Framework Value-Based. Value-based strategy Not just an ACO strategy Provider-based strategy Large or prominent employer strategy

Transcription

1 Framework Value-Based Value-based strategy Not just an ACO strategy Provider-based strategy Large or prominent employer strategy SO A NEW PRESENTATION TITLE SHOULD BE: 1

2 Value-Based Design Concept Defined Reduced Costs Improved patient health Improved delivery and quality of care 2

3 What is an Accountable Care Organizations (ACO s) Triple aim Move from fee for service model to value-based model Value and quality of care, not quantity of care Improved analytics and enhanced medical management Skin in the game - providers accept responsibility for cost and quality of care and share in the financial savings (Not always) Types: Medicare, Medicaid, commercial ACO Growth Number of ACO s Leavitt Partners, Projected Growth of Accountable Care Organizations David Muhlestein, Paul Gardner, William Caughey, Katelyn de Lisle, Dec 2015, Page 1 3

4 ACO Growth Covered Lives Leavitt Partners, Projected Growth of Accountable Care Organizations David Muhlestein, Paul Gardner, William Caughey, Katelyn de Lisle, Dec 2015, Page 2 ACO Contract Types Leavitt Partners & Brookings Institute Origins and Future of Accountable Care Organizations Tianna Tu, David Muhlestein, S. Lawrence Kocot, Ross White May 2015, Page 6 4

5 ACO Lives per Payer Medicare Commercial Medicaid Health Affairs, Accountable Care Organizations In 2016: Private And Public-Sector Growth And Dispersion, David Muhlestein and Mark McClellan, April 21, private-and-public-sector-growth-and-dispersion/ THE VALUE-BASED CONTINUUM ACO s A GOOD STEP, BUT NOT THE ONLY STEP Pay for performance Patient Centered Medical Home ACO attribution model High performance networks ACO-like products ACO 10 5

6 What isn t a commercial value-based strategy? Not A Medicare ACO Overall federally-mandated reductions in Medicare provider reimbursements Quality measures set by federal government Money saving benchmarks set by federal government Financial penalties for not making benchmarks Common misperception that if you can do a Medicare ACO you can offer a commercial ACO 6

7 Dartmouth Medicare ACO NY Times September 10, 2016 article Dartmouth, one of original Medicare models, dropping out Dartmouth reduced medical spending on hospital stays, medical procedures, imaging and tests Still had financial penalties assessed since it did not meet the federally set benchmarks We were cutting costs and saving money and then paying a penalty on top of that. EVP, Dartmouth-Hitchcock Health System Not an old style HMO Old-style HMO (not value-based) Where most providers are today A win-win-win for employers, doctors and patients New paradigm Providers that want to transform Little, if any, health IT or analytics Limited changes in patient behavior Provider payment contingent on volume of services Patient frustration with lack of coordination Earlier identification of at-risk patients with richer information Enhanced patient engagement through proactive, doctordriven outreach Improved cost and quality effectiveness by aligning financial incentives A more satisfying experience when providers coordinate care more effectively 7

8 What is a commercial value-based strategy? Cui Bono Who benefits? Commercial Relationship Not Federal or government programs Must be beneficial to Provider and Plan Sponsor and Patient Market-based decisions Clinical-based decisions Business/financial based decisions that benefit all three 8

9 Population Health What s different about our approach MODEL Provider-centric model Today Payer-led care management telephonic model Member-centric model Future Provider and/or payer-led Care Management activity at the point of care PEOPLE Focus on sick patients only Lack of comprehensive care coordination Focus on Population health Robust care coordination across the continuum of care Patient engagement through digital technology TECHNOLOGY Early stages of Clinically Integrated Network (CIN) Data-driven clinical decision making: Standardized evidence based medicine Predictive analytics at the ACO level and the primary physician level Smart segmentation across the population Improved care coordination workflows ECONOMICS Focus on Unit Cost Concession (UCC) Competitive premium price based on aggressive medical cost reduction strategies How is the experience different? Improved health Group Improved member health Lower costs Increased educational opportunities Greater medical management Increased health education Provider Improved data 9

10 How is the VB provider experience different? Technology Extensive data capabilities and integration ATLAS for Providers Drill-down capabilities on treatments, providers, and quality Daily, weekly, and monthly data/clinical feeds Clinical and financial data integration Business Increased potential patient/client base More patient utilization More revenue for hospital clients Meritain Health s Experience 10

11 ACO s at Meritain Health Become a leader in the value-based field Strong client demand and large hospital niche Leverage parent company (Aetna) assets and capabilities Focus: Commercial, product-based ACO carrier-level capabilities ACO or ACO-like products for provider segment ACO s at Meritain Health What we had to develop Leverage what existed and re-purpose: Clinical programs, reports, marketing, etc. New competencies across many areas: Actuarial, customer service, informatics, account management, etc. Data - organize, load & transmit data to multiple entities Reporting significant effort to generate sophisticated reporting with a new reporting tool Provider-focused rather than plan sponsor-focused Train the enterprise: Sales and account management New approach to brokers, consultants and providers 11

12 ACO s at Meritain Health We now have a product that: Is a strategic resource/partner for providers and large employers Value-based payment methodology with shared savings (upside and downside risk), which incentivizes providers on patient outcomes Includes quality improvement based on specific quality measures, impacting financial compensation Analyzes significant amounts of data and rapidly reports the information to those who need it most the health care provider Identifies high-risk patients earlier via better data management Offers enhanced patient engagement through proactive, doctor-driven outreach Provides a more satisfying member experience when providers coordinate care more effectively ACO s at Meritain Health--Results Banner Health Systems, Phoenix, Arizona Memorial Hermann, Houston, Texas Integris Health System: Oklahoma City, Oklahoma More to come 12

13 ACO s at Meritain Health Even greater results Value-based hospital/provider and large employer strategies Provider segment Providing value-based ACO-like capabilities meet clients where they are and work with them strategically to get where they want to be Results in last four months: 33,000 new members enrolled 16,000 in-force member lives renewed based on value-based strategy 75,000 potential new/current members considered/considering Meritain as their VB TPA partner Catch-all caveat page Significant shift in mentality for provider, brokers, consultants and plans to understand the risk share concept of ACO s and value-based products Broker s/consultants like the concept but struggle with moving from a discount based methodology to value-based model Not all hospitals and providers want to have any funds at risk 13

14 Stop Loss/Reinsurance Considerations Most difficult entity to accept value-based cost reductions Lag effect Difficult to measure non-events from an actuarial viewpoint Change focus to total cost of care in underwriting Need greater sophistication in evaluating value-based situations Consider longer term contracts Annual renewal cycle and less long-term partnership Other Impacted Areas Medical management good and bad news Opportunity for increased and more sophisticated DM, UM and CM More sophisticated providers want to develop in-house capabilities Concierge services good and bad news Opportunities for out-sourcing to mid-level and smaller facilities ACO s and ACO-like providers often feel this is a service they should provide Cost management vendors and services less out-of-network utilization due to steerage Data management companies Data is primary component of value-based contracts and arrangements Partner with TPA s and/or providers 14

15 Questions? 15