discussion with dr. patrick conway of cms on
TRANSCRIPT
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NEHI LIVE! Presents:
Discussion with Dr. Patrick Conway of CMS on “Innovations in Payment & Care Delivery Models with
Illustrations from Leading Healthcare Innovators”July 19, 2017
Boston, MA - Washington, DC - San Francisco, CA
INNOVATION IN PAYMENT AND CARE
Susan Dentzer, President and CEO, NEHI
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ABOUT NEHI• National nonprofit, nonpartisan think thank and
membership organization
• Nearly 100 members across sectors – provider
systems, payers, employers, biopharmaceutical
companies, patient groups, and others
• Collaborate to develop solutions to improve
health, produce better quality health care, and
lead to more sustainable rates of growth in
health spending
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VALUE-BASED CONTRACTING FOR BIOPHARMACEUTICALS
• Imperative: bring pharmaceuticals into value-
based or outcomes-based payment arrangements
• Much current activity among payers and
manufacturers
• Regulatory changes may be needed to facilitate
• White paper at http://www.nehi.net/publications/76-rewarding-
results-moving-forward-on-value-based-contracting-for-
biopharmaceuticals/view
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MACRA AND THE BROADER HEALTH CARE SYSTEM
Convening report at http://www.nehi.net/writable/publication_files/file/macra_nehi_deloitte_report_may_23.pdf
HEALTH CARE WITHOUT WALLS• Financial Update – 1Q 2017
• Recent Activities Update
• Core Programs Update
• Boston and DC Offices Update
• Board Retreat Plans
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• Technology could enable far more distributed health
care, outside of institutional settings, by 2025
• Could increase access, reduce costs, move care closer
to individuals and communities
• Multiple barriers stand in way
• What payment models will best support the move to
more distributed care?
Health System Innovation and Advanced Alternative Payment Models
Patrick Conway, MD, MSc
Deputy Administrator for Innovation and Quality
Director, Center for Medicare and Medicaid Innovation
Centers for Medicare and Medicaid Services (CMS)
DATE: July 19, 2017
NEHI Webinar: “Innovations in payment & care delivery models with CMS and leading healthcare innovators”
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CMS support of health care Delivery System Reform will result in better care, smarter spending, and healthier people
Key characteristics▪ Producer-centered▪ Incentives for volume▪ Unsustainable▪ Fragmented Care
Key characteristics▪ Patient-centered▪ Incentives for outcomes▪ Sustainable▪ Coordinated care
Public and Private sectors
Evolving future stateHistorical state
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Category 1
Fee for Service –
No Link to
Quality & Value
Category 2
Fee for Service –
Link to
Quality & Value
Category 3
APMs Built on
Fee-for-Service
Architecture
Category 4
Population-Based
Payment
A
Foundational Payments
for Infrastructure &
Operations
B
Pay for Reporting
C
Rewards for
Performance
D
Rewards and Penaltiesfor Performance
A
APMs with
Upside Gainsharing
B
APMs with Upside
Gainsharing/Downside
Risk
A
Condition-Specific
Population-Based
Payment
B
Comprehensive
Population-Based
Payment
Alternative Payment ModelsAt-a-Glance
APM FRAMEWORK
The framework is a critical first step
toward the goal of better care,
smarter spending, and healthier
people.
• Serves as the foundation for
generating evidence about what
works and lessons learned
• Provides a road map for
payment reform capable of
supporting the delivery of person-
centered care
• Acts as a "gauge" for measuring
progress toward adoption of
alternative payment models
• Establishes a common
nomenclature and a set of
conventions that will facilitate
discussions within and across
stakeholder communities
The framework situates existing and potential APMs into a series of categories.
Target percentage of payments in
“FFS linked to quality” and “alternative
payment models” by 2016
>80%
~20%
~70%
0%
85%
30%
Alternative payment models (Categories 3-4)
FFS linked to quality (Categories 2-4)
All Medicare FFS (Categories 1-4)
2011 2014 2016
Historical Performance
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The Health Care Payment Learning and Action Network will accelerate the transition to alternative payment models
▪ Medicare alone cannot drive sustained progress towards alternative payment models (APMs)
▪ Success depends upon a critical mass of partners adopting new models
▪ The network will
➢ Convene payers, purchasers, consumers, states and federal partners to establish a common pathway for success]
➢ Collaborate to generate evidence, shared approaches, and remove barriers
➢ Develop common approaches to core issues such as beneficiary attribution
➢ Create implementation guides for payers and purchasers
➢ Accomplishments➢ Common definitions for alternative payment models and
agreement to report publicly
➢ Population-based payment and episode-based payment model workgroups and now focused on implementation
Network Objectives
• Match or exceed Medicare alternative payment model goals across the US health system
-30% in APM by 2016• Shift momentum from CMS
to private payer/purchaser and state communities
• Align on core aspects of alternative payment design
12National Results on Patient Safety
Substantial progress thru 2014,
compared to 2010 baseline
Source: Agency for Healthcare Research & Quality. “Saving Lives and Saving Money: Hospital-Acquired Conditions Update. Interim Data From National Efforts To Make Care Safer, 2010-2014.” December 1, 2015.
21 percent decline in overall harm
125,000 lives saved
$28B in cost savings from harms avoided
3.1M fewer harms over 5 years
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The Innovation Center portfolio aligns with delivery system reform focus areas
Focus Areas CMS Innovation Center Portfolio*
Deliver Care
▪ Learning and Diffusion‒ Partnership for Patients ‒ Transforming Clinical Practice
▪ Health Care Innovation Awards
▪ Accountable Health Communities
▪ State Innovation Models Initiative‒ SIM Round 1 & SIM Round 2‒ Maryland All-Payer Model‒ Pennsylvania Rural Health Model‒ Vermont All-Payer ACO Model
▪ Million Hearts Cardiovascular Risk Reduction Model
Distribute Information
▪ Information to providers in CMMI models ▪ Shared decision-making required by many models
Pay Providers
▪ Accountable Care ‒ ACO Investment Model‒ Pioneer ACO Model‒ Medicare Shared Savings Program (housed in Center for
Medicare)‒ Comprehensive ESRD Care Initiative‒ Next Generation ACO
▪ Primary Care Transformation‒ Comprehensive Primary Care Initiative (CPC) & CPC+‒ Multi-Payer Advanced Primary Care Practice (MAPCP)
Demonstration‒ Independence at Home Demonstration ‒ Graduate Nurse Education Demonstration‒ Home Health Value Based Purchasing‒ Medicare Care Choices‒ Frontier Community Health Integration Project‒ Medicare Diabetes Prevention Program
▪ Bundled payment models‒ Bundled Payment for Care Improvement Models 1-4‒ Oncology Care Model‒ Comprehensive Care for Joint Replacement
▪ Initiatives Focused on the Medicaid ‒ Medicaid Incentives for Prevention of Chronic Diseases‒ Strong Start Initiative‒ Medicaid Innovation Accelerator Program
▪ Dual Eligible (Medicare-Medicaid Enrollees)‒ Financial Alignment Initiative‒ Initiative to Reduce Avoidable Hospitalizations among
Nursing Facility Residents‒ Integrated ACO
▪ Medicare Advantage (Part C) and Part D‒ Medicare Advantage Value-Based Insurance Design Model‒ Part D Enhanced Medication Therapy Management
Test and expand alternative payment models
Support providers and states to improve the delivery of care
Increase information available for effective informed decision-making by consumers and providers
* Many CMMI programs test innovations across multiple focus areas
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Accountable Care Organizations: Participation in Medicare ACOs growing rapidly
▪ 561 ACOs (of which 120 are risk-bearing) have been established in the MSSP, Next Generation ACO and Comprehensive ESRD Care Model programs
▪ This includes 85 more ACOS in 2017 than in 2016.
▪ These ACOs together cover 12.3 million assigned beneficiaries.
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▪ Pioneer ACOs were designed for organizations with experience in coordinated care and ACO-like contracts
▪ Pioneer ACOs generated savings for three years in a row ➢ Total savings of $92 million in PY1, $96 million in PY2, and $120 million in PY3‡
➢ Average savings per ACO increased from $2.7 million in PY1 to $4.2 million in PY2 to $6.0 million in PY3‡
▪ Pioneer ACOs showed improved quality outcomes➢ Mean quality score increased from 72% to 85% to 87% from 2012–2014 ➢ Average performance score improved in 28 of 33 (85%) quality measures in PY3
▪ Elements of the Pioneer ACO have been incorporated into track 3 of the MSSP ACO
Pioneer ACOs meet requirement for expansion after two years and continued to generate savings in performance year 3
▪ 19 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME, MI, MN, NH, NY, VT, WI) reaching over 600,000 Medicare fee-for-service beneficiaries
▪ Duration of model test: January 2012 – December 2014; 19 ACOs extended for 2 additional years
‡ Results from actuarial analysis
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• New CMMI model that will test a payment design that incorporates more limited downside risk (i.e., 8% of revenue) than is currently present in Tracks 2 or 3
• Beginning with PY2018. Also available for PY2019 and 2020 start dates.
• Initial details can be found at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/New-Accountable-Care-Organization-Model-Opportunity-Fact-Sheet.pdf
MSSP Track 1+
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Next Generation ACO Model builds upon successes from Pioneer and MSSP ACOs
Designed for ACOs experienced with coordinating care for patient populations
▪ 44 ACOs will assume higher levels of financial risk and reward than other Medicare ACO initiatives
▪ Model will test how strong financial incentives for ACOs can improve health outcomes and reduce expenditures
▪ Greater opportunities to coordinate care (e.g., telehealth & skilled nursing facilities)
Model Principles
• Prospective attribution
• Financial model for long-term stability (smooth cash flow, improved investment capability)
• Rewards quality
• Benefit enhancements that improve patient experience & protect freedom of choice
• Allows beneficiaries to choose alignment
44 ACOs spread among 20 states
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The bundled payment model targets 48 conditions with a single payment for an episode of care
➢ Incentivizes providers to take accountability for both cost and quality of care
➢ Four Models - Model 1: Retrospective acute care hospital stay only
- Model 2: Retrospective acute care hospital stay plus post-acute care
- Model 3: Retrospective post-acute care only
- Model 4: Prospective acute care hospital stay only
▪ 305 Awardees and over 1143 Episode Initiators as of July 2016
Bundled Payments for Care Improvement is also growing rapidly
▪ Duration of model is scheduled for 3 years:▪ Model 1: Awardees began Period of Performance in
April 2013▪ Models 2, 3, 4: Awardees began Period of
Performance in October 2013
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Comprehensive Primary Care initiative: 2012-2016
474 practices in 7 regions supported by 38 public and
private payers
Practices enhanced care delivery by providing care management, coordinated care, and engaging patients
Diverse supports: PBPM care management fees, shared
savings opportunity, learning and data feedback
Reductions in Part A and B expenditures,
driven by reduced hospital inpatient and
SNF spending
Favorable effects on patient experience and
provider satisfaction
Practices underwent significant transformation in the delivery of primary
care
KEY FINDINGS
BACKGROUND
Four-year multi-payer model designed to strengthen primary care
Comprehensive Primary Care Plus (CPC+) builds on the lessons learned in CPC
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Comprehensive Primary Care Plus (CPC+)
CMS’s largest-ever initiative to transform how primary care is delivered and paid for in America
GOALS PARTICIPANTS AND PARTNERS
CARE TRANSFORMATION FUNCTIONS PAYMENT REDESIGN COMPONENTS
1. Strengthen primary care through multi-payer payment reform and care delivery transformation.
2. Empower practices to provide comprehensive care that meets the needs of all patients.
3. Improve quality of care, improve patients’ health, and spend health care dollars more wisely.
Access and continuity
Care management
Comprehensiveness and coordination
Patient and caregiver engagement
Planned care and population health
• 5 year model: 2017-2021
• Up to 5,000 practices in up to 20 regions
• Two tracks depending on practice readiness for transformation and commitment to advanced care delivery for patients with complex needs
• Public and private payers in CPC+ regions
• HIT vendors (official partners for Track 2 only)
PBPM risk-adjusted care management fees
Performance-based incentive payments for quality, experience, and utilization measures that drive total cost of care
For Track 2, hybrid of reduced fee-for-service payments and up-front “Comprehensive Primary Care Payment” to offer flexibility in delivering care outside traditional office visits
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▪ CMS is testing the ability of state governments to utilize policy and regulatory levers to accelerate health care transformation
▪ Primary objectives include▪ Improving the quality of care delivered
▪ Improving population health
▪ Increasing cost efficiency and expand value-based payment
State Innovation Model grants have been awarded in two rounds
▪ Six round 1 model test states
▪ Eleven round 2 model test states
▪ Twenty one round 2 model design states
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▪ Maryland has the nation’s only statewide all-payer hospital global budget model
▪ The model tests whether hospital global budgets can achieve improvements in quality and reduce per capita hospital cost growth
▪ The All-Payer Model has positive results to date (2014-2016)▪ The state reports approx. $429 million in Medicare hospital cost savings
▪ All-payer total hospital per capita cost growth significantly below the 3.58% target
▪ 30-day all cause readmission rate fell from 1.2% to 0.4% above national rate
Maryland All-Payer Model reports $429 million in Medicare hospital cost savings over three years
▪ Hospitals began moving into All-Payer Global Budgets in July 2014- 95% of Maryland hospital revenue will be in global budgets- All 47 MD hospitals have signed agreements
▪ Model was initiated in January 2014; five year test period
▪ Maryland has proposed building on existing global budgets, towards a population-based total cost of care model.
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Medicare Care Choices Model (MCCM) provides new options for hospice patients
▪ MCCM allows Medicare beneficiaries who qualify for hospice to receive palliative care services and curative care at the same time. Evidence from private market that can concurrent care can improve outcomes, patient and family experience, and lower costs.
▪ MCCM is designed to ➢ Increase access to supportive care services provided by hospice;
➢ Improve quality of life and patient/family satisfaction;
➢ Inform new payment systems for the Medicare and Medicaid programs.
▪ Model characteristics➢ Hospices receive $400 PBPM for providing services for 15 days
or more per month
➢ 5 year model
➢ Model will be phased in over 2 years with participants randomly assigned to phase 1 or 2
Services
The following services are available 24 hours a day, 7 days a week
• Nursing
• Social work
• Hospice aide
• Hospice homemaker
• Volunteer services
• Chaplain services
• Bereavement services
• Nutritional support
• Respite care
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Medicare Advantage Value Based Insurance Design Model offers more flexibility to Medicare Advantage Plans
Allows MA plans to structure enrollee cost-sharing and other health plan design elements to encourage enrollees to use clinical services that have the greatest potential to positively impact on enrollee health
▪ Began on January 1, 2017 and run for 5 years
▪ Plans in 10 states will be eligible to participate➢ Arizona, Indiana, Iowa, Massachusetts,
Oregon, Pennsylvania, and Tennessee
➢ Starting in 2018: Alabama, Michigan and Texas
▪ Eligible Medicare Advantage plans in these states, upon approval from CMS, can offer varied plan benefit design for enrollees who fall into certain clinical categories identified and defined by CMS
▪ Changes to benefit design made through this model may reduce cost-sharing and/or offer additional services to targeted enrollees
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Accountable Health Communities Model addresses health-related
social needs
Awareness Track – Increase beneficiary awareness of available community services through information dissemination and referral
Assistance Track – Provide community service navigation services to assist high-risk beneficiaries with accessing services
Alignment Track – Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries
Awareness
Assistance
Alignment• Systematic screening of all Medicare
and Medicaid beneficiaries to identify unmet health-related social needs
• Tests the effectiveness of referrals and community services navigation on total cost of care using a rigorous mixed method evaluative approach
• Partner alignment at the community level and implementation of a community-wide quality improvement approach to address beneficiary needs
Key Innovations
3 Model Tracks
TotalInvestment >
$157 million
As of May 1, 2017:20 Active Alignment Track sites12 Active Assistance Track sites12 Anticipated Awareness Track sites
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Medicare Diabetes Prevention Program (DPP) Expanded Model
Timeline:
2012 – CMS Innovation Center awarded Health Care Innovation Award to The Young Men’s Christian Association of the USA (YMCA) to test the DPP in >7,000 Medicare beneficiaries with pre-diabetesacross 17 sites nationwide.
2016 – DPP announced as the first ever prevention model to meet statutory criteria for expansion. The Secretary determined that DPP:
• Improves quality of care beneficiaries lost about five percent body weight• Certified by the Office of the Actuary as cost-saving projected net savings of $186
Million to the Medicare Program over a 10 year period• Does not alter the coverage or provision of benefits
MDPP is a structured behavioral intervention with the goal of preventing progression to type 2 diabetes in individuals with an indication of pre-diabetes.
2016 - 2017 – National expansion established through rulemaking, with policies to create a new supplier class finalized in CY 2017 PFS Final Rule and additional policies related to performance-based payment proposed in CY 2018 PFS Proposed Rule.April 2018 – Proposed national availability of MDPP set of services to Medicare beneficiaries.
Medicare Payment Prior to MACRA
The Sustainable Growth Rate (SGR)
• Established in 1997 to control the cost of Medicare payments
to physicians
Fee-for-service (FFS) payment system, where clinicians are paid based on
volume of services, not value.
Target
Medicare
expenditures
Overall
physician
costs
>I
F Physician payments
cut across the board
Each year, Congress passed temporary “doc fixes” to avert cuts (no fix in
2015 would have meant a 21% cut in Medicare payments to clinicians)27
The Quality Payment Program:
• We’ve heard concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient. That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.
The Merit-based Incentive Payment System (MIPS)
If you decide to participate in MIPS, you may earn a performance-based payment adjustment
through MIPS.
Quality Payment Program
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MIPS and Advanced APMs
ORAdvanced Alternative Payment Models
(Advanced APMs)
If you decide to take part in an Advanced APM, you may earn a Medicare incentive payment for
sufficiently participating in an innovative payment model.
Advanced APMs
MIPS
Clinicians have two tracks to choose from:
Quality Payment Program
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Considerations
Improve beneficiary outcomes
Increase adoption of Advanced APMs
Improve data and information sharing
Reduce burden on clinicians
Maximize participation
Ensure operational excellence in program implementation
Quick Tip: For additional information on the Quality Payment Program, please visit qpp.cms.gov
Deliver IT systems capabilities that meet the needs of users
What are Alternative Payment Models (APMs)?
• APMs are approaches to paying for health care that incentivize quality and value.
• As defined by MACRA, APMs include CMS Innovation Center models (under section 1115A, other than a Health Care Innovation Award), MSSP (Medicare Shared Savings Program), demonstrations under the Health Care Quality Demonstration Program, and demonstrations required by federal law.
• To be an Advanced APM, a model must meet the following three requirements:
o Requires participants to use certified EHR technology;
o Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and
o Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a more than nominal amount of financial risk.
• In order to qualify for a 5% APM incentive payment, model participants must receive a certain percentage of payments for covered professional services or see a certain percentage of patients through an Advanced APM during the associated performance year.
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Quality Payment Program
Advanced APMsCurrently, the following models are Advanced APMs:
The list of Advanced APMs is posted at QPP.CMS.GOV and will be updated with new announcements as needed.
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Comprehensive End Stage Renal Disease Care Model
(Two-Sided Risk Arrangements)
Comprehensive Primary Care Plus (CPC+)
Shared Savings Program Track 2
Shared Savings Program Track 3
Next Generation ACO Model
Oncology Care Model(Two-Sided Risk Arrangement)
Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1 - CEHRT)
Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)
Shared Savings Program Track 1+
Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
In future, the following models are expected to become advanced APMs
Keep in mind: The Physician-Focused Payment Model Technical Advisory Committee (PTAC) will review and assess proposals for Physician-Focused Payment Models based on proposals submitted by stakeholders to the committee.
Medicare-Medicaid ACO Model (for participants in SSP Tracks 2 and 3)
New Voluntary Bundled Payment ModelsAcute Myocardial Infarction (AMI) Track 1 CEHRT
Coronary Artery Bypass Graft (CABG) Track 1 CEHRT
Surgical Hip/Femur Fracture Treatment (SHFFT) Track 1 CEHRT
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➢ Eliminate patient harm
➢ Focus on better care, smarter spending, and healthier people within the population you serve
➢ Engage in accountable care and other alternative payment contracts that move away from fee-for-service to model based on achieving better outcomes at lower cost
➢ Invest in the quality infrastructure necessary to improve
➢ Focus on data and performance transparency
➢ Help us develop specialty physician payment and service delivery models
➢ Test new innovations and scale successes rapidly
➢ Relentlessly pursue improved health outcomes
What can you do to help our system achieve the goals of Better Care, Smarter Spending, and Healthier People?
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➢ Alternative payment models greater than 50% of payments
- ACOs
- Bundled Payments
- Comprehensive Primary Care
- Other APMs
➢ Private payer and CMS collaboration critical
➢ States and communities driving Innovation and delivery system reform
➢ Increasing integration of public health and population health with health care delivery system
➢ Patient-centered, coordinated care is the norm
➢ Focus on quality and outcomes
Future of Health System
34
NEHI Members & Partners: Illustrations from the Field
• Dr. Mark Girard, President, Steward Health Care Network, Steward Health Care System
• Dr. Hoangmai (Mai) Pham, Vice President, Provider Alignment Solutions, Anthem
• Dr. Lisa Latts, Deputy Chief Health Officer, IBM-Watson
Steward’s Innovative Community
Care Model
Steward’s Community Care Model
Achieve the quadruple aim:
• Better care of individuals
• Better health for populations
• Lower cost for consumers
• Drive value to physicians outside of the traditional fee for service construct
SHCN is:
With the Vision:
Mission
For:
A Clinically Integrated, Community Based Model
To provide high quality, cost efficient care that is accessible, affordable, and sustainable
Each and every member of the communities we serve (across the entire payer spectrum)
• Patient + MD relationship centered
• Integrated delivery system with hospitals, employed providers and private practice providers as equal partners
• 5 key Pillars
• Physician leadership and governance
• Quality, Outcomes, and Patient Experience
• Clinical and Financial Integration (CI and APMs)
• Payer Agnostic
• ACO infrastructure to support high value care
How we create value
Steward’s Community Care Model:
Lower Total Cost of Care, Improve Quality
“Right Site” care
– Keep appropriate care local: Community Care Model
– Drive down total cost of care
“Right Size” care
– Decrease variation, over-utilization, etc.
Foster strategic partnerships
– Behavioral health, long-term services, social supports
– Tertiary/Quaternary Care
Leverage alternative payments to align incentives
– Payment reforms as a tool, not the goal
– Embrace risk and CI as tool to align clinical and financial incentives
– NGACO, MSSP, BPCI, MACRA, MA, Medicaid ACO, Commercial Risk Contracts, EPO/DPO
– Significant value potential through quality-based achievements, care management, and cost efficiency
Sustainable Access
Value
Over time, these efforts mitigate medical expense trends and premium growth.
Steward’s Community Care Model
Most communities across the nation are either not served or poorly served by traditional Models
• Tertiary/Quaternary (AMCs) Hub & Spoke models underserve many communities, and are often inefficient and expensive
• Employed Physician Group models often specialist dominated and costly
• Community-based private practice physicians have few options to be part of a cost effective ACO
Instead, community-based models are most efficient as they address:
• Over use of Tertiary/Quaternary Care: Only a small % of care requires a tertiary/Quaternary hospital – Community-based models inherently address the overuse of expensive tertiary/quaternary care with comparable quality
• Over use of Specialty Care: Community-based models focus on the relationship between the patient’s primary care provider, not on specialty care, thus more coordinated and cost effective
• Patient Outcomes and Cost efficiency: Well coordinated care within the community can yield enhanced patient outcomes and a much lower cost.
Anthem’s Enterprise Commitment to Value-based Care
Menu of Payment Models Programs at Scale Enterprise-wide Commitment
Pro
vid
er r
isk
& s
op
his
tica
tio
n
Partial and GlobalCapitation
Joints, Maternity, Cardiology, Transplants
Bundled Payment
Upside only, Shared Risk, Multi-Payer
Shared Savings
Hospitals and Primary Care
Pay for Performance
159 Accountable Care Organizations (ACOs)
>76,000 providers in shared savings/shared risk contracts
7.3M members attributed to ACOs and PCMHs
805 Hospitals in Commercial P4P programs
192 groups in Medicaid Specialist P4P pilots
43%
50%
63%
58%
Medicaid
Medicare
Commercial
Enterprise
Anthem Payment Innovation Programs % of Total Medical Spend
National ACO and PCMH Footprint
Count of Attributed Membership
>20K
20-49K
50-99K
100-199K
200-499K
500K+
• Smaller provider practices linked together in virtual panels
• Upside (shared savings only)
Patient Centered
Medical Home (PCMH)
• Larger group practices with enough attributed membership to bear risk independently
• May include upside only or upside/downside risk
Accountable Care
Organization (ACO)
• Performance against Medical Cost Target (MCT); shared savings bonus payments calibrated against quality scorecard performance
Commercial
• Performance against Medical Loss Ratio (MLR) target; shared savings bonus payments calibrated against quality scorecard performance
Government Business
Contract Types Payment Models
Depth and Breadth of Value-Based Arrangements
Commercial Specialty
Medicaid Medicare Advantage
What tools do we give providers today?
Onboard Practice Engage Practice &
Introduce Tools
Set Goals Provide
targeted coaching
Establish stakeholder teams
Training on population health management tools
Reports and Data
PCMS training
Cost of Care Resources
Identify practice goals
Select intervention
Create Transformation Action Plan
Quality improvement coaching
Skills for Care Coordination and Management
Provide feedback on progress
Fiel
d T
eam
Su
pp
ort
An
alyt
ics
& R
epo
rtin
g
Provider Care Management Solutions
•Financial reporting
•Quality
•Utilization
•Longitudinal patient record
Tableau Supplemental Reporting
•Steerage opportunities
•Episodes of Care
•Pharmacy
Data Exchange
•Clinical data integration
•Care management activity
•Results and outcomes
Lisa M. Latts, MD, MSPH, MPBA, FACP
Deputy Chief Health Officer
IBM Watson Health
Moving Towards the Patient
Medical Home:
Developing a Pathway to
Success
Lisa M. Latts, MD, MSPH, MPBA, FACP
Deputy Chief Health Officer
IBM Watson Health
The Future of Health
Is Cognitive
Disruption is Here
$47 trillion3
Cumulative estimated global economic impact of chronic
disease between 2011 and 2030
The number of people over the age of 60 by 2050
2 billion2
The rate medical data is expected to double every by 2020
Every 73 days1
12.9 million4
Global shortage of health-care workers by 2035
1.https://www-03.ibm.com/press/us/en/photo/46588.wss
2. http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf
3.
http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf
4. http://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/
Watson Health © IBM Corporation 2017
What are the consequences of not knowing?
Think of all that has
been accomplished
using only
a fraction of the
available data
Unlock the
possibilities
What answers lie in the data that is not
usable through traditional analytics?
Watson Health © IBM Corporation 2017
Knowledge-Driven Insights Data-Driven Insights
Closing the translational knowledge gap Delivering real-world evidence
Observationa
l DataPublished
Knowledge
Scientific papers
Evidence-Based Guidelines
Reports, Books
Articles, Publications
Electronic Medical Records
Claims, Labs, Images
Health risk assessments, Internet of Things
Social, environmental, behavioral
Cognitive = Knowledge + Data-Driven Insights
Watson Health © IBM Corporation 2017
People excel at:
Common sense Dilemmas Morals Compassion Imagination Dreaming Abstraction Generalization
Cognitive systems excel at:
Natural Language Pattern Identification Locating
Knowledge
Machine
Learning
Eliminate
Bias
Endless
Capacity
HUMANS + COGNITIVE = AUGMENTED INTELLIGENCE
Watson Health © IBM Corporation 2017
Empowering
People
The Central New York Care Collaborative is a lead agency implementing New York State’s Delivery System Reform Incentive Payment (DSRIP) program that connects more than 2,000 healthcare and community based service providers across Central New York with a focus on:
– Movement to Value-Based Care delivery mode to improve the outcomes of care
– Cost reduction which includes decreasing avoidable hospital readmissions and emergency department use by 25% by 2020
– Building connections between provider organizations in a seamless system that is patient-centered
Empowering Communities: Central New York Care Collaborative (CNYCC)
“Working Together for Better Health”Slide provided by CNYCC49 Slide information provided by CNYCC
Data Manageme
nt
Patient Engageme
nt
AnalyticsOperational Research
Empowering Transformation: The Health Transformation Alliance – A Differentiated Platform Solution
Accelerated
Discovery
Collective
Influence on the
Healthcare
Supply Chain
Cognitive
Computing
and
Advanced
Analytics
A Platform
for
Innovation
1 2 3 4
© 2017 HEALTH TRANSFORMATION ALLIANCE
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Questions & Answers
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For additional information, please contactLauren Choi, NEHI Vice President, Policy Partnerships