Understanding Payment Models in a World of Valuebased Care Under MACRA

Transcription

1 Understanding Payment Models in a World of Valuebased Care Under MACRA Mark Schafer, MD Chief Executive Officer MemorialCare Medical Foundation March 23, 2017

2 Capitation and Medicare Advantage 2

3 Agenda 1. Overview of MemorialCare Health System 2. Our Journey into Value-based Care 3. Keys to success with Capitation & Medicare Advantage 4. Questions 3

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5 A Few Facts About MemorialCare Health System Revenue $2.4 Billion Bond Rating AA- stable Hospitals Patient Discharges 69,000 MemorialCare Medical Foundation Patients 730,000 At-risk Lives 265,000 Workforce Employees 11,200 Affiliated Physicians 3,300

6 MemorialCare Hospitals

7 MemorialCare Medical Foundation 261 Employed Providers 170 PCP s 50 Specialists 41 Advanced Health Practitioners contracted Specialists Independent Practice Association 170 PCPs 900 Specialists 17 Employed Primary Care Physicians

8 Growing Outpatient Presence 360 PCPs, 2,200 Specialists >50 PCP Health Centers 12 Urgent Care Centers 10 Imaging Centers 9 Surgery Centers 13 Dialysis Centers 265,000 At-Risk Lives 148,000 HMO Lives 107,000 ACO Lives

9 Journey in Value Based Care 9

10 Capitation versus FFS Living in two worlds at the same time is challenging

11 The ACO Bandwagon0 32,900 18,000 27,000 NEXT GENERATION 20,900 8,600 11

12 400 PCP s >2000 Specialists 9 Hospitals 10 Surgery Centers 19 Imaging Centers 22 Dialysis Centers Boeing Preferred Partnership

13 Reasons for ACO Shift Commercial HMO membership is flat Protect and grow new membership (Boeing, other employers) Marketing and branding opportunity that plays to our strengths Potential financial upside Physician alignment Catalyst for transformation CA HMO Commercial Enrollment

14 HMO vs PPO Cost

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16 In California.. Capitation is 16

17 Benefits of Capitation Upfront Cash Flow Ability to invest in infrastructure and care model redesign Aligns incentives (away from volume) Facilitates physician incentives Creates risk environment 17

18 Keys to Success 18

19 6 Keys to Success with Capitation Data Analytics Robust Medical Management Infrastructure Information at the Point of Care Physician Alignment and Leadership Risk Adjustment Ambulatory Shift 19

20 Data Analytics Modeling and understanding cost trends Risk stratification Identify candidates for: Care management Chronic disease management Special clinics 20

21 Sample Cost Trend Analytics

22 Sample Risk Stratification 22

23 Sample Patient Drill Down **No PHI used not a real patient 23

24 Robust Medical Management Infrastructure Case Management & Care Coordination Special Clinics Discharge Clinics Intensive Outpatient High Risk/Diabetes Provider Contracting & Network Management Sub-capitation of specialists Education of network physicians 24

25 Information at the Point of Care Risk adjustment LYNTY Box Gaps in care Prevention Chronic diseases Identification of network specialists HMO, Boeing, Next Generation, etc 25

26 Sample LYNTY Box 26

27 Sample HCC Gaps 27

28 Physician Alignment & Leadership Network of engaged physicians specialists and PCP s Mechanism to align physicians Panels Risk Adjustment Quality Strong physician leaders Variations in care 28

29 Risk Adjustment Critical to Medicare Advantage capitation Physician Champion Educating physicians Tweaking the EMR Coders/Auditors Ensure appropriate documentation Reward risk level 29

30 Ambulatory Shift Site of service 10 Imaging Centers 9 ASC s 13 Dialysis Centers 12 Urgent Care s Avoidance of admission ED to SNF Focused partnerships (eg. Dialysis)

31 6 Keys to Success with Capitation Data Analytics Robust Medical Management Infrastructure Information at the Point of Care Physician Alignment and Leadership Risk Adjustment Ambulatory Shift 31

32 Questions? Mark Schafer, MD 32