UnityPoint Accountable Care Aligning Provider Incentives in Risk- Bearing, Value-Based Contracts. March 10, 2018

Transcription

1 UnityPoint Accountable Care Aligning Provider Incentives in Risk- Bearing, Value-Based Contracts March 10,

2 Aligning Provider Incentives in Risk- Bearing, Value-Based Contracts

3 UnityPoint Accountable Care Multi-state ACO/CIN Value-Based contracts 250,000+ lives in Value Agreements 50%+ with downside risk = $1B+ 7,850+ Providers 5,542 independent 2,308 employed 45 hospitals Approximately 88,000 lives in Next Generation Model ACO 3

4 Agenda I. Shared Savings Models A. Lessons learned from Past Shared Savings Models II. Current Funds Flow Model (Sharing Risk) & Distributing Shard Savings/Losses A. Funding The Global Incentive Model B. Setting Provider Goals i. Quality Utilization Measures ii. Setting Achievement Levels C. Assessing Provider Performance i. Calculating Quality Scores ii. iii. Applying Risk Adjustments Assigning Tier Reward Levels D. Determining Reward Payouts III. Provider Support

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6 Shared Savings: Lesson Learned in Past Models Learning Action Taken Regional PMPM reporting is often based off of small sample size resulting in significant volatility. Payor data doesn t enable the most accurate PMPM reporting due to missing data. Incentivizing specific actionable metrics drives performance. Every specialty does not need to have its own discrete performance measure. PMPM is a foreign language to most providers. The benefits of aggregating risk pools is lost when you break down PMPMs into smaller pools. Quality and utilization measures have smaller n size requirements to be statistically significant. Use actionable utilization metrics that impact overall PMPM. Using actionable metrics with the greatest opportunity to improve creates focus and higher levels of achievement. Fewer measures with focus on the efforts of the team will achieve expected results. Focus providers on what is familiar specific efforts that are actionable to them (e.g. Post-discharge follow up visits).

7 Self-Insured Health Plan Regional Volatility 7

8 Credibility Why we stopped setting regional PMPM Targets Medicare Shared Savings Program SHARED SAVINGS AND LOSSES AND ASSIGNMENT METHODOLOGY Table 7. Minimum Savings Rate by number of assigned beneficiaries (one-sided model) Savings-Losses-Assignment-Spec-V5.pdf Assigned Beneficiaries Minimum Savings Rate 5,000 5, % 6,000 6, % 7,000 7, % 8,000 8, % 9,000 9, % 10,000 14, % 15,000 19, % 20,000 49, % 50,000 59, % 60, %

9 A - Patient Safety and Adverse Events Composite B - Pneumococcal Vaccine C - Influenza Immunization D - Follow Up After Hospital Discharge M - Annual Wellness Visit E - Risk-Adjusted, All-Condition Unplanned Readmissions F - Risk-Adjusted Admissions for COPD or Asthma in Older Adults G - Risk-Adjusted Admissions for Heart Failure H - Risk-Adjusted Acute Admission Rates for Patients With Diabetes I - Risk-Adjusted 60-Day Acute Care Hospitalization During Home Health Episode J - Risk-Adjusted Emergency Department Use During Home Health Episode K - Risk-Adjusted Skilled Nursing Facility 30-Day Unplanned Readmission L - Risk-Adjusted Skilled Nursing Facility Average Length of Stay Global Incentive Plan - What we do now Performance on the quality and utilization measures correlate to financial performance. QUALITY MEASURES UTILIZATION MEASURES PMPM Shared NGACO Savings Region Lives /Loss Region 1 10,800 (58.29) Region 2 10,400 (58.24) Region 3 20,500 (20.14) Region 4 8,900 (14.01) Region 5 12,100 (1.42) Region 6 9, n/a** Region 7 10,700 n/a* Contract level 82,900 (10.02) or 3 level performance in funds flow. Highest performance. - 2 level of performance in funds flow. - 1 level of performance in funds flow. Lowest performance. *New region data limitations in first year. Regional receives credit for the overall performance level. ** Hospital based measure. No innetwork hospital.

10 Current Funds Flow Model 10

11 Funds Flow Objectives & Scope Funds Flow establishes an incentive-based payment system that rewards providers who are high-performers on key quality/utilization targets. Rewards providers for activities that improve the quality of care, yield better patient experiences, and/or reduce per capita costs Provides transparency in reporting provider performance Creates a platform to share risk across the network Keep it as simple as possible

12 Applying a Withhold to Establish a Risk Pool Physician feedback reinforced that dollars set aside to pay on losses are preferred to asking for a check after the fact. ACOs can elect to participate in PBP within the Next Generation ACO program, and Next Generation Providers/Suppliers agree to various FFS percentage reductions from 0.1% to 99.9%. Reductions applied only to services provided to attributed lives Provides flexibility to scale magnitude over time if desired. CMMI estimates the total reduction to FFS payments of PBP-participating Providers/Suppliers and pays estimate to ACO on a monthly basis. Revenue stream for UPHP to fund incentives. Method for all providers to put meaningful revenues at risk. Provides ability to budget incentives in advance. Other Commercial payors are demonstrating a willingness to execute in a similar fashion. 12

13 3% PBP Withhold For each contributing region, UAC will calculate (on behalf of participating providers) 3% of the Fee-For-Service (FFS) payments from CMS for NextGen beneficiaries.

14 Quality / Utilization Measures 13 Measures, all weighted equally within a provider-type

15 Quality / Utilization Achievement Levels Four Steps! 1. Review past performance data and set achievement levels for each measure. (Level I, Level II, Level III, Level IV) 2. Analyze current performance data, apply risk adjustments, then calculate an average quality score for each provider. 3. Assign an overall tier reward level for each provider. (Bronze, Silver, Gold, Platinum) 4. Determine payout levels/percentages.

16 Set Achievement Levels Step 1 Review past performance data; set three break points for four achievement levels. Each measure will have a set of four achievement levels (I, II, III, IV) We will review months of historical data to set the four achievement levels Measures were reviewed with subject matter experts & subcommittees to ensure that achievement levels will support best practices..

17 Calculate Quality Scores Step 2 Score providers on their current performance year using this point system (one score for each measure): Level I = 1 pt Level II = 2 pts Level III = 3 pts Level IV = 4 pts For example, a Skilled Nursing Facility (SNF1) scores the following on its four measures (B, C, K, L) B Pneumococcal = 4 (based on Region Score) C Influenza = 2 (based on Region Score) K Readmissions = 3 (based on NPI Score) L ALOS = 1 (based on NPI Score) Calculate the average with all scores weighted equally. This will be the provider s average quality score. SNF1 Quality Score: (B + C + K + L)/4 = ( ) / 4 = 10/4 = 2.5

18 Assign Tier Reward Levels Step 3 Review current performance; assign each provider an overall tier reward level Example Overall Tier Reward (Silver, in this example) Bronze Average Quality Scores Silver Gold Platinum New scale New break points

19 Determine Payout Levels Step 4 Payout Levels will be set to achieve these goals: UAC must have sufficient Global Incentive funds to cover the distribution. UAC should distribute (in accordance with the VBPA) all Global Incentive funds that are collected. UAC should set payout levels to strike a risk/reward balance. DISTRIBUTION PERCENTS GUIDELINES Bronze Silver Gold Platinum Reward Payout Levels 75% 95% 105% 110%

20 Global Incentive Plus Shared Savings Global Incentive Plan a b c d e f Region 3% Withhold Global Incentive Payout Payout as % Of Total Withhold Payout as % Of Regional Withhold Shared Savings Distribution Combined Distribution Region 1 $944,557 $1,016, % 108% $2,298,972 $3,315,526 Region 2 $1,492,600 $1,593, % 107% $3,603,668 $5,197,130 Region 3 $5,515 $4, % 78% $9,737 $14,042 Region 4 $413,107 $429, % 104% $970,635 $1,399,828 Region 5 $877,911 $689, % 79% $1,560,140 $2,249,999 Region 6 $675,576 $652, % 97% $1,475,234 $2,127,549 Region 7 $485,042 $440, % 91% $996,555 $1,437,210 Formulas c = b / a total d = b / a e = c * e total f = e + b Region 8 $31,969 $24, % 77% $55,832 $80,519 Region 9 $822,032 $897, % 109% $2,029,226 $2,926,504 Grand Total $5,748,309 $5,748, % 100% $13,000,000 $18,748,309 a total b total e total

21 Connecting Funds Flow to Value Based Contract Success Withhold Incentive Plan Variables Risk Adjusted Lives Risk Adjusted Lives Metallic Tiers Metrics that Drive PMPM Withhold is Based on Care Provided by Contracted Providers Levers / Contractual Management Aligning Tax ID Funds to Risk Acknowledges illness burden and keeps focus on appropriate risk coding Growth of Value Based Lives Creates tools to support referral recommendations for higher performers. Quality and Utilization Management Measures Encourages Keeping Care In Network 21

22 Provider Support 22

23 Funds Flow Dashboard

24 Funds Flow Dashboard cont.

25 Where to focus change-efforts

26 Questions 26