Strategies for Keeping People Healthy and Generating ... · launch and scale • Payments made to...
Transcript of Strategies for Keeping People Healthy and Generating ... · launch and scale • Payments made to...
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Strategies for Keeping People Healthy
and Generating Shared Savings
August 1st 2019
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Mat Kendall, Aledade EVP Provider Networks:
Executive Director of a
Federally Qualified Health
Center in San Jose CA
Chief Operations Officer, Primary Care
Information Project (PCIP), NYC Director of the Office of Provider Adoption
Support (OPAS), Health Human Services
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Agenda:
• Introduction to Aledade
• Overview of Recent Changes to the Medicare Shared Savings Plan (MSSP)
• Impact of Accurate Risk Coding on Shared Savings Programs
• Impact of Annual Wellness Visits (AWVs) on Shared Savings Programs
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Introduction to Aledade:
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Aledade sustains physician independence through
success in value based payment models
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$3 Trillion in national healthcare spending
$1Trillion in estimated waste (33%)*
Shift to value-based healthcare
50% Outcome-Based Medicare payments by 2018
The Problem Market Reaction
There is massive waste in the U.S.
healthcare system
*Estimated $1 trillion in healthcare waste published by the Journal of the American Medical Association (2012), McKinsey & Company (2013), and Harvard Business Review (2015)
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The Move to Value-Based Care Creates New Market Challenges that Can be Overwhelming
Focuses on:
Quantity of services
Individual patient utilization
Focuses on:
Quality of services
Balancing length of stayand readmission reductions
Episode of care (long-term focus)
Population utilization & costs
Fee for Service Value-based Care New Market Challenges
Requires providers to:
Report on quality metrics (higher admin burden)
Connect a system of patient touchpoints
Manage care throughoutthe patient’s lifetime
Treat patients as partnersin their healthcare
Reducing the length of stay
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Aledade’s 360° Center Support Brings it All Together
YourPractice
Policy, Contracting + Governance
Analytics + Pop Health Mgmt App
Education, Training + Local Support
Technology Expertise
Interoperability + EHR Optimization
Community Partnerships
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Why PCPs…Influence 85% of spendAccount for 4% of cost
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Aledade is Building a Movement of Independent Physicians by Aligning Financial Models with Patient Outcomes
27 MSSP ACOs650,000+ Attributed Patients
25 States 6,500+ Providers
430+ Independent Practices
28 Other Value-Based Care Partnerships
90+ Electronic Health Records & Practice Management Systems
$3.6+ Billion Under Management
WA
OR
CA
NV
ID
MT
WY
CO
NMAZ
UT
SD
ND
MN
IANE
KS
TX
OK AR
MO
TN
MS
LA
FL
VAWV
KY
PA
NY
MIWI
ILIN
OH
AL GA
SC
NC
MD
DE
NJ
CT RI
MA
NH
ME
VT
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Aledade’s Experience with Community Health Centers
● In 2017, the FamilyHealth ACO in New York saved Medicare over $3.9M
● FamilyHealth is led by 3 community health centers serving 340,000 patients annually
● The ACO reduced days spent in skilled nursing facilities by 22%, psychiatric hospitalization costs by 8%, and earned a quality score of 83%
● A partner health center in New York that serves over 185,000 patients per year is now providing Medicare Annual Wellness Visits (AWVs) to 71% of their high priority patients
● This equates to $1.36M in increased revenue
● Aledade provides technology and resources to help health centers administer and optimize AWVs
● After partnering with Aledade, the West Virginia Health Center ACO’s risk score increased by 14%
● By accurately coding patients, health centers are able to receive credit from Medicare for managing their complex patient populations
● Aledade provides the tools necessary for identifying and documenting risk opportunities
SHARED SAVINGS INCREASED REVENUE RISK CODING IMPROVEMENT
Aledade partners with community health centers to provide everything you need to create and run an ACO–from practice transformation services to upfront capital and a cutting-edge technology platform.
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Aledade’s Footprint of Community Health Center Partners
● Aledade currently partners with 62 community health centers in 11 ACOs across 12 states ● 3 of these ACOs are comprised exclusively of health centers (Louisiana, West Virginia, and New York)● In 2019, Aledade plans to continue this growth nationally by expanding our partnerships with community health centers across the
US
● Aledade is committed to partnering with high quality community health centers
● In 2018, 98% of our partner health centers were recipients of HRSA Quality Improvement Awards, totaling over $5.1M
● 19 partner health centers were recognized as Health Center Quality Leaders for being in the top 30% for achieving the best overall clinical performance
● 2 received the National Quality Leaders award for exceeding national clinical quality benchmarks
PARTNERING WITH THE BESTWA
OR
CA
NV
ID
MT
WY
CO
NMAZ
UT
SD
ND
MN
IANE
KS
TX
OK AR
MO
TN
MS
LA
FL
VAWV
KY
PA
NY
MIWI
ILIN
OH
AL GA
SC
NC
MD
DE
NJ
CT RI
MA
NH
ME
VT
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The proprietary Aledade “app” tees up data and workflows that drive high-value activities
Integrated data from across the care continuum
Comprehensive patient data & actionable insights
Optimizing care delivery and improving results
90+ EHR types integratedWorklists for high priority AWV, TCM andCCM opportunities
Engaging with the right patients at the right time
Risk suggestionsLocal ADT, HIE and schedule feeds Reduce unnecessary care and costs
Specialist utilization and hospital eventsGenerate FFS, quality bonus and shared savings revenue opportunities
Payer claims data and practice-generated claims
=
Preventive services informationNational labs and pharmacy paid claims Improve staff and patient satisfaction
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Regional Savings : Mississippi and Louisiana
2017-2018:
• $20 million in MSSP and commercial shared savings across Mississippi and Louisiana
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Overview of Recent Changes to the Medicare
Shared Savings Plan (MSSP)
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Conceptual Overview of MSSP ACO
Per Provider
Average annual cost per patient (benchmark): $10,000
Average number of Medicare patients: 300
Average annual total cost of care to Medicare: $3,000,000
Savings potential from better primary care: 5%
Annual savings: $150,000
Percent of savings that go back to Medicare: 60% - 25%
Savings to ACO: $60,000 - $112,500
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• Using CMS’ data and
methodology, Low
Revenue Track 1 ACOs
performed as well as Next
Gen ACOs
• Policies that incentivize
physicians to participate in
low revenue ACOs will
save money and lives
• Low revenue ACOs serve
5x more beneficiaries than
NextGen and are easier to
launch and scale
• Payments made to
physician ACOs reflect
gains, not losses, to
Medicare and payersSource: CMS ACO 2018 Rule, Table 15, and NextGen Fact Sheet
Physician-Led ACOs Outperform All Other ACOs
210
3.15
105
219
126
1.91
112132
-138
-49-83
-107
199
-44.09
135.51
244
-200
-150
-100
-50
0
50
100
150
200
250
300
Low Revenue High Revenue NextGen Aledade
Savings vs Benchmark Additional Savings (Spillover)
ACO Payments Net Benefit/Loss to Medicare
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The Key Takeaways
● Strengthens the program by recognizing the unique value of physician-led ACOs
● Illustrates CMS’ commitment to helping more independent physicians move to value based care
● Boosts likelihood of shared savings earlier
● ACOs and motivates ACOs by introducing shared losses earlier in the program
The MSSP Final Rule is Good for Physician-Led ACOs
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Aledade’s Policy Analysis Played a Key Role in Informing the Rule
January 2016 - Annals of Family Medicine
September 2017 - The American Journal of Managed Care
March 2016 - The American Journal of Managed Care
March 2018- NEJM Catalyst
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There are Three Main Categories of Policy Changes
Glide Path to Risk
Enhanced Flexibility
Regional Benchmarking
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1)The Glide Path Defines the ACO Journey and Migration to Risk
BASIC (E)● Two-sided risk● Upside: 50%● Downside: 30%● Risk Cap: 8% of
FFS revenue
BASIC (A-B)● Upside only● Savings: 40%● Downside: 0%
ENHANCED● Two-sided risk● Upside: 75%● Downside: 40%● Risk Cap: 15%
of total cost
BASIC (C-D)● Two-sided risk● Upside: 50%● Downside: 30%● Risk Cap: 2-4%
of FFS revenue
An ACO in the Basic track will automatically progress to the next level of risk annually
BASIC (5-year agreement)
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2) Enhanced Flexibility Gives ACOs More Control and Mobility
All ACOs can:
● Choose their beneficiary attribution methodology (retrospective or prospective)
● Accelerate their path to risk as desired
ACOs in a two-sided model can:
● Choose their Minimum Savings Rate (MSR)/Minimum Loss Rate (MLR)
○ 0%
○ Symmetrical; 0.5% increment between 0.5-2.0%
○ Symmetrical; based on the number of assigned beneficiaries
● Establish a beneficiary incentive program
● Apply for Skilled Nursing Facility (SNF) 3-day waivers
● Utilize telehealth to a greater extent
By shifting decisions from CMS to the ACO, the ACO can do what is best for them
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3) Regional Benchmarking in Pathways to Success
REGIONAL BENCHMARKING
➢Against whom?• All Medicare FFS beneficiaries in counties
where the ACO has beneficiaries including those in other ACOs and in our ACO
➢Adjustments?• Risk adjustment between beneficiaries not in
the ACO and in the ACO in the benchmark years
• Weighted by the proportion of ACO beneficiaries in each county
➢Continual Improvement still required to succeed as the regional benchmark is essentially a head start
*For ACOs that already in their 2nd contract in MSSP (2014 and 2015 start ACOs) they would move straight to the 2nd contract in Pathways to Success. ACOs in their 1st
MSSP contract (2016, 2017 and 2018 start ACOs) will move to the 1st contract in Pathways to Success
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Impact of Accurate Risk Coding
on Shared Savings Programs
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Attribution
What is attribution?
• Attribution is the assignment of patients to our ACO to determine the savings we’ve achieved. It identifies the primary care provider Medicare views as most responsible for the patient’s care and outcomes.
How does it work?• Attribution is given to the primary care provider who performs the majority of
primary care services over the last 12 months. • By working to ensure that your patients receive all appropriate primary care
services from you (versus other PCPs) you’ll increase the likelihood they’re attributed to you.
• In FQHC NP/PA get attribution starting in 2019.• Annual wellness visits are a great tool to build this relationship with your
patients.
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HCC and Coding- Hierarchical Condition Category
CMS recognized the importance of HCC coding and implemented it in 2004. Demographics + Diagnosis = HCC Score
• When a patient becomes eligible for Medicare, it only knows about his/her demographics composite, which includes age, gender and eligibility status (dual/disabled).
• Why is it important? What you diagnose this year has a direct impact on the anticipated healthcare spend for the patient next year. Failure to accurately capture diagnoses leads Medicare and other payers to believe your patients are healthier than they actually are.
• A higher (and more accurate) risk score indicates a sicker patient, which creates higher expected costs and therefore a greater opportunity to capture shared savings.
Important Point: FQHC’s are historically not very good at accurate coding because with PPS it did not matter…now it does!
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Patient Risk
Why do we care about diagnostic codes?
Diagnostic codes communicate how sick a patient truly is.
How does that work?Medicare calculates how risky a patient is based on:
➢Age
➢Gender
➢Diagnoses
The result is called a patient’s risk score.
Risk Score= 1.45 x $10,000= $14,500
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Patient Risk
Based on these codes, Medicare can estimate how much your entire patient panel (attributed patients) is expected to cost.
Medicare uses this estimate to set our savings benchmark.
Expected Cost
$1 million
Actual Cost
Savings!
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Patient Risk
Medicare ONLY uses the previous year’s diagnosis codes to make these calculations.
HCC Score= 1.45 x $10,000=$14,500
INACCURATE REFLECTION OF ACUITY
HCC Score= 0.723 x $10,000= $7,230
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HCC Comparison
Missed coding opportunities reflect a healthier patient and also have a financial impact on shared savings.
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The 5 D’s of risk coding
• Diabetes⮚ Uncomplicated Diabetes over the age
of 65 is rare!
• Depression⮚ Avoid F32.9 “MDD, single episode,
unspecified”⮚ Active Depression and Depression
in Remission carry the same risk weight.
• Donuts⮚ Do not overlook obesity!⮚ Avoid E66.9 “obesity unspecified”
• Drinking and Drugs⮚ Alcohol and Substance Abuse &
Dependence are in your office every day.
⮚ Screen, Intervene, and Make sure it is Seen.
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Impact of Risk Coding on a FQHC ACO Based on Historical and Clinical Data: $43 million
Based on
EHR BMI
$3.8 million in
missed opportunities
Based on medication/
Historical diagnosis
$7 million in missed opportunities
Based on
EHR data
$3.3 Million in
missed opportunities
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Annual Wellness Visits
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What the Wellness Visit is not
• Not: an annual complete physical exam, with screening lab work.
• Not: an office visit that requires the typical documentation to support a selected E&M charges (99381-99397)
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What the Wellness Visit is
• Is: Once yearly, prevention focusedvisit that includes a health risk assessment and a preventive care plan
• Is: An important opportunity to engage with patients and focus on their long-term health outside of acute visits
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Who Should Come in for a Wellness Visit?
• All Medicare patients
• Three Types: pick the one that’s appropriate for the particular patient
• Since CMS does not require a specific diagnosis code for the AWV, you may choose any appropriate diagnosis code. You must report at least one diagnosis code. Use of Z00.00 is not required/encouraged.
• Billing: FQHC can bill for AWV or E&M (Office visit) but not both; so bill for AWV if you do it even if you also do other things. This is OK if you document properly
G0468● IPPE/Welcome to Medicare : G0402
● Initial Wellness : G0438
● Subsequent Wellness : G0439
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Annual Wellness Visits
Why should a practice conduct Annual Wellness Visits?
AWVs achieve five important objectives:
1. Good for patients, with a focus on prevention
2. Increases accuracy of Medicare’s rating of acuity of patient
panel
3. Increases attribution
4. Captures 8 of the 10 EHR- based quality measures (23 total)• Statin and A1c are captured throughout the year when due for the lab
5. Pays PPS X 1.36 per AWV
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Benefits of AWVs:
In March 2019, Aledade published an
article in the American Journal of
Managed Care (AJMC) about the
impact of AWVs on value based care.
It found:
• AWVs can provide potential savings opportunities of up to $500 for high-risk patients
• Patients with AWVs used fewer
health care services, such as the
Emergency Room, SNF, or in
patient stay, then patients who did
not have AWVs
• Patients with AWVs had better
quality measure documentation
then those who didn’t have an
AWV
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Identify and Perform
Outreach for High Priority Patients due for an AWV
Pre-Visit: Assess patient
needs and prep for
visit
Visit: Assess patient needs
Visit: Address patient needs
Post Visit: Billing &
Follow up
1 2 3 4 5
How Do I Conduct an AWV?
Scheduling/Care
Coordinator
MA, LPN, or
RN
MA, LPN, or
RN
Multiple
RolesMultiple
Roles
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Next Steps in our Partnership
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Preparing for Aledade ACO Launch
1. Our Launch process will begin in August.a. Our team will be reaching out to your CHC Leadership to arrange an
introductory call followed by an on site visit.b. We will begin the interface process with your CHC’s Electronic
Health Record early in the Launch process.
1. On Site, In Person meeting:a. Target audience is all doctors and providers, CEO, Quality
Improvement team members, Billing team members, other key office staff.
1. ACO Kick Off Meeting:a. Date/Location TBD. Will be held for all members of the ACO and in
conjunction with Aledade leadership.
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Closing Thoughts: AWVs and Accurate Risk Coding Can Drive Savings
65 % of Patients Get AWVs + Risk coding improvement = Savings
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THANK YOU
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