Accountable Care and ACOs. Len Fromer, M.D., FAAFP

Transcription

1 Accountable Care and ACOs Len Fromer, M.D., FAAFP

2 It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change. Charles Darwin

3 The Reality: The healthcare world is changing in ways that many of us have never seen in our lifetime, with the possible exception of Medicare.

4 Drivers of Accountable Care Providers, not insurers, who are best placed to make the changes Cost and quality problems resulting from the U.S. s current system of fragmented care Variation in practice patterns Volume based payment systems Current lack of Integration Policymakers understand that the resources that flow from the decisions physicians make with patients account for a major portion of overall health care costs regardless of where that care takes place

5 Principles of Accountable Care An ACO is a local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that can be held accountable for the cost and quality of care delivered to a defined population The goal of the ACO is to deliver coordinated and efficient care. ACOs that achieve quality and cost targets will receive some sort of financial bonus Care for patients across the continuum of care, in different institutional settings Support comprehensive, valid and reliable measurement of its performance

6 Clinical Performance Measurement is Fundamental Clinical performance measures are derived from evidencebased practice guidelines They can be used for quality improvement, public reporting, accountability or pay for performance. Reporting allows for group, regional and national comparison data In most cases, optimal performance is not known because we have not been measuring 6

7 Measuring and Improving Quality Map processes to eliminate waste and remove delays. Identify a set of balanced measures. Build performance measurement into your processes. Choose the appropriate statistics to plot. Use sampling when needed to conserve resources. Plot data in time order every month. Develop excellent visual displays. Monitor measurement results. Use small scale, rapid PDSA cycles to continuously improve.

8 Example: Dashboard

9 Conclusion: You Can t Manage what You Can t Measure Measurement is the foundation for improvement Make measurement and data collection as efficient as possible Monitor results using a dashboard that all can see Report results and look for best practices

10 What If?????? The healthcare provider had updated information on recent patient/provider encounters The healthcare provider had the most recent (even hours old) imaging studies The healthcare provider had the most recent lab data The healthcare provider actually had accurate medication lists The healthcare provider knew who was responsible for coordinating the patient s care The healthcare provider could manage and coordinate a patient s care without face to face contact Technology was utilized to capacity The healthcare provider actually knew which specialists were most effective and efficient

11 The Medical Village

12 Principles of The Patient Centered Medical Home Personal Physician trained to provide continuous, comprehensive care Physician Directed Medical Practice Whole Person Orientation Coordinated Care Quality and Safety Enhanced Access to Care Payment appropriately recognizes added value provided to the overall system

13 A Medical Home for All

14 Great Outcomes Quality Built In Patient Service Practice Management Health IT Primary Care

15 Great Outcomes Patients Office Staff Physicians Community Culture of Improvement Performance Measurement Reliable Systems Quality Built In Patient Service Convenient Access Personalized Care Care Coordination Financial Personnel Clinical Systems Practice Management Health IT Process Automation (EHR) Communication Connectivity EBM Support Clinical Information Systems Primary Care Continuous Healing Relationship Whole Person Orientation Family and Community Context Comprehensive Care

16 Principles of The Patient Centered Medical Home/Accountable Care/Clinical Integration Personal Physician trained to provide continuous, comprehensive care Physician Directed Medical Practice Whole Person Orientation Coordinated Care Quality and Safety Enhanced Access to Care Payment appropriately recognizes added value provided to the overall system Better patient care for the best price

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22 Today Today Pilots Today 2013 Pilots* 2012 Pilots* Source: The Advisory Board, 2010 *Medicare Pilots waiver of anti-trust & anti-kickback

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24 Payment Methodologies Enhanced fee for service Care management fees Capitated, no risk models Shared savings Targeted incentives for quality and efficiency Global or bundled payments Accountable care organizations HIT stimulus incentives

25 Shared Savings/ACO Model Downward pressure on hospital days and ER visits Concept is to share savings from reduced hospital days and other costs with referring physicians Opportunity for hospital at home concept Component of CMS pilot and some Medicare advantage projects and potentially Medicaid Managed Care

26 Global/Bundled Payments Hospitals might control total revenue from admission based on diagnosis based on Diagnosis DRG to include physician component Reimbursement for hospital admission may include 3 days before admission and 30 days after Focus on networks and systems by the government Hospital Systems are becoming active in PCMH discussions

27 Practice Payment Methods Enhanced FFS (Fee for Service) Enhanced FFS +P4P (outcomes based) Enhanced FFS + Care Management Fee (CMF) Enhanced FFS + CMF + incentives (outcomes = quality and efficiency (cost savings) and PCMH recognition) CMF (care management fee)+ incentives CMF + incentives + grants CMF + incentives + shared savings Capitation, no risk + incentives Capitation, no risk with FFS carve outs for procedures and incentives

28 Let s Make It Real for You: Prevention and Wellness Chronic Diseases Population Management Care Teams Your Patients The Patient Pathway

29 Community Resources & Policies Chronic Care Model (CCM) Clinical Information Systems Health System Health Care Organization Decision Support Delivery System Design Self- Management Support Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Slide from E. Wagner Improved Outcomes

30 The Patient Pathway Model Office calls/ s with appointment reminder & instructions to get labs done before visit Group Medical Appointments Group Medical Appointments - Treatment Plan - Treatment Plan Terese: Terese: Diagnosed Diagnosed with with Type Type II II Diabetes Diabetes Diabetes Diabetes Coordinator Coordinator Terese: Terese: 6 6 Months Months After After Diagnosis Diagnosis Diabetes Diabetes Coordinator Coordinator Terese: Terese: 1 1 Year Year After After Diagnosis Diagnosis Diabetes Diabetes Coordinator-Led Coordinator-Led Education Education Diabetes Diabetes Coordinator Coordinator Patient Profile Dashboard Glycemic Control: A1C: 8.4% FPG: ~210mg/dL Blood pressure: 142/90 mmhg Lipids: LDL-C: 98 mg/dl; HDL-C: 37 mg/dl; TG: 151 mg/dl Treatment Physician initiated metformin 500 mg once/day Planned titrations to 500 mg twice per day over ~2 weeks Taking ACE inhibitor/thiazide diuretic at therapeutic doses for blood pressure Taking statin at therapeutic doses Diabetes Self Management Education (eg, physical activity and nutrition) Physician discusses how insulin may be introduced as a treatment option for long-term disease management EMR EMR Review Review treatment treatment plan plan and and determine determine health health literacy: literacy: +Allow +Allow patients patients to to voice voice concerns concerns uninterrup uninterrup ted ted Patient Patient selfselfmanagemen managemen t t Patient Profile Dashboard Glycemic control: A1C: 8.1%, FPG: 195 mg/dl Blood pressure: 136/86 mmhg Lipids: LDL-C: 90 mg/dl; HDL-C: 48 mg/dl; TG: 150 mg/dl Treatment Metformin dose titrated to 1000 mg bid Sulfonylurea added No change in ACE inhibitor/thiazide diuretic and statin dose Next follow-up with physician is scheduled for 3 months later Physician discusses the potential need for a second therapeutic agent and will assess patient s status at next visit EMR EMR Determine Determine patient health patient health literacy literacy Patient self Patient self management management +Does patient +Does patient pay attention pay attention to symptoms to symptoms and problems? and problems? Assess Assess medication medication adherence adherence +Brown bag +Brown bag medication medication review: Patient review: Patient brings ALL brings ALL medications in medications in (even (even supplements/ supplements/ vitamins) and vitamins) and TELLS YOU TELLS YOU how they how they take them take them +Reminder +Reminder checklists checklists Mail/ support reminders with culturally appropriate nutrition guidance & simple physical activities Terese missed last followup appointment: Teach Forward approach to reduce fear of bad news Why appointments are missed: Emotional: eg, fear of insulin Perceived disrespect: Consider flexible office hours Don t understand scheduling system: Reduce wait time Patient Profile Dashboard Glycemic control: A1C: 8.0%, FPG: 190 mg/dl Blood pressure: 132/82 mmhg Lipids: LDL-C: 85 mg/dl; HDL-C: 52 mg/dl; TG: 148 mg/dl Treatment Long-acting basal insulin at 2 units/every 3 days Metformin dose continued at 1000 mg twice daily Sulfonylurea continued DIGMA DIGMA Group Group Education Education -Insulin -Insulin education education class class - -Titration Titration education education --Foot --Foot & & eye eye exam exam EMR EMR Determine Determine patient patient health health literacy literacy Patient self Patient self manageme manageme nt nt +Blood +Blood sugar sugar testing testing and what and what to do with to do with results results Assess Assess medication medication adherence adherence +Proper +Proper insulin insulin usage usage and and storage storage Mail/ support reminders with group education networking/ support

31 Patient Care Pathway Creates a Map of the Patient Experience through the Healthcare System Coordinated care team Patient empowerment Health literacy Patient population management Electronic medical records

32 The Patient Dashboard: A Means to Assess, Monitor, and Modify Test Patient Dashboard Height 5 6" Weight BMI Average of 3 office BP measurements Treatment 160 lbs Initial Visit Data 25.8 kg/m 2 (overweight) 140/89 mm Hg HTN management: ACE inhibitor (ramipril 10 mg qd); (second medication of choice) Diabetes management: metformin 850 mg bid Test Height 5 6" Weight BMI Fasting blood glucose Average of 3 office BP measurements Treatment Patient Dashboard 155 lbs 6-Week Visit Data 25.0 kg/m 2 (slightly overweight) 110 mg/dl 127/78 mm Hg No change to meds Continue nonpharmacologic interventions Focus on lifestyle changes to control blood glucose The information presented in this case is a hypothetical example and not based on an actual patient

33 The Patient Pathway Highlights HIT/EHRs Input findings from the patient assessment Include diagnosis at current visit: uncontrolled blood pressure despite ACE inhibitor therapy Additional information Patient portal referral and explanation Nonpharmacologic measures Adherence assessment Self management tools and tips Input change in treatment Add 2 nd BP medication to ACE inhibitor Reminder: /call patient in 2 to 3 days to assess tolerability Patient Reminders Measure and record blood pressure weekly Office visits Blood work Other Referrals Nonpharmacologic measures Group visit The information presented in this case is a hypothetical example and not based on an actual patient

34 The Patient Pathway Highlights Team Based Care Models: Every Member Plays A Part Shared Responsibilities to Reach a Common Goal Patient Registry Motivational interview Checked medication adherence Updated EMR Distributed educational tools Lifestyle SMBG (diet/exerci se) Outreach to patient after appointment MD date date Nurse/NP/P A date date date date Office Staff date date date date Pharmacy CDE date date date date Sample Task List

35 Evolution of Expectations for Physicians Clinical Integration Team based care Focus on the top of license/training & interest Improved communication Improved data flow & access Right patient at the right time Patient centered aligned incentives outcomes, quality, cost External accountability outcomes, quality, cost

36 The result of the goals of higher quality, better coordinated, more efficient care via PCMH

37 The Value of Primary Care and PCMH One year data from payer pilots has demonstrated that individual practices can provide the equivalent of higher quality at lower cost as published data from large integrated systems

38 The Bottom Line: Value Quality / Cost Maximize the numerator Decrease the denominator

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