The UNC Health Care System & BlueCross BlueShield of North Carolina Model Medical Practice: A Blueprint for Successful Collaboration

Transcription

1 The UNC Health Care System & BlueCross BlueShield of North Carolina Model Medical Practice: A Blueprint for Successful Collaboration January 26, Session Overview Partners in Innovation and Service Carolina Advanced Health BCBSNC Ensuring Quality Care UNCHCS Challenges and Opportunities Lessons Learned Questions? 2 1

2 Part I: Partners in Innovation and Service 3 North Carolina s changing landscape Changing demographics creating varied market pressures for new services Unstable financial landscape spurring hospital acquisitions of physician practices, greater collaboration between providers and insurers Federal focus on care coordination, disease management, and quality Emergence of alternative reimbursement models to change provider incentives Growing demand for value purchasing One constant: costs continuing to climb 4 2

3 BlueCross BlueShield of North Carolina Largest health insurer in North Carolina and one of the 25 largest health insurers in the nation - 4,600 employees serving over 3.7 million customers Serving customers for almost 80 years Commitment to quality and patient satisfaction Commitment to community services - BCBSNC Foundation invested almost $70 million in local communities in BCBS Experience BCBSNC Blue Quality Physician Program Highest level of NCQA accreditation BlueCross BlueShield of Massachusetts Alternative Quality Contract BlueShield of California Pilot Program 6 3

4 The UNC Health Care System Chartered to provide patient care, educate physicians and other providers, conduct research, and promote the health and well-being of the citizens of North Carolina U.S. News & World Report: Best Hospitals Almost 40,000 inpatients and 800,000 outpatients each year UNC Hospitals licensed beds UNC Physicians & Associates - 1,100 UNC School of Medicine faculty members Triangle Physician Network - Almost 100 employed physicians 7 UNC Health Care System Experience NCQA PCMH Recognition Carolina ACCESS Town of Chapel Hill Wellness@Work Community Based Clinics Triangle Physician Network 8 4

5 A unique partnership Develop new relationship between UNC Health Care and BCBSNC to promote partnership and integration across industries Explore financing and delivery models that provide greater value in the changing healthcare environment Create clinical laboratories to test new models and concepts and gain hands-on experience with ACO principles Improve access, delivery, quality, and efficiency by coordinating care across settings Assure sustainability, suitability, and scalability in rural and urban settings Improve the health and wellbeing of North Carolinians 9 Collaboration offers increased value for stakeholders Patient Improved health and wellbeing Better, more confident self-management of chronic conditions Provider More time to fully engage patients in their care Focus on outcomes Information and tools to provide quality care Payer Demonstrate leadership in changing the healthcare system Aligning incentives Creating a sustainable, replicable model 10 5

6 Part II: Carolina Advanced Health 11 What is Carolina Advanced Health? First project through NC Healthcare Innovation, LLC Joint governing board (3 UNC HCS & 3 BCBSNC members) and implementation teams BCBSNC and UNC HCS contribute equally to NCHI NCHI provides oversight and guidance to practice Practice is run through Triangle Physician Network, LLC (UNC HCS affiliate), with financial support from NCHI Three-year pilot project beginning on December 1, 2011 Newly-recruited providers and staff Unique data sharing between health plan and provider BCBSNC Onsite Provider Associate integrated into practice Triangle Physician Network practice with unique branding 12 6

7 Service Agreement Expense reimbursement BCBSNC ASO Groups BCBSNC Subsidiary Operating Agreement UNCHCS Subsidiary Landlord Rent Lease NC Healthcare Innovation, LLC (NCHI) Independent Contractor Agreements Fees Sublease and Asset Lease Funding of net loss Contribution Agreement Provider Contract Claims Triangle Physician Network (TPN) Payments of: FFS Shared savings Practice management Physician / staff employment Care delivery Outside Vendors 13 Primary Objectives Expected Outcomes Test a fundamentally new model for organizing, funding and delivering primary care that is sustainable and can be replicated Build evidence-based care model beyond Level 3 Patient- Centered Medical Homes (PCMHs) Align financial incentives to shared savings Design with a patient-centered orientation & team approach Reduced Healthcare Expenses Increased Patient Satisfaction Improved Patient Health Increased Operational Efficiency 14 7

8 Who will Carolina Advanced Health serve? Practice open to select BCBSNC members: North Carolina State Health Plan BCBSNC ASO Underwritten BCBSNC 5,000 patient panel enriched with chronically-ill adult population (e.g., Coronary Artery Disease; Hypertension; Diabetes; Obstructive Lung Disease; Depression; Asthma; etc.). Patients recruited through targeted mailings and other joint efforts. Patients retained through excellent service, case management, and individualized care plans and follow up

9 17 Carolina Advanced Health Floor Plan 18 9

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11 What makes Carolina Advanced Health different? Access and Convenience Extended hours Open scheduling Telehealth visits Small patient to provider ratio Effective Encounters Pre visit planning Decision support Evidence based protocols Outcome orientation Self Management Support Lifestyle / health coach Decision aids and educational materials Home monitoring Patient One Stop Shopping Primary Care Behavioral Health Pharmacist Phase 2 select Specialists Technological Support Sharing of claims data Disease registries Patient risk stratification Coordination of Care Case management Transition of care program 21 What will Carolina Advanced Health provide? Team based care and active care management (delegated from BCBSNC) Leveraged IS systems Reserved provider time for care management, telephone and e-visits Practice providers and staff incented on quality metrics only Embedded behavioral health and select specialty referral network BCBSNC onsite provider associate integrated into practice Talented providers and staff recruited and trained specifically for practice Unique data sharing between health plan and provider (15 month history for all new patients and alerts for admissions) 22 11

12 Part III: BCBSNC Ensuring Quality Care While Reducing Healthcare Costs 23 Strategic Response to Escalating Healthcare Costs Goal: Better manage medical cost trend and improve health care quality Multifaceted approach includes: New payment models New network structures New pharmacy and care delivery programs And more Quality emphasis: Rewarding outcomes over volume of procedures Collaborating with providers and leading change 24 12

13 The Quality Threshold Meeting a stringent quality threshold is required for either party to participate in shared savings. If quality standards are not met, any gainshare will be donated to a charity dedicated to improving healthcare in NC. Quality metrics include: Submission of application to NCQA for PCMH recognition Meet the following elements from BCBSNC s BQPP program: Each physician uses electronic prescribing software Claims submitted electronically Completion of training focused on cultural competency in medical practice. 25 The Quality Threshold, con t. Score at/above at least 5 out of following 7 measures: 1. Mammograms for women (appropriate/eligible) w/in past 2 years. 2. Cholesterol management for patients with cardiovascular conditions. 3. Diabetic (type 1 and type 2) patients with acceptable LDL levels. 4. A1c for type 1 and type 2 diabetics at acceptable levels. 5. Diabetic (type 1 and type 2) patients age with eye exam within last 24 months. 6. Nephropathy assessment urine microalbumin w/in past 12 months. 7. Aspirin or other anti-thrombotic use in past 12 months

14 The Quality Threshold, con t. Score at/above at least 3 out of following 4 measures: 1. BMI assessments with nutritional counseling for score > Smoking assessment and cessation counseling of patients seen in past 12 months. 3. Depression screening. All patients within past 12 months. 4. Implement at least one patient-centered metric and track for first year. 27 Medical Expense Savings Medical Expense Savings Overview Savings will be based on the difference in Total Claims Cost during each of the three evaluation periods. Savings Payment will require meeting a minimum sample size for group membership for statistical and measurement validity. Savings Payment will be tied to the practice meeting specific quality measures. Outliers will be excluded in an uncomplicated manner. Timing Demonstration will take place over 3 years (2012 through 2014) with an option to continue based upon outcomes and partner agreement. Calculation will occur on a yearly basis during the Demonstration. Carolina Advanced Health 3 Year Model Practice Demonstration Evaluation Period Evaluation Period 2 Evaluation Period

15 Medical Expense Savings Methodology Goal Calculate the Medical Expense Savings for the Model Practice Group as compared to a Matched Control Group during the demonstration. Model Practice Group Model Practice Group will be based on an attribution methodology, additional qualifying criteria and successful matching to the Control Group. Control Group Control Group creation will be based on qualifying criteria and a statistical method known as Propensity Score Matching. Comparison Process Comparison is performed retrospecively based upon concurrent data for the Model Practice Group and the Matched Control Group. Example: 2012 comparison completed in spring of 2013 using 2012 data for both groups. Comparison Carolina Advanced Health Model Practice Group Matched Control Group 29 Medical Expense Savings Model Practice Group Eligibility Group BCBSNC Underwritten, BCBSNC ASO Employees and Select ASO Groups Attribution Group Members must attend the practice, but only a subset will be considered attributed to the model practice. The eligible model practice members are not required to attend the practice. Savings Calculation Group Members must have sufficient BCBSNC membership history to be included. The medical expense savings calculation is based upon this group. Matched Control Group Control Group Eligibility Members must experience at least one encounter during the evaluation year and have sufficient membership history to be included. Control Group Matching Matching the Control Members to the Model Practice Members will be based on a statistical method known as Propensity Score Matching

16 Medical Expense Savings and Payment Medical Expense Savings Total Medical Expenses Calculation is a comparison of the Total medical expenses for each group. Includes all episodes of care and places of service during the evaluation period; not only those episodes and locations associated with model practice. Actual Values and Not Trend Calculation is a comparison of actual expenses and not a prospective evaluation or a trend analysis. Medical Expense Savings Payment If savings are produced, the payment calculation identifies the payment amounts due to the Model Practice from eligible groups for the savings achieved. 31 Part IV: UNCHCS Challenges and Opportunities 32 16

17 Strategic Response to New Reimbursement Models Acknowledging that the health care cost curve is unsustainable and that payment purely for volume is not good for anyone Redesigning a care model that is value driven: Constraining costs, eliminating waste Measuring quality, outcomes, cost Transitioning from a focus on isolated episodes of care to population health management Embracing Patient-Centered Medical Homes Building an IS infrastructure that includes EMR, private UNC health information exchange, data warehouse, patient and referral portals Taking risks on alternative payment agreements 33 What happens if you build the perfect practice and no one shows up? Build a patient panel with target prevalence of chronic illness Market to potential patients Manage physician resentment Get the right incentives: Attract patients with chronic diseases Comply with state and federal regulations Create an environment where patients will allow their care to be coordinated by the practice in a PPO setting with no gate-keeping? 34 17

18 How can we simplify the provider/payer interaction? Do we really have to submit claims? What else can we do to simplify the process? Eligibility Prior authorizations Claims submission Denials 35 How do you attract the most talented providers? What should the financial incentive plan for providers look like? Based on what factors (productivity, quality, both)? Individual v. group? Should we have an incentive plan for staff? Based on what factors? What metrics can be measured reliably? 36 18

19 How do you get the right information to the right people? IS infrastructure - from the ground up or use existing resources? Share care utilization data with the practice Manage the sheer volume of utilization data, in addition to existing data (e.g., systemwide EMR; data warehouse quality metrics; registries; etc.) Patient portals and non-traditional visits

20 39 Part V: Lessons Learned 40 20

21 Lessons Learned Executive sponsorship and direction with physician leadership Building on previous relationships and partnerships Building trust for common goal of patient-centered, quality, affordable care Springboard for other innovations Shifting the negotiation paradigm to move past historical relationships Shifts discussion from us vs. them mentality in contract negotiations Moving forward while worrying about the details Gaining confidence of internal and external stakeholders Shared savings gained from greater efficiencies 41 Lessons Learned (cont.) Defining and agreeing on the roles and operational responsibilities for each partner Educating each partner on unique business practices Navigating state and federal regulatory obstacles Designing and implementing new financing models Coordinated care model leads to better health outcomes, lower costs Will help answer question in North Carolina of whether highly resourced, high-performing medical home can improve outcomes while lowering total cost of care Strategies for reducing administrative costs 42 21

22 Looking Forward Vision to reality Providing enhanced clinical care through information availability and data enrichment Demonstrating successful relationship between insurer and health care provider Aligning financial incentives for improving quality outcomes and medical expense savings Future initiatives built on relationship and synergies 43 Part VII: Questions? 44 22

23 Ted Lotchin Mr. Lotchin is a member of Arnold & Porter LLP s FDA and Healthcare practice group and counsels a broad range of clients, including hospitals and academic medical centers; physician practices; ambulatory service providers; and pharmaceutical and medical device companies, on healthcare regulatory, transactional, and litigation matters. His experience includes developing Accountable Care Organizations (ACOs) and other network affiliation projects. Robert G. Cimo, Jr. Robert.Cimo@bcbsnc.com Mr. Cimo is the Senior Managing Counsel for Corporate Law and Governance at Blue Cross and Blue Shield of North Carolina. He directs transactional matters for BCBSNC and provides counsel on intellectual property, tax and finance, insurance, real estate, election law, HIPAA privacy and security and e-commerce issues. Mr. Cimo heads BCBSNC s Vendor Contract Analysis and Negotiation unit and is lead counsel to BCBSNC s Strategic Development, Legislative Affairs, Diversified Products and Ancillary Markets groups. Gina Bertolini gbertoli@unch.unc.edu Ms. Bertolini is an Assistant General Counsel with the UNC Health Care System and the Legal Director and General Counsel for Triangle Physician Network