NAVIGATING ALTERNATIVE PAYMENT MODELS 2016 Annual Meeting Kansas Grown: Strong, Healthy & Caring Overland Park, KS Learning Objectives Aledade will be presenting on how partnering with our company helps physicians succeed in the world of value based care. In this presentation, we will: 1. Address confusion of providers about impact of new payment models. 2. Provide concrete examples of financial impact of new programs. 3. Identify strategies to help providers thrive in new payment models $3 Trillion Annually ($1T avoidable) 50% outcome based by 2018 1
Replacing Medicare FFS: Merit Based Incentive Payment System Option 1 Merit Based Incentive Payment System (MIPS): Consolidation of 3 Existing CMS programs: Meaningful Use, Value Based Modifier, PQRS Begins in 2019, based on 2017 performance Physicians to receive a composite score (0 100): Quality, resource use, clinical practice improvement activities, meaningful use of certified EHR technology Graded on a curve Option 2 Advanced Alternative Payment Model (A APM): More than nominal risk ACO (eg Track 3) OR Comprehensive Primary Care Plus Pilot Lump sum payment = 5% of previous year FFS Dedicated Reimbursement for Managing Transitions of Care and Patients with Chronic Care TRANSITIONS OF CARE 15% of discharged hospital patients readmitted within 30 days. Patient Contact within 48 hours reduces readmission. $250 for post discharge patient follow up. Fewer hospital days. Reduce chances of hospitalacquired infections. $15,075 CHRONIC CARE MANAGEMENT Patients with chronic conditions have costs 2x higher than average. Monthly $40 payment to provide care management to patients with 2+ chronic conditions. Support for patients and families Reduced duplicative testing Greater medication adherence $52,800 COMPREHENSIVE PRIMARY CARE INITIATIVE Designed to strengthen primary care through multi payer investments (collaboration with commercial payers & state health insurance plans) 4 year, multi payer initiative that provides population based care management fees & shared savings opportunities to 476 practice sites Offers bonus payment to PCPs that provide coordinated care Strengthen and investments to primary care! $70,045 2
BUNDLED PAYMENTS Bundled Payments Engaging the whole care team around a procedure or condition Creates a clearly defined financial model for collaboration on a very specific need Better coordination once people are sick, but no prevention incentives TBD Medicare Shared Savings Program (MSSP) Launched April 2012 Minimum 5,000 Medicare FFS Beneficiaries 3-year contract Track 1: Shared Savings Track 3: Shared Risk Options Over $341 million paid to 92 ACOs in Sept. 2015 ($3.5 million per) Accountable Care Organizations (ACOs) are groups of providers who assume responsibility for the quality and cost efficiency of the health care for a designated patient population 3
Blueprint for an Alternative Payment Model: Case Study of MSSP Primary care providers agree to take responsibility for the total costs accrued by a subset of their Medicare patients 1 4 If the total costs for those patients are less than the benchmark, Medicare splits the difference with the physicians Physicians work throughout the year to make sure that their patients receive the best quality care in the right setting and that any chronic diseases are well managed 2 3 Medicare tallies up how much those patients spent and compares it to a benchmark from previous years Confidential & Proprietary It easy and inexpensive for Primary Care Physicians to form Accountable Care Organizations, but getting real insight into Upfront your Capital patients requires investment Practice Selection Data Analytics New ACO Regulatory Expertise Patient claims data EHR clinical data Local HIE data Practice Real time Redesign patient event surveillance Data Partner Passion Cloud-based Technology Predictive modeling On site team ACO Automated QR Leadership Benchmarking Patient outreach High Performing Independent Primary Care Practices 11 Visibility Beyond the Four Walls SKILLED NURSING POST ACUTE REHAB HOME HEALTH 15% of beneficiaries comprising 17% of total PCP 56% of beneficiaries had plurality of primary care services in the PCP s office comprising 4% of total ED HOSPITAL 19% of beneficiaries had an inpatient hospital visit comprising of 30% of total cost 80% of beneficiaries had an outpatient hospital visit comprising 20% of total cost 28% of beneficiaries had an ED visit comprising 2% of total cost IMAGING CENTER 79% of beneficiaries comprising 3% of total SPECIALIST 66% of beneficiaries comprising 8% of total LAB 97% of beneficiaries comprising 4% of total 4
The ACO Difference Medicare Costs for One Patient AVERAGE TOTAL COST 10,000 $1,000 in shared savings: Increased investment in Primary Care Decrease in preventable ER visits and hospitalizations POST ACO COSTS 9,000 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 13 PCPs Patient s Guide to the System Influence 85% of spend Account for 4% of cost 50% in small practices with low capital reserves Confidential & Proprietary 14 Common Areas of ACO Practice Focus Retain your patients and build loyalty Increase attribution through increased wellness visits; strengthen relationships with patients and guide referrals as needed Avoid unnecessary emergency room visits Outreach post ER visit for follow-up and education; utilize frequent flyer action plans; care compacts with ED and hospitalists Support Patients Going Through Care Transitions Schedule TCM visits and follow-up during recovery to prevent readmissions Ensure patients get high quality care outside your office Manage a pick list and build communications; share and receive patient care summary reports; evaluate quality of cardiologist referral patterns Manage high risk patients Create and execute an effective care plan; chronic conditions quality measures; coordinate care across care team 15 5
ACO Model Growing in Public and Private Sector Growth of ACOs Over Time: Medicare vs. Non Medicare 800 700 600 500 # of ACOs 400 300 200 100 0 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015 Medicare Non-Medicare Total ACO Model Growing in Public and Private Sector Covered ACO Lives Medicare and Commercial Source: The Impact of Accountable Care: Origins and Future of Accountable Care Organizations, Leavitt Partners; 2015 MIPS: Your Reporting Requirements in 2017 Outside of an ACO Category Weight Description of Measure Submission Method Quality (Translation: PQRS Style Measures) Clinical Practice Improvement Activities (Translation: Practice Processes) 50% Pick 6 out of 100 measures (PQRS/MU equality) 1 Outcome Ac1 poor control Controlling High Blood Pressure 15% A menu of over 90 activities with different weights (10 points or 20 points). Need 60 points for full credit Claims GPRO Registries (Bonus Points) EHR Submission (Bonus Points) Attestation Exploring EHR and Registry Submission Can be reported at group level Advancing Care Information (Translation: Rebranded Meaningful Use) 25% 12 Total Measures into 3 Categories (11 Required) Need 100 out of 131 possible points 50 points for just having one in the numerator of the 11 measures 80 possible points for performance on the 8 measures 1 bonus point for reporting the 12 th measure Attestation Exploring EHR and Registry Submission Can be reported at group level Resource Use (Translation: Costs) 10% Total Cost of Care CMS Calculated from Claims 6
MIPS: Your Reporting Requirements in 2017 Inside of an ACO Category Quality (Translation: PQRS Style Measures) Weigh ACO Weight ACO Description of Measure Submission Method t 50% 50% ACO s EHR based quality measures replace the MIPS ACO submits through measures GPRO Measured against MIPS benchmarks so score will vary from the score in the MSSP Clinical Practice Improvement Activities (Translation: Practice Processes) 15% 20% A menu of over 90 activities with different weights (10 points or 20 points). Need 60 points for full credit Practice gets 30 points just for being in an ACO Same Advancing Care Information (Translation: Rebranded Meaningful Use) Resource Use (Translation: Costs) 25% 30% 12 Total Measures into 3 Categories (11 Required) Same Need 100 out of 131 possible points 50 points for just having one in the numerator of the 11 measures 80 possible points for performance on the 8 measures 1 bonus point for reporting the 12 th measure 10% 0% Shared savings takes the place of the cost measure N/A The Future of the Medicare Shared Savings Program MEDICARE SHARED SAVINGS PROGRAM TRACK 3 Track one means that practices have to give 50% of their savings back to Medicare COMMERCIAL ACOs Health care delivery is uncoordinated and inefficient. Health plans want to ensure that $ is spent on high quality care If a practice is willing to take risk, it can get additional revenue Acceleration of risk based contracts which provide additional $ and resources to providers. Programs will vary by payer. More resources to providers! Better, higher value insurance product for consumers/employers Increased resources to providers $222,000 ±5% Questions? Nick Bartz Executive Director for Outreach 7315 Wisconsin Ave, Suite 1000E Bethesda, MD 20814 nbartz@aledade.com www.aledade.com @aledadeaco 7