AHA-AMGA Learning Fellowship. Monthly Webinar February 9, :00-3:30 pm ET

Transcription

1 AHA-AMGA Learning Fellowship Monthly Webinar February 9, :00-3:30 pm ET

2 March 20-21, 2017: In-Person Meeting Gaylord Texan Resort 1501 Gaylord Trail Grapevine, T (817) Check-in is 3:00 p.m. Check-out is 11:00 a.m. Register and reserve your hotel room by FRIDAY, FEBRUARY 3 2

3 Other Reminders Project Plan Updates: Send to Beth! Next webinar: April 13 Upcoming meeting registration and agenda Upcoming webinars Meeting and webinar archives Listserv New! Details sent 1/11/17 add to your whitelist Questions? Contact Beth Sutter at 3

4 Today s Agenda Risk Based Contracting: The Sharp Story Stacey Hrountas, Chief Executive Officer, Sharp Rees-Stealy Mary Lentz, VP Contracts and Managed Care Finance, Sharp HealthCare Project Update: Accountable Health Partners/University of Rochester Robert McCann, MD, Chief Executive Officer Mark Cronin, Chief Operating Officer Project Update: Fisher-Titus Medical Center Laurie Delgado, Senior Vice President Operations Gregory Grant, DO, Chief Medical Officer 4

5 Sharp HealthCare Risk Based Contracting The Sharp Story o o Stacey Hrountas, CEO, Sharp Rees-Stealy Mary Lentz, V. P. Contracts and Managed Care Finance, Sharp HealthCare AHA-AMGA Learning Fellowship February 9, 2017

6 Forming Growing Integrating Advancing Historical Perspective 1940s 1970s 1980s 1990s 2000s 2010s Today 1946 Health care corporation formed First hospital opened, Sharp Memorial Hospital Comprehensive rehabilitation center developed on Sharp Memorial campus Formed Sharp HealthCare Foundation Acquired 3 hospitals Acquired Foundation model medical group Developed IPA model medical group Opened 2 convalescent centers Opened senior center clinic Accepted bundled payments for specialty services Leased 2 hospitals Purchased 2 hospitals Sold 2 hospitals Opened San Diego s only women s hospital Formed CQIC Formed SHP Acquired and sold SMP Acquired retail pharmacies Restructured Hospice, Home Health and Home Infusion Opened Outpatient Pavilion Expanded Ambulatory clinic sites Grossmont Healthcare District G.O. Bonds passed Service line leadership Pioneer, Next Generation and Commercial ACOs 3 new ambulatory clinic sites SHP offered on Covered California SHP offered through CalPERS CVS MinuteClinic San Diego County partnership Expanded residential hospice program Lease extension for Sharp Grossmont Hospital passed 6

7 Sharp HealthCare Today 4 Acute Care, 3 Specialty Hospitals 2 Affiliated Medical Groups 1 Health Plan 22 Outpatient Clinics 5 Urgent Care Centers 3 Philanthropic Foundations An Offshore Captive Insurance Company Acute Rehab, Skilled Nursing, Sub-acute Facilities Home Health, Hospice, Home Infusion Numerous Outpatient and Specialty Services 7

8 Ahead of the Curve Industry Trend Acquire physician practices Sharp HealthCare Demonstrated success with two affiliated medical groups Develop or acquire a health plan Successful commercial health plan Create systems and align incentives for population management Three decades of success in capitation Decrease cost of care Recognized as high-quality, low-cost provider Integrate information systems Integrated information technology systems and infrastructure 8

9 45, ,653 50,790 43,450 Advancing Population Health and Consumerism Senior Enrollees Commercial Enrollees Commercial ACO Members Next Generation ACO 9

10 Multi-Specialty Foundation Model The 501c(3) corporation was formed in 1985 with the purchase of the assets of Rees-Stealy Medical Group, which was formed in o Original 20-year agreement was extended to Provides outpatient services through the provision of facilities and personnel. o 22 clinic facilities and 5 urgent care centers owned or leased by Sharp o Physicians and nurse practitioners are employees of the medical group The medical group is composed of 607 Physicians, NP s and PA s representing virtually every medical specialty Capitated Enrollment of 188,083 and 1,403,577 physician visits during fiscal Total ACO Enrollment 94,240 70% of revenue is pre-paid 10

11 Risk Based Contracting Physicians 35% Institutional Cap 35% Incentive Pool Shared Surplus HMO Administration, Profit and Benefit Riders (e.g. Prescription) 30% 11

12 Risk Based Contracting Employer or CMS Contract Contract Medical Groups Division of Financial Responsibility Contract for Sharing Incentives (HMO Only*) Hospital 12

13 Division of Financial Responsibility SERVICE DESCRIPTION IPA HOSPITAL HMO Hemodialysis / Dialysis IP/OP Fac Hospice Services IP/OP (all non-md services) Hospitalization Services IP Fac Immunizations & Inoculations (medically necessary-not for travel) OP Immunizations & Vaccines (Preventative,SB168) Childhood OP - Immunosuppressive Drugs Injectable Not Part of Outpatient Pharmacy Benefits OP Laboratory/Pathology IP Fac and Prof Laboratory/Pathology OP Fac Laboratory/Pathology OP Prof (hospital based) Mammography OP Fac & Prof Med/Surg Supplies (casts, splints, bandages) Office OP Mental Health IP Fac CO (if Subscriber has benefit) Mental Health IP Prof CO (if Subscriber has benefit) Mental Health OP Fac CO (if Subscriber has benefit) Mental Health OP Prof CO (if Subscriber has benefit) Mental Health Additional Svs under Mental Health Parity Act Observation Room OP Fac Out of Area IP & OP Fac Out of Area IP & OP Prof Outpatient Surgery OP Fac Outpatient Surgery OP Prof Physician Svcs. IP & OP Prof (All Prof. Services except hospital based interp. and Emergency Room initial treatment Prosthetics Surgical Implants - OP (as defined by Medicare) Radiation Therapy OP Fac Radiation Therapy IP Fac Radiation Therapy IP & OP Prof (MD) Radiology IP Fac and Prof Radiology (Diagnostic Only) OP Fac Radiology (Diagnostic Only) OP Prof (at Hospital or OP surgical facility) 13

14 Integration Together, our integrated system and medical groups Accept capitation for assigned members Established a common risk matrix for all plans Agreed upon division of revenue Medical group incentive arrangements 14

15 Aligned Incentives Sharp has aligned incentives with the medical groups Incentive agreement between the integrated system and the medical group - focusing on strategic initiatives The medical groups have aligned with the individual physicians Incentive arrangement between the medical group and individual physicians - focusing on tactical goals to meet the strategic initiatives 15

16 Sharp Rees-Stealy Risk Based Support Structure Manage Out-of-Network Patients and Services Support at Risk Services o Hospitalists o Hospital-Based Neurology o SNFists o Care at Home Population Health 16

17 Sharp HealthCare System Services Business Development/Strategic Planning Information Technology o Cerner/Allscripts o GE o Data Warehouse o McKesson/Crimson Back Office - billing, A/R, claims, enrollment, encounters Contracts Human Resources Legal and Facilities Marketing & Communications 17

18 Advancing Population Health Patient Portal Nurse Navigator Telehealth Visits/Classes Telemedicine Same/Next Day Appointments 18

19 Keys to Risk Based Contract Success Strong physician leadership and culture Strong governance including hospital, physician and operational representatives The power of unintended consequences of incentive arrangements Strategically negotiate equal rates by payor for specific populations Build in protection for new technology and pharmaceuticals No open checkbook rule 19

20 Accountable Health Partners/ University of Rochester Rochester, NY Robert McCann, MD CEO Mark Cronin COO Project: To determine whether, when, and in which Track to enter MSSP. 20

21 Since we last spoke... What have you accomplished since we last met? Baseline information: AHP is a 1,940-physician, 8-hospital organization with 250,000 Commercial, Medicare Advantage, Managed Medicaid and direct-toemployer lives. MACRA regulations have been released and Advanced APM criteria have been expanded. MSSP Track One Plus has been announced and somewhat defined. We conclude that optimizing MIPS is a better pathway than becoming an Advanced APM. 21

22 New Ideas Did you have ideas that were generated since the kick-off meeting which helped you return to your practice and slightly alter your original plan? If so, what were they and how have you modified your project? Optimizing MIPS Our perspective changed from What a pain in the neck! to We could organize well and be successful at this!. 22

23 Outcomes What outcomes are you measuring, and what data do you have so far? We are working on how to plug in community PCPs to URMC MIPS efforts. 23

24 Challenges Have you experienced any challenges or barriers thus far? What are your biggest challenges? Federal uncertainty. Lack of flexibility in governmental contracting. How to bend the cost curve every year, sustainably. Trying to figure all of this out at the same time everyone else is. 24

25 Key Accomplishments It s very important to celebrate the accomplishments you make along the way. Comprehensive care management team, with care managers embedded in PCP practices supported by centralized resources. Implemented an IT solution to connect network providers, aggregate data and report performance to physicians and payers. Developed a portfolio of contracts to spread risk across multiple payers and lines of business. Provide PCMH-accreditation services to network practices. 25

26 Next Steps What are your next steps? Optimize MIPS for all AHP PCPs will be a challenge with private PCPs. Keep our eye on federal developments. Continue to build our capabilities. 26

27 Lessons Learned Describe your lessons learned. Sit loosely in the saddle plan for the long-term but be flexible in the short term. Talk to as many smart people as you can to continuously test your assumptions and to generate new ideas. 27

28 Questions Do you have any questions you d like to pose to the group? What areas have you focused on to bend the cost curve? 28

29 Fisher-Titus Health Fisher-Titus Medical Care 29

30 The Fisher-Titus Health system reflects our organization s comprehensive inpatient and outpatient services ranging from primary care providers and specialists, hospital care, rehabilitation, and long-term care to emergency transport, home health care and pharmacy services. Fisher-Titus Health enhances the coordination of our full range of medical services. Fisher-Titus Medical Center is the flagship of Fisher-Titus Health. The fast-growing entity Fisher-Titus Medical Care currently includes 26 community-based practices and 49 medical providers. 30

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32 OHIO RIVER BASIN ACO ACO/Other Hospitals Fisher-Titus FT Medical Care Bellevue Hospital Independent Physicians We are part of Ohio River Basin ACO that is made up of several hospitals and physician groups. Over 10,000 attributed lives. Ohio River Basin ACO is part of Caravan Health Rural Consortium. The ACO is a Track 1 Medicare Shared Saving Program (up to 50% of shared saving/no penalties) funded by AIM Grant. Fisher-Titus started 2016 with 1700 attributed lives and increased to 2650 attributed lives. PPPM cost (A+B+D) is below target by 8.3% for rolling 12 months.. Focus during the first year was on Care Coordination Services: Implemented Transition Care Management on all patients capturing consistent reimbursement. Chronic Care Management implemented, slow to be accepted by physicians and patients. Implementation on Annual Wellness Visits. Gathering data to develop a Post Acute Care network. 32

33 Since we last spoke... Completed the High Performing Health System Assessment and the Maslach Burn-out Survey. Expanded our project now with two areas of focus: MACRA Preparedness as a Track 1 ACO Redesign of our Care Model to support future success in a risk-based payment environment Evaluated the key components of MIPS to understand any variances that apply as a Track 1 ACO (MIPS APM). Evaluated our performance on all 31 Quality Metrics and validated that our data collection and reporting methods were sound. Established a dashboard and individual physician quarterly scorecards. Began the process of amending physician employment agreements to include a quarterly incentive opportunity based on meeting established quality metrics. Researched framework for a physician-driven care model design that would ensure a team-based approach to managing our patients health, ensure our success as an ACO and under risk-based payment models, and improve physician satisfaction. 33

34 New Ideas Care Model Redesign 34

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36 Patient Flow 36

37 Patient Flow Continued 37

38 Outcomes Increased ACO attributed lives in From 1700 lives to 2700 lives by year end Trialed designated nurse to do wellness visits 19.1% completion of Annual Wellness Visits in 2016 Goal to increase to 50% completion 2017 Implemented Transition of Care Management Services 100% contacted within 2 calendar days to begin service Increase charge capture by end of year to 95%+ Chronic Care Management referrals - 10 cases referred in Goal is to increase to 5% of attributed lives (ACO goal is 10%) Quality Metrics for MACRA/ACO - Meet/Exceed threshold for all 31 ACO measures - Finalize 2016 set goal for

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40 Celebrating Accomplishments Completed a readiness review for how we would perform under MACRA as a MIPS APM. Completed initial 2-day training session for physicians, practice managers, ACO care managers, PHO staff and senior leadership on proposed new Care Model Design and the imperative for driving improvement of both our documentation and riskadjustment scores. Completed the Phase 1 business plan and initiated the hiring process for four LPNs who will perform Medicare Annual Wellness visits for our ACO and other Medicare attributed lives. Goal for implementation is 3/31/17. 40

41 Challenges Physician alignment and acceptance of the new care model. Realizing a return on investment given the funding necessary to support the new model little like taking a giant leap of faith. Ensuring that we provide the necessary level of training and support for physicians and clinical staff that results in better capture of documentation and HCC condition codes -- which gives a more detailed picture of our patients true health while increasing risk scores leading to higher reimbursement rates. Implementation of the Million Hearts Model as part of Care Model Re-design. Data, Data, Data.. 41

42 Next Steps Sharing the HPHS Assessment data with the Board, Leadership and physicians. Utilize data from the HPHS Assessment and the Maslach Burn-out survey when planning a facilitated retreat for physicians and leadership that works on culture alignment, clarity of shared mission, need for change ( the Why ) and what will drive our future success. Review QRUR reports both as a group and for each individual physician within next 3 months. Monitor RAF scores at baseline and then evaluate at 6 months and one year to determine if improvement from baseline has occurred. Complete training of LPNs and staff on AWV components and implement by 3/31/17. Develop Marketing plan and pull strategy for identified Medicare attributed lives by end of February. Complete Phase II of the Business Plan. Pilot scribes with three primary care physicians following the completion of training. Work through shared ownership of the Care Model redesign with NCCN (our PHO) and how services might be offered to independent physician members for a fee. 42

43 Lessons Learned Current care model does not support risk-based reimbursement, nor does it position us to truly manage the care of our patients. Need for more clinical support staff to improve overall workflow and efficiencies. Need for standardization of processes throughout practice locations. The importance of HCC in risk adjustment, portraying the actual health of the patient, thus increasing the anticipated PMPM costs of caring for that patient. This allows more opportunity for shared savings. That we have work to do in this journey with helping physicians and staff understand why we need to do things differently and the importance of having the entire team educated on what s changed in healthcare delivery. 43

44 Questions Is anyone doing work around care model re-design and if so, do you have any suggestions or advice for us? Is anyone else focusing on HCC s codes as a means to capturing higher reimbursement and if so, what one or two things resulted in an improvement of your overall RAF score? Is anyone actively working with individual physicians in helping them to understand their utilization and cost of providing care? Any advice on how to start the dialogue? 44

45 Calculating the risk score and expected expenditure Individual scores and weights are assigned to a patient demographics and HCC and then added together to calculate the total RAF RAF scores are then multiplied by a published denominator to derive an expected annual expenditure. 45

46 E 2 same male same 3 conditions only his CKD is in the setting of DM, on insulin and is obese 46

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49 Thank You! 49