flaacos 2014 conference - strategies to elevate your aco

Copyright 2014 Triple Aim Development Group 1

Hymin Zucker MD, CMO &

Kelly A. Conroy, CEO

Triple Aim Development Group

September 30, 2014

Strategies to Elevate Your ACO

Before Your 3rd Performance Year


Disclaimer:This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Every reasonable effort has been made to assure the accuracy of the information within these pages.

The Triple Aim Development Group makes no representation, warranty, or guarantee that this presentation information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.


If Process is not in Place – You are NOT doing POPULATION HEALTH!!!

Where are you know?

Source: Quote from “Hyman Zucker, MD”

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Basics

5000 Lives

Benchmark (3 Year)

Rebasing/ Updates to Benchmark

Attribution

Adding New Providers

HCC Acuity Of Population

Actual 1 Year Claim Run Out

Quality Reporting

Savings- Final Financial Reconciliation

Copyright 2014 Triple Aim Development Group

Performance Year 3


Anonymous Commitment Survey

Focus 1-3 Changes ( ACO will Help)

Have a Manager of Competition

100% Wellness Visits ( ACO Attribution, Reimbursement, Care Plan, Education 11 Quality Measures)

Transition of Care ( Do You want to Know?)

Care Coordination Management (CCM)

Population Health Processes

must be in Place


Value

Process

Inform A DOC

Coordination Care Gaps

“On Call” Process

Schedule subsequent visits 4 times/year

Missed Appts.

Snow Birds

“Concerned Categories”

The Office Visit


Personalize Care Plan Of Wellness Visits

Patient Education (Responsibility – Meaningful Use II)

Coordination Care Management (CCM) ($40 PMPM X10)

Patient Engagement


Risk of ACO’s abandoning the Program “An additional 52 ACOs reduced health costs compared to their benchmark, but

did not qualify for shared savings, as they did not meet the minimum savings threshold.”

(CMS Press Release 9/17/14)

Of the total 220 ACOs, 53 or 24% made enough savings to receive a check- (CMS Press Release 9/17/14) http://www.cms.gov/Medicare/Medicare-Fee-For-Service-Payment/Shared Savings Program/News.html

“During the second performance year, Pioneer ACOs generated estimated total model savings of over $96 million and at the same time qualified for shared savings payments of $68 million. They saved the Medicare Trust Fund approximately $41 million. The total model savings and other financial results are subject to revision.” (CMS Press Release 9/17/14)

Emerging Thoughts From ACO Peers

http://www.cms.gov/Medicare/Medicare-Fee-For-Service-Payment/Shared%20Savings%20Program/News.html

http://www.cms.gov/Medicare/Medicare-Fee-For-Service-Payment/Shared%20Savings%20Program/News.html


The Churn Risk Adjustment (No individual HCC) Benchmark Lower ( i.e. $600 PMPM) Data/Clinical & Claims Incremental/Continuous Improvement over

yourself Respective Rules Changes (Contract 2) Quality Scores Process vs Outcome

Emerging Thoughts From ACO Peers


CQ HEALTHBEAT, JUNE 30, 2005

“Today, Medicare pays the same amount regardless of quality of care. Some people would argue that in fact, the current Medicare payment system rewards poor quality,” Grassley said. This situation just doesn’t make sense to me, nor should it to beneficiaries.”

Senator Charles E. Grassley(R) Iowa

Senate Finance Committee

Emerging Thoughts on ACOs from Government Point of View

Perverse Incentives

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Few ACOs can deliver on cost and quality today Purchaser’s role is to raise the bar, and simplify the performance Keep the focus on these principles

ACOs must be transparent ACOs must be outcomes- focused ACOs must be patient- centered ACOs must pay providers for quality, not quantity ACOs must address affordability and contain costs ACOs must support a competitive market place ACOs must demonstrate meaningful use of health information technology

To Get desired results will require intense collaboration, leadership, and perseverance.

Commit to multi-year transition to global payment and provide full risk for population

The Current State of Large Purchase Thinking

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70%

16%2-Star 3-Star 4-Star 5-Star

9% 9 %

19% 28%

43 %

59%

56 %

43%

9%5%

1%14%

9 %

4 or 5Stars

16% 29% 37% 55%

2 or 3 Stars

84% 71% 63% 45%

2009 2012 2013 2014

View Beneficiaries Moving to MA Plans with high Quality Scores

Medicare Advantage (MA) Enrollment Rating Perverse Incentives

Make care safer by reducing harm caused in the delivery of care

Strengthen person and family engagement as partners in their care

Promote effective communication and coordination of care

Promote effective prevention and treatment of chronic disease

Work with communities to promote healthy living

Make care affordable

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The Six Goals of National Quality Strategy


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Hospital:

Value-based purchasing, readmissions, healthcare acquired conditions, EHR Incentive Program and Inpatient Quality Reporting

Physician/clinician

Physician value-based modifier, physician quality reporting system, EHR incentive program

End stage renal disease bundle and quality incentive program


Value Based Purchasing

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Goal is to reward providers and health systems that deliver better outcomes in health and health care at lower cost to the beneficiaries and communities they serve.

Hospital value-based purchasing program shifts approximately $1 billion based on performance

Five Principles Define the end goal, not just the process for achieving it All providers’ incentives must be aligned Right measures must be developed and implemented in rapid cycle CMS must actively support quality improvement Clinical community and patients must be actively engaged

VanLare JM, Conway PH. Value-Based Purchasing – National Programs to Move from Volume to Value. NEJM July 26, 2012


Value Based Purchasing Cont’d

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Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a value modifier under the Medicare Physician Fee Schedule (MPFS)

VM assesses both quality of care furnished and the cost of that care under the Medicare Physician Fee Schedule “ The Grading System”

For CY 2015, CMS will apply the VM to groups of physicians with 100 or more eligible professionals (EPs)

For CY 2016, CMS will apply the VM to groups of physicians with 10 or more EPs

Phase-in to be completed for all physicians by 2017 Implementation of the VM is based on participation in Physician Quality Reporting System ( PQRS)


What is the Value-Based Payment Modifier(VM)?

Each group receives two composite scores (quality of care; cost of care), based on the group’s standardized performance (e.g., how far away from the national mean).

Group cost measures are adjusted for specialty composition of the group This approach identifies statistically significant outliers and assigns them to

their respective cost and quality tiers.


* Eligible for an additional +1.0x if reporting clinical data for quality measures and average beneficiary risk score in the top 25% of all beneficiary risk scores

Quality Approach for 2016 (Based on 2014 PQRS Performance)


Eligibility

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The size of a group is determined by how many Eps comprise the group

Definition of Group: A single Tax Identification Number (TIN) with 2 or more individual EPs(as identified by Individual National Provider Identifier [NPI]) who have reassigned their billing rights to the TIN

An EP is defined as any of the following: A physician A physician assistant (PA), nurse practitioner (NP), or

clinical nurse specialist; a certified registered nurse anesthetist; a certified nurse- midwife; a clinical social worker; a clinical psychologist; or a registered dietitian or nutrition professional

A physical or occupational therapist or a qualified speech-language pathologist

A qualified audiologist


How is a Group Practice Defined?

Value Modifier Components

2015Finalized Policies


Performance Year 2013 2014Group Size 100+ 10+Available Quality Reporting Mechanisms

GPRO-Web Interface, CMS Qualified Registries, Administrative Claims

GPRO-Web Interface (Groups of 25+ EPs), CMS Qualified Registries, EHRs, and 50% of EPs reporting individually

Outcome Measures

NOTE: The performance on the outcome measures and measures reported through the PQRS reporting mechanisms will be used to calculate a quality composite score for the group for the VM.

All Cause Readmission Composite of Acute Prevention Quality Indicators: (bacterial pneumonia, urinary tract infection, dehydration) Composite of Chronic Prevention Quality Indicators: (chronic obstructive pulmonary disease (COPD), heart failure, diabetes)

Same as 2015

Patient Experience Care Measures

N/A PQRS CAHPS: option for groups of 25+ EPs


Value Modifier Policies for 2015 & 2016

Value Modifier Components



Cost Measures Total per capita costs measure (annual payment standardized and risk-adjusted Part A and Part B costs)

Total per capita costs for beneficiaries with four chronic conditions: COPD, Heart Failure, Coronary ArteryDisease, Diabetes

Same as 2015 and:

Medicare Spending Per Beneficiary measure (includes Part A and B costs during the 3 days before and 30 days after an inpatient hospitalization)

Benchmarks Group Comparison Specialty Adjusted Group CostQuality Tiering Optional Mandatory

Groups of 10-99 EPs receive only the upward (or neutral) adjustment, no downward adjustment.Groups of 100+ both the upward and downward adjustment apply (or neutral adjustment).

Payment at Risk -1.0% -2.0%Copyright 2014 Triple Aim Development Group

Value Modifier Policies for 2015 & 2016


Measures reported through the GPRO PQRS reporting mechanism selected by the group OR individual measures reported by at least 50% of the eligible professionals within the group (50% threshold option)

Three outcome measures: All Cause Readmission Composite of Acute Prevention Quality Indicators (bacterial pneumonia,

urinary tract infection, dehydration) Composite of Chronic Prevention Quality Indicators (COPD, heart failure,

diabetes)

PQRS CAHPS Measures for 2014 (Optional) Patient Experience of Care measures For groups of 25 or more eligible professionals

What Quality Measures will be Used for Quality-Tier?

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Total per capita costs measures (Parts A & B) Total per capita costs for beneficiaries with 4

chronic conditions: Chronic Obstructive Pulmonary Disease (COPD) Heart Failure Coronary Artery Disease Diabetes

Medicare Spending Per Beneficiary (MSPB) measure (3 days prior and 30 days after an inpatient hospitalization) attributed to the group providing the plurality of Part B services during the hospitalization

All cost measures are payment standardized and risk adjusted.

Each group’s cost measures adjusted for specialty mix of the EPs in the group.


What Quality Measures will be Used for Quality-Tier Cont’d?

• Use domains to combine each quality measure into a quality composite and each cost measure into a cost composite

Clinical Care

Patient Experience

Population/CommunityHealth

Patient Safety

Care Coordination

Efficiency

Total per capita costs (plus MSPB)

Total per capita costs for beneficiaries with specific conditions

Quality of Care Composite Score

Cost Composite Score

VALUE MODIFIER AMOUNT


Quality Tier Methodology

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* Eligible for an additional +1.0x if reporting clinical data for quality measures and average beneficiary risk score in the top 25% of all beneficiary risk scores

• Each group receives two composite scores (quality of care; cost of care), based on the group’sstandardized performance (e.g., how far away from the national mean).

• Group cost measures are adjusted for specialty composition of the group

• This approach identifies statistically significant outliers and assigns them to their respective cost and quality tiers.Low cost Average cost High cost

High quality +2.0x* +1.0x* +0.0%Average quality +1.0x* +0.0% -1.0%Low quality +0.0% -1.0% -2.0%


Quality-Tier Approach for 2016 (Based on 2014 PQRS Performance)

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• Medicare Shared Savings Program (Center for Medicare)

• Pioneer ACO Model• Advance Payment ACO Model• Comprehensive ESRD Care Initiative


Accountable Care Organizations (ACOs)

Primary Care Transformation

• Comprehensive Primary Care Initiative (CPC)• Multi-Payer advanced Primary Care Practice

(MAPCP) Demonstration• Federal Qualified Health Center (FQHC)

Advanced Primary Care Practice Demonstration

• Independence at Home Demonstration• Graduate Nurse Education DemonstrationBundled Payment for Care Improvement• Model 1: Retrospective Acute Care• Model 2: Retrospective Acute Care Episode & Post

Acute• Model 3: Retrospective Post Acute Care• Model 4: Prospective Acute Care

Capacity to Spread Innovation• Partnership for Patients

• Community-Based Care Transitions• Million Hearts

Health Care Innovation AwardsState Innovation Models InitiativeInitiatives Focused on Medicaid

Population• Medicaid Emergency Psychiatric Demonstration• Medicaid Incentives for Prevention of Chronic

Disease• Strong start initiative

Medicare-Medicaid Enrollees• Financial Alignment Initiative

• Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents

CMS Innovations Portfolio: Testing New Models to Improve Quality


No Motivation

Motivation

• Work around “Doctor & Patient” Relationship

HOW DO YOU DO THIS?

• Choice- Work on “Doctor & Patient” Relationship (Tactics & Policies)

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Starts with a Belief!

“If you believe in something, BELIEVE in it all the way”

Walt Disney


Proactive Approach

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Call Kelly A. Conroy, CEO or Hymin Zucker MD, CMO and founding partners of

Triple Aim Development Group

at 561.444.3000

www.tripleaimdg.com


flaacos 2014 conference - strategies to elevate your aco

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