Leveraging Payment Models to Achieve Clinical & Financial Targets Finding the Balance

Transcription

1 Leveraging Payment Models to Achieve Clinical & Financial Targets Finding the Balance Helen Macfie, Pharm.D., FABC For IHI Leading Population Heath Transformation February, 2017

2 living in two worlds at the same time is challenging

3 Strategic scale MOVING TO VALUE Strategicview Integrated delivery model Building scale to support our infrastructure And vice versa Bold Goal 250K now 500K Multiple tests of change jumping in simultaneously Commercial Government Direct to employer Health plan duals, Medicaid focus (+33.5K) Partnerships PMPM and episodic

4 Taking on Risk -today ACO or At Risk CMMI Next Gen Attribution and Key Descriptors PPO, shared savings, no downside risk #Lives:35,093 Reduced cost by11% onpmpm PPO, shared savings, no downside risk #Lives: 31,481 Employers save 8-15% HMO, downside risk on professional claims 7 Founders, shared savings # Lives: 23,000+ across 7 Health Systems Medicare FFS, downside risk 5% year 1 #Lives: 18,042 One of 18 in 2016, one of 45 in 2017 Direct to Employer with Boeing, PPO Convener, downside risk shared #Lives: 8,628 Medi-Cal (Medicaid),Medicare, limited Commercial # Lives: 39,900 total Medicare FFS Cases: 700 annually CABG, PCI, Hip/Knee One of 539 in Model 2

5 Finding the Balance (sheet) CALCULATING RISK It s the right thing to do, but we have to survive at the same time to fulfill our Mission If we don t learn, we won t be ready Medicare is barreling this way Markets already responding If we don t learn at scale, it might not work How much to take on? $3B x 1% = $3M; x 2% = $6M risk tolerance? Impact on Operating Margin and EBIDA Diversified revenue and Pop Health strategies The revenue is deferred!!! ROI polarity mapping Contract terms matter Guaranteed trend (none, blunt, or even negative) Length, quality definitions/gate, out clause, attribution New faces on contracting team Finding partners Physician networks, other systems. Choose wisely ROI Polarity Map Risk of doing Infrastructure costs staffing, IT, disruption Opportunity cost what else could we be doing? Downside risk modeling Risk of not doing Someone else comes in, loss of patients (e.g. Boeing RFP) We don t learn/not ready Pros of doing Mission Learning ahead, deeply Move up the food chain Spread of infrastructure PR and halo effects Pros of not doing Less risk? This too will pass

6

7 Results, redux ACO Shared Savings (S/S) / Care Coordination Earnings (C/C) A Quality Scorecard 100% Yr1 -$1.5M (both) Yr2 -$917K (for C/C; S/S pending) B Yr1 -$750K (for C/C; S/S pending) C Quality Scorecard 100% Yr1 -$1.8M on risk pool savings D Pendingfor Yr 1 E On target, meeting all deadlines CMS Medicare FFS only, 30 day, All Cause

8 Keys to infrastructure Population Health data action INVEST WISELY Simple actions work Daily huddles on admitted ACO patients Why here and what s the plan? Virtual case conferences Manage the high risk Post-discharge clinics Disease-specific (diabetics) Intensive outpatient Population Health IT Tools Committee (PHITT) Selection Capital approval process Linking to Data Warehouse Leverage for both actuarial and daily use

9 p.s. Our view on QPP (MACRA) NOT SO BAD Confusion abounds, we can help! Yes, it s complicated but Opportunity for calm, apply reason 3 programs 1, it s a raise on Part B! Pick Your Pace, 2017 (unless delayed ) Helpful Getting to 0-Sum Plus ACO Participating Provider (vs Preferred, networks narrowing to mitigate attribution risk Over 90% of our physicians will be in MIPS, if they qualify ($30K Part B AND 100 beneficiaries) Physician Society focus Task force Town Halls December, March Member Update Resource help Clinical Training Specialist model Stoplight report by physician & practice Quality Measure gap analysis Claims, EHR, Registry No physician left behind

10 Key lessons? LESSONS LEARNED Build a system of great care as the end-goal Don t count it before you have it in hand (revenue that is ) Claims lag Pay attention to quality gates Choose tools wisely lots of vendors in this space, sometimes the story is the simplest data Don t be afraid of QPP, work it HALO!

11 The only thing we know about the future is that it will be different. Peter Drucker