Strategies for Success in MIPS: A Front Line Perspective. Scott Hines, MD Chief Quality Officer Crystal Run Healthcare July 21, 2016

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1 Strategies for Success in MIPS: A Front Line Perspective Scott Hines, MD Chief Quality Officer Crystal Run Healthcare July 21, 2016

About Crystal Run Healthcare Physician owned MSG in NY State, founded 1996 >375 providers, >30 locations ASC, Urgent Care, Diagnostic Imaging, Sleep

2 About Crystal Run Healthcare Physician owned MSG in NY State, founded 1996 >375 providers, >30 locations ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology Early adopter EHR (NextGen ) 1999 Accredited by Joint Commission since 2006 (1st in NY State) Level 3 NCQA PCMH since 2009

3 Crystal Run Healthcare ACO Single entity ACO MSSP participant (since April 2012) NCQA ACO Accreditation (December 2012) 25,000 commercial lives at risk Medicare Shared Savings Program (MSSP) 13,000 attributed beneficiaries

4 Merit Based Incentive Program (MIPS) Pros 40% of practices did not report PQRS Potential for 3 x maximum (12% in 2019) Potential for additional payment (up to 10%) for exceptional performance Possible short term strategy Cons Complicated; administrative burden Rules of engagement not known until weeks before reporting begins Difficult to gauge performance compared to others 4

5 Components of MIPS 5

6 MIPS Maximize Clinical Quality

7 MIPS Maximize Clinical Quality Continuous Quality Improvement Ongoing performance evaluation Clinicians identify areas for improvement Clinicians identify barriers Clinicians redesign process to address barriers Remeasure to determine impact of change Continue to monitor performance

8 MIPS Maximize Clinical Quality CQI Colon Cancer Screen Barriers >95% of colon cancer screening via colonoscopy <4% return rate for fecal occult blood test cards GI consult prior to colonoscopy Solutions Result tracker for FOBT cards Same day colonoscopy (pending) 8

9 MIPS Maximize Clinical Quality CQI Colon Cancer Screen 9

10 MIPS Maximize Clinical Quality CQI Colon Cancer Screen % 90.00% 80.00% 70.00% Percentage NCQA 75th Percentile 60.00% 50.00% 10

11 MIPS Maximize Clinical Quality CQI Diabetic Eye Exam Barriers Need for dilation Need for another appointment Difficulty obtaining outside records Solutions Point of care retinal cameras Tracker forms 11

12 MIPS Maximize Clinical Quality CQI Diabetic Eye Exam 70.00% 60.00% 50.00% 40.00% 30.00% Percentage NCQA 75th Percentile 20.00% 10.00% 0.00% 1/1/16 2/1/16 3/1/16 4/1/16 5/1/16 12

13 MIPS Advanced Care Information 13

14 MIPS Advanced Care Information 14

15 MIPS Advanced Care Information 15

16 MIPS - Clinical Practice Improvement Activities Patient Centered Medical Home Recognition Maintain old sites Attain status at all new sites 16

17 MIPS Resource Use Internal resource utilization Variation reduction External resource utilization Inpatient/ER Utilization SNF Length of Stay Acute rehab utilization 17

18 MIPS Resource Use Variation Reduction: Definition A cost control measure which seeks to standardize care according to clinical guidelines and eliminate waste amongst those not adhering to national or local practice standards.

19 MIPS Resource Use Variation Reduction: Process Step 1: Analyze Utilization Step 2: Compare utilization between physicians Step 3: Analyze the variation

20 MIPS Resource Use Variation Reduction: Process

21 MIPS Resource Use Variation Reduction: Process What is the source of variation? My patients are sicker My quality is better Are best practice guidelines being followed?

MIPS Resource Use Variation Reduction: Results 2010 2012 Mean

22 MIPS Resource Use Variation Reduction: Results Mean Charges/patient $670 $596 Standard Deviation $228 $155 Coefficient of Variation

23 MIPS Resource Use Variation Reduction: Spread Each department meets with one of the clinical transformation officers quarterly Diagnosis chosen the session before Champions assigned to create BPG Meet to review variation graphs 2-3 takeaways to reduce variation Review trend data for previous diagnoses Choose a diagnosis for following quarter

24 MIPS Resource Use Variation Reduction: Spread DIAGNOSIS DEPARTMENT % CHANGE PP TOTAL $$ CHANGE CHF Cardiology -6% -$53,457 Diabetes PCP/Endocrine -17% -$844,755 Thyroid Nodule Endocrinology -26% -$304,224 Otitis Externa ENT -2% -$2,373 GERD GI -20% -$178,381 Cholelithiasis General Surgery -7% -$11,408 COPD Hospitalists -20% -$9,215 HTN Primary Care -16% -$943,002 Hyperlipidemia FP/IM -19% -$1,150,376 HA/Migraine Neurology -10% -$208,054 Breast Cancer Oncology -7% -$393,622 Lateral Epicondylitis Orthopedics -8% -$27,647 Asthma Pediatrics -10% -$24,570 Asthma Pulmonology +3% +$26,238 Renal Mass Urology -4% -$62,812 TOTAL -14% -$4,187,658

25 Jan-11 May- Sep-11 Jan-12 May- Sep-12 Jan-13 May- Sep-13 Jan-14 May- MIPS Resource Use Variation Reduction: Results 180, , , , , , , , % 100% 80% 60% 40% 20% DistinctPatient Receipts per patient as % baseline 100,000 0%

26 MIPS Resource Use External Strategies Lessons Learned From MSSP Inpatient utilization ER utilization SNF utilization Acute rehab utilization 26

27 APMs The 5 Things Inpatient/ER Utilization 5% reduction in inpatient utilization = 30% reduction in outpatient utilization Audit of 100 admissions 60% of patients did not call before going to the ER Call First Campaign; transportation? 20% of patients came from the SNFs SNF care manager; SNFists 20% of patients came from the office Inpatient coordinator ADT feed from local hospital for ER visits and admissions For ER visits: Post visit calls for appointments and education For admissions: Daily summary to care managers; Weekly summary to providers and nurses Feeds Inpatient Explorer 27

28 APMs The 5 Things Inpatient/ER Utilization 28

29 APMs The 5 Things Inpatient/ER Utilization 29

30 APMs The 5 Things SNF Length of Stay & Rehab Utilization Reducing SNF LOS RFA for preferred facilities SNF care manager SNFists Dashboard pending Reducing Utilization of Acute Rehab Prehab program Choice of facilities 30

31 Summary Determine your appetite for risk Identify opportunities for improvement in clinical quality, resource utilization, clinical practice improvement, and advanced are information. Do not delay and act now! The measurement period for year 1 (2019) starts in six months (1-1-17). 31

32 Strategies for Success in APMs: A Front Line Perspective Aric Sharp, MHA, CMPE, FACHE Vice President, Accountable Care UnityPoint Health July 21, 2016

33 1,500 Physicians UnityPoint Clinic 17 hospitals + 15 rural network hospitals 35,000 employees $4.0 Billion in revenues 10 regions (IA, IL, WI) 2 Insurance Companies ACO: UnityPoint Health Partners

UnityPoint Health Partners Multi-state ACO Clinically Integrated Network Holds Vast Majority of Risk 5000+ Providers (Facilities and Physicians) 3,500 independent 1,500 employed Commercial and CMS

34 UnityPoint Health Partners Multi-state ACO Clinically Integrated Network Holds Vast Majority of Risk Providers (Facilities and Physicians) 3,500 independent 1,500 employed Commercial and CMS Value-Based contracts 360,000 lives in Value Agreements 50%+ with downside risk $1B medical spend in agreements with downside risk 84,000 lives Next Generation ACO Narrow Network for UnityPoint Self Insured Health Plan and HPUPH *UnityPoint Health Partners, L.C. is a wholly-owned subsidiary of UnityPoint Health.

35 Generated Savings or Quality Bonus Current Lives Medical Spend Trend Wellmark 140, % UnitedHC 75, % BCBS of IL 7,000 MSSP-1 90, % Pioneer 8,500 Next Gen 84,000 Medicaid 10,000 UnityPoint Self-Insured 35, %

36 Goals of MACRA Industry Government Group Practice Volume to Value Shift Risk to Providers Understand Options Ensure Beneficiary Choice Learn to Manage a Population Manage Budget Learn to Effectively Take Risk Streamline Quality Programs Get Paid for Value Provided Disrupts Industry at Every Level

38 APM 5% Bonus vs MIPS Impact Range Ann. Part B Rev. Est. 5% Bonus MIPS +/- 4% 2019 MIPS +/- 9% 2022 any beyond Region 1 $ 11,169,534 $ 558,477 $ 446,781 $ 1,005,258 Region 2 $ 24,254,023 $ 1,212,701 $ 970,161 $ 2,182,862 Region 3 $ 1,224,134 $ 61,207 $ 48,965 $ 110,172 Region 4 $ 12,069,334 $ 603,467 $ 482,773 $ 1,086,240 Region 5 $ 2,477,915 $ 123,895 $ 99,117 $ 223,012 Region 6 $ 10,404,460 $ 520,223 $ 416,178 $ 936,401 Region 7 $ 1,992,476 $ 99,624 $ 79,699 $ 179,323 Region 8 $ 12,144,328 $ 607,216 $ 485,773 $ 1,092,990 Region 9 $ 8,244,508 $ 412,225 $ 329,780 $ 742,006 SUBTOTAL $ 83,980,712 $ 4,199,035 $ 3,359,228 $ 7,558,264 Independent Region 10 $ 43,336,398 $ 2,166,819 $ 1,733,456 $ 3,900,276 What is your expected value MIPS vs APM?

39 ALL Quickly At Risk: MIPS Scoring Path Performance Category 2019 MIPS Weighting 2017 PY 2020 MIPS Weighting 2018 PY 2021 MIPS Weighting 2019 PY Quality 50% 45% 30% Resource Use 10% 15% 30% Clinical Performance Improvement Activities 15% 15% 15% Advancing Care Information 25% 25% 25% Will Your or Other s Attention to Resource Use Impact Your Utilization?

40 Alternative Payment Models Advanced APM? Model Next Generation Model ACO 18 # of 2016 Participating Organizations MSSP Track 3 16 Comprehensive ESRD (CEC) Large Dialysis Organization (LDO) MSSP Track 2 6 Comprehensive Primary Care Plus (CPC+) None (Available in 2017) Oncology Care Model with two-sided risk None (Available in 2018) MSSP Track Bundled Payments for Care Improvement 1, Sources:

41 Advanced APMs ADVANCED APM REQUIREMENTS Use of CEHRT MIPS-comparable quality measures APM entities must bear more than nominal risk ADVANTAGES Excluded from MIPS reporting APM Entity eligibility determination Individual participants may be shielded from risk 5% bonus based on APM participation Bonus calculated on entire Part B $ CAH providers are eligible QUALIFIED PROVIDERS MINIMUM THRESHOLD REQUIREMENTS ON PART B REBASED to MSMT. YEAR Revenues 25% 25% 50% All Payor Patients 20% 20% 35% All Payor 50% All Payor 35% All Payor 75% All Payor 50% All Payor 75% All Payor 50% All Payor 75% All Payor 50% All Payor

42 Nominal Risk Requirement Nominal Risk Calculation UPHP s Next Gen ACO (Loss Cap Rate - Marginal Loss Rate MLR ) (15% - 0%) X Total PMPM Spend $704,633,100 = $ within the Loss Corridor $105,694,965 X Marginal Sharing Rate 80% $ at Risk $84,555,972 $ at Risk / Total PMPM Spend = % of Total PMPM Spend Target at Risk. $84,555,972 / $704,633,100 = 12% of Total PMPM Spend Target at Risk. Maximum MLR/MSR must be less than or equal to 4% of target. Marginal Sharing Rate must be greater than 30% Risk requirement is measured at the APM Entity level (UPHP), and risk need not be passed or shared with Qualifying Participants. based upon CMS proposed rules

43 Threshold Calculation for Qualifying Provider Designation # of lives attributed to the APM Entity = % # of Attribution Eligibles OR Part B $ on the lives attributed to the APM Entity Part B $ on Attributed Eligibles = % Attribution Eligibles Will have had at least 1 E&M visit with a clinician that is a participant in the APM Entity, but excludes MA members.

44 Why We Selected the Next Gen Model Continue efforts within Medicare Moves our culture forward to value based care Governmental lines have lower margins Choice of Next Generation ACO Model Prospective attribution Movable HCC risk score +/- 3% over contract 1 st Dollar Sharing of Savings/Loss Broader Waivers Continued influence with CMMI NEW: Selection of Loss/Savings Cap between 5%-15%

45 Why We Selected the Next Gen Model Next Gen MSSP Track 1 MSSP Track 2 MSSP Track 3 Attribution Prospective Retrospective Retrospective Prospective Risk Downside 80% No Downside Select Percent Select Percent Risk Adj. +3% HCC Cannot Increase Cannot Increase Cannot Increase Participants Split TINs Entire TIN Entire TIN Entire TIN Savings/Loss No 2% Corridor 2% MSR 2% MSR 2% MSR Waivers Beneficiary Incentive APM for MACRA Fraud & Abuse SNF 3-day Telehealth Post-discharge Home visit Fraud & Abuse Fraud & Abuse Fraud & Abuse In-Network Reward None None None Yes, If Nominal Risk & Threshold No Yes, If Nominal Risk & Threshold PMT Models PBP, Cap, FFS FFS FFS FFS SNF in 2017 Telehealth in 2017 after CMMI testing Yes, If Nominal Risk & Threshold

46 APM Capabilities for Success Levers Analytic Support Reinforcement HCC Risk Coding Claims & EHR Data Funds Flow Model Utilization Management Learn How to Use Data Meaningful Incentives Sufficient Lives Manage a Population Shared Risk Keep Care in Network Workflows Quality Improvement Favorable Contracts

47 Robust Analytic Approach 6 Claims Feeds Multiple EHRs My Data are Trapped in Silos The Data are a Mess I m Drowning in Data but Lack Useful Insights In Need to Translate Insight into Action Aggregate Data Across the Continuum Clean, Normalize & Validate the Data Transform Data Into Insight Make Insights Actionable Clinical, Financial & Operational Data Source System Agnostic Automated Extraction Data Linked Even w/out Existing MPI Validation Mapping Natural Language Processing Normalization Shared Report Library Predictive modeling Benchmarking Disease Models 47

48 Understand Your Target Next Generation ACO Baseline UPHP NextGen 2016 Benchmark PMPM $ UPHP NextGen Trended PMPM (Most recent actual) $ Est. PMPM Gap - Favorable/(Unfavorable) $ (8.04) Est. Total Dollars Gap - Favorable/(Unfavorable) $ (8,104,320) Includes CMMI change to the standard discount from 3% to 2.25%. PMPMs are from Baseline Benchmark Report and do not reflect quarterly changes

49 Focus Your Efforts

50 Find the Right Patients

51 Understand the Impact Savings Opportunities % Reduction Total NG Regions Only Savings from reducing IP Admits 6.0% $ 7,110,360 Savings from Ambulatory-Care-Sensitive Admits (Avoidable Admits) 6.5% $ 1,557,286 Savings from Preference-Sensitive Conditions (ED Visits) 6.5% $ 182,797 Savings from Readmissions (Inpatient 30-Day All Cause) 6.5% $ 1,745,366 SNF LOS Savings opportunities 3 days $ 3,194,512 Total Savings Opportunities $ 13,790,320 Total Savings Opportunities PMPM $13.68 Each 1 Day Reduction in SNF ALOS = $1M Currently Part A & Part B PMPM is in the lower 1/3 among the Next Generation Cohort Currently 2 Standard Deviations Higher than the Median among the Next Generation Cohort Range of Variation of from 40 to 20, with 15 being targeted best practice

52 Accurate & Compliant HCC Risk Coding We must get paid for the value we are providing Next Gen Avg. HCC Score Large Commercial Payor Avg. Risk Score UPHP- ACO.091 National Avg. = 1.0 1% = $7.5M in target = $5.6 M in Shared Savings UPHP is lower 1/3 in cost for Part A & Part B within Next Generation cohort UPHP-ACO 1.07 Group # Group # Group # Group # Group # Group #7 1.38

53 6 Year Impact Comparison MIPS High $5.1 $6.4 $8.9 MIPS Low $(5.1) $(6.4) $(8.9) Best MIPS Cumulative $5.1 $11.5 $20.4 Worst MIPS Cumulative $(5.1) $(11.5) $(20.4) APM & Accurate Risk Coding APM & Coding Cumulative $(1.1) $10.3 $10.3 $31.3 $42.5 $48.1 $(1.1) $9.2 $19.5 $50.8 $93.3 $141.4 Assumes no change in attribution or PMPM spend, max credit for quality, and net RAF changes after normalization Assumes RAF rebasing in 2019 to 0.97 and RAF equals 1.0 in Does not include opportunity for bonus payments in MIPS from $500M CMS budget $ in Millions

54 Favorable Contract Terms Contract: Attribution or Product Model Broad, Tiered, Narrow Network Attribution: Plurality or Recency: Which Providers Initial Target Setting: Historical Experience, Market- Based Cohort Trend Methodology: National, Market-Based, Historical Experience Target Setting: Billed, Allowed, Paid, Medical Loss Ratio Attribution: PCP Only, PCP+, PCP+ and SCP Care Coordination Payment: None, Reduced from Savings, Not Reduced from Savings Shared Savings: Upside Only, 2-Sided Risk, Full Risk Minimum Savings/Loss Corridor Stop-Loss Medical vs Pharmacy Carve-Outs: None, Selective Benefit Design Adjustments Risk Adjustment Methodology: Demographic, Diagnosis Based, Population, Episode Quality Metrics: How many, which ones, tied to shared savings Quality Target Setting Data & Reporting: Frequency, What s Included Reconciliation Timing Administrative Delegation: CM, DM, UM, Claims Processing Fee Schedule Changes: Withholds

55 Regional Performance Bonus Global Incentive Plan Appropriate Funds Flow Participants at NPI Level Hospital PCP Specialty SNF Home Care Next Gen PBP FFS Reductions by CMS paid to ACO (Works like Withhold) x% x% x% x% x% Gross Revenue for Incentive distribution PBP Revenue Annual Budgeted Incentive Pools Hospital PCP Specialty SNF Home Care Distributions paid to Tax ID, calculated at NPI level Specialties Hospitals PCPs SNFs Home Care Sharing of PY savings or loss is distributed among Regions based on Regional PMPM Performance to Target Prior Year Shared Savings or Losses Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 55

56 Reward Transparent Performance Weighting of measures & risk adjustment required Criteria Hospitals PCP Specialties SNF Home Care UM: Avoid Admits Avoid ED Quality: Readmits PX: From Scorecard UM: Avoidable ED Advanced Imaging SNF LOS Quality: Depression Screening & Follow Up Readmits PX: Getting Timely Appts & Information UM: UM: LOS UM: Unplanned ED Admissions Quality: PX; Access to Specialists Quality: Urinary Quality: Tract Infection (UTI) Falls Readmissions (ACO Pneumo Vac 35) PX: Discussion of meds, PX: N/A pain & home safety with patients? Implement Milliman Care Pathways Care Guidelines Sample Metrics: Final Metrics require appropriate UPHP governance approvals 56

57 Manage Performance High Level KPIs VARIANCE TO TARGET PMPM TREND QUALITY PATIENT RISK SCORE IN-NETWORK SERVICES Hospital Admit/1000 ED/1000 Implement MCH PCP ED/1000 Adv Img / 1000 SNF ALOS Readmission % HCHAHPS Depression Screening & Follow Up Readmissions Timely Appts. & Info HCC Coding % In network Specialty Access to Appts. HCC Coding % in network SNF ALOS UTI Readmission Home Care Unplanned ED Admission Falls Pneumo Vaccination Discussion of Meds, Pain, & Home Safety

58 Connecting Incentives to Key Levers Incentive Plan Variables Population Based Payment (Withhold)% Risk Adjusted Lives Risk Adjusted Lives Metal Reward Tiers Metrics that Drive PMPM Metrics that Drive Quality Global Incentive Plan Pools PBP (Withhold) $ are a Function of the Care Provided by Contract Participants Regional PMPM Targets Levers / Management Aligning Tax ID Funds to Risk HCC Risk Coding Growth of Attributed Lives Referral Management Utilization Management Quality & Patient Experience Will Drive Broad Competition Resulting in Higher Network Performance Keep Care In Network Focus on Collaboration to Produce Regional PMPM Performance

59 Transforming Care T.H.E. Care Model at UnityPoint Health

60 Context is Important TRANSFORMATION ROADWAY

The Road to Value. Aric R. Sharp, MHA, CMPE, FACHE Vice President Accountable Care UnityPoint Health February 3, 2017

The Road to Value. Aric R. Sharp, MHA, CMPE, FACHE Vice President Accountable Care UnityPoint Health February 3, 2017 The Road to Value Aric R. Sharp, MHA, CMPE, FACHE Vice President Accountable Care UnityPoint Health February 3, 2017 1,500 Physicians UnityPoint Clinic 17 hospitals + 15 rural network hospitals 35,000