Preparing Two-sided Risk: Finding Balance of Risk and Reward

Transcription

1 Preparing Two-sided Risk: Finding Balance of Risk and Reward Discussion Guide for Two-Sided Risk Assessments Joseph Damore, FACHE Vice President, Population Health Management (PHM) Premier Inc. Robin Jensen Director, Strategic Projects Baycare Health Partners

2 Agenda 1. Introduction/Purpose 2. Overview of Two-sided Risk 3. Case example: Baycare Health Partners, Inc. 4. Summary/Questions 2

3 Two-sided risk overview Setting Context Are we reaching a tipping point? Lessons learned from those already in two-sided risk Opportunities and challenges Market update and potential disruptors What Should You be Doing to Decide / Prepare What are our options? What should the timing be in the market? How does this decision fit into the overall strategy? What is our potential / projected performance Are we ready? Culturally, politically, clinically, overall capabilities?&a Q & A 3

4 Live Content Slide When playing as a slideshow, this slide will display live content Poll: What is the primary reason you are interested in moving to twosided risk?

5 Setting the Context

6 Burning Platform: Why now? Drivers creating urgency for Population Health Management 1. Aging Population 2. Significant Spend Increase National Health Expenditures, per capita $18,000 $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $ % 20.0% 19.5% 19.0% 18.5% 18.0% 17.5% 17.0% 16.5% 16.0% 15.5% 3. Not Fiscally Sustainable 4. Chronic Conditions Medicare Medicaid Social Security 6

7 What s Next New HHS Secretary Alex Azar Alex Azar Prior: Served as HHS general counsel and deputy secretary under President Bush Spent a decade in the pharmaceutical industry, most recently as president of the American division for Eli Lilly Strong proponent for the expansion of and market competition among Medicare Advantage (MA) plans Partner with FDA s Gottlieb to lower the barriers to entry for generic, biosimilar and other drugs as well as advance other policies to create a more competitive drug market Advance Medicare and Medicaid value-based payment models and risk One of my top four priorities as Secretary will be to use the power of Medicare and Medicaid to drive transformation of our healthcare system from a procedure-based system that pays for sickness to a value-based system that pays for quality and outcomes. Chose Peter Urbanowicz, who previously worked with Azar in the Bush administration and is a former hospital executive, as his chief of staff 7

8 Are We at a Tipping Point? The first MSSP ACOs will reach the maximum time allowed to remain in Track 1 MACRA provides an incentive for clinicians to qualify as an Advanced APM Medicare Advantage (MA) plans continue to gain market share National payers are evaluating options for shifting risk to providers MSSP: Medicare Shared Savings Program ACOs: Accountable Care Organizations 8

9 Commercial Payers are Moving to VBP/C Models: Key Themes from Commercial Payers Consistent message Each payor stated that they are aggressively transitioning to value-based arrangements. Since 2015 each payer has developed a VBP strategy and has begun to implement in selected markets. G L O B A L S T R AT E G Y 50% shared savings/risk by 2018 F O C U S / G O A L Collaboration / meet you where you are 50% shared savings/risk by 2018 Provider sponsored JV health plans & provider partnerships 75% of MA under value-based (with and without shared risk) by 201 Focus is Medicare Advantage vs. Medicare FFS/MSSP 50% share savings/risk by 2018 Prefer to provide supporting tools, data, and services and moving to arrangements with CINs/IDNs Committed to VBP but did not provide specifics. Presented a payment transition strategy, which included capitated payment models. Overall focus to AC arrangements for commercial, Medicaid, and Medicare (very few CIN arrangements) Growing their employed/owned provider network 9

10 What We Wish We Had Known Before Getting Into a Two- Sided Risk Contract We should have thought more carefully about reinsurance for NextGen The embedded risk parameters are pretty good Keep doing what you re doing, but do it better! Really think about MA Make sure to work towards critical mass the network should be narrowed such that a larger percentage of the physician s panel is in a risk-based product Utilize data and criteria to identify high performing providers that creates a narrow network still need to meet network adequacy requirements Require participating physicians to use the same EMR 10

11 Challenges & Opportunities in Moving to Two-Sided Risk Challenges Fear of failure Misaligned incentives Struggling to meaningfully manage care Unable to optimize PHIT Expertise to successfully negotiate contracts Financial losses Negative impact on current MSSP participants. Opportunities Don t leave money on the table Take advantage of arbitrage Scale infrastructure Greater incentives for alignment with providers Market share improvement Stay ahead of competition new and old Top Most Cited Challenges to Succeeding Under 2 Sided Risk Based on MACRA Analysis 11

12 Live Content Slide When playing as a slideshow, this slide will display live content Poll: What is your greatest concern about moving to two-sided risk?

13 Capabilities Framework How do we Succeed? Top Ten Critical Success Factors in Value-Based Risk Arrangements Administrative System C-Suite and physician leadership embrace value based care Systematic administration of risk arrangements Reporting systems to track and drive performance improvement Aligned strategy, leadership and infrastructure Optimized execution of risk arrangements Clinical Provider network includes engaged primary care provider Coordinated care across the continuum is embraced by clinicians Provider network is developed to deliver high value Clinical integration across providers and risk contracts Robust information management and analytics 13

14 Market Overview

15 Percent of Medicare Beneficiaries Trend: Fee for service Population Health Management 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 76.4% 75.4% 67.9% 64.8% 61.7% 54.7% 51.3% 49.5% 45.0% 23.6% 24.2% 25.6% 27.5% 29.1% 30.9% 32.5% 32.2% 34.7% 14.4% 16.3% 6.5% 7.7% 9.2% 0.0% 0.4% 18.3% 20.4% Trad MA ACO Sources: FierceHealthcare: Medicare Enrollment Dashboard: Medicare Shared Savings Program: Next Generation ACO Model: 15

16 Contracts ACO growth as of 2016 Medicare & Commercial Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q Total Commercial Medicare Medicaid Commercial Medicare Medicaid The majority of ACOs and the majority of patients in ACOs belong to commercial insurance plans. Commercial payer are not planning to slow down their transition to value-based payment models Source: 16

17 The growth of Medicare Advantage Total Medicare Private Health Plan Enrollment, (in millions of people) 17

18 Bundled Payment is growing across the country Over 2,000 organizations exploring CMS Bundled Payment programs Live Programs National Market CMS Oncology Bundle 190 practices/16 payers (7/1/16) BPCI ends in 2018 BPCI Advanced in 2018* Mandatory CJR Bundle 67 MSAs* (4/1/16) *Includes tracks to qualify for MACRA APMs Private Market State Market Commercial payers adopting BP arrangements Employers are entering BP arrangements directly with providers Medicaid Episode of Care Arkansas New York Tennessee Ohio 18

19 Vertical Integration Driving Toward High-Value Networks Health System-led Clinician-led Payer/Employer-led Multiple payer arrangements Multiple payer arrangements Retail-led? 19

20 Discussion Questions How quickly is your market moving relative to risk-based contracts? Are the payers looking to implement downside risk contracts? Are there MSSP Track one s in the market in their sixth year? Are there disruptors entering the market? 20

21 What Should You be Doing to Decide / Prepare?

22 What Should You be Doing to Decide/Prepare? Conduct Financial Analyses and Educate on Options Assess Capabilities and Develop Roadmap Align Health System and Pop Health Strategic, Operating and Financial Plans Facilitate Organizational Commitment and Alignment and Execute (and make sure contracts are optimized) 22

23 1 2 3 Factors influencing the speed of transformation to value The organization of medical practices (small groups vs large groups) The homogeneity/heterogeneity of the hospital and physician EMR s and their connectivity The medical community s culture based on concepts such as the relationship and trust with each other and the hospital 8 9 The utilization patterns for health care services and the use of evidence based practices The payer mix in the community, including reliance on commercial payers and fee for service Medicare Factors influencing the speed of transformation in a given market 4 The current total per capita expenditure for Medicare and commercial beneficiaries 10 The organization s readiness for change and the financial stability of the health system 5 The supply, distribution and model for primary care services 11 The core capabilities/infrastructure in place to manage the high risk/high cost and chronically ill populations 6 The readiness of payers to implement a value based payment model 12 The level of transparency for key metrics such as quality and cost 7 The integration of the delivery system into organized contracting and delivery vehicles 13 The likelihood of existing or new, opportunistic competitors moving into value based payment arrangements

24 Two-Sided Risk Decision Points MSSP Option 1: Move to 2-Sided Risk Model Pros: AAPM potential Greater upside opportunity Preventive strategy against disruptors Claims data Waivers Cons: Exposure to losses Repayment mechanism Option 2: Reformulate ACO, Merge, or Join Another ACO Potentially stay in Track 1 Opportunity to expand/contract ACO participation Continuation of MIPS benefit Change must be significant, and it is difficult to determine what CMS will accept Option 3: Depart MSSP, Focus on Medicare Advantage / Commercial VBP Contracts Avoids Medicare ACO financial exposure Potential opportunities for future participation in delivery system reform models Providers may align with competitors Loss of data Loss of waivers Reduced ability to align VBP efforts across payers Increased MIPS reporting burden Potential loss of market share 24

25 Medicare ACO Models Key Information Model Performance Period 1-Sided or 2- Sided Risk MSSP Track 1 3-year period 1-sided MSSP Track 1+ 3-year period 2-sided MSSP Track 2 3-year period 2-sided MSSP Track 3 3-year period 2-sided Next Generation ACO Comprehensive ESRD Care 3-year period (w/2 optional years), started 2016, 2017, year period, started 2015, 2017 Application Period March-Oct for Jan start March-Oct for Jan start March-Oct for Jan start March-Oct for Jan start Number of ACOs (as of March 2018) Geographies 460 Nationwide 55 Nationwide 8 Nationwide 38 Nationwide 2-sided Closed 51 Nationwide Both Closed 37 Nationwide 25

26 Medicare ACO Considerations Moving to 2-sided model: - Can likely leave the program mid-year with no penalty for losses - Claims data can assist with identification of out-of-network utilization Would leaving MSSP have an impact on: - Market share - Physician engagement - Ability to perform on other value-based contracts Hospital VBP (readmissions, HAI, etc.) Commercial agreements Medicare Advantage Medicaid - Hospital operating costs, eg: Growth of low CMI medical admissions Physician participation in cost initiatives - Potential for disruptors to enter the market - Impact on CPC+ - Potential loss of institutional knowledge 26

27 Live Content Slide When playing as a slideshow, this slide will display live content Poll: How aligned is your organization s strategy, leadership and infrastructure as it pertains to moving into two-sided risk arrangements?

28 How do the choices compare given our successes? Case Study: Baycare Health Partners, Inc.

29 Baystate Health Inc. $2.4 billion operating revenue 10,000+ employees Serving population of 830K 4 hospitals, incl. flagship academic medical center Beds: 978 Deliveries: 4,319 ED Visits: 204,452 Inpatient Discharges: 52,829 Surgical Procedures: 37, medical groups, VNA, hospice Owner of Health New England, largest regional health plan 29

30 Baycare Health Partners, Inc. Baystate Health, Inc. 50% 50% Greater Springfield IPA Baycare Health Partners, Inc. Managed care contracting since 1994 ~1,400 providers + 4 hospitals ~115,000 covered lives in commercial value-based contracts Not-for-profit, taxable corporation 100% Pioneer Valley Accountable Care, LLC MSSP: NGACO: ~900 physicians + 4 hospitals ~50,000 Medicare beneficiaries 100% Baystate Health Care Alliance, LLC MassHealth ACO: Baystate clinics + 1 private FQHC ~40,000 Medicaid members 30

31 The Pursuit of Value Transitioning from a Volume-based to Value-based Payment System Goal: improve quality, increase patient satisfaction and lower costs the Triple Aim 31

32 The Transition to Value-Based Health Care The Key: Co-Evolution Payment model and care model must support each other and evolve in parallel. NON-RISK RISK PAYMENT METHODOLOGY FFS Shared Savings Single Payment DELIVERY SYSTEM Fragmented Care Coordinated Care QUALITY & EFFICIENT CARE 32

33 Baycare Value-Based Contracting Journey Commercial Risk Pilot 2010-present ~200 PCPs 2 risk contracts MSSP ~200 PCPs + ~700 SCPs Shared savings Commercial Risk Expansion Broad PHO network (~1,400 physicians) 2 risk contracts Several shared savings agreements NGACO Risk 50,000 lives MassHealth ACO Risk 40,000 lives 115,000 lives 33

34 Common Elements of an Ideal Value-Based Contract Analytics & care management support Medical budget (historical spend, not reset) Quality payments (P4P or linked to risk) Asymmetrical risk corridors Risk mitigation (reinsurance, outliers, carve-outs) PCP capitation and shadow bundles Interim settlement Timely, complete claims data; consistent layout Consistent quality measures Baycare Health Partners, Inc., Springfield, MA 34

35 Risk Mitigation Multiple value-based agreements Stop loss / reinsurance Contractual exclusions / quality bonus pools Experience Population health support from Baycare/PVAC 35

36 Sample Value-Based Contract Terms Two-Sided Risk Shared Savings NGACO Comm'l 1 Comm'l 2 Comm'l 3 Comm'l 4 Comm'l 5 Infrastructure $6.00 pmpm $2.00 pmpm $5.00 pmpm (adult); $1.50 pmpm (pedi) $4.91 pmpm $2.63 pmpm (paid to providers) n/a Quality score reduces budget discount by up to 1% up to $25 PMPM Up to 1% of Premium Gate to Savings up to 5% add'l if in surplus Gate to Savings Quality Measures Health Service Fund (HSF) Surplus Sharing Deficit Sharing 22 measures + 8 pt exp Baseline CY2014 expenses; adjusted for regional & national trend; risk adj; quality & efficiency adj 80% Affects % of shared savings/deficit 29 measures: 8 pt exp; 18 process; 3 outcomes PY 2017 budget, risk & trend adjusted 20%-80%, determined by quality score 4 process measures; 1 outcomes measure 88% of premium 45% - 55%, determined by quality score 16 measures + patient experience survey Baycare Medical Trend vs Market Trend max 50% of Surplus Bonus (only if savings) 4 HEDIS (process/outcomes) + lab data submission Historical expense (DxCG adjusted), trended for inflation 25%/75%, MD/Plan Affects % of shared savings 11 HEDIS measures (process) Historical expense (DxCG adjusted), trended for inflation Must exceed 2% HSF savings threshold Surplus paid as CCF, adjusted Cap at $60 pmpm (combined up or down based on cost & up to 50% of Surplus Cap = 5% No Cap No Cap quality & efficiency) quality performance Cap = 3% of TMC (~$8.50) Cap = 10% of HSF 80%-20%, determined by 80% quality score N/A N/A N/A N/A Cap = 5% Cap at $25 pmpm Risk Mitigation Expenditures above 99th percentile truncated; exc. Part D 80% above $175K PMPY - charged to budget Internal plan-wide pooling; share high-cost RX $100,000 PMPY; exc. Rx & BH >$150k PMPY; exc. BH & OOA $250k or transplants; exc. Rx & BH 36

37 Baycare Value-Based Contract Distributions 37

38 Building Blocks for Two-Sided Risk Baycare Health Partners & Pioneer Valley Accountable Care Physician Alignment Strategy Population Health Initiative Physician Engagement High-Value Network Funds Flow Model Care Management Program Data & Analytics = Foundation 38

39 A Comment on Data & Analytics Data Knowledge Action 39

40 Two-Sided Risk: Strategic Focus of Baycare & PVAC Post-Acute Care Specialty Engagement Quality Acute Care Costly Care Coding 40

41 Two-Sided Risk: Strategic Focus of Baycare & PVAC Post-Acute Care Strategy Tactics Pop Health Infrastructure Results Decrease total cost of care by decreasing inappropriate: o SNF lengths of stay o Emergency room transfers o Rehospitalizations Preferred SNF network Post-acute care manager Warm hand-offs SNFist shared savings program Inpatient redesign PatientPing Other vendors under discussion SNF ALOS Sep-16 Sep-17 % D % NGACO surplus for 2016/PY1 o SNF admits/1,000 o ACE o Why not home? 41

42 Two-Sided Risk: Strategic Focus of Baycare & PVAC Acute Care Strategy Tactics Pop Health Infrastructure Results Decrease unnecessary: o Emergency room visits o Inpatient admissions o Readmissions Care management o Primary care (embedded) o Post-acute o Select specialty care ACO attending in ER PatientPing Imprivata Cortext Other vendors under discussion Care Management Preliminary Results (5 months pre/post intervention April 2016 March 2017, n = 847) ER Visits 21% Inpatient Admissions 43% Readmissions 30% Total Medical Costs 34% Care management integration ACE unit ACO Attending Prelim. Results Diversions per week Total Medical Costs $499K $282K SNF 3-day waiver used only in

43 Two-Sided Risk: Strategic Focus of Baycare & PVAC Specialty Engagement Strategy Tactics Pop Health Infrastructure Results Enhance collaboration with specialists Shadow bundles o ESRD, CHF Premier / Milliman Shadow bundles went live in January 2018 Improve access to specialists, thereby increasing primary care capacity Reduce out-of-area leakage o Future: COPD, Oncology, Others Funds flow model (citizenship) Data sharing Care models Leakage stable at ~10% (Medicare) 43

44 Two-Sided Risk: Strategic Focus of Baycare & PVAC Costly Care Coding Strategy Tactics Pop Health Infrastructure Results Coding: o Ensure accurate and complete diagnosis coding to better identify complex patients in need of more care Best practice sharing Dashboards/ data transparency Funds flow model (citizenship) Coders/Audits LightBeam Health Solutions Works in progress Costly care: o Focus on appropriate utilization and less expensive sites of care Clinical decision support Dashboards/ data transparency Other vendors 44

45 Two-Sided Risk: Additional Drivers of Success ACO leadership and engaged Board Funds flow model Staff engagement and retention Contract design Committed health system 45

46 Two-Sided Risk: Challenges Funding, infrastructure support, sustainability Tax status, reserves Fully implementing pop health building blocks Multiple EMRs Physician and patient/beneficiary engagement 46

47 Two-Sided Risk: Future Enhancements Primary care capitation in a global budget Care management system Care mgt. redesign / team-based care model Optimal clinical integration Additional population health infrastructure 47

48 What are the next steps that should be taken?

49 Questions to be Addressed How Quickly should we Move to 2-Sided Risk? Which Model? How Do We Succeed? Has the Board and Physician & Administrative Leadership been educated regarding strategy and 2- sided risk options that are available and the pros and cons of each? Have we conducted a financial analysis to assess the impact of 2-sided risk? Have we conducted an assessment to assure we have the necessary core capabilities for success in 2-sided risk? Do we have an actuarial analysis of the different options available? Have we developed a gap closure work plan? Do we know what competitors are doing in this space? Have we developed a financial plan? Have we been through a decision point analysis and checklist? Have we developed / conducted: A population health strategic plan ensuring alignment with health system strategy? A risk contract optimization analysis? High value network? Documentation and coding analysis? High functioning care management across the continuum? Provider education? Pop Health Services Organization? Cultural/compensation alignment? Robust PHIT & benchmarking? 49

50 Evaluating New Models Require New Paradigms and Lexicons Variables to Quantify Risk & Reward Tradeoff Impact of Quality Scores on Savings/Loss Ability to Impact Risk Scores Likely Cost and Benefit of Reinsurance Impact of Savings & Loss Caps MACRA Impact Variables to Contemplate Experiences in Working with CMMI vs. CMS Prospective vs. Retrospective Attribution Benefit of Waivers Desirability of Higher or Lower Thresholds Sources: Premier, Inc & Milliman *NextGen to not be offered for

51 Premier / Milliman Financial Model: ACO Track Options (Sample) 51

52 Capabilities Framework How do we Succeed? Top Ten Critical Success Factors in Value-Based Risk Arrangements Administrative Clinical System C-Suite and physician leadership embrace the transformation to value based care Systematic management of risk arrangements Reporting systems to track and drive performance improvement Aligned strategy, leadership, compensation, and infrastructure Optimized implementation of risk arrangements Provider network includes engaged primary care provider Coordinated care across the continuum is embraced by clinicians Provider network is developed to deliver high value Clinical integration across providers and risk contracts Robust information management and analytics 52

53 Live Content Slide When playing as a slideshow, this slide will display live content Poll: How likely is your institution to move into two-sided risk arrangements over the next two years?

54 QUESTIONS Joe Damore, FACHE Vice President, Population Health Management Premier, Inc. Robin Jensen Director, Strategic Projects Baycare Health Partners, Inc. 54

55 Appendix

56 The Fight for Physician Alignment 56

57 Medicare ACO Models Side by Side (1 of 3) MSSPTracks 1 & 2 MSSP Track 3 MSSP Track 1+ Beneficiary alignment Retrospective Possible voluntary alignment in 2018 Prospective Voluntary alignment in 2018 Prospective Voluntary alignment in 2018 Payment rule waivers None SNF 3-day rule SNF 3-day stay rule Quality score impact Adjusts shared savings/losses amount Quality metrics 31 total (for PY18), phased in from pay-for-reporting to pay-for-performance Outcomes-based contracts No requirement No requirement Payment type Normal fee-for-service (FFS) Normal FFS 57

58 Medicare ACO Models Side by Side (2 of 3) MSSP Tracks 1 & 2 MSSP Track 3 MSSP Track 1+ Shared savings/ losses Sharing Rate: Track 1: 50% Track 2: 60% Loss rate: 40% min, 60% max Sharing Rate: 75% Loss Rate: 40% min, 75% max Sharing Rate: 50% Loss Rate: Fixed 30% Caps on savings and losses Performance Payment Limit: Track 1: 10% Track 2: 15% Loss Sharing Limit: Track 1: N/A Track 2: 5% in year 1, 7.5% in year 2, and 10% in year 3 Performance Payment Limit: 20% Loss Sharing Limit: 15% Performance Payment Limit: 10% Loss Sharing Limit: 8% for non-hospital ACOs, 4% for all others Benchmark Set at beginning of the performance period Trended based on per-capita FFS spending growth in four beneficiary categories; adjusted for national growth in per-capita spending Risk adjustment using CMS-HCC model, cannot increase for continuously aligned beneficiaries, but can increase with addition of newly aligned beneficiaries For second agreement period, replaces national trend factor with regional trend factors and regional benchmark updates instead of national FFS absolute growth Same as MSSP Track 1 58

59 Medicare ACO Models Side by Side (3 of 3) MSSP Tracks 1 & 2 MSSP Track 3 MSSP Track 1+ Minimum Savings Rate Track 1: 2.0% to 3.9%, depending on size of attributed population Track 2: Choice of no MSR/MLR, 0.5 increments between 0.5 and 2.0 (symmetrical), or variable by size (2.0% to 3.9%) Same as Track 2 Same as Track 2 ACO Composition Composition of tax identification numbers (TINs) Same as Track 1 Same as Track 1 Governing Body 75% comprised of ACO Participants, 1 beneficiary representative 59

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