Risk-Based Contracting: What s Our Approach?

Transcription

1 Risk-Based Contracting: What s Our Approach? AMGA CEO/Chair/Pres. Leadership Council AMGA National Meeting March 9 th, 2016 Randall K. Gibb, M.D. Chief Medical Officer, Clinic Health Care, Education and Research Mission & Vision Mission Health Care, Education and Research Vision Billings Clinic will be a national leader in providing the best clinical quality, patient safety, service, and value Caradigm. All rights reserved. 1

2 Who We Are An outstanding medical foundation built upon the following cornerstones: A multi-specialty physician group practice in which a community of physicians work together in a collegial manner is at the core of this model. The partnering of physicians, excellent business managers, professional staff, and volunteers create a team whose synergies drive our success. Not-for-profit, community-owned and governed. Mission-driven decision-making dedicated to a higher purpose in the community and the region. An obsessive dedication to quality and service. Organizational Highlights 4 Employ 3,800 employees Group practice with 305 Physicians, 108 PA/NPs Clinic & Hospital Joint Commission Accredited Magnet Designation for Nursing Excellence in 2006 and re-designation in 2011 Multi-specialty Physician Clinic 900,000 patient encounters 10 clinic locations Hospital & Sub Acute Care 305 Licensed Beds 14,500 hospital admissions/year Level II trauma center 45,000 patient ED visits/year Psychiatric Services Youth and Adult Hospital IP & OP Behavioral Health Clinic Aspen Meadows 90-Bed Long Term Care and 55-bed Assisted Living Facility Sub-Acute Care Research Center for Clinical Translational Research Clinical research Billings Clinic Foundation Over $100 million raised Over $48 million in current assets Over $69 million granted to Billings Clinic 2014 Caradigm. All rights reserved. 2

3 Lincoln Flathead Glacier 43-County Service Area Facility & Outreach Locations Toole Pondera Hill Havre Blaine Teton Chouteau Richland McKenzie Sanders Lake Phillips Sidney McCone Dunn Lewis & Fergus Dawson Missoula Clark Cascade Judith Petroleum Lewistown Garfield Glendive Stark Basin Missoula Prairie Wibaux Dickinson Rosebud Granite Meagher Musselshell Fallon Slope Wheatland Roundup Custer Anaconda Golden Jefferson Baker Bowman Valley Forsyth Deer Miles City Adams Sweet Ravalli Lodge Butte Silver Gallatin Grass Yellowstone Bow Big Bozeman Timber Columbu Madison s Billings Livingston Hardin Primary Dillon Carbon Powder Carter Big Horn River Park Red Lodge Secondary Powell Sheridan Lovell Cody Sheridan Crook Greybull Tertiary Gillette Park Bighorn Buffalo Population Sq. Miles Yellowstone145,496 2,635 Secondary 54,505 26,101 Tertiary 395,354 99,065 TOTAL: 595, ,801 Source: Claritas, Inc Population Estimate US Census Bureau Land Area Sizes Worland Hot Washakie Spring s Thermopolis Fremont Riverton Daniels Sheridan Williams Valley Roosevelt Wolf Point Culbertson Glasgow Williston Billings Johnson Campbell Clinic Sites Hospital Casper Clinics Divide Long-term Care Outreach Location Innovation and New Models Emerging science of health care delivery Professionalism can be a powerful driver of value to patients and families Best healthcare organizations can and will deliver on this promise in any payment environment Payment policy powerful however and can enable and/or inhibit 3

4 Challenges to Value In MT Diverse payer market with high percentage of selfinsured groups concentrating on unit cost reduction not care coordination Relatively high penetration of on-site employer clinics with no clinical record sharing High penetration of network-access arrangements for large national payers and large national employees who choose not to directly contract in MT Attribution of PCP Small population with difficulty in aggregating risk, it s all about the denominator Billings Clinic CMS Agreement History PGP Demonstration Model: PGP Transition Demonstration: Medicare Shared Savings Program ACO 2013-Present Track 1 No downside risk, eligible for shared savings, not subject to shared losses MSSP Initial 3 year agreement 1/ /2015 MSSP Renewal 3 year agreement 1/ /2018 4

5 Montana: 147,138 Square Miles, 1,008,243 People Caradigm. All rights reserved. Target Population* Year 1: Calendar Year 2016 MSSP Track 1 (upside risk only) 12,000 patients New West Medicare Advantage 1,500 patients Humana Medicare Advantage 600 patients Pacific Source Commercial 1500 patients Allegiance Commercial 55 patients BCBS MT Commercial 5,500 patients BC Employees and Covered Lives 5,500 patients Total: 26,655 Patients Billings Clinic has ~ 150,000 Unique Patients per year, ~ 85,000 of those have a Billings Clinic PCP assigned *Target population are patients in some type of alternate payment model, besides straight FFS, such as P4P, CCM, MSSP, 2 sided risk, Full Capitation, etc. 5

6 Goals For Value Based Care Successfully implement the Center of Excellence (CoE) care delivery model and complete resourcing for the organizational structure Establish and execute a synergy driven clinical program that consolidates efforts across HCC risk adjustment, CCM program, and high risk patient management across patient populations Rapidly retain, train, and mobilize talented Care Guides and CoE resources to deliver population health programs Significantly enhance leverage with payers and optimize mix of fee for service and risk sharing partnerships, based on capabilities and potential financial benefit Accurately track and monitor the flow of patient populations through the new care delivery model using a more comprehensive set of data, metrics, and analytics HCC/ Clinical Documentation Key Capabilities Risk-Based Contracting Quality measure reporting and performance improvement Disease Management Registries Chronic Care Management Program (CCM) Transitions of Care Management Program (TCM) High risk patient Identification and Utilization management Patient Engagement Modalities (Patient Portal, Wellness Programs) 6

7 Billings Clinic Defines Population Health Managing Three Different Types of Patients Across the Health Care System Patient Type Characteristics Resource Needs High Risk Patient Rising Risk Patients Low Risk Patients ~5% of patients Complex diseases High Utilizers of Care (Inpatient, ER, & Ambulatory) ~15 % of patients Chronic Disease Management Medium Utilizers of Care ~80% of patients Generally Healthy, Conditions easily managed Low Utilizers of Care Ambulatory ICU Intensive Coordinated Case Management Patient Centered Medical Home Disease Management Registries Keep patients from moving into high risk category Wellness Initiatives Patient Portal E Visits Keep patients healthy and loyal Importance of HCC Scoring Under-coding was a major problem Average for state 0.87, we were at 0.76 Educational initiative for primary care providers CDI endeavor system wide Chart preparation prospectively before visit Documented improvement to

8 Business Intelligence Strategy Enable Billings Clinic to create information for clinical, financial and operational decisions quickly and easily through the use of a Business Intelligence System Not a Point of Care Tool (As all Point of Care Activities currently aggregated in Integrated EHR) Caradigm Business Intelligence Reporting Whitecloud Analytics Billings Clinic Employees Using Caradigm BI Analytics Crimson/ Anceta- Optum Analytics Caradigm Enterprise Data Warehouse Verisk Cerner SMS/ Mysis Lawson Avatar Claims Data Premier/ NSQIP & STS Other Lighthouse Analytics Physician Focus Analytics 8

9 Knee Replacement DRG s Scorecard Cost/ Care Variation Analysis 9

10 ACO Report Card Physician Report Card ACO Dashboards & Data: 1. Un-blinded Monthly Dissemination of Data Physician, Pod (Medical Home), Department, Location Text, , Intranet 2. Process: 1. Standing Agenda Item at Department Meetings (including compensation model) 2. Process for physicians to drill down on data (bridge strategy to more sophisticated solutions) 10

11 Pop Health Incremental Total FTEs Billings Clinic Incremental FTEs per Year Description Operations Incremental FTEs Care Navigator Discharge Coordinator Care Manager Social Worker Pacific Source RN Navigator Pharmacist Health Coach LCSW III Professional Counselor Chart review specialist Manager IT Incremental FTEs Application Support System Consultants Care Management Incremental FTEs Social Worker - Supervisor Social Worker Total FTEs Care Navigation- Outpatient Current State 6.3 FTE Oncology RN Navigators ( ~ 800 patients)- Repurpose FTE Cardiology RN Navigators (~ 600 patients) Repurpose FTE Primary Care Hire 5 FTE 1 Heights 2 West End 2 Downtown None in Cody and Miles City 1 FTE Breast Health Navigation (No repurpose) 1 FTE Spine Center Navigation (No Repurpose) 1 FTE Hip and Knee Navigation (No Repurpose) 1 FTE Geriatrics Navigation (No Repurpose) = 18.9 FTE on Care Navigation Currently in place = 3.2 FTE available to repurpose for Population Health = 5.0 FTE new hires 11

12 Summary: RN to High Risk Patient Ratio 1:100 to 1:300 RN to Total population 1:1000 to 1:1500 Health Care, Education and Research Next Steps- Patient Engagement Patient Portal Committee Re- invigorated Report to SET (TBD in March) Virtual Visit pilot to start soon Real time physician feedback 12

13 Next Steps- Regional Quality Meetings with Regional Sites Local CIN discussion ongoing Considering structuring a regional CIN Regional CEO meeting being planned by Regional Operations Expenditure Reduction per Beneficiary Needed to Share in Savings PY1 (CY2013) PY2 (CY2014) Actual expenditures per beneficiary $8,306 $8,625 Benchmark expenditures per beneficiary $8,200 $8,251 Amount per beneficiary to reduce before reaching bchmk $106 $374 Total benchmark expenditures $99,092,722 $101,137,626 Minimum savings rate (MSR) % 2.9% 2.8% Minimum savings rate (MSR) $ $2,825,956 $2,874,198 Person-Years 12,085 12,257 Amount per beneficiary to reduce before reaching MSR $234 $234 Amount per beneficiary to reduce to achieve savings $340 $608 Amount per beneficiary needed to achieve savings $7,966 $8,017 Area expenditures range from approx. $18K to $12,500 Benchmarked to self, strong disadvantage 13

14 Bundle Project: Why Total Joints? Baseline was set FY Engaged Providers Process Improvement initiatives were ongoing Standardizes process agreed upon by surgical group Medicare Bundle Began January 1, 2014 Care Re-design 14

15 CY14 Episode Cost per Month CY14 Post Anchor Costs by Month 15

16 CY14-Q1 Reconcilitation Performance Clinical Episode / Major Joint # of Cases Target Amount Actual Performance Amount (Winsorized) Net Payment Reconciliation Amount DRG 469 with complications 4 $162,943 $180,828 -$17, without complications 69 $1,480,429 $1,475,617 $4,812 Total 73 $1,643,372 $1,656,445 -$13,074 ** *After "true up" **If at risk, would have owed Medicare this amount CY14-Cumulative (6 Months) Reconcilitation Performance Clinical Episode / Major Joint # of Cases Target Amount Actual Performance Amount (Winsorized) Net Payment Reconciliation Amount DRG 469 with complications 7 $280,914 $261,399 $19, without complications 146 $3,133,515 $3,367,417 -$233,902 Total 153 $3,414,429 $3,628,816 -$214,387 ** **If at risk, would have owed Medicare this amount Estimated annual risk if 6 month experience repeats -$428,775 16

17 Surgical Site Infection (SSI) Data by Standardized Infection Ratio (SIR) January 1, 2015 December 31, 2015 Procedure # of Infections Observed # of Infections Expected # of Procedures Performed SIR only calculated if expected > 1 SIR p value 95% confidence interval Cardiac , CBGB chest / leg CBGC chest only * , Colon , Fusion , HPRO , KPRO , Laminectomy * , Refusion Hysterectomy , Overall SIR for 2015 (through December: 0.53) *There were 195 CBGB s & 272 LAM s Jan-Dec. 2015, however one CBGB & Lam was excluded from the SIR due to the duration of the surgery (outlier). Revised Professional Identity Physicians, hospitals, others Fighter pilot to astronaut Acute care to coordinated care across silos Personally and organizationally extremely challenging Hard, messy, challenging, need for new transformation skills Lead innovation 17

18 Thank You! Randall K. Gibb, MD