New Strategies in Value Based Care

Transcription

1 New Strategies in Value Based Care D. Keith Fernandez, M.D. Chief Clinical Officer, Privia Health CEO, Privia Medical Group Gulf Coast

2 none Disclosures

3 Learning Objectives Discuss population health and value based reimbursement and how partnerships, rather than mergers and acquisitions, can benefit the health system.

4 In 4 years Independent Physicians: Privia Medical Group 1,750+ Privia Medical Group Providers 4M+ Unique Patients Seen Last 24 Months $2B President and Physician in Chief MHMD, and CMO Of Memorial Hermann ACO with over 200 Million in savings over First 3 years Medical Spend Managed Under Risk Programs

5 Memorial Hermann and the Memorial Hermann Physician Network MHMD Board CPC System Quality Board Hayes Evidence Based Medicine Pathology Radiology Trauma Emergenc y PM&R Peer Review Pediatrics Primary Care Medicine Evidence Based Surgery CEPC * Orthopedics * CV Services Women Children Critical Care MIC General Surgery Bariatrics Supportive Methods Vendor TF Cardiology Neonatology Nephrology AMIC ENT NSQIP CV Surgery Ob/Gyn Heme/Onc Editorial Robotics Anesthesia Allergy Gastro EQC Documentation PSH Clinic Diabetes Pain VTE Trauma President and Physician in Chief, MHMD, and CMO of Memorial Hermann ACO with over 200 Million in savings over first 3 years clinically integrated physicians, 90% in private practice. Infectious Disease

6 Clinical Programs, continued NW SW Medicine NE SE North Region SW Region Advance Primary Care NE Region SE Region CPC Palliative Care * * * Clinics s Peer Review Credential s Advisory Aging Protocols (creating and measuring EBM practices and order set templates) Performance (setting and monitoring progress against established quality standards and protocols) Products (drives the standardization of vendors, formularies, supply chain decisions) Payment (Pay for performance goals, co-management agreements, ACO project metrics, PCMH elements, bundles) MC Katy West Region Central Region Projects (ED to ED transfer policy, CT scanning in pediatric head trauma, standardized order sets in Observation units, service line, credentialing and privileging standards) TW Sugarland TMC Program Rationalization (Consolidation and concentration of clinical service delivery ie open heart and joint programs)

7 Co-management..to ACO A Direct Experience in a New Accountable Care Organization: Results, Challenges, and the Role of the Neurosurgeon Dong H. Kim, MD; Christopher Lloyd, MHA; Douglas K. Fernandez MD Neurosurgery, Volume 80, Issue 4S, 1 April 2017, Pages S42 S49 Two spine vendors to one Portion of earned bonus dollars to pay for CME s, guest lecturers, research, etc Quality committee evaluate quality metrics for neurosurgery across enterprise System wide leveling document Specific, unblinded data to neurosurgeons by name System wide order sets Shared savings: 8 million over 4 years

8 Table 5: Reduction in Cervical Case Cost per Patient 7, $6,246 6, , $4,857 $4,597 $4,287 4, $3,513 3, , ,

9 Table 6: Reduction in Lumbar Case Cost per Patient 14, $12,791 12, $11,377 $11,456 $10,658 10, $8,765 8, , , ,

10 Advanced Primary Care Practice Quality Innovation Technology Single Signature Contracts Discounts Liability Ins Group Purchasing UC/AH Retail Clinics Data Care Mgmt Disease Mgmt Health Coaches Preventive Care Physician Training HCC Documentation ICD-10 CMEs MU University Physician University Gap Reports At Risk/High Risk Physician Report Cards Pt Engagement Patient Education Patient Access Patient Portal Supp Medicine Post Acute Ambulatory ICU Claims Files EMR data Lab Rx Practice Transformation EMR Point of Care NCQA Practice Assessment GNE Program HOSPITALS/POST ACUTE/IMAGING/LAB Legal Compliance Partnerships Education

11 Preferred Providers and Facilities 29% increas e 25% increas e 10% increas e 30% increas e 24% increas e 4% increas e 16% increas e 25,000 covered lives: ACO Narrow Network

12 MHHS Aetna Narrow Network 27.1% better 26.6% better 28.3% better 47.0% better 5.7% better 42.4% better 47.8% better Aetna ACO Narrow Network, YOY performance

13 High Reliability : Certified Zero Awards 139

14 ACO programs: Lots of Value $4,480,000 to membership $480,000 to neurosurgery co-management physicians $6,180,841 narrow network shared savings $6,000,000 Inpatient Quality and Safety agreement $14,000,000 PCMH/ACO $1,000,000 savings cardio co-management pilot Medicine, Orthopedics, Cardiovascular bonus pools $0 to $75,000

15 Covered Lives January 2016 January 2015 July 2013 United Healthcare Commercial 100,000 BCBS Commercial 80,000 Health Solutions Medicare Advantage 5,500 Aetna Whole Health 26,200 $700M $560M $15M $183M 427,500 Covered Lives $3.2B book of business Aetna Commercial 85,000 $595M Aetna Medicare Advantage 5,800 $49M January 2013 United Healthcare Medicare Advantage 8,800 $75M April 2012 CMS MSSP 47,700 $500M Humana Medicare Advantage 5,000 $43M January 2012 Humana Commercial 18,700 Health Solutions Commercial 48,500 $131M $340M

16 Privia Medical Group Support Services at a Glance Population Health Integrated, Multidisciplinary Care Teams High-Risk Case Management Transitions of Care Program Inpatient Diversion / Extensivist After-Hours Nurse Advice Quality Management Medication Management Risk Adjustment Technology & IT Support Practice Management System Electronic Health Record Patient Portal w Automated Reminders Onsite & Remote User Training Help Desk Support HIE / Data Warehouse Clinical Analytics & Reporting Health Event Engine / Workflow Revenue Cycle Accounts Receivable Charge Capture Payer Rules Library Denials Management Payment Posting Payer Enrollment / EDI Initial / Renewed Credentialing CAQH Set-up / Maintenance Managed Care Commercial Payer Contracting Government Payer Contracting Direct to Employer Contracting Value-Based Contracting Pay for Performance Programs Contract/Fee Schedule Management Reimbursement Analysis Organization & Reporting Dedicated Practice Consultant Clinical Workflow Specialists Performance Reporting Financial / Cash Flow Reporting Strategic Planning / Action Plans HIPPA-Compliance Reviews Meaningful Use Attestation Payer Quality Reporting Profit & Growth Practice Website Marketing Collateral Group Branding / Advertising Digital Marketing Campaigns Online Reputation Management Malpractice Discounts Group Purchasing of Supplies Health Insurance / Retirement

17 Population Health: Nine Key Strategies Access* Acute Events* Referral Steerage* High Utilizers Documentation Attribution Medication Mgmt Quality Referral Utilization* Urgent Care, Open Scheduling, 24/7 Triage, Telehealth Diversion, Transitional Care, Post-Acute Care Tiered Networks, Data on Referral Patterns Complex Care, Social Work, Behavioral Health Risk Adjustment, EMR Workflow and Training Patient Growth, Personalized, Outreach, AWVs Adherence, Generics, Utilization, Specialty Rx Quality Measures, Care Gaps, Patient Satisfaction Decrease over-utilization, PCP education, Consults

18 Data and Incentives to Find Value John Valenti, MD Internal Medicine Partner since January 2014 $1,993 Cost of an MRI w/o Contrast at - Owned Imaging Center $837 Cost of an MRI w/o Contrast at Independent Imaging Center $639 Cost of an MRI w/o Contrast at Independent Imaging Center

19 Imaging FFS PMPM Risk DTE Privia Medical Group Employer Programs: Pre and Diabetes/Surgery/ Primary Care (Adult) Primary Care (Commercial) Lab In office Mobile Path Privia Quality Network Clinical Programs Apps Virtual Med Scribes Bundled Payments Medical Specialties Specialists Partnerships Episodes of Care Pharmacy Infusion Mobile Mini bar Mail

20 Wicked Problems Multiple stakeholders with different values and priorities Issues are complex and tangled The problem changes with every attempt to change it Never been done Nothing to indicate the right answer