coordination of care to mitigate risk in an accountable ... · • track 3 mssp, started 2017; ends...

Julia Andrieni, MD, FACPAssociate Professor of Clinical Medicine, Weill Cornell Medical College

Vice President, Population Health & Primary Care

President & CEO, HM Coordinated Care

President & CEO, HM Physicians’ Alliance for Quality

Coordination of Care to Mitigate Risk

in an Accountable Care Organization

April 21, 2017

AGENDA

2

The Need for Value Based Care: Why?

Medicare Shared Savings Program (MSSP): What? How?

Building a New Model of Care: Infrastructure & Resources

PA

YM

EN

T

MO

DE

LS

INC

EN

TIV

EA RAPIDLY CHANGING HEALTHCARE

LANDSCAPE FOCUSED ON VALUE OF CARE

3

PAYMENT MODELS ARE DRIVEN BY DIFFERENT INCENTIVES

Value Based

Payment

Driven By Care

Coordination

Linked to Quality

and Utilization

Fee For

Service Linked

to Quality

Fee For Service

Driven By Volume

• Pay For

Performance

• Process Measures

• Maximize number of

appointments and

services per patient

• ACOs and CINs

• Bundled Payments

• Outcomes Measures

Driven By Volume

Linked to Quality

Outcomes

AGING POPULATION AND RISING

MEDICARE HEALTH EXPENDITURES

4

3.6M

Texas15.0M

450,000

2015

4.5M405,000

+12%

+11%

<65 years

65+ years

2025

5.6M504,000

2020

Harris County Population Growth2

Houston home to 10% of

Medicare beneficiaries in TX

65+ population projected to

continually grow…… and related Medicare spend

projected to grow accordingly

$11.9K $12.2K

2015 2016 20252019

$17.9K

$13.6K

Increasing opportunity in Medicare market

1. Texas data from Kaiser Family Foundation calculation based on CMS data, 2015. Includes aged and/or disabled individuals enrolled in Medicare Part A

and/or B through Original Medicare or Medicare Advantage and Other Health Plans. Houston-Area data from Health Leaders, FFS only

2. Assumes 9% of the population 65+ across all years based on 2010 census for Harris county; does not account for age-ins; Population Projections from Harris

Country Budget Dept, Feb 2016

3. From CMS.gov, represents projected Medicare FFS expenditure per enrollee

National Med FFS PMPY Cost3

INCREASING MEDICARE PAYOR MIX

DRIVES VALUE-BASED CARE

5

Payer mix is shifting from Commercial

FFS to Government programs,

particularly Medicare

Commercial Payers are signaling

they’re serious about shifting to

Value-Based Care

A KEY DRIVING FORCE BEHIND

MEDICARE’S SHIFT TO VALUE IS MACRA

6

• Establishes annual physician payment updates of +0.5% annually through 2018

• From 2019 – 2025, base payment rates frozen and physicians subject to

performance based - adjustments under one of two methodologies:

Alternative Payment ModelAPM Bonus

- Providers that receive a certain threshold of

revenue from APMs will automatically

qualify for a temporary 5% bonus

- Threshold is 25% in 2019, 50% in 2021,

and 75% in 2023

2

Merit-Based Incentive Program System(MIPS)

Providers that do not meet APM thresholds

must undergo evaluation under MIPS

1. Standard MIPS: Only choice starting 2018:

• Providers publicly scored on combination of

quality, cost, and infrastructure and will

translate into a payment adjustment ranging

from ±4% in 2020 to ±9% in 2025

2. Ease into MIPS, 2017 only:

• Any data submitted avoids neg. adjustments

3. Reduced performance period, 2017 only:

• Submit data for reduced number of days

1

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

New Value Payment Models for Physicians

DRIVE TO VALUE DRIVEN BY

MACRA

7

Merit-Based Incentive

Program “MIPS”

Alternative Payment

Model “APM”

Level of ControlX Uncertain how CMS will score

physicians relative to peers✓ Guaranteed 5% bonus and proactive

management of population

Potential ReturnX Potential for payment penalties

and no gainshare opportunity ✓ Guaranteed 5% bonus plus gainshare

payments

Downside Risk X Physician takes individual risk✓ ACO takes downside risk on behalf of

physicians

ReportingX New burdens, complex

requirements ✓ ACO manages ongoing performance

reporting and analytics

CapabilityDevelopment

X Potential returns do not support infrastructure development/use

✓ ACO provides robust infrastructure applicable across patient panel

Physician-level

considerations:

NET EFFECT: Increased competition for physicians to

consolidate and join ACOs.

VALUE BASED CARE PRINCIPLES

8

CMS given authority to experiment in

redesigning care and payment models

Transition from hospital to ambulatory

setting

Increase focus on wellness and

prevention for chronic illness

Empower the consumer to have more

choice and control over their healthcare

Move from transactional, episodic care to

team-based, coordinated care

Transparency in reporting quality

outcomes and cost

NEW PAYMENT & DELIVERY CARE MODELS:

MANAGING RISK, CREATING OPPORTUNITY

Fee-for-Service

Incentive-based FFS

Pay-for-Performance

Bundled Payments

Partial Risk

Full Risk

Health Plan

DRIVERS:

Federal Regulations

Cutting Healthcare Costs

Increasing Quality & Safety

Consumer Transparency

• Volume-based

• Lowest risk

• No outcome metrics

•Physician Quality

Reporting System

(PQRS)

•Quality & Cost Target

Payments

•Scorecards

•Value-based payments

•Upside only

•Lower-cost FFS

•Rewards Volume

•Diagnosis-related group

(DRG Payments

•Limited upside &

downside

•Shared savings

(gainsharing)

•e.g. MSSP tracks

•Capitated payment

models

•Reward for lower

utilization

•Pop. Health

management

•e.g. Next-Gen ACO

• Full integration

• Continuum of Care

Coordination

• Insurance Plan

Management and Risks

ACO TRACKS VARY IN RISK-

CONTROL BALANCE

10

High

Medium

Low

Level of Financial Risk

Next Gen ACO

Level of Health System Control

Provider Sponsored Health Plan

Medicare Shared Savings Program Track 3


Bundled Payments

Level of Health System Risk

HMCC

Market forces drive rate of change

COMPARISON OF MEDICARE

PROGRAMS

11

More

Attractive

Less

Attractive

Shared Savings

Exposure to

Downside

Rebasing

Fraud & Abuse

Waivers

Data Access

Scale and

“Mindshare”

Defined Patient

Population

Additional Patient

Benefits

MSSP*

Track 1

MSSP*

Track 3

Next Gen

ACO**

Medicare

Advantage Plan

* MSSP = Medicare Shared Savings Program

** Next Gen = Next Generation Program

MEDICARE SHARED SAVINGS PROGRAM

TRACK 3 BALANCES RISK AND SHARED

SAVINGS

12

Track 3Track 1

≤50% savings rate,

no downside

≤75% savings rate,

40-75% loss rate

Access to Claims Data and Fraud & Abuse Waivers (Anti-Kickback, Stark, Gainsharing CMP, Beneficiary Inducements CMP)

ProspectiveRetrospective

Sliding corridor from 2.0-3.9%

based on membership

Discounted by 0.5-4.5%;

National trend adjusted for

regional price

Shared

Savings/Losses

Savings/Loss

Corridor

Type of Attribution

Additional

Benefits

Contract Duration 3 years

• Minimal risk assumed with

upside-only configuration

• Retrospective attribution

complicates care

management

• Favorable shared savings

vs. loss proportions rewards

higher risk tolerance

• Prospective attribution

allows for proactive care

management

Attractiveness

for HMCC

New: Next-Gen ACO

100% shared savings

& loss rate

Contract thru 2018; option for ’19-’20

• Greater level of risk than

currently being considered

within the system

• Generally appropriate for

systems already managing

upside/downside risk

Select 0-2.0% Corridor

Opportunity for up to 3%

value from risk adjustment

2017 MEDICARE ACCOUNTABLE CARE

ORGANIZATIONS (ACOs)

13

ACOs representing 10.5M beneficiaries


Medicare Accountable Care Organizations (ACOs):

• Track 1, started July 2012;

current contract ends 2018

• 50,055 participants

• $1,059 PMPM benchmark,

2015

• $42M* Savings in 2015,

$22M* in 2014, $26M* in

2013

• Track 1, started 2012;

contract ends 2017


• $780 PMPM benchmark,

2015

• $4.5M* Savings in 2015,

$6M* in 2014, $9M* in

2013

• Track 1, started

2015; ends 2018


• $823 PMPM

benchmark, 2015

• $2M Savings

• Track 3 MSSP, started

2017; ends 2019


• $1052 PMPM

benchmark, 2016

Medicare Shared Savings Programs = ACOs

Next Generation ACOs

Medicare Shared Savings Program Track 1 and Track 2

525

36

45

444`

History of Medicare ACOs in Houston:

*Dollars represented is after the 50% savings is shared with CMS

AGENDA

14




WHAT IS A MEDICARE SHARED

SAVINGS PROGRAM (MSSP)?

15

Builds Scale: Attributes substantial covered lives.

Physician Alignment: Participation in MSSP Track 3 may qualify as alternative

payment under MACRA legislation (potential 5% bonus starting 2019).

Data & Reporting: Provides physician experience using quality and utilization

reporting; prospective attribution enables early identification and metrics tracking.

MSSP is a gainshare arrangement (total cost of care) with CMS for Medicare FFS lives that are

attributed to a network of PCPs*; requires application and formation of ACO legal entity

Value to Houston Methodist Coordinated Care

Key Considerations• ACO Model: MSSP application requires formation of ACO.

• Quality Reporting in 4 Domains: Patient Caregiver experience, Care

Coordination/Patient Safety, Preventive health, At-Risk populations (Diabetes and

Depression).

• Network: PCP universe defines the number of attributed lives.

• Time Period: 3 Year Program.

Significant Market Opportunity: Greater Houston region has higher cost & utilization

baseline suggesting opportunity; SNF 3-day waiver presents early savings opportunity.

HOW DOES A MEDICARE SHARED

SAVINGS PROGRAM WORK?

Apply Shared

Savings

Measure Performance

Measure Performance;

Share Savings/LossesEstablish BenchmarkDefine Population

ACO Attributed Population

Medicare fee-for-

service members

in region

Receive care

from ACO

Receive primary care

from ACO

• Will be defined prospectively

(before each performance year)

• Based on primary care services;

gives preference to PCPs over

specialists

Determine per-capita

spending for historical period

• Done Historical spending based

on 3-year period

1

Update for each contract

year (“Performance Year”)

• Trend forward based on

national growth in Medicare

spending

• Apply some risk-adjustment

2

• Determined by

MSSP Track

and ACO

quality

performance

$50

$0

$650

$700

$750

-$50

$700

$750

ACO

55% 45%

CMS

30%

70%

1 2

• Per-capita Medicare

spending on attributed

members

• Must exceed “corridor”

for ACO to share

Bench-

mark

Actual

10

ACO PERFORMANCE DRIVEN BY

4 CORE CAPABILITIES

17

Medical Economics

Analytics & Actuarial

Line Staff & Management

Qu

alit

y

Net

wo

rk P

erfo

rman

ce

Inte

grat

ed IT

Pla

tfo

rm

Car

e M

anag

emen

t

Value-Based Services Organization (VBSO)

(Stratification, Data Ops, Clinical Programs, Informatics, Reporting)

321 4

Medicare Shared Savings

Programs’ core capabilities

drive program performance

ACO CAPABILITIES PROVIDE

CRITICAL FUNCTIONALITIES

18

Quality

✓Comprehensive clinical rules engine that uses

disparate datasets to find gaps in care for Medicare

Shared Savings Program quality metrics

✓Technology-enabled workflow that engages all care

team members in closing gaps in care

✓Quality initiatives and programs compliant with

Medicare Shared Savings Program and National

Committee for Quality Assurance (NCQA)

requirements

Quality metrics are a critical part of ACO performance

Integrated IT is essential to data analytics driving performance to business case



19

Integrated IT Platform

✓Ability to integrate and normalize claims, EMR and CMS

data

✓Stratification engine identifies only “impactable” patients

and matches them to the appropriate clinical program

✓Predictive Analytics necessary for Population Health

Management



20

Care Management

✓Single patient profile that enables coordinated care across

the care continuum

✓ Integrated workflows with Primary Care Physician

Practices

✓ Jointly developed patient care plans that factor in

socioeconomic, behavioral, and mental health

Care management drives medical expense savings



21

Network Performance

✓Access to expanded set of data paired with analytics to

identify key areas of network waste (ED, Home Health,

DME*, SNFs**)

✓Physician education and alignment around the impact of

value-based care initiatives (Quality and Utilization

Metrics)

✓Methodologies to encourage coordination and

collaboration between all care providers, inclusive of

specialists

Network management drives medical expense savings

* DME = Durable Medical Equipment

** SNFs = Skilled Nursing Facilities

AGENDA

22




ACO MODEL OF CARE: PHYSICIAN

LED TRANSFORMATION

• Innovative approaches to clinical

effectiveness and governance.

14

Provides Value to Patients and to Physicians

Value = Benefits (Quality)

Avoidable Costs

Physician-Led Transformation

ACO Governance Board*• 77% of Voting Members are Primary

Care Physicians with attributed

Medicare Fee For Service Patients

• Medicare Fee For Service Patient

Representative on Board* CMS Regulations

VALUE-BASED CARE REQUIRES A

PATIENT-CENTERED APPROACH

24

PATIENT

Primary Care Physician Engagement

PharmacistAligned ExtendedCare Team

Care Management Team

Care Advisor (RN) Social Worker

PCP

Population Health Infrastructure

• Integrated technology platform &

analytics (Epic EHR Systemwide)

• Continuum of Settings:

Comprehensive, integrated, patient-

centered infrastructure

• Requires prepared,

proactive physicians

that interact with

informed, activated

patients

• Physician ACO Quality

Metric Dashboard

• Requires dedicated care

management team to engage with

highest-risk, impactable patients

behind the scenes

• Care team coordinates closely with

Primary Care Physician

POPULATION HEALTH MANAGEMENT

PROGRAM KEY ELEMENTS

25

• Deliver Individualized Care

• Coordinate care between healthcare settings &

providers

• Identify barriers to achieving better health outcomes

• Clinical Integration of care team

• Emphasis on Consumer access and convenience

• After Hours Care Plan

• Advanced informatics to stratify health risks

• Predictive analytics to guide resource utilization

• Quality and Utilization Reports

• Engage and Educate Patients in their own

health

• EHR patient portal, apps, wireless health

monitoring devices

CARE MANAGEMENT

INFRASTRUCTURE

PRIMARY CARE

FOCUSED CLINICAL

NETWORK

DATA-DRIVEN

CLINICAL

DECISION

MAKING

PATIENT

ENGAGEMENT

STRATEGY

• Which Patients will be readmitted in the future? Readmission Risk Scores prioritize work and decrease readmission rates.

• Which Patients, who appear well today, are at risk for developing a serious illness? Target individual risk factors with Complex Care Risk Scores.

• ED Utilization Risk Scores may correlate with Patient Access issues.

USE DATA TO TARGET SPECIFIC

PATIENT HEALTHCARE NEEDS

26

PREDICTIVE ANALYTICS

PATIENT OUTREACH BASED ON

PATIENT DATA

• Which uncontrolled Diabetic patients have not had an appointment in the past 3 months? (Identify Gaps in Care for healthcare under-utilizers)

• Which Diabetic patients have not filled their prescriptions? (Prescription Gap Analysis)

PHYSICIAN DECISION

SUPPORT AT POINT OF

CARE

• Physician reminders in “real-time” at the point of care when patient needs a test, service, or treatment. (EHR capabilities)

• Which Diabetic patients are most likely to be non-adherent to the care plan? (Evaluate patient readiness for change and literacy levels)

Use of IT intelligence to drive improvement in

Clinical Outcomes and Patient SatisfactionMETHOD:

TARGET CLINICALLY IMPACTABLE

PATIENTS FOR CLINICAL PROGRAMS

ImpactableAcute Event

Any Acute Event

Total Cost of Care

Models with more focused outcomes

performed twice as well as those that

attempted to predict general outcomes

Increasing predictive

model performance

Program Generalized Risk

Score

Program-Specific

Risk Score

Complex

Care

Top 2% of the

population

- Members with

multiple co-

morbidities

High Risk of

Disease-related

Ambulatory

Sensitive Condition

Admission

Transitio

ns Care

Next 10% risk with a

claim in each of the

prior 3 years:

- Members who

have an Inpatient

admission

Risk of Unplanned

Readmission 30

Days Post

Discharge

22

POPULATION HEALTH PYRAMID STRATIFYING AND MANAGING RISK

28

HIGH

RISING

RISK

AT-RISK

LOW-RISK

COSTS

RISKS

5-10% of Population

~50% of Health Costs

15-30% of Population

~45% of Health Costs

60-80% of

Population

~5% of

Costs

MGMT STRATEGY

• 1 Nurse Care Mgr. per 200 employees

• Clinical Pharmacist for Rx review

• Diabetic Nurse Educator

• Patient-Centered Medical Home

• Team-based approach to care

• Patient Outreach

• Prevention and wellness focus

• Same-day Patient Access

• Patient Convenience

FOCUS ON MEDICARE-FEE-FOR-

SERVICE COST DRIVERS

29

Avg Cost MFFS Inpatient

Hospital Stay1

Identify high-risk, impactable patients (multiple

chronic conditions) and address patient needs

to prevent Inpatient admissions

Engage patients who are discharged from Inpatient

unit to prevent readmissions; manage follow-up

appts, provide home visits, coordinate Durable

Medical Equipment

Identify high-risk, impactable patients (multiple

chronic conditions) to educate on their symptoms

and appropriate site of care

IP Admissions

Readmissions

Unnecessary ED Visits

Major MFFS cost drivers … … Opportunities exist to coordinate care

1

2

3

Avg Cost ED visit2 Avg Cost MFFS

SNF per Day1

$12.8k $1.2k $466Avg Cost Inpatient

Readmission2

$13k

1. Houston-area Medicare FFS benchmark, MSSP T3 quarterly report, rolling 12 months

ending June 2016 . Adjusted geographically for Sugar Land MSA relative to national.2. National data all LOBs, 2013

HOUSTON-AREA ED UTILIZATION IS HIGHER

THAN NATIONAL BENCHMARKS

30

Utilization Benchmarks

Benchmarking data suggests opportunities related to ED visit utilization

1 National data adj, geographically for local utilization factors in the Houston-Woodlands-Sugar Land MSA.

2 Provided by CMS in Track 3 quarterly reports, for the rolling 12-month period ending June 2016.

3 All MSSP Track 3 ACO’s (n=16) provided by CMS as of in Track 3 quarterly reports Jan-June 2016.

MEDICARE FEE FOR SERVICE VARIATION IN

POST-ACUTE CARE SPENDING –

NATIONWIDE

Post-Acute Care spending averages ~$110 PMPM for Medicare FFS patients; however, this can range from $50-300 PMPM between low-spend and high-spend regions.

31

GOALS OF POST-ACUTE CARE

MANAGEMENT PROGRAMDescription Goal

• Utilize Medicare 3 Day Skilled Nursing Facility Waiver; Patients can be admitted from home and physician office

• Patients seen by PCP within 7 days prior to use of SNF waiver

SNF 3-Day Waiver

Reduce inpatient costs and admissions

• Improve quality of clinical care during SNF stays• Establish standard for patients admitted to SNF

Care Delivery in SNFs

Increase patient satisfactionImprove care quality

• Adapt Care Management programs to engage SNF patients

Care

Management

for SNF

Patients

Reduce SNF LOS and readmissionsImprove care quality

• Reduce variation in Post Acute Care referrals and encourage use of hospice and at home health when appropriate

Site-of-Care Optimization

Reduce PMPM and admissions

• Build close relationships with SNFs and encourage use of high-performing SNFs

• Standardize Preferred Home Health and Durable Medical Equipment agencies

SNF Network & Partnerships

Build, maintain high performing SNF network

5

2

1

4

3

32

INCREASED PATIENT SERVICES

ACROSS THE CONTINUUM OF CARE

33

Hospital Stable HealthPatient

Skilled Nursing

Facility

ED

At Hospital

• Hospitalist and Coordinated Care

Advisor collaborate

• Follow-up appt. scheduled and

medications reconciled

Post-Discharge (30 Days)

• Coordinated Care Advisor confirms

receipt of meds and sends

discharge summary to PCP

• Home visit if high-risk, Telephonic

follow-up for moderate risk

Ongoing Management• High-risk patients moved to

complex care clinical program

Coordinated Care Advisors support patients at Home, in Hospital, in ED and in Skilled Nursing Facilities.

Coordinated Care Advisor Support

ED Admission• ED Physicians work with

Case Management and PCP

for patient care plan

Skilled Nursing Facility• Coordinated Care Advisors

round on patients in SNF

WHAT IS THE ACO VALUE PROPOSITION FOR

PRIMARY CARE PHYSICIANS?

34

Brand Reputation: Physician practices benefit from association with the

Houston Methodist brand and quality.

Potential to Earn Significant Shared Savings: Opportunity to share in

ACO performance based savings on an annual basis.

Technology Support: Real time access to patient data and back-office

support to EMR integration. (ACO Physician Dashboard of Quality

Metrics and EpicCare Link)

Quality Reporting Infrastructure: Medicare Shared Savings Program

participation may qualify for 5% bonus Medicare payment starting in

2019.

Primary Care Practice Patient Resources: Real time access to

dedicated care advisors, population health managers and pharmacists

for complex care, transitions in care and advanced illness care programs.

TOOLS FOR SUCCESS

35

Care

Management

Programs

Quality

Metric

Monitoring

Infrastructure and workflows to track quality

performance and highlight specific action

steps at the point-of-care

Structured and integrated population health

care management programs, capabilities,

and support resources

These levers must be supported by an aligned delivery network with

well-structured governance that prioritizes coordination and high-value

referrals, and by physician-led practice transformation driven by

close engagement and value-based compensation

Pop Health

IT &

Analytics

Technology platform that can not only stratify

risk, but identify “impactable” spending and

integrate into workflow

PCP

Engagement

High performance PCP network aligned to a

value compensation model with collaborative

agreements with specialists

Quality

of Care

Patient

Experience

Medical

Spend

36

TEXAS & HOUSTON ACOS ARE

AMONG THE TOP PERFORMERS

Average 2015 Savings Rates for ACOs

by State

Houston ACO 2015 Performance Summary

14% $89M

~5%

2%

10+M

$2+M

#1 nationwide

performing ACO

433 ACOs nationwide in 2016

29 ACOs

(’16)

50K participants

9K participants

20K participants

Below benchmark

Below benchmark

Below benchmark

Due to high regional Medicare expenditures, HMCC has an opportunity to demonstrate savings.

coordination of care to mitigate risk in an accountable ... · • track 3 mssp, started 2017; ends...

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