Mission: To be your medical home. Vision: To be the model for physician-led health care in America

Transcription

1 Value-Based Contracting: The Good, The Bad, The Ugly Grace Terrell, MD, MMM Cornerstone Health Care President/CEO CHESS President/CEO Mission: To be your medical home Vision: To be the model for physician-led health care in America Values: As a physician owned and directed company, we are committed to ensuring that patient care is efficient, effective, equitable, patient centered, safe, and timely 1

2 How do we develop appropriate payment contracts with health plans and self-insured employers? Before we identify contract terms to show our success and profit, payers want the group to show performance. It s the struggle with putting the cart before the horse. 2

3 Payers have a complex customer base that view performance differently. Individual Medicare Advantage Small Group (SG) (<50 or 100 EEs) Fully Insured Large Group (FI; LG) Administrative Services Only (ASO) Self Insured (SI) Percentage of Lives <10% <10% ~20% ~25% ~45% Percent of Revenue ~5% ~40% ~15% ~35% <5% Profit $$ $$$$ $$$ $ $ Channel Exchange or Direct Direct or Broker Broker Broker or Consultant Consultant or Broker (sometimes) Network Considerations Want their doctors in Must meet CMS Network Adequacy requirements Prefer broad network but will trade access for price Broad access network Network discount Nationwide network Benefit Considerations Standard Standard Less Important More Important Highly Customized Several payors now reimburse for value. 3

4 It is key to negotiate payments and penalties prior to signing contracts with each payor to ensure the metrics selected are ones that your practice can achieve. To evaluate success in the value-based world, incorporate metrics that have Relevance and Importance What is the weight of the health care issue that a potential measure would address in terms of its impact on patients & health systems? Scientific Soundness Is there sufficient evidence that the measure will help patients? Do evidence-based clinical guidelines identify the interventions likely to provide the best outcomes? Validity and Reliability Does the measure capture what it is intended to capture? Does it produce results that are consistent and reasonably stable over time? Gap and Variation in Care Can providers actually do something that benefits patients and results in better performance on the measure? Is care better or substantially better in some places than others? Feasibility Are data needed to report the measures widely available and accurate? 4

5 Negotiate with payers to fund upfront some pieces of the move to value Negotiate for additional funding while developing a story of success 5

6 Re-evaluate your negotiated contracts on an annual basis to ensure you are receiving the latest evidence-based metrics and financial compensation. How can we track or show our performance to develop a story of success? 6

7 Invest in a population health management system or analytical software. Investing in health IT allows health organizations to achieve improvement in: Patient Satisfaction Employee Satisfaction Quality Measures Internal and External Reporting Capabilities Adherence to preventative services Achievement of shared savings 2014 CHESS, All Rights Reserved. 7

8 Cornerstone Timeline 1995 Westchester Building built Extended and weekend hours now offered Premier Building built NCQA Medical Home designations CHC & Oliver Wyman Redesign Care Pathway Redesign Optum & Teradata Tech partners VBR: Negotiating Contracts March Personalized Cardiac Care Program launched April Personalized Cancer Care w/ embedded Primary Care launched June CHC opens its first practice in Hickory July MSSP ACO Personalized Primary Care Program launched 13 CHC practices earn 2011 PCMH Recognition COPD Model Launched March FastMed partnership April Cornerstone Convenience Care opened at Westchester building July Shareholders approve Cornerstone Compact December Gainshares paid out Catawba Valley Medical Center signs contract with CHESS Received highest quality score in NC & ranked 6 th in the nation on quality Cornerstone Health Care, PA formed CHC on EMR December March CHC goes live on PCA Program launched Humedica Mindshare Adoption of new Cornerstone Credo Revised MVV July Service Lines implemented October Shareholders vote to move to PFV Value-based compensation formula implemented February Care Outreach & Life Care Clinics launched Transitions of Care implemented Launch of CHESS November Rite Aid Alliance Labcorp Partnership Strategic Partnership with WFBMC & CHESS CMS NextGen CHC goes full-risk ACO CHESS MSSP ACO participant CHESS Select Lightbeam launch Nephrology Medical Home Launched Touchcare telemedicine begins Lovongo launched April Cornerstone Convenience Care opened at Premier building October AMGA Acclaim Award Winner We needed a comprehensive strategy for our health IT population health management solutions. Population and Clinical Risk Management Financial and Network Management Core Clinical Technology Infrastructure Integrated Data Exchange and Aggregation Performance Management Patient Engagement 8

9 In 2012 we invested heavily in infrastructure to build and buy basic population health capabilities Our early results are promising Press Ganey Award for Patient Satisfaction Selected to patriciate in CMS MSSP Shared Savings program All primary care practices recognized as NCQA Level 3 PCMHs 2013 converted all of our commercial payer contract to valuebased reimbursement 2014 recognized by UHC for improving the health & wellness of MA plan members 2015 AMGA Acclaim Award recipient Top ACO in North Carolina Ranked 6 th in the nation on quality Selected to participate in Next Gen ACO for

10 Health IT helped measure Cornerstone s success Revenue Received from Value-Based Contracts 10

11 Our Results: Ranked 6 th in the Nation on Cost & Quality 11