CIGNA Collaborative Accountable Care

Transcription

1 CIGNA Collaborative Accountable Care Connecting in ways that help make achieving health easier, more effective and more affordable October 14, 2016 Michael L. Howell, MD, MBA, FACP Market Medical Executive/Sr. Medical Director, North and Central FL, USVI

2 Easy access to medical information Best medical doctors, facilities and equipment Abundant supply of health-related resources So why are we still so unhealthy? 2

3 Change the Focus to change the future HIGH $$$ SPENT HIGH $$$ RETURN Traditional Approach Wait and treat Know your numbers assessments Education promoting self-enrollment Incentives for participation Broad flood-light interventions Physical/clinical health focus MINIMAL BEHAVIOR CHANGE Cigna Approach Act to avoid Precise risk and readiness identification Proactive coaching and outreach Incentives for risk reduction Precise laser-light interventions Whole health mind/body focus OPTIMAL BEHAVIOR CHANGE 3

4 Drivers of High Healthcare Costs in the U.S. Physician and facility fee-forservice costs Expensive technologies, procedures, and drug costs Fragmented and uncoordinated care Lack of cost consideration from patients and unhealthy behaviors Expensive end-of-life care Provider consolidation High administrative expenses 9 Drivers of High Healthcare Costs in the U.S. Becker s Hospital Review. January 09,

5 The path to greater Value Patient- Centered Medical Home Right care Accountable Care Organization Right care Right rewards Collaborative Accountable Care Right care Right rewards Right connections Cigna Collaborative Care Right care Right rewards Right connections Right place 160+ collaborative large physician group relationships 1 more than any competitor 2 More than 220 individual hospital arrangements 1 More than 20 specialty groups in four specialty areas 1 1. Cigna internal analysis of existing arrangements as of April Subject to change. 2. Becker s Hospital Review, A year of mixed results, continued growth for ACOs, November

6 Making complex care Easier with large physician groups Traditional care Limited information and a cumbersome process. Can create frustration and fragmented care. Collaborative care The right connections and support. Enables total population management. Sick care = health risks not addressed early or handled separately Actionable, patient-specific information = see and address health risks sooner ( well-care ) PCP has limited patient information and support = nobody coordinating care Embedded care coordinators = help coordinate ongoing care and use of available programs to improve whole health Misaligned financial incentives = unsustainable rising costs Value-based reimbursement model = aligned incentives reward when care quality and costs improve Limited collaboration with other HCPs = limited ability to share and learn best practices Learning collaborative meetings = share best practices and learn from one another Payer not seen as clinical partner/resource = missed opportunities for cost and quality improvement Consultative clinical resources = identify opportunities to improve quality and medical costs and drive better health outcomes For illustrative purposes only. 6

7 Why Cigna Collaborative Care? Features and advantages Largest national ACO program 1 as reported by KLAS Research Largest percentage of covered lives 2 as reported by Becker s Hospital Review Proven individual large group results over multiple years 3 Positive overall program performance results 3 Incorporation of total medical cost impact into pricing models Collaborative care program-specific performance guarantees 4 High ratings for provider collaboration 1 Cigna Cigna is the plan where we have the best relationship and team focus. Others don t bring that to the table. Cigna brings expertise and stability in their team that others don t. Large physician group in Florida, August Accountable Care Payers Performance Report, KLAS Research, assessment of number of Collaborative agreements, and collaboration, October, As of May, Becker s Hospital Review, A year of mixed results, continued growth for ACOs, November Cigna Collaborative Care, Large Group annual results for 2013 versus market average (2014). Comparisons to market are established using Cigna internal claims data. Quality is based on compliance with evidence-based medicine guidelines. 4. Performance guarantees are only available for plans with certain Cigna administered and approved health coverages and services. Employee participation and other requirements may apply. Availability of this program may vary by state and is subject to Cigna approval. 7

8 Rewarding Value: Where HHS target percentage of fee-for-service (FFS) payments linked to quality and alternative payment models in 2016 and 2018* we are going Actively participating in the U.S. Department of Health and Human Services (HHS) Health Care Payment Learning and Action Network HHS framework includes four categories of health care payment:* Category 1: fee-for-service 30% 85% 50% 90% Category 2: fee-for-service with a link of payment to quality Category 3: alternative payment models built on fee-for-service architecture Category 4: population-based payment All Medicare FFS (categories 1-4) FFS with payment linked to quality (categories 2-4) Alternative payment models, including population based (categories 3-4) Cigna has adopted the goals set by HHS, including 90% of payments in value-based arrangements and 50% of payments to organizations in alternative payment models by *Centers for Medicare and Medicaid Services Fact Sheet: Health Care Payment Learning and Action Network Working Together to Move Payment toward Value and Quality in the U.S. Health System." Updated March 25,

9 What exactly is an Accountable Care Organization? An Accountable Care Organization (ACO) provides the framework for a network of doctors and hospitals to share financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending. At the heart of each patient s care is a primary care physician. Accountable care organizations (ACOs) offer integration of local physicians with other members of their healthcare community and reward them for controlling costs and improving quality. While ACOs are not radically different from other efforts to improve the costeffectiveness of healthcare delivery their innovation lies in the flexibility intrinsic to their structure, payments, and risk assumption. Accountable Care Organizations, Explained. September 14,

10 Collaboration Drives improved outcomes Non-Cigna collaborative practice Physicians within the same practice have diverse referral patterns Referrals to preferred providers is inconsistent Physicians knowledge of who is high performing is unknown Use of high-performing specialist is not maximized Cigna customer benefits are maximized Cigna collaborative practice Physicians are educated on who is high performing and why Physicians in the same practice coordinate referral patterns to high-performing specialists Physicians within the same practice more consistently use preferred providers Helps eliminate out-of-network referrals Cigna customer benefits are maximized Cigna collaborative practice earns an incentive for improving both cost and quality 10

11 Value-Based Care: It will take many forms 1. One-sided shared savings Providers share in portion of the savings they achieve in a modified fee-forservice model-only upside risk. 2. Two-sided shared savings Providers take on upside and downside risk in the fee-for-service based model-incentivizes reductions in cost 3.Bundled/episode payments Providers receive single payment for all one patient s services for one episode of care. Providers take most of the risk for the cost of the care within the bundle or episode. 1.Partial capitation/global payments The ACO assumes partial risk in the partial capitation payment arrangementalso known as a professional fee capitation 2.Global payments Provider organization assumes a great amount of risk with global payments. 11

12 Transitioning from Fee-for-service to value-based reimbursements The Key to Transitioning from Fee-for-Service to Value-Based Reimbursement. Health Catalyst.

13 Cigna Collaborative Care Innovative solutions that span the delivery system Large physician groups Specialists Client Hospitals Health care professionals Customers Small physician groups Rewarding health care professionals for improved health, lower costs, and higher satisfaction. Goal: Majority of customers with high-cost conditions or complex needs are cared for by health care professionals with an incentive relationship with Cigna. Information Clinical Resources Incentives 13

14 How Shared Savings models work 14

15 The Cigna Shared Savings model The CAC program is a shared savings model where savings is calculated by the difference in the CAC s total medical cost trend (excluding pharmacy and behavioral health) and the Market Trend (CAC 1.0) or a Trend Target (CAC 2.0). There are 3 steps in determining the annual adjustment to shared savings for the CAC: 1.Trend 2.Performance Index 3.Quality Index Payment / Frequency Any Shared Savings can be returned to the CAC in one of two ways: Prospective payment model: a monthly adjustment to the Care Coordination Fees (CCF) for the following year, or Annual Reconciliation payment model: a flat quarterly CCF and an annual reconciliation payment 15

16 Creating the strategy: Key Focus Action Plan Cigna Collaborative Care - Large Physician Group Key Focus Action Plan (KFAP) CAC Name: XXXXXXXXXXX Updated: XX/XX/XX Item No. Action Item Focus Area Owner Tracking Metrics Baseline Value Target Value Current Value Performance Status On Track Target Completion Date Comments At Risk Off Track 1.0 Initiatives to improve total medical cost Initiatives to improve clinical quality Other: i.e. physician engagement

17 Quality: Meeting the metric 17

18 The Data: Impacting cost efficiency: Cigna Collaborative Accountable Care Advanced Imaging Summary D_AIS_ALL Large Physician Group Market: Alignment Period: Reporting Period: Report Run Date: FL TAMPA Apr Mar Apr Mar /27/2016 Alignment Period Reporting Period Current Period 12 Months Prior Period Practice Market PI 2 Practice Market PI 2 Practice Market Apr Mar Apr Mar Apr Mar Apr Mar Current vs. 12 Months 3 Prior Aligned Patients 6, , % 0.0% Aligned Patients Months 67,443 2,055, % 0.0% ERG Risk Score All OP ADVANCED IMAGING Total Paid $0 $0 0.0% 0.0% Utilization: Scans/ % 0.0% Total: PPPM $0.00 $ % 0.0% CT MRI PET Total Paid $0 $0 0.0% 0.0% Utilization: Scans/ % 0.0% Cost: Paid per Scan 0.75 $0 $ % 0.0% % Preferred Referrals CT % 0.0% % 0.0% Total: PPPM $0.00 $ % 0.0% Total Paid $0 $0 0.0% 0.0% Utilization: Scans/ % 0.0% Cost: Paid per Scan 0.86 $0 $ % 0.0% % Preferred Referrals MRI % 0.0% % 0.0% Total: PPPM $0.00 $ % 0.0% Total Paid $0 $0 0.0% 0.0% Utilization: Scans/ % 0.0% Cost: Paid per Scan 1.08 $0 $ % 0.0% % Preferred Referrals PET Scan % 0.0% % 0.0% Total: PPPM $0.00 $ % 0.0% Nuclear Cardiac Imaging Total Paid $0 $0 0.0% 0.0% Utilization: Scans/ % 0.0% Cost: Paid per Scan 0.99 $0 $ % 0.0% Total: PPPM $0.00 $ % 0.0% 18

19 We have the reports: Actionable and Individual 19

20 Embedded Care Coordinator: The Secret Sauce 20

21 Creating Value-based Relationships with specialty groups focused on: Maternity care Cancer treatment Acute episodes of care Reduce clinically unnecessary variation in the cost and delivery of OBGYN care Achieve quality and cost efficiency targets against predetermined targets Increase collaboration with the OBGYN group Improve the cost and quality of care for customers with cancer Improve coordination of care for customers in active cancer treatment Address appropriate end of life care Eliminate waste in the system Increase quality and decrease cost for an episode of care for: Hip and knee replacements Deliveries Colonoscopies Coronary artery bypass grafts Percutaneous coronary intervention Identify potentially avoidable complications THE CONNECT EFFECT Specific results from individual OBGYN specialty groups include: 15.2 % 6.4 % improvement in its primary cesarean delivery rate 1 improvement in generic 93 % reported overall satisfaction in patient satisfaction survey 5 Highlight dispensing specialty rate 2 value in connect effect bar in design Improved total medical cost performance by 3% 3 1. Cigna Collaborative Care, OBGYN Group in Tampa and Orlando annual results 9/1/2013 through 8/31/2014 versus market average. 2. Cigna Collaborative Care, OBGYN Group in Tampa and Orlando annual results 9/1/2013 through 8/31/2014 versus pre-program benchmark. 3. Cigna Collaborative Care, OBGYN Group in Houston annual results 9/1/2013 through 9/30/2014 versus pre-program benchmark. Note: Comparisons to market are established using Cigna internal claims data. 21

22 Here s the proof Large Physician Groups 74% of doctors and hospitals with two or more years experience have seen success in both total medical costs (TMC) and quality 1 91% have seen success in TMC 1 Large physician groups active two or more years have shown 2% better total medical cost and 2% better quality performance 3 78% have seen success in quality 1 Overall 2:1 ROI for most mature arrangements 2 Three of our highest performing arrangements each removed over $ 3 million from the health care system 4 Cigna collaborative care arrangements continue to produce positive, measurable results. 1.Trend 1% or more below market OR maintenance of 4% or better than market average. Cigna Collaborative Care, Large Group annual results for 2013 versus market average (2014). Comparisons to market are established using Cigna internal claims data. Quality is based on compliance with evidence-based medicine guidelines. 2.Cigna internal analysis of Cigna Collaborative Care, Large Group annual results for 2013 (2014). ROI Methodology = (Total Savings-Total CCF Costs)/Total CCF Costs. Reflects performance since inception of the most mature groups, with experience of two or more years. 3. Average or better trend OR 4% better than market. Cigna Collaborative Care, Large Group annual results for 2013 versus market average (2014). Comparisons to market are established using Cigna internal claims data. Quality is based on compliance with evidence-based medicine guidelines. 4.Cigna internal analysis of Cigna Collaborative Care, Large Group annual results for 2013 (2014). Reflects performance since inception of the most mature groups, with experience of two or more year. 5. Becker s Hospital Review, A year of mixed results, continued growth for ACOs, November

23 Cigna Collaborative Care Florida Large physician groups - Advantage Health Network (Tenet) - BayCare Physician Partners - Broward Health ACO Services - Central Florida Affordable Care - Florida Accountable Care Services - Florida Hospital Medical Group (Adventist) - Holy Cross Physician Partners - Integrated Independent Physician Group - Memorial Health - Millennium Independent Physician Group - Orlando Health Physician Partners - Palm Beach Accountable Care Org. - Primary Partners - PrimeHealth Physicians - Tampa Bay Integrated Healthcare Network Specialty groups - Florida Cancer Specialists - Florida Orthopedic Institute - Florida Woman Care - Vital MD - Women s Care Florida - North Florida ObGyn Hospitals Tampa GA Ft. Myers - Adventist Health System - HCA Florida (statewide) - Health First Inc. - Holy Cross Hospital - Jackson Memorial System - Mount Sinai - North Broward Hospital District - Orlando Health - Parrish Medical Center - St. Cloud Regional Medical Center - Wellington Regional Medical Center - Tenet Healthcare DE Jacksonville Orlando Miami Market-Specific Results Large physician groups Achieved a 4% lower than market total medical cost performance Overall spend on emergency room visits per thousand is 12% lower than market Cervical cancer and breast cancer screenings rate were both 5% better than market Overall advanced imaging PPPM is 10% lower than market Specialty groups Improved 15.2% in primary cesarean delivery rate Improved 6.4% in generic dispensing rate Achieved 3.7% rate for early elective deliveries, better than the national rate of 5% Blue map area indicates Cigna Care Network available Cigna Collaborative Care, specialty group annual results for September 2013 through September 2014 (2015). Cigna Collaborative Care, individual large physician group annual results for 2014 versus market average (2015. Comparisons to market are established using Cigna internal claims data. Quality is based on compliance with evidence based medicine guidelines.. Cigna internal data as of June Illustrative purposes only. 23

24 What do we need to Move the Needle on collaboration? 24

25 What s Next? Large physician groups Continued expansion and performance improvement Introduce prospective trend target pilot with select groups Introduce risk sharing pilot with select groups Incorporation of patient experience measures into incentive model Specialist groups Continued focus on improving quality, lowering cost, improving patient safety and avoiding complications Expand OB/GYN arrangements Expand Oncology arrangements Expand Episode of Care programs for deliveries, hip and knee replacement and colonoscopies Establish new Episodes of Care programs for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) Integrating behavioral and pharmacy components into arrangements Hospitals Continued focus on improving quality, lowering total medical cost and improving patient satisfaction Continued use of existing quality measures including: Quality process measures Readmission rates Hospital acquired complications Transition of care activities following discharge Evolving quality and safety measures Expansion of transition of care programs Integrating behavioral metrics for psychiatric units Small physician groups Potential pilot in select markets with a focus on: Pharmacy optimization Chronic conditions 25

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27 Thank you