Rapid Fire Workshop: Pioneer ACOs After the Ink Has Dried

Transcription

1 RFB This presenter has nothing to disclose Rapid Fire Workshop: Pioneer ACOs After the Ink Has Dried Moderated by Carol Beasley, Vice President, IHI Tuesday, December 11 11:15 AM 12:30 PM Intent and Format Intent: Brief, high-value presentations on experiences to date of four Pioneer ACOs Format: Presentations of ten minutes/ten slides Five minutes of question and answer facilitated by the session moderator. 1

2 Session Agenda 11:15 AM 11:25 AM Introduction by Carol Beasley, IHI 11:26 AM 11:41 AM Genesys Health PHO, Southeastern MI, Trissa Torres 11:42 AM 11:57 AM Beacon LLC, Central, Eastern, and Nothern Maine, Mike Donahue 11:58 AM 12:13 PM Michigan Pioneer ACO, Southeastern MI, Suzanne White 12:14 PM 12:29 PM Bellin Thedacare Healthcare Partners, Pete Knox, Jim Dietsche 12:30 PM Wrap Up Pioneer ACO Overview Initiated by CMS for Medicare beneficiaries First performance period started January 1, 2012 Moves from shared savings to population based payment model Balanced with requirements for care quality and patient experience Additional information at: 2

3 Guidance to Presenters Brief overview of the ACO, e.g. type of structure and governance, strategy, and set-up. How do you plan to get shared savings? What s working now? What are the big surprises/challenges? Next steps for your ACO. Transforming to ACO: Early Lessons Learned from Genesys Health System, Flint Michigan Trissa Torres, MD, MSPH, FACPM Sr. Vice President Continuum Portfolio, IHI Prior Medical Director of Genesys HealthWorks Population Health Initiatives Dec

4 Genesys PHO GenesysHealth System, an integrated health system with full continuum of care and primary care PHO GenesysPhysician Hospital Organization (PHO), a collaboration between GenesysHealth System and GenesysPhysicians Group Practice includes 170 PCPs contracting with 400 Preferred Panel Specialists Selected by the Center for Medicaid and Medicare Services (CMS) as a Pioneer Accountable Care Organization (ACO), initiate Jan 2012 Approximately 18,000 attributed Medicare lives Shared savings/shared risk payment model 7 Genesys: Unique at Onset Longstanding commitment to transformation driven by longstanding financial pressures In early 1990s, combined hospitals and took ~700 beds out of the system Strong PCP base x 17 yrs Success with managing risk Health Navigator interventions x 17 years Alignment with vision & strategy, strong leadership commitment Articulated PHM model and Triple Aim outcomes 4

5 Genesys HealthWorks Key Elements of Population Health Management Strong primary care practice team focused on prevention and chronic care Engaged activated patients Longitudinal care plan coordinated across the system, optimizing care transitions High reliability, quality, experience and safetyassured at all points of care Community engagement to create healthy environments Superior information management and reporting capabilities Aligned payment systems Genesys Views ACO as Opportunity To further align payment model with care model To scale up and spread HealthWorks care model to larger proportion of population served To bring other members of the continuum in line with both the care model and payment model (specialists, hospital, homecare) Key Question: Is our system sustainable during the transformation process? 5

6 Early Utilization Impact: First Six Months Pioneer ACO data minimally available during the first six month period Since the Genesys PHO Pioneer ACO started in January 1, 2012, Genesys has experienced the following. Inpatient utilization: relatively unchanged Inpatient length of stay (LOS): relatively unchanged Observation cases: significantly increased Home Health visits: moderately increased ER visits: overall visits increased, volume of lower acuity cases decreased ACO capture of out of network use: unchanged to date The Power of Aligned Incentives and Physician Specific Data Significant difference in physician performance when their financial incentives are aligned Data for managed care patients showed only 15% out-of-network use CMS ACO data initially showed 40% out-of-network use* From April through June 2012, only aggregate data available Discussion of aggregate level data did not change out-of-system use patterns Reports showing out-of-network use by PCPnow available Initiated face-to-face coaching visits Results pending *Patient incentives not aligned 6

7 Alignment Accelerates Physician Engagement and Improvement Many historic barriers to collaboration have been dramatically lessened Primary care and specialists embraced the opportunity to work together on governance, finance and care redesign Established standardized improvement methodology and cross continuum improvement teams Leveraged co-management physicians previously trained in a standardized improvement Frequent and Repeated Communication Pays off Engaging key stakeholders using consistent communication mechanisms is crucial Weekly Updates provide a quick and transparent snapshot of the week s highlights Keeps leadership stakeholders up-to-date Helps address uncertainty inherent in a demonstration project Provides an opportunity to learn real time along with the Genesys executives Explanations of the ACO model need to be repeated several times to ensure even health care finance savvy stakeholders understand the risk sharing concepts, funds flow, and change in drivers when becoming an ACO Time and resources needed to adequately communicate and educate on the transformation to fee for value should not be underestimated 7

8 Benefits of Taking the Early Risk Positioned Genesys as a leader in the transformation of health care Attracted other organizations interested in partnership opportunities Attracted other payers interested in evolving payment models Still to Come Evolve Payment Model Optimize Care Transitions across continuum Expand patient, family and community engagement Example: Advanced Care Planning Ongoing commitment to Health System transformation, not just a product line Integrate into Graduate Medical Education curriculum Demonstrate Triple Aim outcomes Deliver care model community wide 8

9 Accountable Care Organization IHI Forum 12/11/12 Together We re Stronger 9

10 EMHS Progress to Accountable Care Organization ACO 2012 Bangor Beacon Community Patient Centered Medical Homes IT infrastructure and results- driven quality improvement (2008 Davies Award) Together We re Stronger Clinical integration as a component of the model 20 10

11 Together We re Stronger Growth of Lives Under Care Coordination Together We re Stronger 11

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13 EMHS Approach to Population Health 1) Up front payment for defined care coordination deliverables and meeting quality/utilization targets (recouped by employer/payor with first dollar of shared savings) 2) Expectation of a plan design that requires selection of a PCP, incentive for those with chronic conditions to utilize care coordinators, and contains more then the de minimis E.D. copay 3) Attributed population will be based on: PCP s associated with Beacon Health contracted members in Kennebec County All members who have either selected Beacon Health, PCP residing in the geography for Washington, Aroostook, Piscataquis, Penobscot, Hancock, Somerset and Waldo counties, or, members residing in the above geography who have not selected a PCP. Beacon Health will receive a performance bonus upon achievement of savings for each year of the agreement. Beacon Health and contracting party will mutually agree upon thresholds for triggering the performance bonus. For the first year of the Program BH will not pay a performance penalty in the event the Program fails to achieve savings compared to trend; and for the second and third years, BH and the contracting party will mutually agree on risk corridors and associated performance penalties in the event of losses compared to trend. 25 Together We re Stronger Lessons Learned 1) Leadership Team comfortable with ambiguity We just set sail in an unfinished boat, that requires constant construction to stay afloat, heading to an uncertain destination, in a dense fog. 2) Communicate, communicate, communicate Patients Providers Staff Community 3) Develop infrastructure with clear expectations and accountability 4) CEO mandate to allow changes other than through normal bureaucratic channels Together We re Stronger 13

14 December 11, 2012 Michigan Pioneer ACO Providers Primary Care Physicians 169 Specialists 55 Total ACO Physicians 224 Type of Practice Private Physicians 142 Faculty 53 Employed 14 Visiting Physician 15 Total 224 Medicare attributed 19,700 covered lives to the Michigan Pioneer ACO 28 14

15 Michigan Pioneer ACO Beneficiary Profile Current Comparative Costs for DMC ACO Medicare Patients Average Per-patient Annual Medicare Expenditure US $12,245 Michigan Pioneer A $18, Michigan Pioneer ACO Beneficiary Profile Hierarchical Condition Categories National 1.0 Michigan 1.04 Detroit 1.21 Michigan Pioneer ACO Death rate for seniors in Detroit 60% higher & hospitalization rate 43% higher than rest of the State Average disease burden >3 chronic illnesses 30 15

16 Detroit is a Primary Care Desert 500,000 (65%) of Detroiters live in a MUA 300,000 below the poverty line Wayne County Rank (of 82) Health Outcomes 81 Mortality, i.e. premature death 80 Morbidity, e.g. poor or fair health; poor mental health days, low birthweight 80 Health Factors 82 Health Behaviors, e.g. smoking, obesity, alcohol, auto fatalities, STDs, teen birthrate 70 Clinical Care, e.g. uninsured, PCPs, avoidable hospitalization, diabetes and mammography screening 67 Social & Economic Factors, e.g. HS graduation, employment, children in poverty, low social support, violent crime 81 Source: Physical Environment, e.g. air pollution, access to recreation, access to healthy food Our Motivation Safety Net Institution Using the ACO to accelerate our learning Building a risk platform 32 16

17 Our Priorities Align physicians around quality Even before shared savings are realized Evidence-based platform EMR Registry Reporting on Quality Metrics 33 AMBULATORY PREVENTION & CHRONIC DISEASE MANAGEMENT WEIGHTING = 1/3 QUALITY-SAFETY BONUS POOL DM-1 HbA1c - Good Control < 8 % < 40% 40 and < 70% 70% Compliance % diabetics w/ HbAIc <8% from most recent office visit this quarter DM-2 Blood Pressure Management < 40% 40 and < 70% 70% Compliance % diabetics with BP < 140/90 from most recent office visit this quarter DM-3 Lipid Control LDL < 100 < 40% 40 and < 70% 70% Compliance % diabetics with LDL < 100 from most recent office visit this quarter DM-4 Aspirin Use < 40% 40 and < 70% 70% Compliance % diabetics with ischemic vascular disease taking daily aspirin from most recent office visit this quarter DM-5 Tobacco Non Use < 40% 40 and < 70% 70% Compliance % diabetics who are tobacco nonusers from most recent office visit this quarter HTN-1 Blood Pressure Control- (140/90) < 40% 40 and < 70% 70% Compliance % hypertensives with systolic BP < 140 and diastolic BP < 90 mmhg from most recent office visit this quarter Influenza Vaccination < 40% 40 and < 70% 70% Compliance % patients >50 years who received influenza vaccination Sept-Feb of the year prior to the measurement period Pneumococcal Vaccination > 65 yrs. and at risk populations < 40% 40 and < 70% 70% Compliance % patients 65 years who ever received a pneumococcal vaccination Provider Total Points < 8 8 and < Provider Payment 0 50% 100% 34 17

18 HOSPITAL CARE TRANSITION WEIGHTING = 2/3 QUALITY-SAFETY BONUS POOL Post-discharge Visit Within 7 Days January 1, June 30, 2012 July 1, December 31, 2012 < 40% 40 and < 60% 60% Compliance < 60% 60 and < 80% 80% Compliance Medication Reconciliation at Discharge < 70% 70 and < 90% 90% Compliance % patients 65 years discharge from any inpatient facility and seen within 60 days in the office by the PCP who had a reconciliation of the discharge meds with current meds documented Re-admission Rate % decrease from baseline rate < 10% 10 and < 15% 15% Compliance OR OR Baseline Performance Percentile 75th Percentile Provider Total Points < 4 4 and < 8 8 Provider Payment 0 50% 100% 35 Our Strategies Risk Strategy De-risked physicians immediately Shared savings early on Selling A & B Shares to increase alignment 36 18

19 Our Strategies Muffling the Variability 37 Our Strategies Have decreased in network re-admissions by 50% 38 19

20 Our Strategies Creating Our Own Risk/Contingency Arrangements Community Partners DAAA Personalized Care at Home 39 Our Strategies Understanding the boundaries of risk sharing Despite elegant agreements, must have a boots on the ground approach 40 20

21 Our Strategies Real time info on patients Including out of network notification Re-engineering hospital care Real-time notification of any touch Protocols to align care management with medical /nursing care Uniform discharge processes- Project Red Inpatient PowerPlans to promote care reliability 41 Our Challenges Our demographic Physician behavior: FFS versus Quality Incentives Out of network spend Analytical tools Data lag & data warehouse Competition from shared savings ACOs 42 21

22 Rapid Fire Pete Knox Executive Vice President Chief Learning & Innovation Officer Jim Dietsche CFO/Vice President System Resources 697 Physicians 57 Primary Care Locations 3 Tertiary Hospitals 4 Critical Access Hospitals 1 Psychiatric Hospital with full-service Behavioral Health Clinic Hospice & Palliative Care Services Skilled Nursing Facilities (1 system-owned) 44 22

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24 Pioneer Tying Pioneer Projects to our Metrics & Definitions of Success for Pioneer 47 Pioneer Tying Pioneer Projects to our Metrics & Definitions of Success for Pioneer (closer look) Once our targets for savings and quality were set, we defined how projects will help us achieve those targets. We aligned projects under the appropriate category: Projects that help generate the saving to Medicare and projects that are focused on our quality scores. We tied those projects back to the responsible organization and put a dollar amount to how their work contributes to the target. Projects are numbered and correspond to areas that need to be addressed in the driver diagram

25 Pioneer Defining Which Projects to Target by Creating a Driver Diagram 49 Pioneer Defining Which Projects to Target by Creating a Driver Diagram (closer look) 50 25

26 Pioneer Examining a Subset of the Pioneer Population Defined criteria to subdivide the Pioneer population Broke Pioneer population into 4 subsets based on spend and chronic diseases Purpose To identify how the subsets varied from one another To identify how to best manage the health and experience for each subset To identify the largest areas for opportunity to make improvements for the population 51 Pioneer Examining a Subset of the Pioneer Population Super Users 52 26

27 12/11/2012 Pioneer Examining a Subset of the Pioneer Population Super Users (closer look) 53 Thank You! 54 27

28 RFB This presenter has nothing to disclose Rapid Fire Workshop: Pioneer ACOs After the Ink Has Dried Moderated by Carol Beasley, Vice President, IHI Tuesday, December 11 11:15 AM 12:30 PM 28