Medicare Payment Reform: CMS/CMMI Pilots Ted Praxel, MD, MMM, FACP, Medical Director, Institute of Quality, Innovation and Patient Safety, Marshfield Clinic
Marshfield Clinic Participation in the Centers for Medicare and Medicaid Services Physician Group Practice Demonstration and Transition Demonstration Projects Theodore A. Praxel, MD, MMM, FACP Medical Director Institute for Quality, Innovation and Patient Safety June 20, 2012
Formed 1916 Physician led 501(c)3 783 physicians in 86 specialties 6,450 employees 56 regional sites More than 370,000unique patients/year 76K Medicare, 58K Medicaid Over $1 billion in annual revenue Security Health Plan (170,000 Member HMO) Division of Laboratory Medicine Education Foundation Research Foundation Family Health Center FQHC (76K patients, 443K encounters annually) Seven Dental Clinics in underserved areas An Academic Campus of UW School of Medicine and Public Health
MISSION The mission of Marshfield Clinic is to serve patients through accessible, high quality health care, research and education. VISION Marshfield Clinic will be the preferred system of cost-effective, evidence-based, quality health care. Through research, education and standardization of quality, we will reduce the burden of disease, disability and the cost for our patients and communities.
Centers for Medicare and Medicaid Services Physician Group Practice Demonstration Project First value based purchasing demonstration applied to providers Goals Improve efficiency (decrease costs) while improving quality (measured on 32 quality metrics) for assigned vs. comparison group of Medicare beneficiaries in the same geographic location getting care from non-site providers. Improve coordination b/t Part A & Part B expenditures Align reimbursement with quality Reward for improving health outcomes
Centers for Medicare and Medicaid Services Physician Group Practice Demonstration Project Marshfield Clinic selected as 1 of 10 participating sites nationally All are groups of > 200 physicians Long term commitment Application 2002 Baseline data 2004 Originally 3 years starting 4/1 annually Extended to 5 years (5 th year completed 3/31/2010)
Feedback Dashboards Population based Patient Lists By Condition Physician practice Applications Point of Care Patient Dashboard PreServ Planned Visits Team based care External influences Public Reporting Health Care Reform Payer Requirements New Models of Care Patient Centered Medical Home Care Coordination Accountable Care Organizations Patients Entering the Care System Patient Care Turning Data into Action Better Value Education Guidelines Computer based CME Improved Patient Outcomes Decreased Costs
Interventions ALL interventions for the listed initiatives are applied to ALL Marshfield Clinic patients.
CMS PGP version 1 - ~$56 M Exceeded 130 of 133 metrics over 5 years
CMS PGP Transition Demonstration - Methodology Quality measures 41 measures compared to 32 in the PGP version 1.0 Of the 41 measures 24 measures are carried over from PGP 1.0 17 are new measures Payment methodology shared savings. Comparison group is the per capita national change in Medicare expenditures, not regional comparison.
Patient Centered Medical Home 6/23/10 BOD Approval 6/23/11 Last application submitted NCQA Recognition Achieved August 2011 Level 3 (highest level) 34 primary care sites Last RN care coordinators hired April 2012 Specialty Care Coordination Quality Measures Accountable Care Organizations ACO Health Information Technology Patient Experience Better Care Primary Care
Technical strategies Easier Data Collection Data Sharing EHR/EMRs Adaptive strategies - Harder Technical vs. Adaptive Strategies Working to develop processes for implementation Developing consensus Getting through the Five Stages of Data Denial, Depression, Anger, Bargaining, Acceptance Leadership on the Line: Staying Alive through the Dangers of Leading Heifetz, Linsky HBS Press 2002
Next Steps Notice of intent for Medicare Shared Savings Program submitted May 2012 Complete evaluation and submit application for MSSP effective for 1/1/2013 Evaluate and implement discussions re: value based methodology with other payers
Questions?
Pioneer ACO Jeff Squier, Executive Director, Bellin- ThedaCare Healthcare Partners
PHPR Summit Pioneer ACO M:\D-NEWHVN\Quality-Performance\P4P\WI Payment Reform Initiative\PHRP Summit - Pioneer ACO presentation1.pptx
Structure: Clinically Integrated PHO Scale: 700 Physicians 354 Independent 340 Employed Bellin Health & ThedaCare, Inc. 8 Hospitals M:\D-NEWHVN\Operations\ACO\Federal Regulation - ACO\Pioneer\Mid-year Pioneer Meeting Physician Compensation Presentation.pptx
Decision Making Process Why Pioneer ACO Pilot
Wal-Mart wants to be your MD dramatically.... lower the cost of healthcare.. become the largest provider of primary healthcare services in the nation. 21
STRATEGIC PARTNERSHIPS High Coordination FUTURE -$ $$ Low Risk TODAY -$ High Risk REIMBURSEMENT Low Coordination
10,500 Healthcare Partners Pioneer ACO Simulation Results 10,000 9,500 National Trend 9,000 8,500 8,000 7,500 7,000 6,500 Base Healthcare Partners Trend 2006 Baseline 2007 2008 2009 Savings National Target 23
Challenges in Implementation Pioneer ACO Pilot
Corresponding Business Framework Shareholder Shares Investment Dividends Bellin ThedaCare Healthcare Partners Physician & clinic partners asked to participate Obtain units of risk/reward & costs Financial support for improvement & efficiency Equal distribution of Shared Savings / Losses
Team Based Approach SNF Example of After Care Process: Clinical & Data Analysis Team After Care cost issue identified by CMS claims & Thompson Reuters report Confirmed by claims data (After care is 15-20% of all payments) High Level Overview Not actionable Analysis of payments by After Care category (SNF, Home Health, Hospice, Swing bed) Identification of high cost / high use facilities Determination of Length of Stay and readmission rates by facility Detailed analysis Actionable Info. Determine clinical actions necessary (augment with clinical results & data)
Coordination between multiple government agencies Outside the box thinking does not work well in a highly regulated environment CMMI has its plate full (SSP, Pioneer, CPCI, Innovation Challenge, etc.) CMS Bureaucracy
A Ha s Pioneer ACO Pilot
Pioneer ACO Shared Savings / Losses & Costs 100% The Model 694 Physicians Shared Savings / Losses & Costs 50% of Total Hospital System Shared Savings / Losses & Costs 50% of Total 354 Independent Physicians 26% of Total 340 Employed Physicians 24% of Total Equal to or greater than 50% of Independent Physicians participate Independent Physician receive between one and two units Less than 50% of Independent Physician participate Independent Physician receive one unit and health systems will assume remaining units
3 Musketeer affect: all for one and one for all CMS needs us in the pilot Influence CMS s decision process Registry expansion Provider engagement
Impact Pioneer ACO Pilot
Questions?
Medicare Shared Savings ACO Mark Kaufman, MD, Senior Vice President and Chief Medical Officer, Dean Clinic
Dean and St. Mary s Accountable Care Journey Partnership for Healthcare Payment Reform Summit June 20, 2012
Dean and St. Mary s Dean Health System Multi-specialty physician group practice 800 providers with over 1.5 million ambulatory visits per year Network of more than 60 locations St. Mary s Hospital in Madison Part of SSM Healthcare in St. Louis First ever health care winner of the Malcolm Baldridge Quality Award Part of SSM of Wisconsin Hospitals in Madison, Baraboo and Janesville plus SNFs Strategic partnership since 1912 Joint ownership Dean Health Insurance - 320,000 members; largest HMO in Wisconsin Navitus - over 2 million customers SMDV rural clinics and ASCs Page 35
Being Accountable for Care Nothing new for Dean and St. Mary s Long standing commitment to delivering better care at a lower cost At risk for medical costs since 1983 through Dean Health Insurance Commitment to transparency in outcomes reporting WCHQ HEDIS Page 36
Why Consider Pursuing Formal ACO Designation? Natural evolution in our value based journey Dean s current revenue stream has major capitation basis Adding Medicare ACO patients will further catalyze Believe that reimbursement will continue to shift from fee for service to value based care ACO aligns with Dean and St. Mary s emphasis on patient-centeredness, clinical quality, service and costeffective care Page 37
Medicare Options Less CMS Risk Continuum More Medicare Cost Comprehensive Primary Care Bundled Payments X4 ACO Track 1 ACO Track 2 Pioneer ACO Medicare Advantage = Insurance Product Page 38
ACO Comparison Considerations Pioneer and MSSP similarities 33 quality performance metrics Financial gain sharing opportunities Pioneer and MSSP distinctions Track 1 does not have downside financial risk Pioneer and Track 2 have downside financial risk Only Track 2 limits the downside financial risk Page 39
Pioneer versus MSSP Decision Dean and St. Mary s applied to be a Pioneer ACO We were very proud to be offered Pioneer but, ultimately, declined the opportunity We have applied for MSSP Track 2 with anticipated start date of July 1, 2012 Page 40
Why MSSP Track 2? Timing issues were the primary drivers Plan to manage our estimated 17,000 ACO patients very intensively All patients: HRAs; shared decision making; health promotion/outreach Moderate risk patients: all the above plus DM and remote care coordination High risk patients: all the above plus CM, CC, home care social support and palliative care Data and sophisticated analytics will be essential In the process of building an integrated data warehouse with robust CRM capabilities The additional 6-12 months that MSSP affords was a key factor in our decision Pioneer start date was 1/1/2012 Page 41
Why MSSP Track 2? Secondary considerations MSSP Track 2 limits the downside financial risk while Pioneer does not MSSP Track 2 has a larger gain sharing opportunity compared to Track 1 Our relatively low cost of care makes MSSP Track 2 more attractive than Pioneer because of the different methodologies to update baseline benchmarks Page 42
Page 43 Delivering Value
ACO Challenges Managing as a carve out and at the point of care Timeliness of data from CMS Building a data warehouse based on Epic ACO population risk stratification CRM capability Achieving the appropriate balance between investment in medical management and return Financial and clinical Page 44
Dean and St. Mary s ACO Journey Page 45
A Special Thank you.
Speakers and Panelists Keynote Speaker Valinda Rutledge, MBA, Director Patient Care Models Group, Center for Medicare & Medicaid Innovation (CMMI) Payment Reform: The Medicaid Perspective Brett Davis, Medicaid Director, Wisconsin Department of Health Services From Episodes to Bundles: Two Sides of a Risk Coin Francois de Brantes, MS, MBA, Executive Director, Health Care Incentives Improvement Institute
PHPR Pilots: Accelerators and Key Learnings Panelists Total Knee Replacements Kevin Boren, CFO, Meriter Hospital Valerie Klitzke, Senior Business Planning Analyst, Meriter Health Systems Kate Willhite, MSOLQ, Executive Director, Orthopedic Associated/Manitowoc Surgery Center John Foley, Vice President, Anthem Blue Cross Blue Shield Sean Jindrich, Business Operations Specialist, UWHC Orthopedic & Rehabilitation Administration Brian Collien, Vice President, Network Development & Provider Relations, Unity Health Insurance Diabetes Jeff Squier, Executive Director, Bellin ThedaCare Healthcare Partners Michael Jaeger, MD, Medical Director, Anthem Blue Cross Blue Shield Shelly Johnson, Director of Provider Network Development, WEA Trust
Integrating Payment Reform, Delivery System Redesign, and Transparency Dean Health Plan and WCHQ : Partnership in Total Cost of Care Lon Sprecher, President and CEO, Dean Health Plan Kelly Court, Chief Quality Officer, WHA and WHCQ SMARTCare Panelists Tom Lewandowski, MD, FACC, Appleton Cardiology ThedaCare Anthony C. DeFranco, MD, FACC, Secretary/Treasurer, Wisconsin Chapter, American College of Cardiology Tim Bartholow, MD, Medical Director, Wisconsin Medical Society
Medicare Payment Reform: CMS/CMMI Pilots Physician Group Practice Demonstration: Lessons Learned Ted Praxel, MD, MMM, FACP, Medical Director, Institute of Quality, Innovation and Patient Safety Marshfield Clinic Pioneer ACO Jeff Squier, Executive Director, Bellin-ThedaCare Healthcare Partners Medicare Shared Savings ACO Panelists Mark Kaufman, MD, Senior Vice President and Chief Medical Officer, Dean Clinic
The Alliance Anthem Blue Cross Blue Shield of Wisconsin Business Health Care Group of SE Wisconsin Gunderson Lutheran Health System Hayward Area Memorial Hospital and Water s Edge Holy Family Memorial Humana Meriter Health Services Metastar The Monroe Clinic ProHealth Care Rural Wisconsin Health Cooperative ThedaCare ThedaCare Center for Healthcare Value UnitedHealthcare of Wisconsin UW Health Wisconsin Collaborative for Healthcare Quality Wisconsin Department of Health Services Wisconsin Health and Educational Facilities Authority Wisconsin Health Information Organization Wisconsin Hospital Association Wisconsin Medical Society WPS Health Insurance