APMS AND THE NEED FOR HIGH-VALUE PROVIDER PARTNERS BEYOND HOSPITALS & PHYSICIANS

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1 APMS AND THE NEED FOR HIGH-VALUE PROVIDER PARTNERS BEYOND HOSPITALS & PHYSICIANS David Muhlestein, PhD JD Vice President of Research Leavitt December 1,

2 GRANT-FUNDED RESEARCH 18-month research project funded by the Robert Wood Johnson Foundation Title: Defining High-Value Providers for ACO Partnerships Grant ID: Methodology: Literature review Expert panel meeting Interviews with ACOs and provider associations Qualitative analysis of transcripts Output: Issue brief series & research paper

3 PRESENTATION OVERVIEW Partnering for accountable care Decision-making framework High-value provider criteria 3

4 WHY DO ACOS NEED PARTNERSHIPS? 4

5 ACO GROWTH 28.6 Million Lives Number of ACOs Number of Lives Covered (Millions) 0 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q # of ACOs # of Covered Lives 5

6 ACO GROWTH VS CONTRACT GROWTH # of ACOs and Payment Arrangements # of ACOs # of Payment Arrangements Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Source: Leavitt Partners Center for Accountable Care Intelligence 6

7 RESULTS SUGGEST CONSOLIDATION ISN T REQUIRED Performance by ACO Size Rate of Earned Shared Savings by ACO Type Quintile Number of ACOs Mean Number of Beneficiaries Net Savings/Loss Per Beneficiary Smallest 78 5,608 $ ,614 $ ,555 $ ,979 $ Largest 79 46,692 $ Shared Savings Rate 40% 35% 30% 25% 20% 15% 10% 5% 0% Hospital System Physician Group Integrated Source: Muhlestein, Saunders, McClellan. Medicare ACO Results for 2015 [Health Affairs Blog] Sept. 9,

8 HOW SHOULD ACOS APPROACH PARTNERING? Framework 8

9 DEFINING THE TERMS: WHAT IS HIGH VALUE? Value in health care: Health outcomes achieved per dollar spent High-value provider: A provider (organization or individual) who delivers care in a way that yields high quality outcomes at the lowest possible price/cost High-value system (ACO): A system that facilitates the development of high-value providers, and encourages them to interact in ways that increase overall value for its patients, its community, and society. 9

10 DECISION-MAKING FRAMEWORK 1. An assessment of the needs of the population for which the ACO is taking responsibility 2. An assessment of opportunities to intervene and eliminate or address any risks the population faces 3. An evaluation of the level of sophistication needed in the partner and assessment of what is available in the market. Population Needs Intervention Opportunities Partner Needs 10

11 UNDERSTANDING YOUR POPULATION: WHY IS IT IMPORTANT? The needs of the population will define your partnership strategies as it relates to: Access Health IT Care management infrastructure Additional staff Community resources What does understanding your population allow you to do? Customization Build strategic competencies to fulfill specific, predetermined needs. 11

12 WHICH PROVIDERS WILL HAVE AN IMPACT? Contribution to Total Health [CATEGORY NAME] 40% [CATEGORY NAME] 15% Genetics [VALUE] 10% 5% [CATEGORY NAME], [CATEGORY NAME] J.M. McGinnis et al., The Case for More Active Policy Attention to Health Promotion Health Affairs 12

13 PROVIDER PARTNER SEQUENCING While there s no right answer, ACOs tend to follow a phased approach to provider partnership Physicians Hospitals Post-Acute Care Behavioral Health Pharmacy Phase 1 Phase 2

14 WHAT CHARACTERISTICS SHOULD ACOS LOOK FOR IN THEIR PARTNERS? High-Value Provider Criteria 14

15 NO MATTER THE TYPE, ALL PROVIDERS SHOULD HAVE THE CHARACTERISTICS OF HIGH VALUE High Value Culture Patient-Centeredness System & Public Accountability Team-Based Care HIT Systems Performance Improvement Systems Financial Readiness

16 HIGH-VALUE POST-ACUTE CARE PROVIDERS Why partner? Often stewards of highest cost patients, especially in their last years of life Important for enabling smooth care transitions and reducing hospital readmissions Things to consider: PAC industry encompasses a large variety of provider types (e.g., SNF, LTCH, IRF, HHA). Consider which type will best fill population s needs Providers level of consolidation, infrastructure sophistication, and health reform acumen vary greatly Example evaluation criteria: Are they interested in learning about the ACO, its metrics, and how you can work together? Are they properly staffed? What are their clinical resources? Are they willing to have an ACO physician round in their facility on a daily basis? Are they looking to maximize Medicare stays to support their financial goals? Are they able to track and share patient data?

17 HIGH-VALUE BEHAVIORAL HEALTH PROVIDERS Why partner? Unique insight into patients mental, social, and physical needs Help patients to engage in self-management to improve lifestyle behaviors and enhance treatment compliance Things to consider: Due to inadequate supply of providers nationwide, ACOs may have to be less critical of potential partners Example evaluation criteria: Do they provide adequate access to patients? Are they willing to work with PCPs to co-create care plans? Is there ongoing measurement to assess the success of the intervention? Do they have meaningful quality improvement programs in place? Are they willing to practice onsite at ACO locations?

18 HIGH-VALUE PHARMACY PROVIDERS Why partner? Represent one of the most widely available provider touchpoints Medication treatment is often key to the neediest and most expensive patients Things to consider: ACOs will need to determine what combination of retail vs. clinical pharmacy resources will have the greatest impact National retail pharmacies carry brand recognition and geographical coverage, but local groups will have flexibility in their operating strategy Example evaluation criteria: Clinical pharmacy Are they residency trained? High emotional quotient? Skilled communicators with providers and patients? Retail pharmacy Ability to share data? MTM services? Good use of pharmacy technicians? Automated dispensing? Reputation in the market?

19 KEY TAKEAWAYS Population needs should inform partnership strategies The types of providers considered to be necessary for ACOs are expanding Characteristics of high value are manifested differently based on provider type 19