarterly JOC meeting includes Brown & Toland and Cigna Medical Directors to identify savings opportunities Actionable Reports Suite of clinical and financial reports are provided quarterly Network Development Contracting opportunities pursued Preferred providers identified in terms of cost and quality CO ACO Annual Master

13 Alignment of Population Attribution Model Primary Care and OB s with 24-month claims lookback Quarterly attribution model with some patient churn. Member engagement High-risk members and those undergoing transitions of care are engaged by Brown & Toland care management team Customized member mailings for urgent care, disease management, etc. ACO Products ACO products in development Delegated Activities Delegated Activities Care coordination for high risk and transitions of care patients Collaborative Activities Brown & Toland Embedded Care Coordinator works with Cigna s designated care manager to identify best programs for patients Collaboration for care management, disease management, behavioral health, and pharmacy management Ancillary services steerage including high-tech radiology Benefit details are provided to help guide patients to appropriate services Opportunities for delegation Tighter integration of authorization process for high cost services Timely notification to primary care providers regarding out of network utilization Medical Management delegation for population management CO ACO Annual Master

14 Data Management Actionable reports Robust daily, monthly and quarterly reports are timely and actionable Clinical analysis conducted and opportunities shared during quarterly review meetings Customized reports provided upon request Designated analyst could be beneficial Clinical decision support tools - icollaborate patient management tool identifies opportunities for transitions of care and high risk patient management Early outcomes Excellent results in Year 2 beating the market trend by 5.4% with significant Shared Savings SeaView IPA Kooros Samadzadeh, DO Medical Director Reviewing Anthem Commercial ACO CO ACO Annual Master

15 SeaView IPA Independent Physician Association Located in west Ventura County - 47,000 HMO lives combined 120+ primaries and 250+ specialists 3 large PCP groups, 8 small groups, and many solo PCP s Multiple EMR systems not fully integrated Multiple hospital systems Anthem Blue Cross PPO ACO June, 2013 start date Attributed membership count variable in year one Currently at 14,000 lives for year two ACO Structure Attribution model Identifies the Primary Treating Physicians (PTP) in IPA s network Based on two years retro claims Shared savings (on the entire attributed population) No downside risk IPA s share of savings variable, based on Quality Metrics AND Engagement rate of 50% with the Targeted Membership (chronic conditions 2+/risk calculator 4+) Care coordination fees PMPM fee paid only on the 2+ chronic conditions Health plan member outreach - minimal CO ACO Annual Master

16 Data Sharing Flooded by information Predictive risk model reports Risk based on disease process (DxCG) Risk based on active deterioration (Hot Spotter) Risk based on readmission probability (RPM) Care opportunity gaps report Chronic condition report Pharmacy, radiology, and specialist utilization data ED and inpatient data Use of the HP Data Generic pharmacy PTP report card Radiology utilization PTP report card Target high risk population for care coordination ED utilization list Daily RPM report member outreach Physician outreach meetings Member mailings CO ACO Annual Master

17 Drivers of Performance Original vision (HMO mindset) How to apply an ACO product with HMO tools? Lower cost center diversion and disease management Reality (ACO mindset) Support the members keep them healthy! Outreach for the most vulnerable Tailored member education Joint provider visits by ACO CM and the member Support the providers keep them in the loop! Comparative reporting Quality metric and risk reporting EMR dashboard if clinics can support it Provider Outreach Member reports Quality care gaps reports Attributed members and predictive risk reports Referral for care coordination by risk (4+) Generic pharmacy and other utilization reports ED utilization access to care FFS model appeal quality care gaps for those without robust tracking system CO ACO Annual Master

18 Outcomes Not Diet HMO Lessons learned being applied into HMO activities Unexpected savings in first year Reduction in brand name use but increase in total Rx Reduction in bed days and admits but increase in LOS Reduction in outpatient facility utilization Slight increase in professional claim costs but reduction in visits Dramatic increase in membership for year two Increase potential for savings with higher membership More stable membership count in year two Responsive HP to contract adjustments Questions? CAPG Commercial ACO Committee Co-Chairs John Jenrette, MD, CEO, Sharp Community Medical Group Marvin Labrie, CEO, Physicians Medical Group of Santa Cruz Contact Steve Linesch, SVP, CAPG CO ACO Annual Master