Rural and Independent Primary Care.

Transcription

1 Rural and Independent Primary Care

2 Agenda 2015 Results from Rural ACO Participants Fundamental population health programs. Overview of additional rural value-based payments Opportunities for free technical assistance in practice transformation. Proprietary & Confidential, Not for Distribution 2

3 Caravan Health 23 MSSP ACO s 6,000 Clinicians 55 PPS Hospitals 92 Critical Access Hospitals 168 Rural Health Clinics 39 FQHC s 500,000 Medicare lives 32 states 1 Practice Transformation Network 11,000 Clinicians 800 Independent Practices 3

4 Caravan Health Services and Programs Establish Care Coordination programs Establish Wellness and Prevention programs Population Health Management software and analysis Evidence-based medicine programs 24/7 Access program Patient Satisfaction program Clinically integrated networks Advocacy Legal and financial services 4

5 Our Triple Aim Provide Better Care Lower Per Capita Cost Improve Financial Sustainability 5

6 Why Quality Matters: Disparities in Quality of Care Between Rural and Urban Better Same Worse 100% 80% % 40% 20% % Source: AHRQ 2 Patient Safety (n=19) Person- Centered Care (n=16) 2 1 Effective Treatment (n=44) Healthy Living (n=27) Access (n=25) Key: n = number of measures. Better = Population received better quality of care than reference group Same = Population & reference group received about the same quality of care Worse = Population received worse quality of care than reference group Proprietary & Confidential, Not for Distribution 6

7 Rate per 100,000 Population Disparities in avoidable hospitalizations for all conditions per 100,000 population, by residence location, Total Large Central Metro Large Fringe Metro Medium Metro Small Metro Micropolitan Noncore 2,300 RURAL 1,800 1, Achievable Benchmark:938.6 per 100,000 Population 800 Source: AHRQ Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and 2012 State Inpatient Databases quality analysis file and AHRQ Quality Indicators, version Proprietary & Confidential, Not for Distribution 7

8 Disparities in Life Expectancy Between Rural and Urban are Growing 50,000,000 Rural Americans x 2.4 years lost = 120 million years lost by today s rural residents. Rural vs. Urban Death Rate per 100,000 Source: AHRQ Proprietary & Confidential, Not for Distribution 8

9 Rural Value-Based Payments Proprietary & Confidential, Not for Distribution 9

10 Rural Value-Based Payments Medicare Incentive Payment System (Starts 2017) Up to 9% penalty or 27% bonus by 2022 $3- $9 PMPM Medicare Shared Savings Program (Open) Average Payment = $7.34 PMPM AIM Funding = ~$7.50 PMPM Comprehensive Primary Care Plus (Regional-FFS only) Average Payment = $16.50-$32 PMPM NextGen ACO Shared Savings Program (Open) $8 PMPM Million Hearts (closed) $10 PMPM for 30% of Medicare patients CONFIDENTIAL 10

11 MSSP Program Elements All reimbursement stays the same for all providers Quality reporting and care coordination is required If savings are realized, payor will share savings with the provider Bonus payments are adjusted downward based on quality scores All claims data is provided to participants Waivers of Stark, Anti-trust, Anti-Kickback and Patient Inducement regulations MSSP Track 3 also can have 3-day admisssion SNF Waiver Patients have full choice on where to go for care. Proprietary & Confidential, Not for Distribution 11

12 All MSSP Results 0.58% Savings Proprietary & Confidential, Not for Distribution 12

13 Advanced Payment 2.28% Savings Proprietary & Confidential, Not for Distribution 13

14 Advanced Payment Model Success! Note: Total Savings is likely understated due to only accounting for attributed lives and does not reflect savings on patients that were not attributed at the end of the performance year. Typical ACO attribution churn is 20-40% per year. Source: Proprietary & Confidential, Not for Distribution 14

15 2015 MSSP Results - COST Three out of five of our 2015 ACO starts showed savings, and our 2015 average savings is 2.57 times higher than all other 2015 ACO starts. $7,342, qualifying shared savings $3,598, shared savings paid

16 30 Hospital CFO s In Charge Stop = 0 Slow Down = 0 Keep Going = 30 Best Year Ever = 6

17 2015 MSSP Results QUALITY Our second year ACO s quality score went from 68.9% to 96.88% in one year. All first year ACO s reported successfully.

18 2016 Rural ACO Cost Trends

19 2016 MSSP Results -- ENGAGEMENT All but one community has hired a Care Coordinator (145/146) to do chronic care management (great new rural jobs!) 97% are coming to Quality Improvement Workshops to learn how to implement AWVs, CCM and TCM with their patient populations 98% (143/146) of communities have begun performing AWVs on Medicare patients and 42,394 have been conducted! 4,305 patients currently in CCM 6,895 patients been followed for TCM 87% of Care Coordinators are regularly attending monthly cohort calls with Caravan Health Coaches to share best practices 97% of communities (141/146) now have a 24/7 nurse advice line 92% (134/146) are using Lightbeam, Caravan Health s analytics tool for population health management 98% (143/146) are holding quarterly steering committee meetings.

20 MACRA Proposed Rule: Table 64 CMS says 73% of practices with fewer than 25 clinicians will pay penalties under MACRA Proprietary & Confidential, Not for Distribution 20

21 Preparing Clinicians For Value-Based Payments Background: Spring 2016: ACO Medical Director Summit 21 ACO Medical Directors 6 Hospital CEOs Physician-led discussion on how to align physician compensation with new payment models. Now is the time to begin the conversation Proprietary & Confidential, Not for Distribution 21

22 Population Health Common Elements of Success Prevention: Annual Wellness Visits Chronic Care Management Advanced Care Planning Behavioral Counseling Depression Screening Mental Health Support 24/7 Access Coding: Complete and accurate documentation of all chronic conditions is key to correct payment under value-based models. Quality: Process Pre-visit Planning Patient Satisfaction 10/3/

23 Population Health Current Revenue Opportunities Fee Schedule: Annual Wellness Visits Chronic Care Management Advanced Care Planning Behavioral Counseling Depression Screening Value-Based Payments: Medicare Incentive Payment System Medicare Shared Savings Program NextGen ACO Shared Savings Program Mandatory or Voluntary Bundled Payments Comprehensive Primary Care Plus Million Hearts 10/3/

24 What Are We Trying To Improve? Quality Cost Most practices do not have processes in place to promote wellness and address gaps in care which are key quality measures. We need to establish the processes and workflow to address these issues. Reduce unnecessary care In value-based payments, payments are multiplied times HCC scores. We need to improve our coding to get paid what we are worth. Practice Economics We need to spend an extra hour with each of our Medicare patients each year to address prevention, care gaps and appropriate coding. How do you pay for that? We will need to fund the staff to do this work in order to be sustainable.

25 Value of Wellness Visit in Population Health Gather as much data as possible on lives Refer patients to Care Coordinator Find patients who are at risk Develop a consistent primary care relationship Refer for appropriate followup services 25

26 Example: 25% Wellness Visits Pre-AWV Post-AWV Proprietary & Confidential, Not for Distribution 26

27 Example: Didn t Do Wellness Visits Proprietary & Confidential, Not for Distribution

28 Nurses Excel in Wellness Visits Source: Hattiesburg Clinic Proprietary & Confidential, Not for Distribution 28

29 CMS Proposes $900 Million Increase for PCPs -- Specialists Pay the Price Proprietary & Confidential, Not for Distribution 29

30 2017 Physician Fee Schedule Updates Removes 24/7 direct supervision requirement for Chronic Care Management in RHCs and FQHCs Allows Advanced Care Planning by telemedicine Implements important new programs and payments that are great for patients and providers Behavioral Health Integration: Psychiatric Collaborative Care Model (GPPP1, GPPP2, GPPP3) General Behavioral Health Integration (GPPPX) Additional payments for outpatient visits with mobility-related disability patients (GDDD1) Cognitive and Functional Assessment and Care Planning (GPPP6) Comprehensive Assessment and Care Planning (GPPP7) Re-evaluating underpayment for Diabetes Self Management Training Proprietary & Confidential, Not for Distribution 30

31 Psychiatric Collaborative Care Model Overcomes the lack of psychiatrists, particularly in rural areas. Doctors or care coordinators are trained to implement all programs with monthly consultation and review with a psychiatrist. More than 80 peer reviewed publications supporting effectiveness. New payment model will enable practices to set up program and be successful. Proprietary & Confidential, Not for Distribution 31

32 New Diabetes Prevention Program 5-10% of pre-diabetic patients develop Type 2 diabetes each year. Introducing CDC s National Diabetes Prevention Program 16 core group sessions on diet and exercise in six months Monthly maintenance sessions 7,804 enrolled, saved Medicare $2,650 per enrollee, lost 5% of weight Program begins 1/1/2018 for non-clinical staff Preventive service no copay, but providers must bill under Part B If patient attends 14 core sessions and loses 5%, provider gets $27.92 PMPM for six months, then $15 PMPM for monthly sessions (50 patients -- $12,876 first year, $9,000 per year afterward. Provider can charge non-medicare patients to participate. Can use non-clinical staff but GREAT FIT for care coordinator. Great for patients. Synergy with rural needs and rural mission. Proprietary & Confidential, Not for Distribution 32

33 Physician s Viewpoint on Value- Based Payments Payment based on cost and quality is inherently wrong, due to high variability of patients. Doctors want a program that is measurable and fair. CEOs are very nervous about having this conversation. Proprietary & Confidential, Not for Distribution 33

34 Physician Recommendations Have a conversation! Everyone s payments will be affected going forward. There is still time to play Fantasy Football Pay for engagement: Percentage of patients who have annual wellness visits Percentage of eligible patients in chronic care management program Attendance at Steering Committee Meetings Attendance at Quality Improvement Workshops, Taking Leadership roles Viewing evidence based medicine webinars. Proprietary & Confidential, Not for Distribution 34

35 In Conclusion MACRA is the biggest change to physician payments in a generation; Don t fear QPP, there s decent upside potential; Don t jump to risk; Now may be the time to begin discussions on Physician contracts; If RHC or FQHC, consider voluntary reporting. You don t want to get left behind, or be perceived as a low-value provider. Proprietary & Confidential, Not for Distribution 35

36 What Should You Do Now? Perform wellness visits on all of your patients. Embed a care coordinator in your practice. Start a Diabetes Prevention Program. Start working on integrating behavioral health. Prepare your boards to be flexible. This takes trial and error. Join a non-risk bearing Clinically Integrated Network. Keep up with your EHR. Code Baby Code! Get your HCC scores right. Join an ACO. Keep up with announcements of new models. Get free training, software and support by joining National Rural Accountable Care Consortium Practice Transformation Network. Proprietary & Confidential, Not for Distribution 36

37 Learn More Join Our PTN: Set up Care Coordination Services Maximize Wellness Visits Increase your Medicare revenue by $20 PMPM Increase your quality by 20% or more Provide 24 hour advice nurses for your patients Get help implementing new programs discussed today. IT S FREE Go to and click on Apply Now Or info@nationalruralaco.com

38 Thank You