Delivering Value Based CareDelivering Value Based Care: Strategies for Success Presenters Tammie...

Delivering Value Based Care:

Strategies for Success

Presenters

Tammie Galindez, MHA,

CHFP

AVP, Value Based Care

Conifer Health Solutions

Stephanie Mills, MD, MHCM

President

inHealth Strategies

2 © 2017 Conifer Health Solutions, LLC. All rights reserved.

Objectives

At the end of this course, you will be able to:

▪ Discuss what is driving the shift from volume to value

▪ Describe foundational elements of a value cased care

strategy

▪ Describe how technology and data can be leveraged to

decrease cost while informing a broader clinical strategy

▪ Describe strategies to engage a broad coalition of

stakeholders across the care continuum

▪ Describe the impact of an effective wellness and care

management plan on population health management and

reimbursement


Introduction to Fee-For-Value Payment ModelsDefinition Value to provider

P4P & Medical Home

Bundled Payments

Shared Savings (upside only)

Shared Risk (upside/downside)

Full Risk/Capitation

Medical Home and Pay-for-Performance models provide

financial rewards to providers for a narrow list of quality

and cost metrics.

The episode payment for a specific DRG, inclusive of most

costs and typically inclusive of the hospital stay and costs

incurred 30 to 90 days post hospital discharge.

• Aligns providers around quality goals

• Allows for collection of data to show quality

improvement

• Experiment with value-based arrangement on a

limited basis

• Moves service line to integrated delivery model

• Analyze and drive up/down stream care to

preferred network

With both Shared Savings and Shared Risk, the integrated

network is held accountable for the total cost performance for

a defined population. With Shared Savings the network is

rewarded for reducing the cost for the defined population

below a set cost target with a percentage of the total savings.

The integrated network receives a set premium amount

per aligned member, from which claims are paid for a

defined scope of services.

• Movement to domestic utilization to drive

savings and quality goals

• Optimize cost of network to drive savings

• Larger sharing of savings

• More aggressive actions to utilize network

providers and evaluate who is in network

• Manage utilization and network usage to ensure

network optimization

• Limit network to provide providers

Under Shared Risk the network has the potential for

greater reward opportunity of the total cost savings, and

also assumes a percentage of the cost increases above a

negotiated target.

Form Clinically Integrated Networks Manage the Population Advise on Financial Risk

Capabilities needed


Factors fueling the shift to value-based payments

CMS - MedicareMedicare has 80 alternative payment

models which are being applied to non-

Medicare Advantage lives:

• 20% (8 Million) of Medicare FFS lives

are in Medicare ACOs1

• At least 3.6 Million additional lives

are tied to other alternative payment models

(i.e. CJR, Comprehensive ESRD,

Oncology Care Model)

• 30% of Medicare payments tied to quality

through APM’s as of 3/3/2016

Consolidation of models is expected specifically

around:

• Service line / condition specific bundles

(e.g. CJR, Cardiac Bundle)

• Pushing more risk to providers

(e.g. NextGen ACO)

1 MSSP (7.2M), Pioneer (0.6M), NextGen (est. 0.2M)

“Our target is to have 30% of Medicare payments tied

to quality or value through alternative payment

models by the end of 2016, and 50% of payments by

the end of 2018.”

Sylvia Burwell, Secretary HHS, Jan. 2015

85% 90%

50%

2016 2018

All Medicare FFS

Medicare FFS linked to quality

Alternative payment models

30%

Target percentage of Medicare FFS linked to quality and alternative

payment models in 2016 and 2018

Source: CMS.gov


MACRA is a federal program that will be a catalyst

for further transformation

In 2015, “The Medicare Access and CHIP Reauthorization Act of 2015” is passed, creating the framework to

redesign how CMS pays physicians.

In April 2016, CMS released the MACRA Proposed Rule outlining a Part-B physician payment methodology

update that would replace existing PQRS and Meaningful Use initiatives with a more robust and streamlined

program.

Under the new program, physicians will fall under one of three reporting and payment “Tracks”

MIPS (Merit-Based Incentive Payment System)

• Traditional track for providers not in a value-based program

MIPS – APM (Alternative Payment Model)

• Track for providers that participate in a CMS value-based initiative

Advanced APM

• Requires significant share of revenue in contract with two-sided risk and EHR requirements

Today, the most widespread Alternative Payment Models are the CMS ACO programs.

Physicians that participate in Alternative Payment Models, such as ACOs, benefit from less burdensome quality

reporting to CMS and are positioned for favorable Part-B payments.


Other factors fueling the shift to value-based

payments


Commercial and Medicare are driving alternative

payment models with ACOs

1199

505

617

77

0

200

400

600

800

1000

1200

1400

Q22011

Q32011

Q42011

Q12012

Q22012

Q32012

Q42012

Q12013

Q22013

Q32013

Q42013

Q12014

Q22014

Q32014

Q42014

Q12015

Q22015

Q32015

Q42015

Q12016

Total Medicare Commercial Medicaid

Source: Leavitt Partners ACO Landscape Presentation; April 8, 2015

ACO contracted payment arrangements by payer type

Number of arrangements


Growth in ACOs and value-based arrangements is

projected to be regionalized based on 4 characteristics

Urban Environment Disease Burden

Payer Fragmentation Large Employer Concentration

Rising population in

urban areas increase

the regional market

opportunity as well as

Payer and Provider

competition

As the Payer

market

continues to

grow, there will

be more

innovative and

attractive

payment models Leavitt Partners Center for Accountable Care

Intelligence

Census.gov

Fortune 1000

companies tend

to cluster in urban

areas – attracting

more population

and service

providersBased on Aug. 2014, Geolounge.com

Individuals with

chronic diseases

benefit most from

care coordination;

moreover, they have

a higher rate of

utilization


0

200

400

600

800

1000

1200

ACOs

ACOs have had strong growth in past 5 years

-

5

10

15

20

25

30

Q42011

Q42012

Q42013

Q42014

Q42015

Q12016

Lives…

Growth in ACOs

Lives (left), Number of ACOs (right), number of payment

arrangements (right)

• ACOs have been

expanding covering

more lives and

signing more

payment

arrangements

• 9% (28M) of U.S.

population is under

the care of an ACO

• Estimates vary from

41-177M lives

contracted for by

ACOs in 2020

Lives (M)

ACOs

Payment Arrangements

Source: Leavitt Partners ACO Projections White Paper;

December 22, 2015


Shared savings are the most common risk arrangements with

shared risk having the most lives per contract

Reported non-Medicare reimbursement models for ACOs

Percent (4.1M lives reported)

1 Leavitt ACO Database. Only Non-Medicare ACOs reporting payment arrangements; 16% of ACOs covering greater than 12M lives did not report payment model

• Majority of non-

Medicare payment

arrangements are for

shared savings

• Average lives per

arrangement are:

• 24K for shared

savings

• 48K for shared risk

• 28K for capitation

• Even the low growth

scenario of ACOs would

create a 46% growth in

the market

69% 63%

7%13%

23% 24%

ACOs Lives

Shared Savings Shared Savings and Shared Risk Capitation


Characteristics in-play confirm regionalized

concentration that supports VBC’s market-based

growth strategies

Source: Leavitt Partners Value-Based Payments Market Analysis

1 Quantitative indicators in appendix

The Northeast,

Michigan-

Chicago corridor,

and Pacific

Northwest will

quickly be

seeking to

transition to

Value-Based

Payments.

Darker shades indicate

geographies with higher

probability of moving towards

Value-Based Payments


Driving factors of activity for Value-Based Payments

Source: Leavitt Partners Value-Based Payments Market Analysis


There is upside in revenue and market share as rate of

risk-adoption by providers increases through 2020

0

20

40

60

80

100

120

2016 2017 2018 2019 2020

Scenario A Scenario B Scenario C

Source: Leavitt Partners Projected Growth of ACOs: December 2015

Scenario A: baseline scenario – most likely to happen

Scenario B: baseline scenario with impact of MACRA removed

Scenario C: Market B scenario with ACO financial outcomes becoming

increasingly negative

ACO Covered Lives Projections

Millions CAGR

39%

25%

10%


FOUNDATIONAL

ELEMENTS TO

EFFECTUATE A VALUE

BASED CARE STRATEGY


Value based care strategy foundation


Actionable Data is Key to Achieving CIN Success


Strategies to succeed in value-based models

Form clinically

integrated

networks

• Form provider partnership with aligned incentives

• Articulate causes of low cost and quality (including those

providers)

• Provide transparency into cost and quality results

• Enable virtual integration a lower cost alternative to

employment

Manage the

population

• Identify the high risk individuals who would benefit from

care management

• Coordinate care for individuals, diving individuals to the

preferred providers, when appropriate

• Educate to move individuals to self-management

Manage

financial risk

• Negotiate risk-based contracts

• Report and manage financials of risk-based contracts,

providing advice on how to improve

• Perform transactions for delegated risk (e.g. claims,

customer service)


OPTIMIZING RESULTS

Strategic touch points | Focus on “health”

• Focusing on “health” and not “hospital” care

• Driving value-based care: cost and quality

• Redesigning care: connecting silos across environments

• Fostering relationships with providers in care delivery

• Developing practical solutions in the face of competing priorities

• Linking to innovative payment models

© 2017 inHealth Strategies, LLC

Health care expense trends | Making the case

• Employer expense growth rates have slowed since 2010: 4-5%

• Premium increases outpace incomes in all states

• Average annual premiums = 20-25% of median income

• Increased out-of-pocket expenses for workers

• Employee premium contribution nearly doubled in the past decade,

increasing 93 %

• Deductible expense doubled from 2003-2013

• High deductibles are becoming the norm

The Commonwealth Fund, Issue Brief, January 2015


Caring for populations


Achieving outcomes


FMOL Health System | A case study


Healthy Lives | Population health in action• >13,000 employees and >17,000 insured members

• 75% participation rate

• >$20 million in savings over 5 years

• Quality measures exceed national benchmarks

• Five years in a row with no premium increase for members

• Recognized by the National Business Group on Health:

Best Employers for Healthy Lifestyles in 2012-2016


Analytics

• Integrate

Claims, clinical, well-being & care management data warehousing

• Analyze

Relational database tools

Financial, utilization, quality, risk stratification, predictive modeling & engagement

• Manage

Integrated care management platform, protocols & documentation

• Share

Dashboards, executive summaries & ad hoc reports

Connect with clinicians via portal & EHR options


Health risk assessments

• Assess emerging risk

• Enhance claims data

• Engage individuals

• Track progress


Well-being for your populations


Engaging individuals

• Tailored incentive programs

• Participation & outcomes-based

• Link to employer & community activities

• Automated web management


Care management & coaching


Connecting with providers

• Patient-centered approach

• Care management workflow integration

• Data integration: linking claims and clinical data

• Strong governance processes to drive best practice

• Transparency


Imperatives for providers | How do we get there?

• Leverage your strengths

• Build relationships

• Invest in analytics

• Optimize your care

management resources

• Be creative



APPENDIX


DefinitionAccountable Care Organizations (ACO): A network of hospitals, employed and affiliated physicians collaborating through a

robust care coordination program designed to improve the quality and efficiency of care delivered to is aligned patients.

Commercial ACOs engage in the full range of value based payments with private payers. Medicare ACOs are contracted with

CMS.

Bundled Payment: Bundled payments are fixed amounts of reimbursements for a predefined set of services. There are two

specific programs CMS have in place to move the initiative forward: Comprehensive Care for Joint Replacement Model (CCJR)

and Bundled Payment for Care Improvement (BPCI).

Clinically Integrated Network (CIN): Partnering between employed and affiliated providers in an attempt to better negotiate

collectively with payers on reimbursement arrangements.

Medicare Shared Savings Plan (MSSP): A broad CMS ACO program with varied bonus models that establishes quality and cost

targets for providers who are early adopters of value based payment arrangements. The program has been widely adopted under

its current design. There are three main Tracks within the MSSP program with increasing risk/reward. There are 433 Medicare

ACOs today; 411 are in Track 1 with no downside risk.

Next Generation ACO: TA new Medicare ACO model introduced by CMS in 2016 that offers providers the maximum opportunity

for upside bonus rewards of any Medicare ACO program. This model also includes downside risk and has many of the same

attributes of Medicare Advantage plans.

Pay for Performance (P4P): Financial incentives give to providers for meeting certain criteria such as achieving optimal

outcomes for patients

Pioneer ACO: The Medicare ACO program was introduced in 2012 for provider networks that had experience with value based

models and wanted greater risk/reward opportunities. The program will sunset at the end of 2016 and has been replaced with the

Next Generation ACO program.

Glossary of terms

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