Clinically Integrated Networks and Population Health The next chapter in healthcare

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Eunice Franklin
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1 Clinically Integrated Networks and Population Health The next chapter in healthcare M A T T H E W M A T U S I A K, D H S C, F R I P H ( UK) M T ( A S C P )

2 Health System Challenges While the Uninsured Capture the Public s Attention, Cost and Quality Are the Root of the Problem ~51M Uninsured Americans Cost: Healthcare Spending ~ 17% of GDP Quality: Lags Other Developed Countries

3 Health System Challenges

4 CMS shift to risk based payments G O A L F O R C M S Q U A L I T Y B A S E D P A Y M E N T S ( P A R T I A L R I S K [ V A L U E ] B A S E D ) G O A L S F O R C M S N O Q U A L I T Y, N O P A Y M E N T ( F U L L R I S K [ V A L U E ] B A S E D )

5 Aligning Economic Incentives Emerging Reimbursement Methodologies Reward High Value Providers 1. The Goal Increase Healthcare Value Improve Quality Reduce Costs Tactics Prerequisite Value-Based Purchasing Reduce Preventable Readmissions Reduce Hospital Acquired Conditions Bundled Payments Electronic Health Records Accountable Care Organizations Source: Healthcare Financial Management Association 5

6 CMS shift to risk [value] based payments By 2020 risk [value] based

7 Medicare Access and CHIP Reauthorization Act (MACRA)

8 In Value Based Contracts - Risk Is King Tier 3 Tier 2 Financial Risk: High Mode of Payment: Full or partial capitation and extensive bundled payments. Additional Incentives: Highest level of shared savings and bonuses if per beneficiary spending is below agreed-upon target, but greatest amount of risk (full) if spending is above agreed-upon target. Financial Risk: Moderate Mode of Payment: Fee-for-service, partial capitation, some bundled payments. Additional Incentives: More shared savings and bonuses if per beneficiary spending is below agreed-upon target, but also some (partial) risk if spending is above agreed-upon target. 8 Tier 1 Financial Risk: Low Mode of Payment: Fee-for-service Additional Incentives: Some shared savings and bonuses if per beneficiary spending is below agreed-upon target. No risk if costs are above target. S.M. Shortell, L.P. Casalino, and E.S. Fisher, How the Center for Medicare and Medicaid Innovation Should Test Accountable Care Organizations, Health Affairs 29, no. 7 (2010):

9 Most CMS risk [value] based (innovation) programs have two criteria Cost Reduction and Proper Utilization Quality Cost Reduction and Proper Utilization Quality

10 Benchmark HCC Risk Score Risk Score C O S T # of Patients (2-3.99%) Risk Adjusted Benchmark Calculated Threshold Threshold Adjusted Benchmark Q U A L I T Y CMS Metrics Final Cost Calc. QM Reduced Savings (penalty) Quality Metrics Overage Returned Savings Shared

11 Example (Risk and Reward)

12 What is an Accountable Care Organization or Clinically Integrated Network? I N T E G R A T E D P O P U L A T I O N H E A L T H

13 Population Health Conceptual Framework

14 Integrated Population Health Population profiling: Predictive modeling to risk-stratify the population Primary prevention: Driven by patient and physician reminder systems Case management: Case managers in each office provided by health plan create patient-centered intervention plans Disease management: Address needs of moderate-risk chronic disease patients Remote monitoring: For high-risk or post-hospital discharge patients using home interactive voice response and in-home wireless devices Transitions of care management: Case manager contacts and manages transitions for all patients leaving hospitals or other settings Pharmaceutical management: Medication adherence and reconciliation by physicians and case managers Life planning: Case managers facilitate advance directive discussions RJ Gilfillan et al. Value and the Medical Home: Effects of Transformed Primary Care. Am J Manag Care. 2010;16:

15 Integrated Care: PCMH and ACO

16 ACO Envisions Integrated Care Hospital Payers Patients Other Healthcare Providers Specialists Primary Care Providers 16

17 ACO vs. Earlier Delivery Models ACOs and PCMHs Both models promote the use of enhanced resources (e.g., EHRs, patient registries) PCMHs do not offer explicit incentives for providers to work collaboratively to reduce costs/improve quality Hospital Efficiency Agreement PCMH model calls for primary care providers to take responsibility for coordinating care PCPs are not gatekeepers which limit access to care 17

18 ACO vs. Earlier Delivery Models Historic Cost Containment (e.g. HMOs) ACOs have greater variability in types of payment and risk arrangements HMO providers not rewarded or penalized for meeting quality and cost targets HMO focused on prevention and lower utilization ACOs focus on prevention and correct utilization to management care Patients required to stay in network

19 ACO vs. Earlier Delivery Models New ACO Model Focused on improved management of chronic conditions and disease appropriate utilization Physicians are accountable for the outcomes and expenditures (one sided moving toward two sided risk structure) One sided little to no risk of repayment if metrics not met Two sided great risk of repayment if metrics not met Can distribute saving or levy penalties when targets are not met ACO model calls for primary care providers to take responsibility for coordinating care PCPs are not gatekeepers which limit access to care Patients are not required to stay in network or utilize only ACO providers

20 BAXTER REGIONAL CLINICALLY INTEGRATED NETWORK BAXTER PHYSICIAN PARTNERS

21 Baxter Regional Clinically Integrated Network DATA IS NEEDED TO ENSURE INFORMATION LEADS TO KNOWLEDGE

22 What access do you have to DATA? What access does the CIN have to patient information? All claims data (from insurance providers) All clinical data (from ACO providers) If you are seen by a provider in the CIN, the CIN has the data! What information do we need to ensure the provider can take care of the patient? Problem is getting the data needed barriers and technology Problem with data overload and asking the right question CIN has a data analytics tool Lightbeam Captures, defines and identifies various type of data, creating information, resulting in knowledge Used as both retrospective and prospective

23 Cerner Amb. Clinical ecw Walmart Clinical E-MDs Clinical (RFM) MSSP Clinical Interfacing FTP Site Health Jump AllScripts (2017) BRMC Employee Health Program Pioneer Claims ProCare Rx - Claims Core Source Claims ecw BLP Clinical FTP Site ecw Lightbeam MSSP CCLF Future Programs ecw NARMC Clinical NARMC Employee Health Medicaid BRMC Inpatient Greenway Clinical Health Fusion Clinical LWIS Claims BCBS Mercy (2017)

24 Care Management K E Y T O S U C C E S S

25 Key Components of Care Management

26 Care Management Success Factors

27 Let s Look at Medicare Shared Savings Program

28 MSSP Criteria Criteria Cost Reduction and Utilization Benchmark from CMS (Benchmark and Risk Adjusted Benchmark) Reduce cost by at least 2% to 3.99% from Benchmark before shared saving is possible (Threshold Adjusted Benchmark) Quality 34 Quality Measures (Penalty for not achieving quality) Must meet quality across entire spectrum The big difference in timeliness and completeness of data ACO gets data monthly with days lag ACO gets all claims data from CMS, not just internal to ACO providers Who qualifies as an ACO patient? Assignment by E&M Coding (office visit) Yesterday you may have been a patient, today you are not. Today you are a patient, tomorrow you are not

29 Where do our patient s go?

30 Benchmark CMS has given the ACO a benchmark of $700 PPPM (or $8,400 per patient per year) Currently 14,000 patients Total spend cannot exceed $117,600,000 Benchmark is for entire care of patient (Part A, Part B, Part D) Inpatient Home Health DME Office Visits Pharmacy

31 Current Spend ($686 PPPM)

32 Asking the right question ER utilization R I G H T Q U E S T I O N L E A D S T O R I G H T A N S W E R?

33 ER Visits by Facility

34 ER Frequent Flyers

35 Top Patient (N=112)

36 Do we have an ER over utilization problem?

37 We DO NOT have an ER over utilization problem? N O N A T I O N W I D E E R U T I L I Z A T I O N F O R P A T I E N T > 6 5 Y E A R S O F A G E I S V I S I T S P E R K P A T I E N T S A C O I S R U N N I N G 4 0 V I S I T S P E R K P A T I E N T S W E A C T U A L L Y H A V E A M I S - U T I L I Z A T I O N I S S U E, N O T A N O V E R U T I L I Z A T I O N I S S U E

38 Other useful data R I G H T Q U E S T I O N L E A D S T O R I G H T A N S W E R?

39 Pharmacy By Prescriber

40 DME By Prescriber

41 Quality

42 Quality Measures Major Difference ACO Quality is based on patient, not facility Does not matter where the procedure was performed Barrier Technology needs to send data in correct format (e.g. LOINC, SNOMED, CPT, ICD10, etc.) Must contain all needed information or audit will fail

43 Quality Measures (Falls Screening)

44 Quality Measures (Falls Screening)

45 Questions

Growth and Success of Accountable Care Organizations (ACOs) in the US from Dennis Horrigan June 2016

Growth and Success of Accountable Care Organizations (ACOs) in the US from 2010-2016 Dennis Horrigan June 2016 Introducing Dennis Horrigan Dennis R. Horrigan President and Chief Executive Officer Catholic