Post on 07-Jul-2020
Joe Damore, FACHEVice President
The Current State of the Journey to Accountable Care and Population Health Management: Aligning Payor Arrangements with New Delivery Models
October 31, 2012
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Introduction/purpose
Public policy update
Market trends
Premier’s experience and lessons learned
Care transformation
Payment models
Summary/questions
Today’s agenda
Public policy update
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Health reform’s hidden agenda
1966 1972 1978 1984 1990 1996 2002 2008 2014 2020 2026 2032 2038 2044 20500
5
10
15
20
25Actual Projection
2.5 Percentage Points
1 Percentage Point
Zero
Differential of:
Percent of GDP
Total Federal Spending for Medicare and Medicaid Under Assumptions About the Health Cost Growth Differential
Tax rates 2050:10% 26%25% 66%35% 92%
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What drives our debt? Government spending as share of economy
Source: CBO
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““Things do not get Things do not get better by being left better by being left alonealone””
–
Winston Churchill
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Projected Medicare enrollment
Source: 2012 Annual Report of the Boards of Trustees for the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds
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Mandate upheld as a tax/penalty
State opt out means less uniform, more state-by-state coverage expansion
Hospitals in states that opt-out could be harmed by DSH cuts
No turning back on payment reforms
Probable delay in overall coverage expansion
Expect more litigation around ACA
Next pivot point is the election
Healthcare politics: SCOTUS implications
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Presidential election: too close to call, now!
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Endgame: Electoral College Ds lock or lead: 19 states/247 votes; Rs: 24 states/206 votes
270 Votes needed to win
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Oct 1
Beginning of fiscal year
Important dates on the legislative calendar
OCTOBER
NOVEMBER
Nov 6
Election dayNov 7-
Dec 31
“Lame duck”
session range
Late Nov –
early Dec Retiring or defeated members have to be out of their offices
DECEMBER
Dec 31
Expiration of Bush tax cuts, unemployment benefits & “doc fix”
JANUARY
Jan 2
Sequestration occurs
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Track one-push
Legislative “push/pull” to accountable care
Cuts to Medicare FFS SystemReadmissions penalty
HACs penalty
Partnership for Patients
Value-based purchasing
Meaningful use penalties
Private payors and Medicaid
Bundled payment: 2016?
Track two-pull
Disrupt existing system
Medicare Shared Savings Program (MSSP)
Pioneer
State/Federal duals demo
Medical home demo; new Innovation Center Primary Care Initiative
Reducing readmissions from nursing homes demo
Bundled payment demos
Market trends
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How the market is responding
Provider consolidation•
Presence Health; Dignity Health; Ascension; for-profits
Payer consolidation and information technology acquisitions
•
Consolidation: CIGNA acquired HealthSpring, WellPoint acquiring
Amerigroup, Aetna acquiring Coventry•
IT Acquisitions: Aetna acquired Medicity & UnitedHealth Group acquired Axolotl
Physician groups creating ACOsPrivate payer, federal and state payment reforms
•
Hawaii Medical Service Association model•
Blue Cross Blue Shield of Massachusetts -
Alternative Quality Contract
•
CMS -
Bundled Payment, VBP, etc.
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New collaborations and partnerships•
Banner Health, Aurora, and Heartland partners with Aetna on accountable care collaboration
•
Texas Health Resources partners with Healthways on “proactive well-being improvement”
•
Evolent Health partners with MedStar on population and health plan management solutions
Changes in employer and employee coverage practices•
18% increase in HSA products in 2011; greater focus on fitness and prevention
How the market is responding (cont’d)
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Consumer directed health plans
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Enhanced care management and technology advances will continue to reduce inpatient volume
Increase in physician-hospital integration and alignment
Economic pressure driving cost reduction (scale) and new revenue sources (retail health, technology etc.) in integrated delivery systems
Health reform driving health plans to technology investments and consolidation (including partnerships with delivery systems)
Major market trends
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Blending of integrated delivery systems/health plans/technology firms/medical groups
Consolidation/aggregation of health systems
Continued growth in both commercial and government shared savings arrangements
Major market trends (cont’d)
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Number of public and private ACOs is growing
Source: Center for Accountable Care Intelligence, “Growth and Dispersion of Accountable Care Organizations: June 2012 Update (06/2012)
– 310 ACOs in 45 states and the District of Columbia–
First ACOs (10 organizations) part of the PGP Demonstration project beginning in 2006 – 32 CMMI “Pioneer”
participants, program began January 2012–
Roughly 30% physician organization led– Medicare Shared Savings Program
–
04/01 –
27 ACOs selected to participate. –
Majority of organizations physician organization led–
07/01 –
89 ACOs selected to participate in second cohort–
09/06 –
Over 150 applicants for 1/1/12
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Federal ACOs across the country
21
Key ‐
NJDEMD
WA
IL
WI
LA
AR
MO
IA
MN
KS
NE
SD
NDMT
WY
CO
NM
ID
UT
AZ
NV
CA
OR
MA
RICT
SC
NC
VAWV
PA
VTNH
ME
FL
GAALMS
TN
KY
MI
OHINDC
MO
NY
TX
OK
= PGP Transition Demo= ACO Pioneer= MSSP (April 01 start date)= MSSP (July 01 start date)
# expected to double in January, 2013
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Integrated/accountable care 2011-2012 market developments
United HealthCare Oncology Bundled PaymentUnited HealthCare purchases OptumSeveral NFP Blue’s Plans move to care management and Shared Savings arrangements (MN, MI, Horizon, Hawaii, MA Alternative Quality Contracts, CareFirst PCMH etc.)Central Maine Healthcare/Bath Iron Works Shared Savings AgreementCigna-Piedmont Physician Group ACO agreement HealthCare Partners-Anthem ACO AgreementCalPERS ACO with CHCW/Hill Medical GroupFour Shared Savings contracts between Fairview Health System and Minnesota Health Plans
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Integrated/accountable care 2011-2012 market developments (cont’d)
All 10 PGP Participants renewed to participate in the PGP II CMS ProgramUnited Health Care Group purchase of Monarch Physician GroupCigna Primary Care physician (PCMH) network development (Phoenix) Highmark purchases West Penn/Allegheny Health SystemCommunity Care of North Carolina Medicaid model expanded to other states (Alabama, etc.)Nationwide Children’s Hospital Medicaid Capitation programAetna partners with Heartland Health and Banner HealthAetna establishes Accountable Care Solutions (ACS)UPMC and The Advisory Board form Evolent
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New payment models: Delivery systems and Blue Cross plans
Minnesota Blue Cross and major delivery systemsHorizon Blue Cross with AtlantiCareBCBS Michigan with Marquette General HospitalHMSA with Hawaii Pacific HealthBlue Cross of Massachusetts AQC programBlue Shield of California/CHW/Hill Medical Group (CalPers)CareFirst BCBS in Maryland building largest PCMHBCBS Illinois-Advocate ACO
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January 1913
““The past 50 years The past 50 years have been marked by have been marked by advances in the science advances in the science of medicine.of medicine.
The next 50 will be The next 50 will be marked by marked by improvements in the improvements in the organization and organization and teamwork of how health teamwork of how health care is deliveredcare is delivered””..
– Charles H. Mayo
Premier’s Partnership for Care Transformation (PACT)
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Partnership for Care Transformation (PACT)
Our mission is to support our members on their journey to managing, measuring and improving population health in an efficient manner by providing members:
•Structure and support for members to share knowledge, experience and best practices;•Expertise in areas that are key to successfully implementing accountable care; and,•Tools and templates to reduce duplication of effort and to reduce the time to implement accountable care principles and programs.
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““I use not only all of I use not only all of the brain that I have, the brain that I have, but the brains I can but the brains I can borrow.borrow.””
–
Woodrow Wilson
The power of collaboration
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The Premier ACO model
A group of providers willing and capable of accepting accountability for the total cost and quality of care for a defined population.
A group of providers willing and capable of accepting accountability for the total cost and quality of care for a defined population.
Payor Partners
Insurers
Employers
States
CMS
Core components:•People Centered Foundation•Health Home•High-Value Network•Population Health Data Mgm•ACO Leadership•Payor Partnerships
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Definition of success: Improving Triple Aim™ population outcomes
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Implementation Collaborative members
As of 8/30/2012
31
NJDEMD
WA
IL
WI
L A
AR
MO
MN
KS
NE
SD
NDMT
WY
NM
ID
UTNV
OR
MA
RICT
SC
NC
VAWV
PA
VTNH
ME
GAALMS
KY
MI
OHIN
DCMO
NY
TX
OK
IA
FL
TN
CA
CO
AZ
HI
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Readiness Collaborative members
32
As of 7/31/12
NJDEMD
WA
IL
WI
LA
AR
MO
IA
MN
KS
NE
SD
NDMT
WY
CO
NM
ID
UT
AZ
NV
CA
ORMA
RICT
SC
NC
VAW V
PA
VTNH
ME
FL
GAALMS
TN
KY
MI
OHINDC
MO
NY
TX
OK
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Seven Integrated/Accountable Care market segments
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Member gaps and top priorities Based upon ~ 100 Accountable Care assessments
Broad and robust primary care networkPhysician alignmentHealth Home (Patient Centered Medical Home)Clinical integration modelCare managementEMR/HIT and informatics Payor alignment with care managementLeadership, culture and transformation
Payor Partners
► Insurers
► CMS
►
Employers
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Collaborative learnings thus far
Managing populations, not just patients, requires fundamental change within most healthcare systemsFundamental transformation will be clinical, with financial/payment, HIT, and legal changes to support clinical changePhysician leadership and professional management is pivotal Significant
culture shifts will need to occur within organizationsCare models to define evidence-based standards of care delivery and coordination across the continuum of care are critical building blocks to an ACOExecutive leadership within C-Suite and Board are vitalKeys to success include a primary care foundation, plus PCMH and comprehensive informatics across the continuumVariability of models is a given…flexibility and innovation is market drivenShared learning collaborative is both a motivator and supportive structurePrivate payor readiness to alter reimbursement and share data to support ACO model varies widelyUnknowns are plentiful…public and private sector have a lot to learn to effectively transform health care
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Lessons Learned: Payor partnerships
Which population segments are we going to target?What role should the payor play (care management, etc.)?What criteria should we use to evaluate potential payor partners?What are the important areas in contracting with a payor?
•
Transparency•
Timely and comprehensive data•
Shared savings•
Care management role
Care transformation and payment models
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Create the vision for Population Health Management
Payor PartnersPeople Centered Foundation
Health Home
Payor Partnerships
IntegratedLeadership
Population Health Data Management
Clinical Integration
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Foundational Philosophy: Triple Aim™
The bridge from FFS to accountable care
What are the underpinning
building blocks?
CurrentFFS
System
AccountableCare
Measurement
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Integration and new payment models Where to engage?
Pay for Performance
MSSPBundled Payment Initiative
Shared Savings
Pioneer ACO (CMMI)
Capitation
Movement to integrated care and new payment models
Value Based Purchasing
Partnership for Patients
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Ten Percent of Hospital Medicare revenue at risk by 2017
Value Based Purchasing
Readmissions and hospital acquired conditions penalties
Inpatient Quality reporting participation incentive program
Meaningful Use incentive payments
Source: AHA
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Shared Savings model
-3 -2 -1 0 1 2 3
Expe
ndin
g
Year
Projected Spending
Actual Spending
Shared Savings
Target Spending
ACO Launched
Source: Lewis, Julie. “What Could be Next for Health Reform? The Debate In Washington” Presentation. The Dartmouth Institute for Health Policy & Clinical Practice.
2009-07-02.
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How are delivery systems addressing the new financial realities?
Operational cost (production) reductionsFocused factory modelAddressing appropriateness of careNew revenue opportunities (e.g. provider-sponsored health plan, retail pharmacy, chronic disease management, etc.)Greater focus on health/wellness/prevention/chronic disease managementReducing redundancies by integrating services (physician services)Health plan partnerships (new payment models)Post-acute care partnerships
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Chronic disease management across the continuum in the six major disease areas (asthma, diabetes, CHF, COPD, hypertension, and chronic depression)Patient Centered Medical Home (Health Home)Managing High Risk PopulationsPalliative/end of life careAppropriate utilization of expensive diagnosticsPharmaceutical use/costs (e.g., use of generics)Replacement of more expensive location of care with less expensive location (e.g., family practice office vs. ER).
Areas of per capita cost reduction
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Transformational funding
Care management
Shared savings
Key components of new payor contracts
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Increase market share/growth
Reduce costs/improve processes/rationalize capacity
Grow new revenue areas (retail health, urgent care, hospital in the home, etc.)
Develop new payor agreements (infrastructure funding, care management, and shared savings)
Financial strategies for success during the healthcare transformation
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Common barriers to success
Leadership commitmentCultural changeSize / market presence Financial resourcesPhysician relationsLack of primary care networkInformation technology
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Where is reform really going?
““The pub crawl to capitation.The pub crawl to capitation.””
www.premierinc.com
Joe_damore@premierinc.com
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