Transcript Dell Presentation Template Standard 4:3 Layout

ACOs for Real: Does it
make sense for your
organization?
Betsy Block
Director of Accountable Care
Solution Strategies
Dave Marchand
CTO
Healthcare & Life Sciences Services
CMS timeline for reform
2010
2011
2012
2013
HIPAA 5010
PQRI
PQRI (eRx)
ARRA
2014
2015
ICD 10
Penalty for
non
submission
of PQRI
PQRS
Penalty for
non
compliance
Meaningful Use
No Matching
Payment
Reduced
Payment for
HAC
Hospital Acquired Conditions
Accountable Care Organizations
Penalties for High Rates of Readmissions
Inpatient Value Based Purchasing Program
Bundled Payment Pilot
Source: Kaiser Family Foundation Health Reform Source 11.10.2010
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Accountable Care Organizations:
What are they
Under section 3022 of the
Affordable Care Act, Medicare
providers and suppliers
participating in Accountable
Care Organizations (ACOs)
can continue to receive
traditional FFS payments and
are eligible for additional
payments based on meeting
specified quality and savings
requirements.
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What Constitutes an ACO?
Who belongs to an ACO?
An ACO consists of a collection of providers in a given geography
that can include primary care physicians, hospitals, specialists,
home care, etc.
What are they Responsible for?
100% of the healthcare and costs for a defined group of patients
What Functions do they Perform?
• Coordination of all care activities between the providers in an
ACO
• Measurement and improvement of outcomes and costs
• Financial management and distribution of cost savings across
ACO
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Early Success in Clinical Integration
• Advocate Physician Partners, Chicago
• 3400 physicians, 8 hospitals, 280,000 Capitated lives, 137
performance measures
Performance Year
Incentive Funds
Distributed
2005
$12.4 million
2006
$16.7 million
2007
$25.0 million
2008
$28.2 million
2009
$32 million*
* Estimated from 2010 Value Report, Advocate Physician Partners
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PGP Demonstration
Organizational Characteristics of PGP Participants
Region
Organizational
Structure
Number of
Physicians
Part of
Integrated Delivery
System?
Includes
AMC?
Owns or
Owned an
HMO?
Not For
Profit?
Northeast
Faculty/
Comm. Group
Practice
907

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
West
Group Practice
232

Geisinger Clinic
Northeast
Group Practice
833

Middlesex Health
System
Northeast
Network Model
293

Marshfield Clinic
Midwest
Group Practice
1,039
South
Group Practice
250
Park Nicollet Clinic
Midwest
Group Practice
St. John’s Clinic
Midwest
Participants
Dartmouth-Hitchcock
Clinic
Billings Clinic
Forsyth Medical Group
The Everett Clinic
University Of Michigan
Faculty Group Practice










648



Group Practice
522



West
Group Practice
250
Midwest
Faculty
Practice
1,291




Source: CMS; Commonwealth Fund; WSJ, “Healthcare Overhaul Increases Rewards for Efficiency,” 11/2010
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The “secret sauce” of ACOs
• Clinical Integration is a physician and
provider led effort
• Internally motivated to monitor themselves
and deliver better quality and higher value –
not something that is forced on them from
the outside
• The “secret sauce” is the empowerment of
the physicians
• Financial incentives are important but not
the only motivating factor in a successful
ACO
• Need to foster an entrepreneurial attitude
and a desire to seek out novel solutions and
accept the challenge to explore and learn
how to make this work
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CMS ACO Development Timeline
Governance
7/1/2011
• Legal organization
• Measures
• Incentives
• Participants and TINs
• Application
• Beneficiary
representative
• Senior medical
director
• Executive under
governing body
• Marketing materials
must be authorized
• PSA determination of
ACO
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Data
Infrastructure
• Claims Data
• Quality Data
• Reporting
• Population ID
• Ancillary Data
• Disease Registries
• Pt Satisfaction
(CAHPS)
• Summary of care
documents
• Beneficiary access to
med record
• Available to public
using CMS format
Profiling
Analyzing
1/1/2012
• Recruit members
• Establish connectivity
• Train on use of
reporting tools
• Benchmarks
• Pull Reports
• Verify Data
• Care management:
mechanism for care
coordination
• Risk Management: ID
high risk individuals
and develop care
plans
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Proposed CMS ACO guidelines
ACOs can choose between 2 options:
Track 1
– Shared savings for Year 1 and 2, Year 3 is shared savings and shared
losses (if any) over certain threshold
– Savings and Losses are capped
– Bonus for including a FQHC or RHC
– 50% shared savings up to 7.5% of benchmark
Track 2
–
–
–
–
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Shared savings and shared loss (if any) all 3 years
Savings and losses are capped
Bonus for including a FQHC or RHC
60% shared savings up to 10% of benchmark
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CMS Math: Estimates per ACO, based on
100 ACOs
Year 1
Year 2
Year 3
Bonus
Payout
$8,000,000
Cost
$1,755,251
Bonus left
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$1,265,897
$1,265,897
$4,287,075
$3,712,925
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Total 3 years
Source: CMS -1345-P Proposed Rule Medicare Shared Savings Program: Accountable Care 3. 31.2011 p.350
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Infrastructure Cost Estimates For ACO Prototype
(ACO includes 200 beds, 80 PCPS, 150 SPC)*
Categories of Costs
Start Up
Network Development and Management
Care Coordination, Quality Improvement and Utilization
Management
$2,275,000
$2,900,000
$405,000
$1,515,000
Clinical Information Systems
$2,350,000
$1,500,000
$285,000
$385,000
$5,315,000
$6,300,000
Data Analytics
Total
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Ongoing
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* White Paper - THE WORK AHEAD: Activities and Costs to Develop an Accountable Care Organization, AHA
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Do we really need to do this?
As a small community hospital,
you may wonder if you have to
form an ACO or CI program
There are a number of reasons
you should:
– Commercial payers moving
to ACO model too
– Competition for community
primary care physicians is on
the rise
– Integrated delivery networks
are forming
– Clinical integration
principles are very
successful in smaller
hospitals
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Technology
Infrastructure
needed by ACOs
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Healthcare
Healthcare Information Landscape is rapidly
changing
ARRA/HITECH
HC REFORM
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7/7/2015
ICD-10/5010
CONSOLIDATION
CONSUMERISM
Healthcare
More Information is becoming DIGITAL
Diet &
Exercise
Medical
Images
Medications
Genomics
Results
Proteomics
Histories &
Encounters
Digital
Pathology
Procedures
Smart Medical Devices
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Healthcare
Data must be Shared, Aggregated, and
Analyzed
Health Information needs
to be EXCHANGED within
Communities
Physicians
Hospitals
Health Plans
Long
Term
Care
Public
Health
Agencies
Standardized Analytics &
Informatics solutions drive
improvements in QUALITY &
EFFICIENCY
Consumers
Pharmacies
Laboratories
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Other Medical
Intermediaries
Healthcare
Care
Coordination /
Transitions
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3
3
10
Care
Coordination /
Information
Systems
At Risk Populations
Heart Failure
At Risk Populations
COPD
At Risk Populations
Frail Elderly
At Risk Populations
Diabetes
At Risk Populations
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Preventative
Health
Care
Coordination
2
Patient Safety
5
Patient / Care
Giver
Experience
4
8
2
7
7
Proposed Initial Quality Measures by
Domain
Coronary Artery
Disease
At Risk Populations
Hypertension
Healthcare
Data + Analytics will drive Quality and
Efficiency
Individual/Patient
• Care Gap Management
• Preventative Health
• Outreach/Education
Community
• Identified Data Analysis
• Care Coordination
• Financial Analysis
Population
• Disease Management
• Care Improvement
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Healthcare
Where does the Data come From?
Manual or Automated
Quality
Measures
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EMR/PM/HIS
HIE
7/7/2015
• Targets for quality and care
management standards
• Medical records
• Clinical outcomes
• Patient billing/Charge Master
• Labs, Rx
• Encounters
• Histories
Payers
• Historical patient data
• “outside” treatment information
• Reimbursement rules
Other
• Surveillance data
• Adverse drug events
• Genomics/Imaging
Healthcare
Dell’s Health Strategy – “In the Cloud”
Simplifies use with interoperability that creates a true “healthcare system”
Hospitals
Physicians
Payers
Other
Life Science
Healthcare Cloud Platform
Data Management
Mobility
Interoperability
Security
Healthcare Solutions
Analytics
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Image
Archiving
Electronic
Medical
Records
Revenue
Cycle
Services
Payers
Solutions
Reporting
& Alerting
Portals
Healthcare
Patient Outreach Future Possibilities
Medication Reminder Example
d JaneDoh Reminder to take 2 -100mg SOMA tablets
(sent at 8pm local time)
Alerting Example
Generic Alert
#AllergyAlert #HighPollenCount Plano, TX 5-12-2011
Patient Specific Alerts
Pollen or
Pollution
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d JaneDoh #HighPollenCount 5/12/11
Patient List
d JohnDoh #HighPollenCount 5/12/11
take <med_name>
wear mask outside
Healthcare
Wrap Up
• Whether the current rules for an ACO survive as is or are modified,
the concept of clinical integration and shared cost savings will
survive
• The infrastructure needed for an ACO consisting of separate
provider entities in a community is the same infrastructure needed
for a single provider entity, such as a health system, to improve
quality and efficiency
• The key to improving quality and efficiency is consistent ways to
gather the data, compare the results, and look for patterns of
improvement
• A cloud based infrastructure enables a standard set of
interoperability and analytics tools to be utilized across ACO’s
resulting in further efficiencies and sharing of best practices and
innovation
• Change is Inevitable
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Healthcare
Thank You
Betsy Block
(317) 225-6244
[email protected]
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Dave Marchand
(972) 577-5595
[email protected]