Physician-led ACOs: Opportunities & Challenges

Transcription

1 Physician-led ACOs: Opportunities & Challenges Farzad Mostashari, MD Founder/CEO, Aledade Inc, former National Coordinator for Health Information Technology May 13, 2015 Physician Webinar Series #16

2 Welcome to the Physician Community Webinar Series Sponsored by the HIMSS Physician Community A complimentary virtual event that will be held monthly. Covers a wide range of topics on Medical Informatics, HIEs (Health Information Exchange), Standards and Interoperability, emeasures and Quality Initiatives, and how it affects, impacts and involves physicians. For more information see or contact Lauren Kaderabek at lkaderabek@himss.org.

3 Welcome to the Physician Community Webinar Series Sponsored by the HIMSS Physician Committee Please insert all questions in the chat box located on the bottom right of your screen. A copy of the recording, slideset, CAHIMS and CPHIMS forms will be available for download within 24 hours on the Physician Community Webinar Series Archive Page

4 Moderator and Speaker Moderator: Patricia L. Hale, MD, PhD Associate Medical Director for Informatics Albany Medical Center HIMSS Board of Directors Member Speaker: Farzad Mostashari, MD Founder/CEO, Aledade Inc, former National Coordinator for Health Information Technology

5 Speaker Bio: Farzad Mostashari, MD Dr. Farzad Mostashari is the CEO and Founder of Aledade, a company dedicated to partnering with independent primary care physicians to form Accountable Care Organizations. He is the former National Coordinator for Health IT at the Department of Health and Human Services. He founded the NYC Primary Care Information Project, which equipped 1,500 physicians with electronic health records to improve population health, and has been a visiting fellow of the Engelberg Center for Health Care Reform at the Brookings Institution.

6 Learning Objectives What is an Accountable Care Organization? Medicare Shared Savings Programs Succeeding as an ACO How to Choose an ACO?

7 Fee for Service Health Care: The Wrong Incentives Fee for Service Health Care has created a system where doctors are Fee rewarded for for ordering more Service test, referrals, and Health procedures Care health care has volume. created a system But the where system does not reward doctors providers are for keeping patients rewarded healthy and for creating value. ordering more test, referrals, and The result...

8 Accountable Care: Lasting Health Care Reform Accountable Care Organizations (ACOs) are groups of providers who assume responsibility for the quality and cost efficiency of the health care for a designated patient population

9 ACOs Are Growing Rapidly As of 2015, 420+ ACOs have been established across the country, representing 7.8 million Medicare beneficiaries In 2014, Medicare distributed over $300 million to 53 ACOs

10 Types of Accountable Care Organizations All cost reductions go to payers; no financial incentive for providers to deliver high-quality care at lower cost ACO: Shared Savings Payers set quality targets and baseline costs per patient; ACO receives reimbursement if quality targets are met and costs come below baseline

11 Avoiding Hospital Admission: Current FFS System Primary Care Provider Implements a Flu Shot Drive Increasing Adherence by 300 Patients 3 Patients Avoid Hospital Admission Due to Pneumonia Total Savings for Medicare: $27,144

12 Avoiding Hospital Admission: Current FFS System Provider Financial Results from Flu Shot Drive Total Savings for Medicare: Drive Cost: $1,500 Flu Shot Profit: $567 $27,144 $933 Net Loss for Provider ($567 - $1,500)

13 Avoiding Hospital Admission: MSSP ACO 3 Patients Avoid Hospital Admission Due to Pneumonia Medicare Savings: $13,572 Total Savings for Medicare: $27,144 ACO Successfully Participates in ACO Successfully Participates in Medicare Shared Savings Medicare Shared Savings Program Program ACO Shared Savings $13,572

14 ACOs: The Role of Primary Care Physicians We waste about $1T per year in US healthcare Patients and primary care doctors are the players who win when money is saved 80% of providers are digitized, so we have the data we need to identify waste and capture savings We have new payment models that reward providers for saving money Most of the savings come from avoiding hospital visits and specialists

15 A Network of Primary Care Providers Primary Care Physicians are Best Positioned to Coordinate Care and Drive Savings Primary Care Doctors Own the patient relationships and trust These doctors influence 85% of downstream cost and only account for 5% of costs. They dictate: What treatments Which hospitals Which specialists Which tests and drugs Primary care providers are the quarterbacks of the system it s time they were paid and treated like it

16 Physician-Led ACOs: Early Results In 2013, 24% (53/220) of qualifying ACOs earned shared savings and those ACOs generated savings of $652 million, taking home >$300 million in bonuses 72% of the ACOs that earned savings were % physician-led. 28% 72%

17 Case Study: Rio Grande Valley ACO Health Providers Rio Grande Valley ACO 18 primary care docs and 20 mid level practitioners in 13 practices Focus on practice changes Central role for Information Technology Year 1 results: $20 million in total savings $11 million return to ACO Per Patient Costs went from $14,100 to $12,000 Top 5% in the nation for diabetes control

18 Case Study: Palm Beach ACO Palm Beach ACO case study 130 primary care docs in 83 independent practices Central ACO staff of 13 Focus on practice changes Year 1 results: $22 million in total savings $11 million return to ACO Hospitalizations per thousand fell by 5.8% ($6.5 million) SNF costs reduced by 16.6% ($6.7 million)

19 Key Factors: ACO Selection When choosing an ACO, consider four key factors: Characteristics and Composition Does the ACO include specialists, or just primary care providers? Cost and Reimbursement Provider and Partner Engagement Data and Technology Are there upfront costs? How are shared savings dispensed among ACO participants? Will ACO management provide in-office guidance and expertise? Who owns patient data? Does ACO management provide analytical capabilities and EHR optimization?

20 Key Questions to Consider when Choosing an ACO Character and Composition: Who are the other members in the ACO and how are the selected? What are the Board and Committee expectations of the providers? What are the procedures for removing an unengaged provider or partner? How easy is it for a provider to drop out of the ACO? What types of patients is the ACO focusing on helping?

21 Key Questions to Consider when Choosing an ACO Cost and Reimbursement: How will the ACO generate savings? How will the savings be distributed? What are the initial and on-going operating costs of the ACO?

22 Key Questions to Consider when Choosing an ACO Provider and Practice Engagement Does the ACO understand the Medicare rules and is it looking to align report? Does the ACO provide local assistance? Is it virtual, in the office or both? What is the provider s level of choice is deciding whether to implement a given workflow or intervention? Are there ACO expectations around health information exchange participant and ADT hospital feeds? Does the ACO facilitate such participation? Does the ACO provide expertise on care coordination and billing for care coordination?

23 Key Questions to Consider when Choosing an ACO Data and Technology Does the ACO supply supplemental data to the payer data? What data expectations does the ACO have for the practices? Who owns the data? Does the ACO supply data analytics? Do those analytics support practice transformation and care coordination? Does the analytics return justify the data expectations (i.e. is the juice worth the squeeze?) EHR Technology requirement? Portion of providers on EHRs? Does the ACO provide EHRs or other technologies?

24 How Different ACO Types Compare Characteristics and Composition Costs and Reimbursements Physician / Practice Engagement In-Practice Support Patient Expectations Patient Focus Data / technology Approach Hospital-organized Grow hospital network; shared savings competes with bottom line Use hospital infrastructure; apply savings after expenses Minimal; hospital-led Minimal; practice remotely reports metrics Maximize hospital capacity/technology use In hospital network; hospital holds patient data Use hospital information exchange, analytic tools Insurer-organized Improve data collection for provider tiering; centralize care management Use insurer infrastructure, apply savings after expenses Moderate; leverage central administrative support Minimal; practice submits reports like P4P programs Use centralized tools/resources In insurance plan; insurer holds patient data Use insurer claims-based analytic tools Aledade, Primary Careorganized Maintain independence; focus on unnecessary costs (ED visits, hospitalizations) to achieve savings Optimize provider s existing infrastructure, no ACO costs, savings distributed before expenses Moderate; providers comprise ACO leadership Consistent; trusted, capable on-the-ground staff partners with practice Better care; stronger physician/patient relationship All; provider holds patient data Comprehensive support community information exchange, #DrHIT EHR

25 Q&A Farzad Mostashari, MD Founder/CEO, Aledade Inc, former National Coordinator for Health Information Technology Contact Dr. Mostashari:

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