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 employees $4.0 Billion in revenues 10 regions (IA, IL, WI) 2 Insurance Companies ACO: UnityPoint Accountable Care
Why The Road to Value Value: What the customer is willing to pay for. Federal budget constraints driving reimbursement model changes. Continued financial deterioration and margin pressure on hospitals. Patients exposed to increasing share of cost of care and thus are taking on an increasing consumer mindset High Deductibles (30% of households don t have liquid assets to even pay) Narrow Networks Dr. Ellie Increasing price sensitivity leads to greater competition and the need for a clear value proposition
Road to Value has Multiple Lanes TRANSFORMATION HIGHWAY
Clinical Transformation 2014-15 Planning, 2016-18 Implementation T.H.E. Care Model at UnityPoint Health
Business Transformation UnityPoint Accountable Care LC Multi-state ACO Clinically Integrated Network Holds Vast Majority of Risk 5000+ Providers 3,500 independent 1,500 employed 43 hospitals Value-Based contracts 360,000 lives in Value Agreements 50%+ with downside risk $1B medical spend in agreements with downside risk 99,000 lives in Next Generation ACO Narrow Network for UnityPoint Self Insured Health Plan, MA, Commercial UnityPoint Accountable Care, L.C. is a wholly-owned subsidiary of UnityPoint Health.
Road to Value Contract Results $24 Million in Savings Incentives through 2015. Current Lives 2012 2013 2014 2015 2016 Wellmark (BCBS of IA) 140,000 ( 17 0) $11M United Healthcare 75,000 BCBS of IL 7,000 $1M? MSSP-1 90,000 Pioneer 8,500 Next Gen 72,000 ( 17 100,000) Medicaid 10,000 UnityPoint Self-Insured 35,000 -$3M $0
MACRA Final Rule with comment period MACRA 10.14.16 Advanced
MACRA Timeline 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026+ Jan-Jun 0% Jul-Dec 0.5% Annual Updates New Payment Structure Begins in 2019 0.5% 0.5% 0.4588% 0.5% 0% 0% 0% 0% 0% 0% MIPS Baseline Payment Adjustment MIPS:.25% Qualified APMs:.75% (+/-) 4% (+/-) 5% (+/-) 7% (+/-) 9% (+/-) 9% (+/-) 9% (+/-) 9% (+/-) 9% MIPS Exceptional Performance Adjustment $500 million provided annually by HHS Not to exceed 10% APM Bonus Payment APM Participants Excluded from MIPS 5% 5% 5% 5% 5% 5%
MACRA Strategic Insights MIPS can be used to start, but quickly consider advancing to APM concepts and initiatives. Both MIPS and APMs incorporate risk. MIPS math is not optimal as competition increases. Physicians focusing on utilization with no recoupment of savings Must be able to take and manage risk long term in APMs How can/will you help your region make the transition?
2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 Math as the Competition Increases Assume MIPS 50%tile Performance 1.14 1.12 1.1 5% annual lump sum for APM clinicians, 2019-2024.75% annual update for APMs,.25% annual update for MIPS, 2026+ 1.08 1.06.45%-.05% Annual Updates 1.04 1.02 APM MIPS 1 0.98 0.96 0.94
Pick Your Pace MIPS A Place to Start, but Game On! Not participating in the Quality Payment Program: If you don t send in any 2017 data, then you receive a negative 4% payment adjustment. Test: If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment. Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small positive payment adjustment. Full: If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment. Source: https://qpp.cms.gov/
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 60% 50% 30% Resource Use 0% 10% 30% Clinical Performance Improvement Activities 15% 15% 15% Advancing Care Information 25% 25% 25% How Will Your or Other s Attention to Resource Use Impact You Financially?
Alternative Payment Models Advanced APM Model 2016 Participating Organizations Next Generation Model ACO 18 45 2017 Participating Organizations MSSP Track 3 16 36 Comprehensive ESRD (CEC) Large Dialysis Organization (LDO) 12 37 MSSP Track 2 6 6 Comprehensive Primary Care Plus (CPC+) MSSP Track 1 411 438 14 regions, 13,090 clinicians Bundled Payments for Care Improvement 1,522 1,364
Why UnityPoint Selected NGACO Continue Medicare efforts on lower margin business Advance our value based culture Prospective attribution Movable HCC risk score +/- 3% 1 st Dollar Sharing of Savings/Loss Broader Waivers Continued influence with CMMI
APM Capabilities for Success Levers Analytic Support Reinforcement Favorable Contracts Claims & EHR Data Funds Flow Model Risk Coding Capture Analytic Driven Approach Meaningful Incentives Utilization Management Manage a Population: Tools Shared Risk Keep Care in Network Workflows Quality Improvement Sufficient Lives
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
Risk Coding Capture Accurate & Compliant We must get paid for the value we are providing We are lower 1/3 in cost for Part A & Part B within Next Generation cohort Next Gen RAF UnityPoint Accountable Care 0.91 National Avg. = 1.0 1% = $7 M in target = $5.6 M in Shared Savings Large Commercial Payor Avg. Risk Score UnityPoint Accountable Care 1.07 Group #2 1.12 Group #3 1.17 Group #4 1.17 Group #5 1.22 Group #6 1.31 Group #7 1.38
NGACO Risk Score Progression 2015 vs 2016 Risk Score based on Next Gen claims data: 72,069 attribution. 2015 YTD Time Period Jan 2015 Feb 2015 Mar 2015 Apr 2015 May 2015 Jun 2015 Jul 2015 Aug 2015 Sep 2015 Oct 2015 Nov 2015 Dec 2015 HCC Risk Score 0.524 0.580 0.637 0.683 0.720 0.753 0.780 0.793 0.793 0.856 0.898 0.937 % Increase over Prior Month NA 10.7% 9.8% 7.3% 5.3% 4.6% 3.7% 1.6% 0.1% 8.0% 4.8% 4.4% 2016 YTD Time Period Jan 2016 Feb 2016 Mar 2016 Apr 2016 May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 HCC Risk Score 0.594 0.670 0.762 0.822 0.873 0.917 0.956 1.000 1.038 1.039 1.089 1.136 % Increase over Prior Month NA 12.7% 13.8% 7.9% 6.2% 5.1% 4.2% 4.6% 3.8% 7.3% 7.3% 7.3% % Increase 2016 over 2015 13.5% 15.5% 19.6% 20.3% 21.3% 21.9% 22.5% 26.2% 30.9% 21.3% 21.3% 21.3% 1.200 1.000 0.800 0.600 0.400 0.200 0.000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2015 YTD 2016 YTD
Robust Analytic Driven Approach Robust Aggregated Data 6 claims feeds, 3 EHR feeds Understand the Target Understand Global Opportunities Focus the Efforts Find the Right Patients
Understand The Target Next Generation ACO Start 8/31 + Runout UAC 2016 Benchmark PMPM $ 757.67 UAC Trended PMPM $ 765.71 Favorable (Unfavorable) $ (8.04) $ (3.86) Estimated Total Favorable (Unfavorable) $ (8,104,320) $ (3,286,397)
Understand Global Opportunities 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 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
SNF ALOS Focus the Efforts Skilled Nursing Facility ALOS 35 Skilled Nursing Facility Average Length of Stay for NGACO 30 25 20 15 SNF ALOS Linear (SNF ALOS) 10 5 0
Focus the Efforts
Focus the Efforts Emergency Dept. Visits for United Healthcare 25
Find the Right Patients
Mange A Population: Tools 1. Preferred Post Acute Network MCG for Discharge Decision Support 2. ACR Select within Epic for Advanced Imaging Utilization 3. Clinovations for HCC Risk Coding 4. Predictive Modeling in OptumOne Identify High Predictive Patients and Intervene 5. Stanson Health (evaluation period) For Best Practice Alerts 6. EDCCP - Focus on ED high utilization patients 7. Annual Wellness Visits 2017 focus for UnityPoint Clinic (13% current)
Meaningful Incentives 1. UnityPoint Clinic Physician Compensation 14% linked to performance Will move to 30% over next 3 years 2. UnityPoint Accountable Care LC Funds Flow Model Migrating to Shared Risk Incentivizes Quality and PMPM Performance Will Utilize a Tiered Structure (Gold, Silver, Bronze) 3. UnityPoint Health Management Compensation Migrating to Value Adding PMPM to incentives in 2017
Where to Focus (MIPS or APM) 1. Basic quality metrics, (6/300 metrics) but Build your analytics platform Use tools for best practice alerts to hardwire process 2. HCC Coding (Resource Use) Helps in MIPS Resource Use Consider tools to hardwire process 3. PCMH (full credit) or (4/90 Improvement Activities) Need a way to address High Risk Patients Need a way to identify and close gaps in care 4. Timing Considerations to Leap to APMs Margins, Market, Momentum of Change
Other Considerations 1. MSSP Track 1+ Lower Risk APM 2. CMMI Mandatory Bundles (On Hold) 3. What might change legislatively ACA Repeal and Replace Chinks in the Armor of MACRA 1. Pace of Change (Merits to Increase & Decrease) 2. Price Transparency
Transparency Coming Went Live 12.12.2016