the 5 pillars of value-based care - caravan health · 2018. 7. 26. · 3 helping providers navigate...

traveling together for better care

The 5 Pillars of Value-based Care

Lynn Barr, CEO, Caravan HealthMay 15, 2018

5 Value-based Care Pillars• Wellness & Population Health Strategies

• Performance Improvement & Quality Initiatives

• Clinical Integration & Physician Engagement

• Data Integration & HCC Coding

• Scale and Strategy

The healthcare industry is moving from Fee-for-Service to

Value-based Payments.

CMS is driving this change through highly-complex programs.

Providers need expert help to qualify, participate, and succeed.

2www.CaravanHealth.com | Proprietary & Confidential, Not for Distribution

Agenda

3

Helping Providers Navigate the Challenges of Value-Based Payments

CPC+MACRA

§ Founded in 2013

§ 38 Accountable Care Organizations

§ >14,000 Providers

§ >1,000,000 Patient Lives

§ Results (cms.data.gov)

§ 95%- 97% Quality Scores

§ >10x National Average of Shared Savings

ACOs Practice Transformation

About Caravan Health

www.CaravanHealth.com | Proprietary & Confidential, Not for Distribution

Wellness & Population Health Strategies


Current thinking and efforts create a disproportionate focus on existing chronic patients.

A better approach is to monitor all patients, healthy and chronically ill.

Chronic Care Managementis only ONE focus.

What’s Different About an Effective Population Health Strategy for Value-based Payment Models?

www.CaravanHealth.com | Proprietary & Confidential, Not for Distribution5

Empower Your Nurses


Build your primary care capacity.Utilize nurses and medical assistants to meet patient needs and provide additional support to providers.

Medicare allows important preventive services to be billed under provider supervision.

Physicians get more time to attend acute patient needs, and patients benefit from more attention overall.

Population Health Nurses Generate Income

Population Health Nurse

Wellness Visits

($118/yr)

Chronic Care

Management ($45-$90/mo)

Advanced Care

Planning ($86/yr)

Behavioral Health

Integration ($126/mo)

Cognitive Assessment & Planning ($238/yr)


8

Trained Nurses Excel at PreventionNo AWV

(n=15,232)AWV done by MD/NP

(n=446)AWV done by QMnurse (n=2,863)

Men up to date on AAA screen 70.1% 77.7% 83.8%

Women up to date on mammogram 42.2% 61.1% 74.0%

Women up to date on bone density 45.3% 63.5% 75.1%

Up to date on PCV-23 vaccine 33.4% 57.6% 58.4%

Up to date on depression screening 1.9% 3.4% 94.9%Up to date on Health Risk Assessment 1.9% 2.0% 94.3%Up to date on Fall Risk Screening 1.9% 2.0% 94.3%

Up to date on ADL Assessment 1.9% 2.0% 94.3%

Up to date on Smoking Cessation screen 1.9% 2.0% 94.3%

Up to date on End of Life Plan screen 1.9% 2.0% 93.8%


Source: Hattiesburg Clinic

Performance Improvement & Quality Initiatives


Have a Plan to Execute

Focus on executionDon’t just have a plan – focus on the end result.

Identify new resourcesDedicate new resources and technologies to project planning, management and tracking above and beyond clinical staff and technology investments.

Adapt to New ProcessesEven if you are a high-performing health system, you might have to do something different to produce extraordinary results as an ACO.


Build on Performance

Teach

Expertise & Compliance

Practice Transformation

Clinical Excellence

Intelligence & Analytics

Guidance through the complex regulatory environment and governance procedures

Drive clinical and non-clinical transformation initiatives

Lead the physician engagement aspects of value-based care

Healthcare data experts delivering mission-critical insights

Improve

Implement1

4

2

Report 3



Keep ScorePracticeABC

Category Metric PointsPointsPossible

RNCareCoordinatorinplace ✓ 6 6PhysicianLeaderinplace ✓ 6 6LightbeamInterfaceStatusasofX/X/XXXXdate InDev. 4 6#ActiveMedicareAWVCases-Claims+EHRInterfaceDataQ12017 300 0%ofpatientswithAWV-fullcreditforover50% 41.0% 4 6#ActiveMedicareCCMCases-SelfReportedQ12017 140 0%ofpatientsinCCM-fullcreditforover10% 17.0% 6 6#ActiveMedicareTCMCases-SelfReportedQ12017 170 0%ofpatientsinTCM-fullcreditforover10% 8.0% 4 6BillingAWV ✓ 4 4BillingCCM ✓ 4 4BillingTCM ✓ 4 4BillingAdvanceCarePlanning(ACP) X 0 4PatientSatisfactionTabletUtilizationRate 27.0% 6 6Qualityscore 100.0% 6 6TotalCost-fullcreditforreductionbeyondstatisticalthreshold -3.2% 6 6EDutilization-fullcreditforreductionbeyondstatisticalthreshold -2.5% 2 2SNFutilization-fullcreditforreductionbeyondstatisticalthreshold 3.0% 0 2IPutilization-fullcreditforreductionbeyondstatisticalthreshold -1.0% 2 2RepresentativeatBoardMeeting ✓ 4 4ACOChampionatRoadMapCall ✓ 2 2PracticeManageratRoadMapCall ✓ 2 2CareCoordinatoratRoadMapCall ✓ 2 2AttendQIW ✓ 4 4AttendCareCoordinatorCohortCalls ✓ 4 4AttendQuarterlySteeringCommitteeMeeting ✓ 3 3AttendCohortCalls ✓ 3 3

TOTALSCORE 88 100

ACOBOARDSCORECARDADDITIONS/ADJUSTMENTSAttendEBMWebinars X 0 2AttendCohortCalls ✓ 2 2AttendPhysicianLeaderCohortCalls ✓ 2 2

Status

PhysicianLead

ACOMedicalDirector

KeyBillingIndicators

CareCoordination

Outcomes

LeadingIndicators

StaffEngagement

Use a scorecard to keep focused on goals and pinpoint areas of weakness.

Metrics should be based on efforts towards goals such as AWV percentage rate or cohort meeting participation.

13

Detailed Roadmap Keeps you on Track Theme

January February March April May June3 July August September October November December

In3Person3Meetings ACO3Launch3333333333333Annual3Wellness3Visit3

Workshop

Chronic3Care3

Management3(CCM)3

Workshop

Annual3Symposium3333

Advanced3Care3

Management3Training

Population3Heath3

Nurse3Cohort3Call

Pop.3Health3Nurse3and3

Practice3Managers3

Cohort3call

Physician3Leader3

Cohort3CallPopulation3Health3

Nurse3Cohort3Call


Practice3Managers3

Cohort3call

Physician3Leader3

Cohort3Call3

Population3Heath3

Nurse3Cohort3Call


Practice3Managers3

Cohort3call

Physician3Leader3

Cohort3Call3

Population3Heath3Nurse3

Cohort3Call


Practice3Managers3

Cohort3call

Pop.3Health3Nurse3Office3

Hours


Hours


Hours


Hours


Hours


Hours


Hours


Hours


Hours


Hours


Hours


Hours

ACO3Medical3Director3

Cohort3Calls3


EBM3Committee3


Cohort3Calls3


EBM3Committee3


Cohort3Calls3


EBM3Committee3


Cohort3Calls3

Community3Provider33

Meeting3


Meeting3


Meeting3

ACO3Champions Steering3Committee3Prep Steering3Committee3Prep Steering3Committee3Prep

Executive3Director3

Meetings

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Monthly3ED3Cohort3

Calls3

Compliance Compliance3Meeting Poster3Audit Compliance3Meeting SelfMAssessment Compliance3Meeting Compiance3Meeting

Board3and3Steering3

Committee3MeetingsBoard3Chair3Prep Board3Meeting

Steering3Committee3

Board3Chair3PrepBoard3Meeting

Steering3Committee3


Steering3Committee3


Lightbeam3Users Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting

20183Performance3Year3

Quality3Reporting33

Webinar

Quality3Reporting3

Webinar

Quality3Reporting3

Webinar

Quality3Reporting3

Webinar

Quality3Reporting3

Webinar

Quality3Reporting3

Webinar

Quality3Reporting3

Webinar

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

Weekly3MIPS3Office3

hours

3Road3Map3Call 3Road3Map3Call Road3Map3Call

Workshop3

(Recommended)3or3

Road3Map3Call

Road3Map3Call Road3Map3Call

Workshop3

(Recommended)3or3

Road3Map3Call

3Road3Map3Call 33Road3Map3Call 3Road3Map3Call Road3Map3Call

IT3Interface3KickMoff3

Meeting3


Meeting3


Meeting3

Initial3Claims3Feed3and3

LB3Access33

Monthly3Claim3Feeds3

Updates


Updates3and3Attribution3

Updates


Updates


Updates



Updates


Updates


Updates



Updates


Updates


Updates



Updates

Analysts

Performance3and3Planning Wellness3and3Prevention Care3Management3 Continuous3Improvement

Clinical3Meetings

90MDay3Advancing3Care3Information3(Recommended) ACOMCAHPS

Quality3Team

Practice3Team



20162017

Caravan Health ACOs

2016 2017

PREV-12 30th 50th 31.65 57.25

MH-1 * * 3.4 6.06

DM-2 * * 16.78 9.49

CARE-2 60th 80th 53.7 75.69

DM-7 * * 39.61 45.71

PREV-8 60th 70th 66.57 73.36

PREV-6 50th 60th 59.85 64.98

PREV-5 60th 60th 62.69 67.81

PREV-9 60th 60th 64.84 68.76

PREV-13 * * 77.78 80.34

PREV-7 70th 70th 71.6 73.27

PREV-10 90th 90th 92.97 94.57

IVD-2 90th 90th 90.85 92.15

HTN-2 60th 60th 69.47 67.82

CARE-1 * * * 75.87Medication Reconciliation Post-Discharge * *

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet 90th 1.43%

Controlling High Blood Pressure 60th -2.37%

Preventive Care and Screening: Influenza Immunization 70th 2.33%

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 90th 1.72%

Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 60th 6.04%

Statin Therapy for the Prevention and Treatment of Cardiovascular Disease * 3.29%

Colorectal Cancer Screening 60th 8.56%

Breast Cancer Screening 60th 8.17%

Diabetes: Eye Exam * 15.40%

Pneumonia Vaccination Status for Older Adults 70th 10.21%

Diabetes: Hemoglobin A1c Poor Control * 43.45%

Falls: Screening for Future Fall Risk 80th 40.95%

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan 50th 80.89%

Depression Remission at Twelve Months * 78.34%

2017 Quality Measures Year to Year Comparison: Caravan Health

Benchmarks Measure RatesMeasure

2017 2016 to 2017 % Change

Clinical Integration and Physician Engagement


16

Everyone Needs to Join a Team

Do You Want to be the Chef or the

Lunch?

Value-Based ContractsReward Clinical Integration• PCPs are the heart of the network• Hospitals are the soul (and usually the sole source of funds)• Specialists are the frosting on the cake

Your Network MayAlready Be Under Attack• Privia• Aledade• Competing health systems

If You Lose Your Network,You Lose…• Communication across providers• Referrals• Reputation• Contracting opportunities


Solidify Provider Relationships


Ensure your physician contracts encourage a

collaborative work environment

Establish a level of trust between providers to leverage each other’s

strengths

Keep an open line of communication so PCPs,

specialists and facilities can most effectively work

together

18

ACOs Meet All CIN Requirements

ACO/CIN

Physician Leadership

Participation Criteria

Performance

Improvement

Information Technology

Payor Contracting

Legal Entity and

Waivers

Flow of Funds



Maintain Independence and Control

Every community of providers operate independently and are paid on their own performance.

Independent providers can fully participate in value-based payments while retaining their autonomy.

All health care decisions are kept local.

Data Integration & HCC Coding


Maximize Power of Claims and EHR Data


Analyze your population to understand prevalence of chronic illness, hospitalizations and related costs.

Prioritize areas for improvement and identify where you need additional resources based on which population has the most clinical and financial risk.

Plan early for in-house and outsourced expertise.Ingesting claims data and drawing meaningful reports takes time.

Gain a Deep Understanding of Your Patients

Source: Margaret Mary Health Community Hospital


Patient ID Provider 12 Mo Costs ATI ScoreER Visit Count

Chronic Conditions

Prob. High Total Cost

Predictive Risk

ScorePatient 1 RHC $11,953 8.16 21 12 0.02 0.645Patient 2 Provider 7 $16,823 8.25 15 15 0.39 3.856Patient 3 Provider 8 $13,016 9.37 13 15 0.2 2.641Patient 4 Provider 1 $56,295 9.36 11 17 0.21 2.744Patient 5 Provider 6 $21,167 9.45 9 16 0.1 1.914Patient 6 Provider 1 $7,856 9.36 9 15 0.35 3.619Patient 7 Provider 2 $8,432 8.82 9 4 0.05 1.331Patient 9 Provider 5 $16,011 9.61 8 15 0.21 2.716Patient 10 Provider 5 $19,744 9.53 8 11 0.11 1.975Patient 12 Provider 1 $7,111 9.46 8 10 0.08 1.648

Analytics Provide New Insight into Old Problems

Rehab /Care Center #1 Rehab /Care Center #2 Rehab /Care Center #3

AverageCost per Day

$399.94 $468.80 $329.35

Risk Adjusted AverageCost per Day $189.18 $219.41 $66.53

Admissions 52 20 4

Nursing Home Compare Score

5 out of 5 stars 4 out of 5 stars 3 out of 5 stars

23

Source: Tri-state Memorial Hospital


Get Your Coding in Order

Ensure you receive credit for the sicker patients you treat• Your benchmark cannot go up from

better identification of sick patients, but it can go down.

• Numerous ACOs have found that inattention to HCC-coding workflows has been the difference between collecting shared savings and falling below the minimum savings rate.

• Integrating coding best practices into your workflow can help you get credit for caring for sicker patients without driving your clinicians crazy.


© 2017 Lightbeam Health Solutions | All rights reserved. | Confidential. Please do not copy or forward.

HCC Correct Coding – MA

Optimize RAF Scores


Scale and Strategy



The Future of Population Health Depends on Scale

Participants need to form collaborative ACOs with more than 100,000 lives to minimize impact of statistical variance and administrative burden

Greater likelihood of predictable shared savings through:• Lower minimum

savings rates • Better link between

effort and outcome

Be fully prepared for future risk models, payer and employer contracting and provider based health plans, which also need scale

28

In Most Cases Savings Are Modest


Caravan ACOs consistently save 1% per year

Caravan ACOsMSSP National Average

$107$126

$222

Year 1 Year 1 Year 2*

n=52,925

On average, ACOs savings and losses fall between -0.2% and 0.5%

2015 Starts

2016 Starts

2016 Starts

Savings Per Beneficiary Per Year

n=221,262($4) ($4)

$25 $3

($29)

$54

$16 $31

($22)Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Year 1 Year 2 Year 1

2013 Starts

2014 Starts

2015 Starts

2016 Starts

Unpredictable Results are Unsustainable

• Small ACOs experience savings and losses plus or minus 10-20% simply due to statistical variation in health care spend and in HCC coding in performance and benchmark years

• 73% of MSSP ACOs have fewer than 20,000 lives


Savings and Losses by Size of ACO

-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,0002013 2014 2015 2016

Wild Swings in Performance are Common


Year over Year Changes in ACO Savings and Losses by ACO Size

-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000

2013/2014 2014/2015 2015/2016

Impact of Random Winnings and Losses on Organizational Culture

Failure is an orphan…. • Losing while you’re trying

hard is deflating. • Finger-pointing and blame

break out

• Dis-engagement creeps in• Is it you or is it bad luck?


While success has many fathers…• Winning breeds deeper

engagement and re-investment• New initiatives become easier

to sell internally • But did you really deliver

excellence or did you get lucky?

Scale and Strategy


Where Does the ACO Program Stand Today?

• About 1/3 of all hospitals and clinicians participate in the program.• Under the Track 1 model CMS pays random earnings by chance.• MSSP will mature into downside risk to remain sustainable for Medicare.• Under risk models, providers will pay CMS random losses by chance.

Secretary of Health and Human Services Alex Azar talks tough to hospitals…

“…make no mistake: we will use these tools to drive real change in our system. Simply put, I don’t intend to spend the next several years tinkering with how to build the very best joint-replacement bundle — we want to look at bold measures that will fundamentally reorient how Medicare and Medicaid pay for care ….

….As just one example, we are looking at our efforts regarding Accountable Care Organizations. The program was intended to give providers three years to learn how to accept risk and share savings, but the results have been lackluster.….

….as costs continue to skyrocket, the current system simply cannot last.”


Basics of ACOs

1 Centers for Medicare and Medicaid, Fast Facts

Provides opportunities to learnto effectively manage population health while avoiding unnecessary penalties.

All existing reimbursement does not change.

Established by the Affordable Care Act to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs.

ACOs are groups of Medicare providers that work together to coordinate care for the Medicare fee-for-service patients they serve. The goal is to deliver seamless, high-

quality care for these beneficiaries, rather than the fragmented care that often results

from a fee-for-service payment system.

Participants are in an Advanced Payment Model. If they take downside risk, they are in a qualifying advanced payment model, eligible for the 5% MACRA bonus and are exempt from MIPS.


Forming an ACO

Multiple models (physician-led, hospital-led); if an ACO is formed by more than one provider, then the ACO must be a separate legal entity.

• ACO professionals in grouppractice arrangements

• Networks of individual practices of ACO professionals

• Partnerships or joint venture arrangements between hospitals and ACO professionals

• Hospitals employing ACO professionals

• Federally qualified health centers

• Rural health clinics

Must serve at least 5,000 Medicare fee-for-service patients.

Agree to participate for at least 3 years, meet other program requirements such as a governing body, processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost measures and coordinate care.

Eligible entities


Medicare Shared Savings ProgramThe Medicare Shared Savings Program rewards ACOsthat lower their growth in health care costs while meeting performance standards on quality of care and puttingpatients first.To participate, eligible providers must form or join a Medicare ACO, then the ACO must apply to CMS.

April 2018 May 1–31 Jul 1–312018

December2018

January 1, 2019

Form corporation, obtain EIN and open bank account.

Notice of Intent to Apply submission period.

Application submission period.

Application approval or denial decision.

Begin first ACO performance year.

Estimated Application Process Deadlines

• Develop strategy.• Engage

Physicians.• Recruit

independents.• Seat Initial Board.• Approve Pre-

Participation Waivers.

Now – March 2018

ApplicationProcess Deadlines



Shared Governance: Shared Accountability, Local Control

Two types of participants: Principal Participants & Participants. A principal participant is the entity that loans the MSO fees to the ACO on behalf of itself and the participants in its community.

If shared savings are earned, the principal participant recovers its fees before shared savings are paid to the participants. If shared savings are not earned, the ACO has no obligation to repay the fees and the loan is forgiven.

Each Principal Participant in the Caravan Collaborative ACO has one vote.

All participants will be required to promote wellness, prevention and chronic care management and consistently document chronic conditions for HCC coding purposes. They will be required to report quality measures and comply with program regulations. If in Track 1, they must also report Advancing Care Information.

Membership. Flow of funds.

Voting. Expectations.

Shared Savings Distribution

• Based on 2015, 2016 and 2017 data, we expect that the Collaborative ACO will save 1% in the first year, 2% in the second year and 3% in the third year.

• The ACO will ultimately determine the sharing distribution, but Caravan Health recommends the following based on its experience:o Principal participant loaned amounts are repaid, and Caravan Health

receives 10%, with the remainder distributed as:a. 40% based on share of attributed lives.b. 40% based on quality as measured by the MSSP program, with 20%

divided among all practices who meet the threshold and 20% going to the top half of the quality score distribution, based on attributed lives.

c. 20% based on special initiatives specific to the ACO, informed by Caravan Health recommendations. The first year will be focused on chronic care management.


Won’t Those Other Participants Lower My Cost and Quality Performance?

• The model requires mutual accountability and transparency to work.• Non-performing participants WILL be removed annually if they do

not remediate.• ACO participants generally perform very well on quality.• Caravan Health ACO Participants score >95% in quality.

NO PARTICIPANT CAN HURT YOU MORE THAN STATISTICAL ERROR!


Why Take Risk?

• New MIPs delay will reduce maximum performance adjustment to 2-3% of Part B payments – and only if you have a perfect score.

• ACO participants taking risk will get 5% lump sum payments that are not counted in shared savings – making your specialists happier and more attractive to others in value-based payments.

• CMS is steadily increasing incentives for risk-takers• Higher rewards for MSSP performance• Reduce risk corridor to 0.5% or lower• Direct admissions to SNFs• Telehealth to patients homes as a billable visit• Exempt from MIPS and Meaningful Use• 0.5% higher annual increases in Part B starting in 2026• More to come….


41

Caravan Health Creates Results

Revenue Quality

Shared SavingsMIPS

For 2014 starts, average inpatient revenue is up by 7% and outpatient revenue by 17%. For the 2015 starts, average gross inpatient revenue is up by 4%, and outpatient gross revenue by 15%.

Within one year of ACO participation, Caravan

Health hospitals increased their overall quality score by 15%.

In 2016, Caravan Health ACOs generated savings

greater than 10x the national average.

All Caravan Health ACO partners are projected to score 87% or higher under MIPS and are expected to get an upward adjustment of Part B payments in 2019.


Next Steps• Continue to invest in primary care.• Join a Practice Transformation Network to get FREE technical

support and bring immediate value to your community • www.nationalruralaco.com• Others listed at https://innovation.cms.gov/initiatives/Transforming-

Clinical-Practices/

• Consider joining an ACO to improve care to your community, accelerate your transformation and prepare for whatever comes next.

• Local initiatives• State-based initiatives• National initiatives


Thank Youtraveling together for better care

www.caravanhealth.com | [email protected] | 916.542.4582

Lynn BarrCell: 925-876-5315

[email protected]

the 5 pillars of value-based care - caravan health · 2018. 7. 26. · 3 helping providers navigate...

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