Transcript PowerPoint - Modern Health Care Organizations

How Payment Reforms Can Help Achieve a
High Performance Health System
Karen Davis
President
The Commonwealth Fund
www.commonwealthfund.org
[email protected]
Second National ACO Congress
November 1, 2011
LHCO 215
Dec. 01, 2011
Robert Kaplan
Payment and Delivery System Reforms that
Contribute to High Performance Health System
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Accountable care organizations (ACOs)
Medical homes
Value-based purchasing
Enhanced care coordination/chronic disease management; bundled
payment
Health information technology; Beacon communities
Combination strategy in innovator communities
Timeline for Payment and System Innovation
2010
2011
2012
Productivity
Improvement
10% Medicare Primary Care
Increase
Medicare Shared
Savings (ACOs)
Patient Centered
Outcomes Research
Innovation Center
CMMI)
Pioneer ACOs
All-Payer Demos and Health
Innovation Zones
Bundled Payment for
Care Improvement
Initiative
Value-based Purchasing
for Hospitals
2013
National Medicare Payment
Bundling Pilot
Medicaid Primary Care up
to Medicare Levels
Timeline for Payment and System Innovation-Cont.
2014
Independent Payment
Advisory Board (IPAB)
2015
Value-based Purchasing for
Physicians
Reduce Payment for Hospital
Acquired Infections
Accountable Care Organizations
Key Elements of Success for
Accountable Care Organizations
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Strong Primary Care Foundation
Accountability for Quality of Care, Patient Care Experiences,
Population Outcomes, and Total Costs
Informed and Engaged Patients
Multi-Payer Alignment
Calculation of Shared Savings and Payment of ACOs
Innovative Payment Methods and Organizational Models
Balanced Physician Compensation Incentives
Timely Monitoring and Support
Criteria for Entry and Continued Participation
Mission
Recent ACO Development
Medicare Shared
Savings Program in
ACA
Pioneer ACO Model
through CMMI
Physician Group
Practice Transition
Demonstration
Shared Savings Payments
2-3.9 percent minimum
savings threshold
1 percent minimum savings
threshold
Minimum savings threshold
calculated using a sliding
scale based on the number
of assigned beneficiaries
Patient Assignement
Retrospective; 5,000 patient minimum
Retrospective or
prospective; 15,000 patient minimum
except in rural areas
Retrospective based on
services by PCPs; 8,383 to 44,609
patients in original PGP demo base year
Limited to primary care
physicians; FQHCs and
CAHs must partner with
eligible providers
Primary care physicians,
non-physician clinicians,
certain specialists all eligible;
FQHCs and CAHs eligible
10 large, multi-specialty
groups that participated in
previous 5-year Physician
Group Practice demo
Three periods: CY2012,
2013, 2014
Three periods: CY2012,
2013, 2014
CY2011, 2012
Governing Board
75 percent of the board must be
representatives of
participating provider groups
More lenient
More lenient
Multi-Payer Alignment
More lenient
Provider Participation
Contract Period
50 percent of ACO revenue
must come from outcomes-based
contracts, including
contracts with private payers
Source: M. Zezza, The Pioneer Accountable Care Organization Model: An Alternative to the Medicare Shared Savings
Program, (New York: The Commonwealth Fund, forthcoming 2011).
More lenient
Brookings-Dartmouth ACO Pilot Site Program:
HealthCare Partners
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Large medical group and independent practice association (IPA) in Los Angeles, CA
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Developing an ACO with Anthem to provide care coordination for 50,000
Anthem preferred provider organization (PPO) members
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ACO is physician-owned and governed, and will include 1,000 primary care physicians
and 1,700 specialists
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Success factors
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Stable leadership
Consistent emphasis on prevention and health promotion
Integrated health information technology (HIT) infrastructure
Use of effective care coordination and care management
Extensive experience taking on full risk capitation
Solid payer-provider relationship (including active involvement in a joint implementation
committee)
Brookings-Dartmouth ACO Pilot Site:
Monarch HealthCare
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Large independent practice association (IPA) located in the Southern, Northern, and
Coastal regions of Orange County, California
Developing an ACO with Anthem to provide care coordination and care navigation
support for 25,000 Anthem PPO members in Orange County
ACO is physician-owned and governed, and will include approximately 500 of its 850
primary care physicians
Success factors
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Strong executive leadership
Trust and transparency in partnerships
Extensive experience taking on full risk capitation
Solid payer-provider relationship (including active involvement in a joint implementation
committee)
Mercy Health System Improving Coordination Of
Care For Medicaid Beneficiaries
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Improved care coordination by
placing care managers in provider
settings affiliated with Mercy Health
System
Cost savings of $37.70 PMPM for the
patient population that received
improved care coordination
Rate of hospital admissions per 1,000
members per year was reduced 17
percent among treatment group;
length-of-stay dropped 37 percent
Hospital Admission Rate Per 1,000 Members Per Year, Before And
After Coordinated Care Management, 2008 And 2009
Mount Auburn Cambridge Independent Practice
Association
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Boston-area independent practice association (IPA) forged relationships among
physicians and a hospital to share in savings generated by improved quality and lower
costs
High-risk case management program for patients at Mount Auburn Hospital and in the
community, discharge planning, pharmacy management, referral management,
utilization review, and related information services including performance reporting to
physicians on utilization and quality improvement
Participating physicians encouraged to adopt a common electronic health record (EHR)
system that interconnects with the hospital's clinical information system to share
laboratory and radiology results
Physicians in the IPA have achieved notable results on 12 of 23 measures of ambulatory
care quality on which they were rated by the Massachusetts Health Quality Partners
(MHQP)
Exceed both state and national benchmarks for the care of diabetic adults, preventive
care for children and adults, and appropriate use of imaging tests for lower back pain.
GRACE’ Model Leads To Better Care
For Dual Eligibles
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Geriatric Resources for Assessment and
Care of Elders (GRACE) is an integrated
care model targeting low-income seniors,
many dually eligible and most with multiple
chronic conditions
Utilizes in-home assessments by a team
consisting of a nurse practitioner and a
social worker to develop an individualized
plan of care
High-risk patients enrolled in GRACE had
fewer visits to emergency departments,
hospitalizations, and readmissions and
reduced hospital costs compared to control
group
Two-year GRACE intervention saved
$1,500 per enrolled high-risk patient by the
second year
Average Total Health Care Costs Among GRACE Intervention And
Usual Care (Comparison) Patients In High-Risk Group, Years 1–3
INTERACT Collaborative Quality
Improvement Project
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Interventions to Reduce Acute
Care
Transfers (INTERACT) II helps
nursing home staff identify,
assess, communicate, and
document changes in residents'
status
Three strategies:
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identifying, assessing, and managing
conditions to prevent them from
becoming severe enough to require
hospitalization;
managing selected conditions, such
as respiratory and urinary tract
infections, in the nursing home itself;
and,
improving advance care planning
and developing palliative care plans
as an alternative to acute
hospitalization for residents at the
end of life
INTERACT II Shows Potential to Reduce
Hospital Admissions
Hospitalizations per 1,000 resident days
What’s Next?
Implementation and
the Path Ahead
Strategic Implementation of Reforms
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Payment models are complimentary 
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Leveraging other payment initiatives (medical home, meaningful use, P4P
payments, etc) can help finance start- up costs and maximize returns on
clinical transformation efforts
Need to experiment with different approaches
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ACOs – Accountability of all services for an entire population, which helps ensure no cost-shifting and overall policy goals
of better health and lower total costs are being met
Bundled Payments – Accountability for select services and conditions, which helps ensure important gaps in care are
addressed and specialists are included in efforts to better coordinate care
Not sure what works best
Vary with local market characteristics and provider experience with care management
Early evidence shows that most successful innovators are those with multiple
initiatives
Culture Change
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Early and critical step for accepting accountability
Requires evolution in relationship between providers, payers and patients
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Providers and payers must move beyond adversarial negotiations around payment rates toward collaborations for more
efficient care. Not only about payment reform, but also data analytics and benefit redesign to support higher-value care.
Providers and other providers need to become better at working with each other to coordinate care – includes engaging
in best practice sessions, sharing expert opinions and synthesizing patient-centered outcomes research to develop practicechanging innovations.
Providers and patients also need to work better together.
Requires time to equip patients, and their care support team,
with the information needed to feel confident about making efficient and effective health care decisions.
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ACO movement is a great signal that the cultural change is happening
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Will not be easy, there will be failures as well as success
Need strong commitment and vision
A New Era in Health Care Delivery:
How Payers and Providers Can Help
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The U.S. has passed historic legislation that will help usher in a new era in American
health care
Will make major strides toward achievement of goals of affordable coverage for all while
slowing cost growth
However, realizing the potential is not assured
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Oversight and system of tracking health system performance will be needed
Effective implementation is a big hurdle
Stakeholders need to work together toward success of reform
Learning rapidly as innovation is tested and experience is gained and applying that knowledge to spread
successful innovation are essential
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Providers and payers to come together and help make it work
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Active participation in innovative payment pilots
ACOs: California Style
ACO Congress
John E. Jenrette, M.D.
Chief Executive Officer
Sharp Community Medical Group
November 2, 2011
Accountable Care Organizations (ACO)
Working Definition
A provider led organization
whose mission is to manage the full
continuum of care and be accountable for the overall costs and
quality of care and be accountable for the overall costs and
quality of care for a defined population
Goals Of Accountable Care Organizations
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Reduce, or at least, control the growth of health care costs
Maintain or improve health of a population
Improve in both clinical quality and patient experience and
satisfaction
Opportunities for Improvement
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Improved prevention and early diagnosis
Reductions in unnecessary testing, procedures, and referrals
Reductions in preventable Emergency Department visits and hospitalizations
Reductions in infections and adverse events in the hospital
Reductions in preventable readmissions
Use of lower cost treatments, settings, and providers
CMG Care Transformation Model
Clinical and Operational Systems
Accountable Care Organization
Medical Group
& Enterprise Level Activities
Advanced Primary Care Under
Patient-Centered Medical Home
Patient & Family
SMG Care Transformation Model Clinical Systems
Accountable Care organization
Skilled Nursing Facilities
Ancillary Services
-Free-Standing ASC &
Diagnostic Testing Centers
Home Care
-Home Safety
-Post Discharge
visits
-Home Health
Hospice
-Home
Palliative Care
Hospitals
-SNFists
-On-site Case Management
-Efficiency Rating Systems
“Preferred Facilities”
-Service Line Integration
-Medical Staff Alignment
-Incentives for Efficiency
-Quality (SCIP, Leap Frog)
-Safety
Medical Group
-Outcomes & Evidence
Based Medicine
& Enterprise Level Activities
-Call Coverage
-PCP/SCP Incentives
-ER Avoidance Programs
Pay for Performance
-Urgent Care
DME
Hospitalist, Post
-End of Life (Palliative Care)
-Integration &
Discharge follow-up
-Transition of Care
Oversight by Care
-Coordination of
Management
Behavioral & Mental
Health Services
-Care management
(Acute, Chronic,
Inpatient, SNF)
-Health Coaching
Advanced Primary Care
(Shared Decision
Under patient-Centered Medical Home
Making)
-Cost Effective Medical Mgmt &
-Prevention & Wellness
Utilization of Services (SCP,
-Point of Care Analytics
Ancillary)
& Clinical Decision
-Access, Same Day
Support
Appointments, e-Visits
-Gaps in Care
-Patient Satisfaction & Loyalty
-Population Mgmt &
-Provider & Office Staff
chronic Care Prescribing
Patient & Family Satisfaction
Program
-Personal Health Record
-Patient Portal
-Health Risk Assessment
-Patient Engagement &
Activation
SMG Care Transformation Model
Operational Systems and Structure
Accountable Care organization
-Contracting (Evaluate
Ancillary Services; SNFs,
Home Care
-Facility Evaluation (ASCs)
-”Sales” &
Marketing
-Strategic Planning
-Medical Group-Hospital
“Systemness” & Network
Development
-Governance & Legal Structure
-Financial Incentives & Alignment
(Shared Savings, Bundled payments,
Partial Cap, Full Cap)
-Measurements Sets &
Targets
Medical Group
Health Plan role for
& Enterprise Level Activities
Incentives, Payment
Models and Data
-Clinical Support Infrastructure of Care Mgmnt Teams & Programs
Exchange
-IT Infrastructure (HER, Care Mgmnt Platform Analytics
. Clinical Decision support, E-Prescribing, Predictive Modeling
tools)
-Financial
Incentives
-Measurement Sets
& Operational Tools
Advanced Primary Care
-Network Development
-Contracts (PCP/SCP)
-Participation Criteria,
Report Cards,
Monitoring &
Under patient-Centered Medical Home
Corrective
-Point of Care analytics
Action Plans
-Work flow Redesign &
-Job Descriptions for
-Health Care
Process Changes
Additional Staffing
Team
-Education of Staff,
-Adequate
primary Are Base
Education
PCPs, Team
-Financial Modeling
-Measurement Sets,
Dashboards
Patient & Family
-Value Based Benefit Design
-Benefit and Product to Steer
Patients
-Enrollment in Model
(Attribution)
-Communication Strategy
Pioneer ACO
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3 year agreement, can be extended 2 more
15,000 Medicare FFS beneficiaries
Must demonstrate ability to take risk “hit the ground running”
30 pilots
June 28 – Letter of Intent
August 19 – Application
September 19 – Interview at HHS
Health Information Technology
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Coordination of Care
Reminders/outreach
Team/care plan coordination /
transitions of care
Referral management
Diagnostic results management
Shared decision support
Access
Secure messaging
Care teams
Remote monitoring
PHR/EHR access
Patient engagement tools
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Payment Reform
Efficiency measurements
Pay for performance and quality
Gain sharing contribution tracking
Risk and acuity measurement
Predictive modeling
Comparative effectiveness analytics
Using Individualized Guidelines to Op4mize Cost
and Quality for
Accountable Care Organiza4ons
David Eddy, MD PhD
Founder and Chief Medical Officer Emeritus Archimedes
Keys to success for ACOs
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ACOs need to optimize health outcomes while keeping costs within a defined budget
A significant portion of the savings must come from reducing preventable
hospitalizations
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Preventable hospitalizations are responsible for one out of every 10 health care dollars spent
Preventing these hospitalizations will require:
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Physicians identifying and delivering the right preventive treatments for the right patents
Activating patents to take the suggested treatments, based on their preferences
The current situation
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Physicians decisions determine how the vast majority of healthcare dollars are spent
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Which people get which tests and treatments
These decisions are determined largely by population-‐based guidelines
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Example: JNC 7 guideline for hypertension
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“Treat if SBP > 140”
“If have diabetes or renal failure, treat if SBP > 130”
To improve the efficiency of healthcare we need to improve guidelines
Fortunately, this is possible
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There are inherent limitations in how guidelines are currently designed and applied
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Focus on one variable at a time (e.g., BP)
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Use sharp thresholds (e.g., SBP > 140)
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Ignore the continuous nature of risk factors
Are qualitative, not quantitative
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Understate the importance of other risk factors
Assume all guidelines are equally important
No information to aid MD-patent decision making
It is possible to do better
It is possible to do better
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“Individualized Guidelines”
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Take into account all the important information about a patent
Consider all the risk factors simultaneously
Take into account the continuous nature of risk factors
Consider all potential treatments simultaneously
One-‐by-‐one and in all combinations
Develop a prioritized list, in order of expected Benefit
Can identify thresholds to achieve desired objectives for quality and cost
Present information on actual risks and benefits to each patient
Individualized guidelines can improve quality
and lower costs
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Example: JNC-‐7 guideline for blood pressure
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Use ARIC population
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Treaperson’s BP > 140/90
If they have t if a diabetes or chronic kidney disease, < 130/80
“Atherosclerotc Risk In Communities”
12,000+ people age 45-‐65 at start of observation
Followed for 12+ years
2710 eligible for new hypertension treatment at start
Recorded MIs, strokes and other outcomes
Can use observed MIs and strokes to determine benefit of different management strategies for
hypertension
Superiority of Individualized
guidelines
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Absolute magnitudes of events prevented and costs saved depend on many factors
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Risk of CVD in population
Electiveness of BP treatments
Cost of hypertension medications, visits, tests
Cost of treating MI’s strokes
But relative superiority of Individualized guidelines is not sensitive to these
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Approximately 45% greater benefit at same cost
Approximately 65% greater savings at same benefit
Requirements for using individualized
guidelines
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Electronic access to person-‐specific data
 Basic data every physician already uses
Risk/benefit calculator
 Spans all the important risk factors, treatments, and outcomes
 Accurately calculates risks, and effects of treatments
Incentive to both increase quality and control costs
Accountable Care Organizations are ideally positioned to implement individualized
guidelines
Four ways ACOs can use Individualized guidelines
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Identify individuals who will benefit considerably from treatment but are currently
missed
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Identified by traditional guidelines, but currently untreated
Give physicians and patents quantitative information about risks of adverse events and
benefits of treatments
Identify priorities for outreach programs
Calculate incentives for physicians and patents
Bottom line for users
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Improved health outcomes
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For every 1 million members, an estimated 1400 heart attacks and strokes would be averted annually
Reduced costs
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An estimated $98 million saved annually
Summary and conclusions
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Traditional guidelines have served us well
 Evidence-‐based
 Easy to remember, use, explain, and apply
 Appropriate for the technology of the time
 Guidelines were new, records were all on paper
But they have limitations
Now possible to move to next generation
 Better data, information systems, validated mathematical models
ACOs can use individualized guidelines to help improve outcomes and reduce costs
Disclosure
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Archimedes is a healthcare modeling company based in San Francisco
Archimedes is a subsidiary of Kaiser Permanente
I will describe
 An application developed by Archimedes (IndiGO)
 An implementation of IndiGO by Kaiser Permanente
 An evaluation by KP Care Management Institute
The application is available to any health system, health plan, or medical group