Population Health Management and Accountable Care Organizations

Cliff Fullerton MD, MS

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Agenda

• Payer Agenda• Market Response • Population Health • Equitable care example• Population Health Management• Accountable Care Organizations

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Payer Agenda

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What’s Driving Population Health?

Increase access to care ►Coverage for prevention ►Emphasis on quality measures

Affordable Care Act

Value Based Payments (ACOs, BPCI, Medicaid SIM Grants) ► Medicare Advantage Growth (over 7% per year; 38% total Medicare by 2021)

Commercial PayersHealth Care Reform Task Force

Reduce business expenses ►Improve convenience and coverage for employees ► Increase bargaining power with payers

Employers

Centers for Medicare and Medicaid Services

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Medicare Payment at Risk under CMS Quality-Based Payment Reform Initiatives

Financial Timeline Related to Quality Measures2013 2014 2015 2016 2017 2018

Hospital 1.00% 1.25% 1.50% 1.75% 2.00% 2.00%VBP

ReadmissionsReduction 1.00% 2.00% 3.00% 3.00% 3.00% 3.00%Program

PQRS 1.5% penalty 2.00% 2.00% 2.00%

E-Rx 0.5% incentive 0.5% incentive Incentive ends1% penalty 1.5% penalty 2.0% penalty

HAC Reduction 1% penalty Program if in bottom 25%

LTACH/Hospice/Ipt Rehab 2% ReductionQuality Reporting for nonreporting

Physician VBP Application of VBP Modifier applied to allModifier modifier applied to groups of >100 physicians

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VBP Domain Weighting Changes

Core Measures70%

HCAHPS30%

FFY 13HCAHPS

30%

Core Measures45%

Out-comes25%

FFY 14

HCAHPS30%

Core Measures

20%

Outcomes30%

Efficiency20%

FFY 15

HCAHPS25%

Core Measures10%

Outcomes40%

Efficiency25%

FFY16

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Relevant Components of SGR Repeal Legislation

1) Sustainable Growth Rate, 2) Also includes six budget offsets and enshrinement of chronic care management code, 3) Electronic health records, 4) Government Accountability Office, 5) Remote patient monitoring, 6) U.S. Department of Health and Human Services, 7) Children’s Health Improvement Program.

Provider Payment Reform Select Provider-Related Provisions3

• Requires EHRs3 be interoperable by 2018; prohibits providers from blocking information sharing

• Requires GAO4 report on barriers to telemedicine, RPM5 use

• Requires HHS6 to propose permanent physician-hospital gainsharing program

• Halts phase-out of global surgery codes• Extends two-midnight rule by six months

• Repeals SGR1 formula• Defines two tracks for provider payment • Consolidates multiple Medicare physician

incentive programs into single payment adjustment

• Increases transparency of utilization, payment data

• Requires CMS to pay for care management services

Source: H.R. 2: Medicare Access and CHIP Reauthorization Act of 2015; Advisory Board Company interviews and analysis.

©2015 The Advisory Board Company

Providers Must Choose Enhanced FFS1 or Accountable Care Option

SGR Repeal Creates Two Tracks for Providers

Fee for service.Meaningful useValue-based Payment Modifier.Physician Quality Reporting System.

Source: H.R. 2: Medicare Access and CHIP Reauthorization Act of 2015; Advisory Board Company interviews and analysis.

Track One: Merit-Based Incentive Payment System (MIPS)

2019: -4% to +12% at risk

2021: -7% to +21% at risk

2020: -5% to +15% at risk

2018: Last year of separate MU, PQRS, VBM penalties

2015 – 2019: 0.5% annual update 2026 and on: 0.25% annual update

2020 – 2025: Frozen payment rates

2022 and on: -9% to +27% at risk

Track Two: Advanced Alternative Payment Models5 (APM) 6

2019 - 2024: 5% participation bonus

2016: APM-30%Overall-85%

2018APM-50%Overall-90%

2026 and on: 0.75% annual update

2015 – 2019: 0.5% annual update 2020 – 2025: Frozen payment rates

Rolls MU2, VBPM3, PQRS4 into onebudget-neutralprogram withsingle payment

Requires significant share of revenue in contracts with two-sided risk, quality measurement (“APM revenue”); PCMHs7

serving Medicare population exempt from downside risk requirement

ACOs have saved Medicare $417 million

Value Based Payment

Goals

Current-20%5)Alternative payment entities are defined as select Medicare programs.6) Includes partial qualifying mechanism that allows providers that fall short of APM revenue requirements to report MIPS

measures and receive corresponding incentives or decline to participate in MIPS.7)Patient-centered medical homes.© 2015 The Advisory Board Company

2019 - 2024: Increasing APM 2 sided risk. 25-75%

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Year 1 Year 2 Years 3+

50% 45%30%

10% 15%30%

25% 25% 25%

25% 25% 25%

Quality Resource Use Meaningful Use Clinical Practice Improvement

Multiple Medicare Incentives Aggregated Into MIPS

Source: H.R. 2: Medicare Access and CHIP Reauthorization Act of 2015; Advisory Board Company interviews and analysis.

©2015 The Advisory Board Company

1) Merit-based Incentive Payment System.2) U.S. Department of Health and Human Services.

25% 100% 125% 150%

-10%

0%

10%

20%

30%2019

2020

2021

2022

Score Will Determine MedicarePayment Adjustment

Percent of Score Threshold Met

Payment Adjustment (%)

High performers eligible for additional incentive

Nonreporting providers given lowest score

MIPS Score Comprised of Four Categories

1

2016

30%

85%

2018

50%

90%

CMS Timeline for Transition to Value-Based Reimbursement

By 2018, 50 Percent of Payments in Alternative Payment Models

Historical Performance2011 2014

0%

~20%

>80%

~70%

Goals

Payments linked to alternative payment models FFS linked to qualityAll Medicare FFS

Source: Centers for Medicare and Medicaid Innovation (“CMMI”) Center, Bundled Payment Summit, June 2015 10

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Primary Care Measures

Multiple sources of primary care measures

Government Centers for Medicare & Medicaid Services Agency for Health Care Research & Quality

Private Sector Contracts BCBS, Aetna, Humana, United, Cigna. Consultants and others

Independent Organizations National Committee for Quality Assurance National Quality Forum The Joint Commission U.S. Preventive Services Task Force American Diabetes Association, et. al. BTE Specialty societies

Government PQRS - 29 Meaningful Use - 33 ACO - 33 Medicare Advantage-Varied

Private Sector Contracts Clinical Service - e.g. access Patient satisfaction Productivity Health status

Independent Organizations PCMH Efficiency measures Disparate measures Condition focused

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Commercial Payer Example• Agree to gather and report, within thirty (30) days of an Participant’s first visit, and semi-annually

thereafter, and in a manner that is compliant with HIPAA and other applicable laws, the following Quality Measures.

• Health Status• SF-12 physical score (current version)• SF-12 mental score• Single question: state of health today

• Intermediate Clinical Outcomes• BP (systolic and diastolic) <130/80 for DM and <140/90 for CAD• A1C <7.0• LDL <100 for DM and CAD• Selected additional HEDIS measures as mutually agreed to by the parties

• Satisfaction and Communication• Clinic visits• Nights and weekends• Care Coordinator communication• Physician communication

• Health-related Productivity• Missed work days• Ineffective work days

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Experience/Challenges Aligning with disparate measures

Private vs. Medicare vs. Medicaid Standardized Measures/Thresholds vs. Patient Preferences

Balancing focus vs. completeness Focus on a few key measures Example-Diabetes:

Emphasize: HbA1c < 7, BP <130/80, LDL <100, ASA and tobacco use Not retinal, microalbuminuria, foot exam

Internal benefits of national metrics Bonuses and incentives. Evaluate performance Lessens internal debate

Cost Internal Staff Vendor support Working with multiple EHRs or non-EHR community medical staff

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Market Response

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Iora Qliance MDVIP Kaiser One Medical Group

Panel Size < 1,000 800 – 1,000 300 – 600 2000+

Fee $50-60 pmpm $79/month $1,500 - $1,800/yearmembership

$149 - $199/year

membership

TMC Reduction

> = 15%. Dec admits 40%

20%. Dec admits 60%

> = 15%. Dec admits 10%

20% > = 15%

Team Members

Doctor, RN, Health Coach. Integrated BH

Generally-traditional

Physician, APP, Nurse, SW, Pharm,

et. al.

Technology

Access Expanded hours

7 days/week Concierge Varied 24/7 care, email consults

Practice model

PCP center. CMS large employers.

Collaborative specialists.No billing

PCP center. CMS, Large employers.

Salaried.No billing

Concierge. Wealthy.

Integrated physicians and HP

Service. ConsumerismSelf-manage

Support. Young and active.

Competitive Provider Models

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Kaiser Redesigned Primary Care

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Competitive Provider Payment Models

Retail Clinics MD Live

Panel Size N/A N/A

Fee Sports physical - $39A1c Check - $59

Flu Symptoms - $79 (vs. typical medical group

fee of $80-200)

$25 - $35 for phone, web and email visit services

Team Members Family Nurse Practitioners, Physician Assistants

Board Certified IM, FP, ED and Pediatricians

Average of 15 years experience

Access 7 days/week, walk-in + appointment, < 20 minute wait (in and out in 1 hour)

24/7/365, holidays included

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My Daughter’s Sentra

• What is #1 for her?• How do you sell this car?• How do you service this car?• Is units sold or per unit profit more

important?• 20 yrs. ago this car would have

been a luxury. It is now a commodity.

• What drove this change?

My Lexus

• What is #1 for me?• How do you sell a Lexus?• How do you service a Lexus?• Is units sold or per unit profit more

important?

What is/might soon be commoditized in medicine?

What is not?

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Only 36% of Family Physicians and 37% of Internists report being happy at work

Only 61% of Family Physicians reported being happy at home

45.8% of physicians reported at least one symptom of burnout.

Highest rates - family medicine, general internal medicine, and emergency medicine.

87% of physicians are moderately to severely stressed daily.

PCP Survey Results

1“Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population,” Archives of Internal Medicine, 2012. 2http://www.cejkasearch.com/news/press-releases/ Nov 29, 2011

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So where does this leave us?

Increased Payer DemandsCompetitive Pressures

CommoditizationData demands

Stressed physicians

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Population Health

What is Population Health?

• “…a precise definition has not been agreed upon…” Am J Public Health

• “No concise definition of the term appears in this volume.” Why Are Some People Healthy and Others Not? The Determinants of Health of Populations

• “Population health, as defined, has been critiqued as being so broad as to include everything—and therefore not very useful in guiding specific research or policy.” www.improvingpopulationhealth.org

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Value

Value = Quality (+Access) Cost

Population Health Introduces Two New Mandates

The “Triple Aim”

STEEEP Care

“The overarching goal for providers, as well as for every

other stakeholder, must be improving value for patients”

– Michael E. Porter –

#1: Manage those not engaged in care

#2: Control Costs

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Why the Focus on Population Health? Common clinical populations that are managed

Payer Chronic disease Race/ethnicity/ Risk

This helps set strategy Funding and incentives Technology resources - information management and delivery Coordination plans Team members Grants and pilots Educational needs - patients/families and providers Community resource Supports the case for clinical integration

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Equitable Care:Community Health Workers

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As defined by Texas Health and Human Services Commission: • A person who, with or without compensation, is a liaison

and provides cultural mediation between health care and

social services, and the community• A trusted member, with a close understanding, of the ethnicity, language,

socio-economic status, and life experiences of the community served• Assists people to gain access to needed services and builds individual,

community, and system capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, patient navigation and follow-up, community health education and information, informal counseling, social support, advocacy, and participation in clinical research

Community Health Workers (CHW)

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Low Health Literacy Materials

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CHW Program Outcomes

Primary Care Connection (ED)January 2012 - October 2014

• 10,744 referrals (contact with a CHW)

• 58% made an appointment with a PCP

Community Care Navigation (IP) January 2012 - October 2014

• 5,429 referrals (contact with a CHW)

• 78% made an appointment with a PCP

Outpatient ClinicPairing a CHW with a clinician (RN, RD or Exercise Specialist) for

16 week pre-diabetes program resulted in: • 5.6% change in BMI,

• 6.0% change in waist size • 70% improvement in A1c control• 66% decrease in poor A1c control

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CHW Program Outcomes

Hospital Admissions Comparison for Patients with Established Follow-up (Random Assignment to Care Navigator vs. Usual Care)

Randomization Group Changes

Time (Days) After Index Encounter A: Care Navigator B: Usual Care P-value Absolute Diff. % Change

30 2.3 ( 2 / 86) 5.9 ( 15 / 255) 0.190 -3.6 -60.5 60 3.5 ( 3 / 86) 9.0 ( 23 / 255) 0.095 -5.5 -61.3 90 4.7 ( 4 / 86) 12.2 ( 31 / 255) 0.047 -7.5 -61.7

*Care Navigator Intervention was 90-days in duration 180 15.7 ( 13 / 83) 15.7 ( 39 / 249) 1.000 0 0 365 17.3 ( 9 / 52) 22.4 ( 35 / 156) 0.433 -5.1 -22.9

• P<0.05 considered as statistically significant• Number of CN interventions needed to prevent 1 hospital admission (1/.075)= 13

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Total Direct Cost

Hospital A Hospital B Hospital C Hospital D $-

$2,000,000.00

$4,000,000.00

$6,000,000.00

$8,000,000.00

$10,000,000.00

Change in Total Direct Cost 1 Year Pre and Post Intervention at a Charity Clinic

Pre-Intervention

Post-Intervention

Campus

Dolla

r

59%

51%

33% 43%

(n = 4,327 patients)Note: Direct cost decreased across all campuses.

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Total Direct Cost

Hospital A Hospital B Hospital C Hospital D $-

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

Change In Direct Cost2 Years Pre and Post Intervention at a Charity Clinic

Pre-Intervention

Post-Intervention

Campus

Dire

ct C

ost

33%

17%13% 13%

(n = 2,382 patients)Note: Direct cost continued to decrease in year 2

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Population Health Management

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Four Chronic ConditionsComprise 74% of Costs

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Cardio-vascular Disease

Cancer Diabetes Obesity Other Chronic

All Other Total Health Care Costs

33%

20%

10%11%

9%17% 100%

74% of Total Cost

% Preventable80%

Heart Disease/Stroke

30% - 60% 80%Type II

Nearly all can

improve

Source: U.S. Senate Republican Policy Committee. Federal Constraints on Healthy Behavior and Wellness Programs: The Missing Link in Health Care Reform. April 21, 2009.

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FINANCING: PRIVATE LABEL & PAYER

ALLIANCES

Population Health

5% of the sickest patients account for 50% of Health Care

Spending

15%

5%

80%

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Which group do we prefer to treat today?

The Playbook for Population Health

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Common Misconceptions about Population Health Managers

Tackle an overwhelming number of initiatives

Make an expensive upfront investment in advanced IT

Own assets across the entire continuum of care

Hire a large number of staff members in new roles

Playbook for Population Health

1. Set a prioritized list of key initiatives and ensure all stakeholders are aware

2. Invest in basic information exchange, analytics, and patient-facing technology

3. Develop preferred partner network with shared culture and accountability

4. Train and redeploy existing staff to match new demand for patient services. In addition, spread “Best Practices” for already established APHS, Disease Management, Care Coordination, PCMH design

Very few organizations

begin with “What does Population

Health mean for us?”

Source: Health Care Advisory Board interviews and analysis.

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FINANCING: PRIVATE LABEL & PAYER

ALLIANCES

Population Health

15%LVN, MA Health Coach

5% RN Health Coach

80%Wellness

Program w/ Coaching,

Preventative Services,

Auto outreach

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– The sickest 5% drive half the cost; intensive needs

– The 15% “rising risk”: timely effort to prevent worsening

– 80% Healthy people need prevention and education

Population Health Portfolio

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Access Extended hours. Teams. Asynchronous care. Partnering, e.g. retail clinics. Self management. Apps.

Patient-Centered Medical Homes

Physician directed teams. EMR. Coordination with specialists. Service. Disparities.

Care Coordination Care coordination. Health Coaching. Care management. Social work. Clinical pharmacist. Care navigation.

Data Analytics/Reporting

Connectivity.Aggregation. Analytics. Risk stratification. Dashboards and reporting.

Evidence-based Medicine Guidelines/protocols that are created and agreed to by the providers.

Wellness and Prevention

Technology-apps, portals, Withings. Coaching. Automated outreach. Benefits design. Community/govt engagement. “Contemporary nutrition”, eg GMO, pescatarian, vegan.

PCMH

Population Health Performance

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Cul

ture

Infr

astr

uctu

re

Fund

ingPopulation Health

management is a culture shift for

physiciansAnd hospitals

BUTPhysician and

hospital engagement has been excellent

ACO Infrastructure

+Contracting

+Benefit Design

=All essential for

performance

High performing population health

infrastructure must be funded

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Accountable Care Organizations

Health Care Transformation

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Meaningful use

Hi Tech

Big Data

Decreasing Costs

ACO’s(A Significant Force)

EMR Adoption

Personalized Medicine

ACOs have been deemed to be an

effective means for achieving the Triple Aim as introduced by the Institute of

Healthcare Improvement.

Forces transforming

Health Care

PCMH

Affordable Care Act 101

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The Affordable Care Act of 2010

Included several system reforms intended to address deficiencies

in the way health care was deliveredin the U.S.

The Term “Accountable Care” Describes

A group of health care providers working collaboratively to

coordinate comprehensive health care services for a defined patient

population. They are committed to being

jointly accountable to patients and third party payers for the quality, appropriateness and efficiency of

health care provided

ACO’s Nationwide

There are over 400 ACOs considered operational and

steadily extending their presence nationwide.

ACOs and Clinical Integration

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Clinical Integration – The Key to Real ReformAmerican Hospital Association

“Clinical integration is considered essential to true systemic change and meaningful reform that expands coverage, improves quality and care coordination, rewards effective and efficient care, promotes innovation and control cost.”

American Hospital Association. February 2010. Trend Watch. Clinical Integration – The Key to Real Reform

ACOs Reorient Health Care

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Promote Collaboration

Facilitate Population

Health

Integrate and Align

Financial Incentives

Prompt/direct benefits for

employers and insurers

Demonstrate Value

Industry experts agree that the most effective approach for reorienting the health care system to efficiently and effectively

manage growing patient panels with complex medical conditions is for health providers to initiate ACO models that provide the infrastructure and incentives to facilitate population health

through collaboration across the continuum.

”

Source: Health Affairs: Payment and Delivery. How The Center of Medicare and Medicaid Innovation Should Test Accountable Care Organizations

585 ACOs total in the United States 12% increase from 522 in 2014 127% increase from 258 in 2013

49-56 million patients (roughly 15-17 percent of total population) are served by ACOs

ACO Update

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Independent vs. Aligned

Independent ACO Employed

Income (rev-costs)

Autonomy/flexibility

Admin/analytics SupportContracting power(terms and rates)Ability to create value (mission)Manage Risk

1. Employment-Hospital2. Indep-Group <103. ACO->500 physicians w/ hospital partner4. Average of each group

Degree of Alignment

Exercise:Assign 1-3 + rank for each cell to each. Individually.

What the Industry Experts Say

ACO leaders from both the Pioneer program and private ACOs interviewed were encouraged by their experience to re-direct their vision and culture away from a volume-based model toward a value-based

model of care that is much broader than just achieving immediate quality, satisfaction and financial thresholds

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Quality Cost Measures Investment

Pioneer Program Results: Performance Year Three (2014)

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20 participants improved the quality of patient care for 622,265 beneficiaries

55% (11) lowered costs enough to generate shared savings of $82MMean quality score increased to 87.2% (from 85.2% in Year 2 and 71.8% in Year 1)

Improvement in 28 of 33 quality measures; average improvement of 3.6% across all quality measuresStrong improvement over Year 2 results in medication reconciliation (70-84%), screening for clinical depression and follow-up plan (50-60%) and qualification for an EHR incentive payment (77-86%)

Source: Centers for Medicare & Medicaid Services.

Quality Cost Measures Investment

MSSP Program Results: Performance Year Three (2014)

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92 Shared Savings Program ACOs held spending $806M below targets, earning performance payments of more than $341M (58 ACOs held spending $705M below targets in 2013, earning more than $315M in payments)

Total net savings to the Medicare Trust Funds of $465M ($383M in 2013) An additional 89 ACOs reduced costs compared to benchmark, but did not qualify for savings

Improvement in 27 of 33 quality measures for Shared Savings ACOs reporting in both 2013 and 2014

Source: Centers for Medicare & Medicaid Services.

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The Accountable Community for Health

PCMH

Progression of Care

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“The Ideal Practice”

https://vimeo.com/95983455

What do you see that is different than the standard practice?

Advantages for practice?Advantages for patients?

Using new tools to scale successful models.45 For 45

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Patient Service Expectations

• Access– E-visits– Tele-Health– Extended hours on site or aligned

• More time with your physician when needed, eg top 5%• More wellness support• Health coach if needed• Ease of check-in with PCP • No bill to manage when seeing PCP except for elective

services, eg Botox

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Patient Requirements/Recommendations

• Select a PCP• Sign your care plan pact• UTD on preventative services• Complete HRA• Contact your team before seeing a new

specialist

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Physician BenefitsThe Quadruple Aim

• No need to justify a visit claim. Will need to document for coding, quality and service.

• Decreased Prior Authorizations• Team support• More time with patients• Technology support: Tele-health and e-visits• Rewarded for high performance• Rewarded for managing complicated patients

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• Physician, RN, CMA

• NP/PA with CMA• 20-25 patients daily – Focus could be chronic disease with protocols, walk in, or

wellness exams

• RN Health Coach - in person and virtual

• Health Coordinator - virtual

• Social work - shared – Social determinants of health, behavioral health, EOL

• Clinical pharmacist - virtual

• Community Health Workers

• Chaplin

• Retail Clinics

• Technology - Emmi, self management apps, etc

Team

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Patient Education/Self Management

• Physician and RN trained in motivational interviewing and shared decision making

• Health Coordinator – follow up on instructions regarding medications and goals, assist with APS education for resistant patients. (in place)

• Self management tools available on portal, EMR. (asthma, diabetes, HF, etc)

• Self Management apps liked to digital self

• Multimedia options-Education and Shared Decision Making

• Group visits , e.g. DM with CDE

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Integrated Behavioral Health

• IMPACT- Improving Mood: Providing Access to Collaborative Treatment

• Tele-psych , e.g. Breakthrough

• The Big White Wall

Identification

•MA administers PHQ-2 during rooming-in process•Positive screen triggers LCSW referral

Referral

•LCSW assesses patient via psychosocial assessment and screening tools• Initiates a treatment plan

Follow Up

•At specified visits, patient reassessed using screening tools•When remission achieved, patient discharged from behavioral health

Step Up or Down

• If patient is challenging, PCP and LCSW may schedule a conference call with a designated psychiatrist to staff case and decide on treatment

Safety plan

• If patient is at risk for danger to self or others, clinic staff has a safety plan in place

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Performance Measures

• Efficiency– High cost imaging (preferably by guidelines adherence as opposed to actual volume)– Generic prescribing– Ambulatory sensitive ED visits – RAF Score for panel

• Quality/Safety– High risk drugs/Medication adherence– Broad PCP quality measures. 40-50?– Percent of patient HRAs that have been assessed and care plan entered. HRA to include absenteeism

and presenteeism questions. Plan will include managing these issues. • Coordination

– 72 hr post DC OV– Quality referrals-complete info for consultant and coordinated

• Access – 24/7 meaningful phone access– Walk-in and Extended hours at clinic or coordinated, eg retail clinic– E-visits/Tele-health

• Patient experience/satisfaction– Patient engagement.

• Performance on these metrics provides the funding through cap and/or shared savings, e.g. Iora, Qliance

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Typical Day for Physician

• 8:00 a.m. - 8:20 a.m. – Review appointments for the day, hospitalized patients, high risk patients, selected NPP charts, dashboard review of populations

• 8:20 a.m. - 8:30 a.m. – Team huddle. Remind of current initiatives and ABC projects, assess appointments for the day

• 8:30 a.m. - 12:30 p.m. – 30 minute appointments

• 12:30 p.m. - 1:30 p.m. – Lunch, patient calls, and catch up

• 1:30 p.m. - 5:00 p.m. – 30 minute appointments

• 5 p.m. on – Patient calls and catch up

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Questions / Discussion

Exercise