Steven E. Wegner, MD JDChair, NCMS Accountable Care Task Force

Paul Cunningham, MDNCMS Accountable Care Task Force

1

Steve Wegner

sew@ncaccesscare.org

(919)380-9962

2

What is this?

…and why should I care?

3

4

- Peter Orszag, N Engl J Med, 2007

5- Baicker et al. Health Affairs web exclusives, October 7, 2004

“ Even if federal health overhaul is rejected by

the Supreme Court or revamped by Congress,

the market must continue to change. The

system that brought us to this place is

unsustainable. Employers who foot the bill for

workers’ health coverage are demanding that

BlueCross identify the providers with the

highest quality outcomes and lowest costs.”

- Brad Wilson, President of BlueCross BlueShield of North Carolina6

“ACOs consist of providers who

are jointly held accountable for

achieving measured quality

improvements and reductions in

the rate of spending growth.”- Mark McClellan, Director of the Engleberg Center for Health Care Reform at the Brookings Institution

7

8

ACOs are not gate keeper; ACOs do not require patient enrollment.

ACOs do not require changes to benefit structures.

Can provide or manage continuum of care as a real or virtually integrated delivery system.

Are of a sufficient size to support comprehensive performance measurements.

Are capable of internally distributing shared savings payment.

9

FFS Capitation ACO

Payment Model Providers are paid per service

Providing fixed, "upfront" payments unrelated to volume of services changes incentives.

Reduces incentives to increase volume and can work with other reforms that promote coordinated, lower-costs quality care.

Requires patients to enroll with specific providers

No Yes-Patients must enroll with designed provider

No-Patients can be assigned based on previous care patterns.

Strenghtens primary care/fosters care coordination

No- Little incentive to support primary care or coordination

Yes Yes

Fosters accountability for total per-capita costs and imporved quality

Little incentive to manange total per-capita costs or improve quality

Accountable for per capita cost Accountablity for costs in the form of shared savings with eligiblility for shared savings.

10

More doctors are

joining hospitals and

health systems rather

than go into private

practice.

More doctors are

joining hospitals and

health systems rather

than go into private

practice.

11

12

Triple aim:

◦Population health status and outcomes of care

◦The care experience

◦Total cost of care – Delivering the outcomes

Tightly aligned physician network

Contracting capability

Large enough population base

Willingness to accept common cost and quality metrics

Sufficient data infrastructure

13

1. People-centered foundation

2. Health Home

3. High-Value network

4. Population health data management

5. ACO leadership

6. Payer Partnership

14

Fee-for-service plus bonus

Bundled payments plus bonus

Global capitation

Partial capitation

15

These Principles are:

1. Stakeholders should identify specific targets that reduce cost.

2. Evaluate objectively whether these targets were met.

3. They should share success financially.

4. Should engage in a process of continued monitoring.

16

1. Quality

2. Cost effectiveness

3. Care-coordination

17

ACO ImpactACOs have access to medical, pharmacy, and Laboratory claims from payers

Care Effectiveness/ Population Health

• Cancer Care Screenings• Diabetes Care (LDL and H1c tests, eye exams, etc.)• Coronary Artery Disease Care (LDL test)

Safety• High-risk medication for the elderly• Appropriate testing for patients using high-risk

medications

Patient Engagement

Overuse/ Efficiency

• Imaging for low back pain (in absence of “red flags”) during first 30 days

• Inappropriate antibiotic prescribing• Utilization rates of select services (e.g., C-

section)18

ACO ImpactACOs use specific clinical data (e.g., electronic laboratory results) and limited survey data

Care Effectiveness/ Population Health

• Immunization rates for children and adolescents• Patients with diabetes whose blood sugar (H1c) is in control• Patients with diabetes or ischemic vascular disease whose

lipids (LDL) are in control• Patients with hypertension whose blood pressure is in control

Safety • “Never events” in hospitals

Patient Engagement

• Physician instructions understood (CAHPS)• Care received when needed (CAHPS)

Overuse/ Efficiency

• Episode-based resource use – linked to quality measures for common medical (e.g. diabetes, AMI) and common surgical conditions (e.g. hip replacement)

19

Reduced hospitalizations and other wastes.

Care coordination and care transition for chronic disease and complex patients.

Internal process improvement.

Informed patient choices.

Prevention and wellness.

20

Coordination between PCPs and specialists.

Support for preventing complications in specialty care and reducing costs.

Successful ACOs will promote more effective specialists care and PCP-specialists coordination and higher-value specialty care.

21

1. Quality

2. Cost effectiveness

3. Care-coordination

22

1. Quality

2. Cost effectiveness

3. Care-coordination

23

4. Culture of teamwork

X 2

Best practices for specialty coordination with medical homes

Best practices for all specialty procedure registries/patient tracking for improving care-and supporting meaningful performance measurements

24

Improved professional working environment

Realization that at some point volume and intensity will not be able to be increased further

Understanding that the care currently being delivered is not in the best interest of our country or patients

Knowledge of continued reform attempts by all healthcare stakeholders to improve quality and bend the cost curve

25

Steve Wegner

sew@ncaccesscare.org

(919)380-9962

26