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Health Economics Research: Collaborating with ACOs to Improve Patient Data Todd Berner MD Director, Health Economics & Clinical Outcomes Research Astellas Scientific and Medical Affairs 3 rd Partnering with ACOs Summit March 18, 2014

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Page 1: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Health Economics Research:Collaborating with ACOs to Improve Patient Data

Todd Berner MDDirector, Health Economics & Clinical Outcomes ResearchAstellas Scientific and Medical Affairs

3rd Partnering with ACOs SummitMarch 18, 2014

Page 2: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

“Todd Berner is a paid employee of Astellas. The opinions stated in this presentation do not necessarily reflect those of Astellas.”

Page 3: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Muller RW, ECRI Institute Conference 11.28.2012

Page 4: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

NAACOS Survey of 35 ACOs First year start-up experience:

“What were your most vexing problems?”

• Meeting implementation schedules• Finding suitable software• Delays in getting claims data• Developing new skill sets to analyze data• Obtaining addresses of assignees• Slow stand-up of IT systems• Data inconsistency from CMS• Translating data into actionable information for care managers

and providers

NATIONAL ACO SURVEY CONDUCTED NOVEMBER 2013 www.naacos.com accessed 3.12.2014

The typical ACO is risking $3.5 million, plus feasibility and

pre-application costs, until it can get “cash flow relief”

from possible savings

At least one-third of the ACOs took out legal debt to finance

their venture So many are certainly

banking on recouping investment costs

Page 5: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Estimated Number of Lives Covered by ACO Contracts

Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013

Page 6: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Total ACOs Over Time

Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013

Page 7: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Physician Led ACOs:Physician practices have the potential to encourage hospitals to compete

on price and quality for the allegiance of physician sponsored ACOs

Page 8: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Reasons for Slowing in Growth of ACOs

• Reason 1: Tapped Out Market for Trailblazers• Reason 2: No Proven Model to Follow• Reason 3: Payer Delays

Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013

Page 9: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Providers Assuming Risk:

• Nationwide, about 120 provider-sponsored health plans are owned by hospitals or health systems or are in the process of applying for license to own health plans

• Few provider-owned health plans will participate in exchanges

• About 15% of hospitals had PPOs, 13% HMOs and 5% fee-for-service products in 2011, with percentages relatively flat over a decade, according to AHA’s latest data

Health Plan Week August 19, 2013 Volume 23 Issue 28

There are limitations for smaller provider organizations in taking full risk and

becoming an insurance plan, “because you need large numbers in terms of how

capitated rates are set.”

Page 10: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

• North Shore-LIJ began a health plan for its 50,000-some employees and their families about four years ago

• North Shore is the primary network and UnitedHealthcare the plan’s administrator, provides the “wrap” network

• More than 85% of inpatient services occur at North Shore-LIJ facilities

• Benefit design encourages employee base to use their health system and lowers costs

• The Plan’s experience, coupled with market changes under the reform law and interest from employers and unions, allowed the move into fully insured products and to become an insurance company

Health Plan Week August 19, 2013 Volume 23 Issue 28

North Shore-LIJ:

Started With Own Workforce

North Shore-Long Island Jewish (LIJ) Health System is marketing an array of commercial products under North Shore-LIJ CareConnectIt will sell individual and small-group options on the exchange and individual and group products off the exchange

The delivery vehicle is an exclusive provider organization (EPO) offering only in-network benefits falling on the low end of 2014 pricing ranges for various metal levels

Page 11: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Catholic Health Initiatives (CHI)

• Colorado-based CHI, a nonprofit system, operates in 18 states and includes 86 hospitals; 40 long-term care, assisted- and residential-living facilities; two academic medical centers; and home health agencies

• CHI has been developing its strategic plan for how it should participate in risk-based relationships with the payer community

• CHI sponsors health benefits for as many as 70,000 workers, so they are at risk for their own employees

• CHI purchased Soundpath Health, Inc., a Medicare Advantage (MA) plan in Washington state, for $24 million in 2012

• CHI also is involved in bundled pricing, the Medicare Shared Savings Program, a couple of ACOs, and a managed Medicaid globally capitated program in Nebraska

• The health system is involved in a growing number of “value-based relationships” with insurers —offering financial underwriting gains if CHI demonstrates that it meets certain quality, cost and service measures

• In 2014 and 2015, CHI will make a significant investment in electronic health records and informatics for better evaluation of patient data and claims, taking active opportunities to learn about the populations they’re serving, and how to better manage their care and costs at the same time

Health Plan Week August 19, 2013 Volume 23 Issue 28

Page 12: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014
Page 13: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

• Anchored by the system's two flagship academic medical centers, with referral volume generated

by a large group of employed and aligned physicians and by multiple community hospitals within the Partners system.

• Largest non-university based research enterprise in the United States with over $1.6 billion in research revenue

• Research revenue provides a meaningful source of revenue diversification and contributes to Partners' ability to recruit physicians

• The system is affiliated with Harvard University for medical training.• There is significant consolidation and merger and acquisition activity among Boston area hospitals

resulting in the emergence of networks of physicians and hospitals with overlapping geographies that are competing for similar patient populations

• Multiple academic medical centers in Boston are pursuing similar strategies.• Partners acquired a moderately sized healthcare insurance company (Neighborhood Health Plan) in

2013 NHP generated a 1.0% margin in FY13 Two thirds of NHP's business is Medicaid managed care, exposing the system to rates dictated by the state

Focus on cost control has lead to increased government regulation in Massachusetts Growth of health insurance products that provide financial incentives for cost control could limit

patient care revenue growth in future years

Moody’s Investors Service Jan 27,2014

Page 14: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Innovation Health Plans: Inova Health System + Aetna

“Streamlining the process”• Jointly owned health plan serving Northern Virginia

Inova provides care to more than 1.1 million Northern Virginia residents annually Aetna provides health care benefits to approximately 570,000 members in Virginia

• Aetna Health benefits administration and care management capabilities

Inova Health care delivery

• The partnership will promote clinical integration of the health care community Health system will engage community physicians to focus on promoting wellness Improve patient outcomes through better care coordination Streamline access to patient information Aetna will support Inova with technology that makes it easier for physicians to exchange information

and track their patients’ care across all settings.• Commercial and Medicare Advantage HMO and PPO products will be offered in Northern

Virginia as part of the joint venture The new products will give employers and consumers access to less expensive, more coordinated and

integrated health care fostered by the partnership and engagement with community physicians.

“Both Inova and Aetna believe that shared accountability translates into a powerful new value proposition for consumers,”

Mark T. Bertolini, Aetna chairman, CEO and president

Page 15: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Listening to the Patient Voice in Research

Page 16: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014
Page 17: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014
Page 18: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

“When you come to a wall that is too high to climb,

throw your hat over the wall, and then go get your hat.”

-Old Irish Adage

Page 19: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

HECOR Value Evidence Generation

Access

Page 20: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Real World Evidence:Efficacy vs. Effectiveness

Example- • RCT data

• Extremely high placebo response rates• Difficult to show efficacy for drug compared to placebo• It is essentially all non-pharmacologic therapy compared to

non-pharmacologic therapy + drug• Real World data

• All of the behavioral, non-pharmacologic intervention associated with the RCT moves over to the drug side of the ledger

• This becomes a comparison of activated, engaged Rx recipients vs. those with just an Rx

Page 21: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Winning under reform:Critical success factors

High quality; reduce costs

Ability to aggregate clinical capabilities and deliver evidence-based care

Access to capital

Ability to aggregate lives

Physician / Hospital alignment

Ability to aggregate and analyze data

Ability to engage consumers

Manage transition with one foot in FFS and stepping into risk-based contracting

Ability to manage risk

Understand benefit design

Page 22: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Opportunities for ACOs to Better Manage Costs

• Consider distinctions among medications• Acquisition costs• Utilization• Overall medical costs

• Identify interventions• Utilization management strategies• Drug formulations• Best practices for risk management• Care coordination

Page 23: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Identifying the various Stakeholders

Page 24: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

The Imperative to Remain Relevant

• Forging new types of relationships to answer questions of relevance to ACOs

• Developing a “Change Package”

Page 25: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014
Page 26: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Sample Research Project #1:Primary Nonadherence to Medication within a Health System• Phase 1

Retrospective database analysis that will help evaluate the treatment patterns and health care resource utilization amongst our population of interest. This will build the foundation to understanding the adherence rates, discontinuation rates and switching rates within this population. This will quantify the burden of both primary and secondary nonadherence. We will also identify patient and prescriber characteristics for this population, and evaluate the factors associated with patients being non adherent or discontinuing. Stratification between age will be conducted to evaluate the Medicare population versus non-Medicare (>=65 y/o versus <65 y/o). We will assess factors associated with the nonadherence or discontinuation of the various therapies. It would be ideal to evaluate patients newly initiated on therapy and possibly prevalent users. Both primary and secondary nonadherence will be evaluated. Newly initiating therapy patients will be defined as no prior history of therapy in the prior 12 months.

• Phase 2 Study focusing patients newly initiated on therapy. Once we define discontinuation, primary non adherence,

secondary non adherence, we will send them a survey to ask the reasons. This will help examine the real world reasons for why patients are non adherent or discontinuing. Survey will be designed or a prior validated survey could be used. We may use an existing instrument since this may be easy for operational purposes.

• Phase 3 Intervention built from the findings from Phase 1 and Phase 2. Explore which types of interventions would

be needed to help improve care and overall adherence in this population. Phase 1 and Phase 2 findings will be evaluated with Clinical Leadership to figure out ways to intervene and what the Health System can do as next steps.

Page 27: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014
Page 28: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Sample Research Project #2:Performance Improvement within a Health System with Significant

‘leakage’ of patient care outside the system

• In order to assess treatment approaches, project will explore a number of measures:

Compare the number of visits during which condition was:

was in the problem list

listed as a diagnosis

drug was prescribed for the condition

Examine appropriateness of referral patterns:

For purposes of this project, a primary care provider should try at least one drug for this condition– but only one – before referring to a specialist

Referrals made without trying any drug or after prescribing more than one will be classified as potentially inappropriate or suboptimal

We will also distinguish between referrals from the Health System’s primary care clinic system vs others

Examine the use of diagnostic testing and imaging

Examine the use and documentation of validated symptom assessment tools.

Compare the use of different treatment options among those that we can identify via the EHR

Page 29: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Sample Research Project #2:Performance Improvement within a Health System with Significant

‘leakage’ of patient care 

# Condition specific

Rx’s

# Condition specific

medication classesReferrals

Use of diagnostic

toolsTreatment Options

Patient Characteristics          

Age          

<65          

65+          

Race          

Wh          

Other          

Sex          

M          

F          

Insurance Status          

Medicare          

Medicaid          

Commercial          

Provider Characteristics          

Primary care physician          

Other primary care provider          

Specialist          

Hospital #1          

Hospital #2          

Page 30: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Sample Research Project #3:EHR Based Condition Specific Prompts and HCP Decision Support

National Quality Strategy--The Future of Quality MeasurementONC, AHRQ, CMS Presentation. September 14, 2012

Page 31: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

Sample Research Project #3:EHR Based Condition Specific Prompts and HCP Decision Support

• Clinical Decision Support (CDS) Detect potential safety and quality problems and help prevent them

Detect inappropriate utilization of services, medications, and supplies

Foster the greater use of evidence-based medicine principles and guidelines

Organize, optimize and help operationalize the details of a plan of care

Help gather and present data needed to execute this plan

Ensure that the best clinical knowledge and recommendations are utilized to improve health management decisions by clinicians and patients

Osheroff JA, Pifer EA, Teich JM, et al. Improving Outcomes with Clinical Decision Support: An Implementers' GuideChicago: HIMSS; 2005.

Page 32: Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

-Johann Wolfgang von Goethe