An Introduction to Value Based Care. Evan Richards Product Leader Value Based Care Solutions May 2016

Transcription

1 An Introduction to Value Based Care Evan Richards Product Leader Value Based Care Solutions May 2016

2 2016 General Electric Company All rights reserved. This does not constitute a representation or warranty or documentation regarding the product or service featured. All illustrations are provided as fictional examples only. Your product features and configuration may be different than those shown. Information contained herein is proprietary to GE. No part of this publication may be reproduced for any purpose without written permission of GE. DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCT DIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE A COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITY REMAIN AT GE S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLE REGULATORY CLEARANCE. * GE, the GE Monogram, Centricity and imagination at work are trademarks of General Electric Company. General Electric Company, by and through its GE Healthcare division.

3 Agenda Session Introduction The Triple AIM and the Affordable Care Act What is Population Health Management? What is Financial Risk Management in Healthcare? Putting it Together Value Based Care GE Healthcare Solutions for Value Based Care Questions

4 Session Introduction Objective Develop a foundation of knowledge on the emergence of Value Based Care as the predominant care delivery model. The foundation will include Population Health and Care Management, Financial Risk Management and the GE solutions that can support these components. Approach Each section of the course is intended to educate on specific components of Value Based Care, the sum of which will provide the foundation knowledge needed.

5 Agenda Session Introduction The Triple AIM and the Affordable Care Act What is Population Health Management? What is Financial Risk Management in Healthcare? Putting it Together Value Based Care GE Healthcare Solutions for Value Based Care Questions

6 Institute for Healthcare Improvement (IHI) Improve Health and Healthcare Globally What is it? Framework for achieving these goals New models of care and financing Tools and models for population stratification Expanding capacity for preventive services How does it work? Engage people in their health status and care Elevate and redesign the role of primary care Evaluate populations and implement population specific preventions and interventions Align costs with health outcomes and adapt rapidly Coordinate technology and systems to ensure patient centric care

7 The Affordable Care Act (ACA) Access to Care Mandates and Exchanges Expansion and Subsidies Benefits Design Quality of Care Outcomes based Incentives Increase Primary Care Services Extend existing quality programs Wellness Programs Cost of Care Medical Loss Ratio Outcomes based Incentives Administrative Simplification

8 Access to Care and the ACA Mandates Benefits Exchanges Expansion and Subsidies Small and large employers, Individuals Federal tax based penalties Essential covering urgent/emergent Bronze, Silver, Gold for traditional coverage Small business and individual coverage Private exchanges are increasing Medicaid expansion and Dual Eligibles Premium and Out-of-Pocket Subsidies

9 Quality of Care and the ACA Outcomes Based Incentives Increased Primary Care Services Extend Quality Programs Expand Wellness Programs Payments are tied to outcomes/pop health Shared Savings to Capitation Provision of essential benefits; Medicare Exp. Accountable Care, Patient Centered (PCMH) PQRI, Value Based Purchasing, MU Consolidate requirements where possible Sponsor employer led wellness programs Include Wellness Programs in the MLR

10 Cost of Care and the ACA Medical Loss Ratio 85% of Premiums for Care; Includes Wellness Downstream to Providers with Capitation Administrative Simplification Completion of the HIPAA Txns Adds more electronics specs Outcomes Based Incentives Payments are tied to outcomes/pop health Shared Savings to Capitation

11 The Triple AIM and the Affordable Care Act Summary Population Health Per Capita Cost Care Experience Access to Care Cost of Care Access to Care Quality of Care Access to Care Quality of Care

12 Agenda Session Introduction The Triple AIM and the Affordable Care Act What is Population Health Management? What is Financial Risk Management in Healthcare? Putting it Together Value Based Care GE Healthcare Solutions for Value Based Care Questions

13 What is Population Health Management? A population can be defined as a narrow group of patients such as heart failure patients seen at a specific hospital. It can also be defined as a large and diverse group of people whose responsibility for care has been assigned one or more related healthcare entities. Prevention of Illness Population Health Management is a multifaceted approach to ensuring the well remain well, and the ill are proactively and effectively managed back to health. The approach encompasses analytics, clinical protocols and guidelines, workflow management tools, and patient engagement methods. Engagement of Patients in their Health Management of Chronic or Complex Cases

14 Prevention of Illness Wellness Programs Specific target groups Smoking Cessation Nutrition Pre-Natal Classes Yoga/Fitness School Programs Early Testing Family Hx Predictive Analytics Genetic Cancer Screen Early Colonoscopy Alzheimer's Primary Care Trusted Relationship(s) over time Referral Networks Coordination of Care Routine Exams Access to Appointments

15 Management of Chronic/Complex Conditions Cohorts EMR/Analytics CHF Patients Bypass Patients Diabetic Patients Match Cohorts to Programs Protocols Clinical Programs CHF Example Prevent ER Visit/Admit Self reporting Weight Home Visit for Med Compliance Innovation Tele-medicine Funds for Shelter Home Visits for Primary Care Results show in decreased readmissions and ER visits

16 Engagement of Patients in their Health Access Primary Care is the Key Essential Benefits PCMH Medicare B PCP Dual Eligibles Education Nutrition and Exercise Preventive Disease Management Effective Chronic Disease Management Tools Apps Face to Face Portals Branding and Stickiness One and Done

17 Agenda Session Introduction The Triple AIM and the Affordable Care Act What is Population Health Management? What is Financial Risk Management in Healthcare? Putting it Together Value Based Care GE Healthcare Solutions for Value Based Care Questions

18 What is Financial Risk Management in VBC? Financial risk management is the practice of accepting value based payments for the provision of care for a specified population. Member and Benefits Management To be successful with financial risk management, an organization must be able to provide consistent and high quality care at a consistent and reasonable cost. When care provided is great, and the expenses are predictable, financial rewards will be realized. Financial risk management encompasses operational and transaction processing functions as described to the right. Risk Management Transaction Processing Medical Management Network Adequacy

19 Member and Benefits Management Member Attribution ACO, PPO, HMO Programs Enrollment Processing Start and End Dates Source system and downstream needs Assignment Narrow Networks Primary Care Providers Direct Employer Contracts Benefits Responsible Party for administering Benefits Financial Risk and/or Clinical Risk Accumulators Healthcare Exchange

20 Medical Management and Network Adequacy Network Adequacy High quality/low cost Geographical considerations Service line balance Easy access to services Medical Management Authorizations and Referrals Clinical Determinations Balance of Services Referral to the Appropriate Provider/Network

21 Risk Management and Transaction Processing Risk Management Monitoring of financial position in risk pools Actuarial function to calculate rates Connect financial performance and Population Transaction Processing Referrals and Authorizations Tracking Clinical Determinations Claims Adjudication Encounter Management Customer Service Patient Calls Provider Payment Issues Referrals and Authorizations Other

22 Agenda Session Introduction The Triple AIM and the Affordable Care Act What is Population Health Management? What is Financial Risk Management in Healthcare? Putting it Together Value Based Care GE Healthcare Solutions for Value Based Care Questions

23 Operational Models for Value Based Care Several operational models exist to support Value Based Care. Typically, within a health system, or across provider organizations the models are: ACO, CCO, CIN ACO/CCO Provider Based Health Plan Clinically Integrated Network Delegated Risk Model Direct Employer Contracts Direct Employer Contract Delegated Risk Model Provider Based Health Plan

24 Characteristics of Operational Models in Value Based Care Accountable Care Organizations Government and Commercial Plans Focus on quality and costs Revenue is FFS + Incentive (Cap is coming) Attributed membership Can cross healthcare entities Starting point for VBC efforts Clinically Integrated Networks Involves multiple, specialized organizations Similar to an IDN on the delivery side Revenues is FFS and shared incentives for quality and cost High operational maturity Focused on competitive advantage in the market All plans Attributed membership in some cases Care Coordination Organizations Government focused today Commercial plans increasing Focus on coordinating care for specific populations Revenues are administration fees and quality incentives CCO does not always provide the care Delegation of medical management from the plan

25 Characteristics of Operational Models in Value Based Care Direct Employer Contracts Risk is borne by one or both parties Allows grater margins for one or both parties Volume is key to the provider Revenue is premiums + incentives Service experience + quality of care + costs are key to the employer Must be well branded, and operationally mature to be successful Provider Sponsored Health Plan Risk is borne by the provider org Lower risk as provider quality/cost is more known Payer ops differ greatly and can pose risk to success Revenues are premiums High business process outsourcing to start Focus on employee population first Delegated Risk Provider Traditional provider organizations taking risk Revenue is capitation for medical services + admin fees for outsourcing plan functions Member services, medical management and claims adjudication Expenses are capitation and some FFS Ranges from specific services to full capitation Benefits are similar to the Provider Health Plan

26 Characteristics of Operational Models in Value Based Care Government Programs CMS Next Gen ACO CMS Bundle Programs CMS MACRA State Programs Similar to Pioneer and other ACOs Requires operational maturity in care coordination to be successful Focus on value payments up front (like a capitation) Lower quality reporting restrictions Intended to incent more providers to engage Hospital focused on high dollar episodes Complete Joint Replacement required for some BCPI is a demo program focused on 4 models of payment Slow adoption in the market Requires collaboration across participants Connects MU like technology needs with care coordination and patient engagement MIPS Rolls MU EP and PQRS together APMs Allows more experimentation with value payments (like capitation) Focus on shifting risk (full) to provider organizations Adds quality and patient engagement to existing managed Medicaid State of IL is moving quickly to full capitations for Medicaid recipients

27 Agenda Session Introduction The Triple AIM and the Affordable Care Act What is Population Health Management? What is Financial Risk Management in Healthcare? Putting it Together Value Based Care GE Healthcare Solutions for Value Based Care Questions

28 Value Based Care Solutions Portfolio Centricity Financial Risk Manager Centricity Bundled Care Manager Centricity Advanced Contract Manager Centricity Patient Portal + HCO Centricity Informatics Member and Benefits Management, Utilization Management Risk Management, Claims, Capitation and Premium Processing Coordination of Services for Packages (Transplant, Joint, Trials) Bundle definition, Payment Distribution, Financial Analytics Underpayments, Proration, Facility and Professional Services Integrated with Centricity Business (BAR and HPA) Patient Administrative and Clinical Functions Healthcare Objects Service layer for Centricity Business and FRM Analytics platform for broad VBC analytics Currently partially built or FRM Care Management While not in the VBC portfolio, integration with Caradigm and/or other partners is critical to success in VBC 28

29 What Fits Where in VBC Solutions? Access to Care Quality of Care Cost of Care Centricity Financial Risk Manager Centricity Patient Portal Healthcare Objects Centricity Financial Risk Manager **Caradigm (or Partners) Healthcare Objects Centricity Bundled Care Manager Centricity Financial Risk Manager Centricity Advanced Contract Manager Workflow, Analytics and Insights 29

30 Evan Richards Value Based Care Solutions, GE Healthcare Questions?