Johns Hopkins PCMH-ACO Roundtable Minutes 1/17/12 Compiled by: Meghana Gadgil Dr. Gary Noronha welcomed the Roundtable members in Dr. Brancati s absence. We began our discussion with a presentation by Dr. Scott Berkowitz, Assistant Professor in the Division of Cardiology and Medical Director for Accountable Care. JHM Response to Emerging CMS Opportunities Accountable Care: Continuum of opportunities Healthcare Innovation Challenges Bundled Payment Medicare Shared Savings Program (ACO) Comprehensive Primary Care Pioneer ACO Healthcare Innovation Zone (HIZ) $1 billion Cooperative agreements Up to $30 million over 3 yrs No limit on number of applications per institution Priority areas: Job generation: improve quality, reduce costs, increase jobs Rapidly deployed and sustainable - create structure and processes. 1. Not a vehicle to fund clinical research 2. Umbrella jhm proposal span the continuum of care. 1. Fund lots of smaler proposals, but don't double-collect on same patients Nov 14th-release of challenge grant (JHM operating committee) Dec 14 th Umbrella proposal, modeled on original HIZ concept Dec 19 th LOI submitted Dec 28 th Fred Brancati and Kostas Lykestos selected to write proposal Tiered care management strategies, modeled on EBMC, targeting those patients with high likelihood of increased spending in next year Care management by new workforce Patients generally medicare medicaid beneficiaries Special considerations for higher cost patients Acute care re-design JHH JHBMC, all patients receive some interventions, more for higher need Links with community efforts in geographic area of 7 zip codes Modeled on JHHC pilot efforts, including risk screens with post-d/c home/skilled services, inter-disciplinary care, ED care algorithms, etc. Reaching out to skilled nursing facilities to improve post-acute care transition Incorporating Bayview Medical Center care center algorithms, with geriatrics input via nurse
educator (reduce readmissions by half) Transition guides from acute care to snf Bundled Payment Initiatives 4 models Submitted LOI for models 2 (retrospective acute care stay and PAC) and 4 (prospective) Big picture: gain-sharing, team-based payment, episodic payment Data: Receive medicare data from CMS in Feb Determine which clinical departments goals to pursue Programs start in summer/fall Medicare shared savings program Provider-based arrangement, where providers are accountable, coordinate and organize proposed rule 3/11 formal rule october 2011 Annual program april july 2012 3-yr program. Patients are free to participate or not. Providers: broad inclusion, now FQHCs and rural health clinics Primary care by both MDs and non-mds 33 measures Required governance and legal entity capable of distributing savings Fee-for service payment 2 tracks: Carrot Carrot and stick Electronic health records use is now voluntary. Plans: Forego 2012 entrance while full investment in other opportunities consider creating an ACO workgroup in 2012 to assist in completing readiness Formulate process for evolution of our measures Synergy: Epic, JHM 3.0, JHHC other transformation efforts Inter-dependent: no more silos Vision Leading by example Delivery: reform principles to next generation Discussion: Deborah Trautman: Lieutenant governor s health enterprise system. Fascinating to see how other initiatives can be complemetary or conflicting. S. Berkowitz: Lieut. Governor supporting health innovation zones, based on economic enterprises (up
to $10,000). It s not on the scale of CMS, but it is a great opportunity to see how that can work within our system. Brooke Cunningham: How do you pick which DRGs to choose. S. Berkowitz: The most important things in bundled payments is that you have provider-leaders in each departmet who want to take this on. There is software that can look at things like complications, comorbidities, and the cost associated with this. There is a cultural pragmatic way to implement this based on the people involved, acute and community (post-acute), but also needs an analysis to figure out which are the most likely to be involved. Kathy Montgomery (UM): Quality measures integrated in all of your models. One thing is to get at them in all environments, and then you need to analyze them. S. Berkowitz: We don t have consistent ability among our primary care sites. Generally JHCP are ahead of the game among our primary care sites. My belief about this is that it's not about that JHCP is so far ahead, it's about how to bring everyone else up to par. We are lucky to have the Armstrong institute, it's scope includes the repository for all data. They can ascertain where we are in relation to quality measures. In the comprehensive primary care program, they will include similar measures to the 33 we are including in the ACO program. There are similar measures across the board. We have the chief medical information officer, and an analytic group involved. We have to have an exchange with reporting entities - this is one of the most important objectives. Niharika Khanna: In designing your ACO model, seemed like you were including all primary care settings, with the hospital and community-based ones. S. Berkowitz: This is all theoretical. You are ultimately responsible for the total cost of care. Start by thinking about all the potential components. How can we get all of them up to the level where they can compete, and generate more beneficiary numbers. The creation of an ACO can also be incremental can start one year with one campus, but hospital costs are the main cost. It's hard not to consider the hospital site. You can start in one site and expand from there. Bill Queale: I m trying to understand the payment structure. It's still fee-for-service, not changing things substantially. Does that mean that the primary care provider would get paid $x dollars for a service, then at end of the year, either shared savings would be distributed, or if spending exceeds it, you are penalized? S. Berkowitz: There are two models. The carrot only: if you drive up costs, there is no penalty. Carrot and stick: there is a minimal savings level, and minimal loss level. If you reduce the costs below the minimal savings ratio, reduce costs by 3%, then there is a sum of money may not go to you as an individual, but is lumped together. Breaking it down at the level of a provider is difficult. There are generally refined process outcome measurements to determine who gets what. Gary Noronha: This group was developed to bring together research people from JHM with operations people. How are ways to get involved in studies? S. Berkowitz: The ACO part, it's harder as we don't have a model or program, mostly it is strategy now.
Regarding the PCMH, there is tremendous opportunity. On the CMMI grant side, there are opportunities as well, the program will be up by September. Probably better to have something more established to get involved with the data. Brooke Cunningham: Now if there is an incremental model, what would a Hopkins ACO look like? S. Berkowitz: I think you need to have interventions that include acute care but also span the community. You need the infrastructure to support an ACO. We don't have any guidance on how the HSCRC is going to treat this. I don't see any way to do it without including aspects of each of those on the continuum. Scott Feeser: There is the idea that specialists will giving up something in this model. S. Berkowitz: If you have an efficient system, and get right patients to the right providers, you can draw from a bigger catchment. You need to employ people at the top of their license, so that you do what you need to do. Some of that generated utilization within constructs is involved. I fully believe that everyone can win, but the system has to support that. How do labor dynamics work with this? Imaging appropriateness, how often do you need to see the specialist. The biggest impediment is that change is hard. Our second speaker was Dr. Niharika Khanna, Associate Professor, University of Maryland School of Medicine. Leader, Education and Training: Maryland Patient Centered Medical Home Pilot Program Maryland Learning Collaborative: Multipayer Program for Patient Centered Medical Home We were trying to form the building blocks to get the primary care workforce up to speed. Coming from an academic department, we focus on primary care research and training. Our department wants us to have community engagement. There were collaborations with other schools. Participating carriers: aetna, carefirst, cigna, coventry, united, medicaid, medicare advantage MLC Leadership: Meets once per week. Physicians, nurses, health IT people, lead transformation coach (consultant) Steering committee from all medical societies Education Advising Consultation Multi-media for outreach Academic visits to specifically address one concept. Leadership building within a practice. Implementation and dissemination model (PCMH medical home intervention strategy) Kaiser has the lead on care management: they are provider and payer, and utilize Health IT (EPIC)
Selection of practices by MHCC: Practices entered data we selected 61 53 practices 2 FQHCs 15 practices are 20% or greater medicaid enrollees 339 practitioners 230,000 patients attributed Cross-cutting issues: Access to care Workforce development (most practices wanted MAs and care management teams rather than RNs) Communications and outreach (primary care indices are about access and quality there were 3 counties with low measures and no pcmhs) Healthcare delivery and payment reform Public health, safety net and special Implementation model: Developing this is a moving target Within practices: practice redesign champions and teams. Quality measures, chronic disease and patient self-management Practice redesign team: 1. physician champion (oversees the project from the clincian point of view, enthusiasm, motivates physician and staff) 2. lead admin person 3. lead clinical or clerical staff member Several implementation models: Trying to nest PCMH in a specialist neighborhood Incorporating HIT Primary care management teams (should we integrate mental health, medication treatment management?) Clinical and utilization performance = shared savings Year 1: Report on clinical measures Year 2: Meet utilization targets Year 3: Meet clinical targets Fee-for-service + fixed transformation payment + incentive payment (shared savings) Practice Transformation: (25 recognized practices) Solid foundation Quality improvement mentality Leadership which is central HIT
Maryland Learning Collaboarative http://medschool.umaryland.edu/familymedicine/mdlearning/default.asp PCMH Learning Collaborative website http://mhcc.maryland.gov/pcmh/ Challenges: Most important: how do you maintain the transformation of practices Creating resource linkages Discussion: Gary Noronha: NCQA certification process: much easier the 3 rd time than the first time. There are some things that don't change deeply. Ongoing process Kathy Montgomery: These are across the state, and there is a tremendous cross-section of practices. How willing they are to change and share is important. The exchanges across this diverse group are impressive. It won t happen overnight. Michelle Hawkins (director of care management JHHC): the process of training care managers is complex. I'm not sure they have the knowledge and depth to take on this role. A: Our intent is not to train an MA to be a care manager. It is to have a PA-MA team to provide care management. Scott Feeser: There different levels of care management. There's a lot of space. N. Khanna: We want to be prescriptive about the functions of a care management team, but not prescriptive about who performs those functions. We have care management as a team at Hopkins medicine, each are doing tasks that are appropriate to their level. Quality measures: even large organizations like ours struggle to report these measures. It will be interesting to see what info we get on this first level. N. Khanna: The toughest is depression measure. Specify those diagnosed with depression, on medication. We appreciate clinically that at day 85 acute depression is over. The measure is at 6 months, so many of these practices will fall down on this measure. This needs to be changed. The next PCMH-ACO Roundtable is scheduled for Tuesday, March 20 th from 12-2 pm in the Powe Room, 1500Q, 2024 E. Monument St. Please visit our website at http://www.hopkinsmedicine.org/gim/pcmh-aco/index or contact me at mgadgil2@jhmi.edu with any further questions or ideas on future speakers. Thank you!