The Emergence of Value-Based Care: Present and Future Tense

Transcription

1 The Emergence of Value-Based Care: Present and Future Tense Erik Johnson, Vice President for Value-Based Care May 2016

2 What Is Value-Based Care? While the concept of value-based care has existed for years, the passage of the Affordable Care Act accelerated its momentum in health care delivery Value is typically measured by the Institute for Healthcare Improvement s Tripe Aim, which includes an approach to manage the health of a population across the continuum of care. It measures: Patient experience Quality of care Cost of care Value-based care is primarily a public policy driven concept, the economic objective of which is to reduce per capital health care resource utilization while maintaining or raising the level of quality Organizations that are able to achieve value in this context will prosper; organizations that do not adapt and innovate will continue to depend on FFS and diminish with it 2

3 Provider Reimbursement Is An Enabler of Integrated Care Value-based reimbursement Global payment/ capitation Shared Risk Degree of risk managed by provider Fee for service Pay for activity/ coordination Payment for service or activity Pay for performance Attain measure targets Bundle payment (single bearer of risk) Bundle payment (risk among providers) Manage event/ condition Shared Savings Manage a population Level of provider sophistication and collaboration 3

4 Managing Episodes Does Not Equate to Managing a Population Episodic Risk Population Health Risk Examples: DRGs Bundled payment Examples: ACOs Capitation (MA Capitation, Commercial Capitation) Emphasis on efficiency and best practice Emphasis on prevention, eliminating episodes 4

5 CMS is Driving Innovation and Commercial Market Is a Fast Follower CMS has been the most ambitious payer in the country - ACOs - Bundled Payment (BPCI, Complete Joint Replacement) - Primary Care Transformation - Alternative Payment Models Commercial and Medicare Advantage payers are fast followers - ACOs - Narrow Networks - PCMH - Bundled Payment (to a lesser extent) Employers are tinkering with new models and approaches - Direct to provider - Third party network/coe - Consumerism - Telehealth 5

6 CMS Has Been Driving Innovation For 10 Years Setting the Foundation Measurement Regimes Incentive for Infrastructure Development Payment and Delivery Reforms Hospital Inpatient Quality Reporting Physician Quality Reporting System CMS Ceases Paying for Hospital Acquired Conditions Health Information Technology for Economic and Clinical Health Act Affordable Care Act Meaningful use incentives First generation of Medicare Shared Savings Program Hospital Value-Based Purchasing and readmission penalties Physician value-based modifier Implementation Begins Merit based incentive payment system and alternative payment models 6

7 The Era Of Value-Based Payment Is Already Here 9.00% Value-Based Payment Puts Nearly 9% of the DRG Payment at Risk 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% VBP Readmission Penalties Meaningful Use HAC SOURCE: CMS VBP= Value-Based Payment HAC = Hospital Acquired Conditions 7

8 CMS Payment Innovation Accelerating In Next Five Years, Followed By MA By 2018, HHS is targeting 50% of Medicare payments though alternative payment models (APMs) and 90% through quality or value APMs include ACOs, bundled payments and advanced primary care medical homes CMS appropriated $10B per year for the next 10 years for innovation efforts Nearly 7,000 organizations patriciate in BPCI Medicare Advantage (MA) plans are aggressively moving into value-based models; additionally, MA is experiencing significant growth, from 10 million enrollees in 2009 to expected 20 million in 2020 SOURCE: CMS; HHS 8

9 Success Is Not Easy: MSSP First and Second Performance Year First Performance Year Results Second Performance Year Results 25% ACOs generated savings 28% ACOs generated savings 204 ACOs with reported results 333 ACOs with reported results 53 ACOs generated total savings of $650 million 92 ACOs generated total savings of $800 million 49 ACOs received $300 million 86 ACOs received $341 million 4 ACOs missed out on receiving $20 million 6 ACOs missed out on receiving up to $15 million 1 ACO had losses of almost $10 million 2 of 3 Track 2 ACOs produced net shared savings 9

10 BPCI Program Has Generated Board Interest and Participation Organizations participating are given the flexibility in selecting the clinical bundle, developing partnerships across the continuum of care within their communities, and determining how to redesign care delivery. Models linking payments for multiple services received during an episode of care. Retrospective Payment (acute care Inpatient, acute care Inpatient plus post-acute care, and post-acute care only). Prospective Payment for acute care stay only 48 bundles BPCI Models BPCI Model 1 BPCI Model 2 BPCI Model 3 BPCI Model 4 Retrospective Acute Care Hospital Stay Only Retrospective Acute and Post Acute Care Retrospective Post Acute Care Only Prospective Acute Care Hospital Stay Only SOURCE: CMS 10

11 Medicare Advantage: Significant Growth Total Medicare Private Health Plan Enrollment, In millions: MA is experiencing significant growth Total eligible beneficiaries that choose Medicare Advantage (MA) increased from 24% to 31% from 2010 to 2015 The number of MA enrollees have increased by 10 million in 2009 to an estimated 20 million in 2020 % of Medicare Beneficiaries: 13% 13% 16% 19% 22% 23% 24% 25% 27% 28% 30% 31% Distribution of Enrollment in Medicare Advantage Plan, by Plan Type, 2015 Traditional Feefor-service Medicare 69% Medicare Advantage 31% HMO 64% Local PPO 24% Regional PPO 7% PFFS 2% Other 3% The total distribution of enrollment in Medicare Advantage plans is heavily HMO weighted Enrollment in HMOs grew more than other plan types growing from 5.3 million beneficiaries in 2004 to 10.7 million in SOURCE: CMS, and MPR Total Medicare Advantage Enrollment, 2015 = 16.8 Million 11

12 Transformation from Medicare Fee-For-Service to Medicare Advantage Medicare FFS patients use more resources than patients in value-based models Key Operating Indicators Inpatient Acute Admits/K Inpatient Acute Days/K IP Acute Readmit Rate Skilled Nursing Facility Admits/K Skilled Nursing Facility Days/K Skilled Nursing Facility Readmit % Medicare FFS ,400-1,450 High Teens ,200-4,250 High Teens Successful ACO ,000 Mid Teens ,300-2,350 Low Teens Illustrative Example Medicare Advantage Low Teens Low Teens 100 admits/k at $10,000 per admit for a 40,000 member ACO = $40,000,000 value annually Same Population Different Population, Same PCPs 12

13 Following CMS Lead, Value-Based Care is Proliferating in the Commercial Market As employers demand containment of health care costs, plans are launching hundreds of Commercial ACOs and other value based pilots The Health Care Transformation Task Force, made up of 20 health systems and insurers, committed to make 75% of contracts value-based by 2020 Other major payers are doubling down on value based care - Aetna dedicated 15 percent of its 2013 spending on VBC efforts and intends to grow that amount to 45 percent by Blue Cross Blue Shield health plans spend more than $65B annually, about 20 percent of spending on medical claims, on VBC - United Healthcare plans to increase payments tied to value-based arrangements to $65 billion by end of Anthem ramping up value-based payment around country SOURCE: Health Care Transformation Task Force 13

14 Accountable Care Organizations Take Multiple Forms ACO MODEL Model Characteristics Payer Roles Payment Models Adapted Integrated Delivery ACOs Single entity acts as Payer, Provider(s), or groups of providers and possibly with employers Stronger in organization alignment, and accept financial risk associated. Pre-defined set of patients Sets up financial incentives, for performance (bonuses or shared savings) Seek total responsibility for total cost of care Provide risk management assessment, data analytics, and possibly disease management Full spectrum of payment model can be used from limits to FFS increases to global capitation. Shared Savings between Provider, Payer and employers. Could include some form of global capitation Virtually Integrated ACOs Two varieties - Primary Care focus or Full spectrum with PCP & Specialty groups Primary care focused designed between Payer and PCP. Easy to govern, focus on preventive care Full Spectrum - Wider range of services. Challenging to govern Primary care focused Payer is closely involved with PCP, in setting up financial incentives, infrastructure etc. Full spectrum Payer will provide infrastructure assistance and financial incentives for performance. Primary care focused PCP s control small portion of total medical cost. May enter into performance-linked bonuses, but not shared savings. Could assume more risk, but not total cost of care for patient population - two-sided shared savings, not global payment. Provider Led ACOs Provider group formed & led Possibly physicians with or without hospitals, substituting payers with third party to provide support functions. Since no payer involved, focus on care coordination for improved cost and possible savings Payers role is least in this, may be none Possibly physicians with or without hospitals, substituting payers with third party to provide support functions. Mainly FFS chassis, focused on capturing shared savings (for providers) 14

15 Continued Growth of Public and Private ACO-like Models is Projected The growth of ACOs in public and private programs has increased from 64 in 2011 to 744 in early 2015 (Figure 1). Lives Covered (millions) Figure 2. Estimated Future Growth of Lives Covered by ACOs Million 70 Predicted SOURCE: Leavitt Partners Projected growth of ACOs will contribute to cover over an estimated 70 million people by 2020, and more than 150 million by 2025 (Figure 2). 15

16 Haven t We Seen This Movie Before? Adoption of health IT at the bedside and in the office setting Development of value-based payment methodologies Advancement of clinical science Is this enough to guarantee a happy ending this time around? An increasing willingness of physicians to seek employment arrangements with hospitals 16

17 Typical Value-Based Care Delivery Challenges Limited Expertise Outdated Technology Limited Data / Analytics Limited Change Tolerance (culture) Lack of Strategy Inability to Assess Risk Limited Population Insights Misaligned Network and Leadership 17

18 To Achieve Value-Based Care, A Set of Coordinated Capabilities Are Necessary 10 High Performance Network Management 1 Value-based Care Strategy & Governance Population Health Management & Quality Enterprise Risk & Financial Management 11 Product Leadership Data Management Consumer Engagement Enabling Technology Business Operations Excellence Analytics & Reporting Organizational Change & Talent Acceleration 18