strategies for keeping people healthy and generating ... · launch and scale • payments made to...

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Strategies for Keeping People Healthy

and Generating Shared Savings

August 1st 2019

Confidential & Proprietary

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Mat Kendall, Aledade EVP Provider Networks:

Executive Director of a

Federally Qualified Health

Center in San Jose CA

Chief Operations Officer, Primary Care

Information Project (PCIP), NYC Director of the Office of Provider Adoption

Support (OPAS), Health Human Services


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Agenda:

• Introduction to Aledade

• Overview of Recent Changes to the Medicare Shared Savings Plan (MSSP)

• Impact of Accurate Risk Coding on Shared Savings Programs

• Impact of Annual Wellness Visits (AWVs) on Shared Savings Programs

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Introduction to Aledade:

4Confidential & Proprietary

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Aledade sustains physician independence through

success in value based payment models

www.aledade.com5


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$3 Trillion in national healthcare spending

$1Trillion in estimated waste (33%)*

Shift to value-based healthcare

50% Outcome-Based Medicare payments by 2018

The Problem Market Reaction

There is massive waste in the U.S.

healthcare system

*Estimated $1 trillion in healthcare waste published by the Journal of the American Medical Association (2012), McKinsey & Company (2013), and Harvard Business Review (2015)

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The Move to Value-Based Care Creates New Market Challenges that Can be Overwhelming

Focuses on:

Quantity of services

Individual patient utilization

Focuses on:

Quality of services

Balancing length of stayand readmission reductions

Episode of care (long-term focus)

Population utilization & costs

Fee for Service Value-based Care New Market Challenges

Requires providers to:

Report on quality metrics (higher admin burden)

Connect a system of patient touchpoints

Manage care throughoutthe patient’s lifetime

Treat patients as partnersin their healthcare

Reducing the length of stay


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Aledade’s 360° Center Support Brings it All Together

YourPractice

Policy, Contracting + Governance

Analytics + Pop Health Mgmt App

Education, Training + Local Support

Technology Expertise

Interoperability + EHR Optimization

Community Partnerships


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Why PCPs…Influence 85% of spendAccount for 4% of cost

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Aledade is Building a Movement of Independent Physicians by Aligning Financial Models with Patient Outcomes

27 MSSP ACOs650,000+ Attributed Patients

25 States 6,500+ Providers

430+ Independent Practices

28 Other Value-Based Care Partnerships

90+ Electronic Health Records & Practice Management Systems

$3.6+ Billion Under Management

WA

OR

CA

NV

ID

MT

WY

CO

NMAZ

UT

SD

ND

MN

IANE

KS

TX

OK AR

MO

TN

MS

LA

FL

VAWV

KY

PA

NY

MIWI

ILIN

OH

AL GA

SC

NC

MD

DE

NJ

CT RI

MA

NH

ME

VT


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Aledade’s Experience with Community Health Centers

● In 2017, the FamilyHealth ACO in New York saved Medicare over $3.9M

● FamilyHealth is led by 3 community health centers serving 340,000 patients annually

● The ACO reduced days spent in skilled nursing facilities by 22%, psychiatric hospitalization costs by 8%, and earned a quality score of 83%

● A partner health center in New York that serves over 185,000 patients per year is now providing Medicare Annual Wellness Visits (AWVs) to 71% of their high priority patients

● This equates to $1.36M in increased revenue

● Aledade provides technology and resources to help health centers administer and optimize AWVs

● After partnering with Aledade, the West Virginia Health Center ACO’s risk score increased by 14%

● By accurately coding patients, health centers are able to receive credit from Medicare for managing their complex patient populations

● Aledade provides the tools necessary for identifying and documenting risk opportunities

SHARED SAVINGS INCREASED REVENUE RISK CODING IMPROVEMENT

Aledade partners with community health centers to provide everything you need to create and run an ACO–from practice transformation services to upfront capital and a cutting-edge technology platform.


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Aledade’s Footprint of Community Health Center Partners

● Aledade currently partners with 62 community health centers in 11 ACOs across 12 states ● 3 of these ACOs are comprised exclusively of health centers (Louisiana, West Virginia, and New York)● In 2019, Aledade plans to continue this growth nationally by expanding our partnerships with community health centers across the

US

● Aledade is committed to partnering with high quality community health centers

● In 2018, 98% of our partner health centers were recipients of HRSA Quality Improvement Awards, totaling over $5.1M

● 19 partner health centers were recognized as Health Center Quality Leaders for being in the top 30% for achieving the best overall clinical performance

● 2 received the National Quality Leaders award for exceeding national clinical quality benchmarks

PARTNERING WITH THE BESTWA

OR

CA

NV

ID

MT

WY

CO

NMAZ

UT

SD

ND

MN

IANE

KS

TX

OK AR

MO

TN

MS

LA

FL

VAWV

KY

PA

NY

MIWI

ILIN

OH

AL GA

SC

NC

MD

DE

NJ

CT RI

MA

NH

ME

VT


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The proprietary Aledade “app” tees up data and workflows that drive high-value activities

Integrated data from across the care continuum

Comprehensive patient data & actionable insights

Optimizing care delivery and improving results

90+ EHR types integratedWorklists for high priority AWV, TCM andCCM opportunities

Engaging with the right patients at the right time

Risk suggestionsLocal ADT, HIE and schedule feeds Reduce unnecessary care and costs

Specialist utilization and hospital eventsGenerate FFS, quality bonus and shared savings revenue opportunities

Payer claims data and practice-generated claims

=

Preventive services informationNational labs and pharmacy paid claims Improve staff and patient satisfaction


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Regional Savings : Mississippi and Louisiana

2017-2018:

• $20 million in MSSP and commercial shared savings across Mississippi and Louisiana


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Overview of Recent Changes to the Medicare

Shared Savings Plan (MSSP)


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Conceptual Overview of MSSP ACO

Per Provider

Average annual cost per patient (benchmark): $10,000

Average number of Medicare patients: 300

Average annual total cost of care to Medicare: $3,000,000

Savings potential from better primary care: 5%

Annual savings: $150,000

Percent of savings that go back to Medicare: 60% - 25%

Savings to ACO: $60,000 - $112,500


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• Using CMS’ data and

methodology, Low

Revenue Track 1 ACOs

performed as well as Next

Gen ACOs

• Policies that incentivize

physicians to participate in

low revenue ACOs will

save money and lives

• Low revenue ACOs serve

5x more beneficiaries than

NextGen and are easier to

launch and scale

• Payments made to

physician ACOs reflect

gains, not losses, to

Medicare and payersSource: CMS ACO 2018 Rule, Table 15, and NextGen Fact Sheet

Physician-Led ACOs Outperform All Other ACOs

210

3.15

105

219

126

1.91

112132

-138

-49-83

-107

199

-44.09

135.51

244

-200

-150

-100

-50

0

50

100

150

200

250

300

Low Revenue High Revenue NextGen Aledade

Savings vs Benchmark Additional Savings (Spillover)

ACO Payments Net Benefit/Loss to Medicare


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The Key Takeaways

● Strengthens the program by recognizing the unique value of physician-led ACOs

● Illustrates CMS’ commitment to helping more independent physicians move to value based care

● Boosts likelihood of shared savings earlier

● ACOs and motivates ACOs by introducing shared losses earlier in the program

The MSSP Final Rule is Good for Physician-Led ACOs


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Aledade’s Policy Analysis Played a Key Role in Informing the Rule

January 2016 - Annals of Family Medicine

September 2017 - The American Journal of Managed Care

March 2016 - The American Journal of Managed Care

March 2018- NEJM Catalyst


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There are Three Main Categories of Policy Changes

Glide Path to Risk

Enhanced Flexibility

Regional Benchmarking


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1)The Glide Path Defines the ACO Journey and Migration to Risk

BASIC (E)● Two-sided risk● Upside: 50%● Downside: 30%● Risk Cap: 8% of

FFS revenue

BASIC (A-B)● Upside only● Savings: 40%● Downside: 0%

ENHANCED● Two-sided risk● Upside: 75%● Downside: 40%● Risk Cap: 15%

of total cost

BASIC (C-D)● Two-sided risk● Upside: 50%● Downside: 30%● Risk Cap: 2-4%

of FFS revenue

An ACO in the Basic track will automatically progress to the next level of risk annually

BASIC (5-year agreement)


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2) Enhanced Flexibility Gives ACOs More Control and Mobility

All ACOs can:

● Choose their beneficiary attribution methodology (retrospective or prospective)

● Accelerate their path to risk as desired

ACOs in a two-sided model can:

● Choose their Minimum Savings Rate (MSR)/Minimum Loss Rate (MLR)

○ 0%

○ Symmetrical; 0.5% increment between 0.5-2.0%

○ Symmetrical; based on the number of assigned beneficiaries

● Establish a beneficiary incentive program

● Apply for Skilled Nursing Facility (SNF) 3-day waivers

● Utilize telehealth to a greater extent

By shifting decisions from CMS to the ACO, the ACO can do what is best for them



3) Regional Benchmarking in Pathways to Success

REGIONAL BENCHMARKING

➢Against whom?• All Medicare FFS beneficiaries in counties

where the ACO has beneficiaries including those in other ACOs and in our ACO

➢Adjustments?• Risk adjustment between beneficiaries not in

the ACO and in the ACO in the benchmark years

• Weighted by the proportion of ACO beneficiaries in each county

➢Continual Improvement still required to succeed as the regional benchmark is essentially a head start

*For ACOs that already in their 2nd contract in MSSP (2014 and 2015 start ACOs) they would move straight to the 2nd contract in Pathways to Success. ACOs in their 1st

MSSP contract (2016, 2017 and 2018 start ACOs) will move to the 1st contract in Pathways to Success

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Impact of Accurate Risk Coding

on Shared Savings Programs

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Attribution

What is attribution?

• Attribution is the assignment of patients to our ACO to determine the savings we’ve achieved. It identifies the primary care provider Medicare views as most responsible for the patient’s care and outcomes.

How does it work?• Attribution is given to the primary care provider who performs the majority of

primary care services over the last 12 months. • By working to ensure that your patients receive all appropriate primary care

services from you (versus other PCPs) you’ll increase the likelihood they’re attributed to you.

• In FQHC NP/PA get attribution starting in 2019.• Annual wellness visits are a great tool to build this relationship with your

patients.


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HCC and Coding- Hierarchical Condition Category

CMS recognized the importance of HCC coding and implemented it in 2004. Demographics + Diagnosis = HCC Score

• When a patient becomes eligible for Medicare, it only knows about his/her demographics composite, which includes age, gender and eligibility status (dual/disabled).

• Why is it important? What you diagnose this year has a direct impact on the anticipated healthcare spend for the patient next year. Failure to accurately capture diagnoses leads Medicare and other payers to believe your patients are healthier than they actually are.

• A higher (and more accurate) risk score indicates a sicker patient, which creates higher expected costs and therefore a greater opportunity to capture shared savings.

Important Point: FQHC’s are historically not very good at accurate coding because with PPS it did not matter…now it does!


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Patient Risk

Why do we care about diagnostic codes?

Diagnostic codes communicate how sick a patient truly is.

How does that work?Medicare calculates how risky a patient is based on:

➢Age

➢Gender

➢Diagnoses

The result is called a patient’s risk score.

Risk Score= 1.45 x $10,000= $14,500


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Patient Risk

Based on these codes, Medicare can estimate how much your entire patient panel (attributed patients) is expected to cost.

Medicare uses this estimate to set our savings benchmark.

Expected Cost

$1 million

Actual Cost

Savings!


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Patient Risk

Medicare ONLY uses the previous year’s diagnosis codes to make these calculations.

HCC Score= 1.45 x $10,000=$14,500

INACCURATE REFLECTION OF ACUITY

HCC Score= 0.723 x $10,000= $7,230


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HCC Comparison

Missed coding opportunities reflect a healthier patient and also have a financial impact on shared savings.


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The 5 D’s of risk coding

• Diabetes⮚ Uncomplicated Diabetes over the age

of 65 is rare!

• Depression⮚ Avoid F32.9 “MDD, single episode,

unspecified”⮚ Active Depression and Depression

in Remission carry the same risk weight.

• Donuts⮚ Do not overlook obesity!⮚ Avoid E66.9 “obesity unspecified”

• Drinking and Drugs⮚ Alcohol and Substance Abuse &

Dependence are in your office every day.

⮚ Screen, Intervene, and Make sure it is Seen.



Impact of Risk Coding on a FQHC ACO Based on Historical and Clinical Data: $43 million

Based on

EHR BMI

$3.8 million in

missed opportunities

Based on medication/

Historical diagnosis

$7 million in missed opportunities

Based on

EHR data

$3.3 Million in

missed opportunities

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Annual Wellness Visits

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What the Wellness Visit is not

• Not: an annual complete physical exam, with screening lab work.

• Not: an office visit that requires the typical documentation to support a selected E&M charges (99381-99397)


35

What the Wellness Visit is

• Is: Once yearly, prevention focusedvisit that includes a health risk assessment and a preventive care plan

• Is: An important opportunity to engage with patients and focus on their long-term health outside of acute visits



Who Should Come in for a Wellness Visit?

• All Medicare patients

• Three Types: pick the one that’s appropriate for the particular patient

• Since CMS does not require a specific diagnosis code for the AWV, you may choose any appropriate diagnosis code. You must report at least one diagnosis code. Use of Z00.00 is not required/encouraged.

• Billing: FQHC can bill for AWV or E&M (Office visit) but not both; so bill for AWV if you do it even if you also do other things. This is OK if you document properly

G0468● IPPE/Welcome to Medicare : G0402

● Initial Wellness : G0438

● Subsequent Wellness : G0439

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Annual Wellness Visits

Why should a practice conduct Annual Wellness Visits?

AWVs achieve five important objectives:

1. Good for patients, with a focus on prevention

2. Increases accuracy of Medicare’s rating of acuity of patient

panel

3. Increases attribution

4. Captures 8 of the 10 EHR- based quality measures (23 total)• Statin and A1c are captured throughout the year when due for the lab

5. Pays PPS X 1.36 per AWV


38

Benefits of AWVs:

In March 2019, Aledade published an

article in the American Journal of

Managed Care (AJMC) about the

impact of AWVs on value based care.

It found:

• AWVs can provide potential savings opportunities of up to $500 for high-risk patients

• Patients with AWVs used fewer

health care services, such as the

Emergency Room, SNF, or in

patient stay, then patients who did

not have AWVs

• Patients with AWVs had better

quality measure documentation

then those who didn’t have an

AWV


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Identify and Perform

Outreach for High Priority Patients due for an AWV

Pre-Visit: Assess patient

needs and prep for

visit

Visit: Assess patient needs

Visit: Address patient needs

Post Visit: Billing &

Follow up

1 2 3 4 5

How Do I Conduct an AWV?

Scheduling/Care

Coordinator

MA, LPN, or

RN

MA, LPN, or

RN

Multiple

RolesMultiple

Roles


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Next Steps in our Partnership

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Preparing for Aledade ACO Launch

1. Our Launch process will begin in August.a. Our team will be reaching out to your CHC Leadership to arrange an

introductory call followed by an on site visit.b. We will begin the interface process with your CHC’s Electronic

Health Record early in the Launch process.

1. On Site, In Person meeting:a. Target audience is all doctors and providers, CEO, Quality

Improvement team members, Billing team members, other key office staff.

1. ACO Kick Off Meeting:a. Date/Location TBD. Will be held for all members of the ACO and in

conjunction with Aledade leadership.

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Closing Thoughts: AWVs and Accurate Risk Coding Can Drive Savings

65 % of Patients Get AWVs + Risk coding improvement = Savings

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THANK YOU

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