ACOs & the Accountable Care Era: Emerging Healthcare Risks & Exposures. Jeffrey Lunn, CPCU Senior Strategist, Healthcare

Transcription

1 ACOs & the Accountable Care Era: Emerging Healthcare Risks & Exposures Jeffrey Lunn, CPCU Senior Strategist, Healthcare Ohio Hospital Association June 10, 2014

2 Accountable Care & Emerging Healthcare Risks: Learning Objectives List 3 imperatives of the accountable care era. Identify 3 emerging risks or liabilities in accountable care. Describe the alignment of the MPL & patient safety industry with accountable care. 2

3 Accountable Care & Emerging Healthcare Risks AGENDA Reform & the Accountable Care Era Emerging Risks Alignment with the Patient Safety & MPL Industry 3

4 The MPL Standard of Care Historic Healthcare Changes in US Is the MPL Standard of Care evolving? 4

5 Why Reform Healthcare? The American Paradox Standardization vs. Clinical Variation Cost & Quality Sustainability & The Tipping Point 5

6 Why Reform Healthcare? Average spending on health per capita ($US PPP*) Total expenditures on health as percent of GDP 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 United States Canada Germany France Australia United Kingdom United States France Germany Canada United Kingdom Australia 0 0 * PPP=Purchasing Power Parity. Data: OECD Health Data 2011 (database), version 6/2011. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance,

7 The Reality of Healthcare Reform Payment Reform Migration of Reimbursement Models Fee For Service to Capitation Shared Savings, Bundled Payments, Episodic Payments, Global Payments Transfer of Risk from Payer to Provider Financial (Cost of Care) Clinical (Quality of Care) 7

8 The Reality of Healthcare Reform Payment Reform = Accountable Care Accountable for Cost & Quality Financial & Clinical Alignment Financial & Clinical Integration Accountable Care = Value Based Care (aka VBC ) 8

9 What is Value Based Healthcare? Value = Quality Cost 9

10 Value Based Healthcare-HFMA s Road Map 10

11 The Accountable Care Imperatives Reduce Costs Improve Quality Increase Patient Safety VALUE Based Care not Volume Based! 11

12 The Accountable Care Imperatives Population Health Management Integration/Coordination Minimize Clinical Variation Health Information Technology (HIT), Interoperability & Health Information Exchange (HIE) Transparency/Accountability CLINICAL & FINANCIAL INTEGRATION OF CARE 12

13 Payment Reform Enables Delivery Reform Restructuring Delivery Models Provider Alignment & the Continuum of Care New Models Accountable Care Organizations (ACOs) Accountable Care Entities (ACEs) Patient Centered Medical Home (PCMH) Federal, State, Private Sector Rejuvenated Traditional Models Integrated Delivery Networks (IDNs) Physician Hospital Organizations (PHOs) Independent Practice Associations (IPAs) 13

14 Structure of the Evolving Delivery Model Payer (CMS, BCBS, etc.) ACO, CCO, ACE, etc Acme Hospital Employed MDs of Acme Atlantic Primary Care Pacific Surgical Care Suburban Surgicenter 14

15 Accountable Care Organizations (ACOs) A group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization's payment is tied to achieving health care quality goals and outcomes that result in cost savings. ( Medicare ACO Size: Minimum 5,000 beneficiaries Public versus Private Payer ACOs Medicare, Medicaid, (i.e. OR with CCOs), United Health et al 15

16 The Accountable Care HIT Framework 16

17 Population Health Management By Dale Sanders Sr. Vice President Health Catalyst 17

18 Clinical & Financial Integration History Structural, Financial, Operational, Cultural & Technological Requirements Governance Issues (for Delivery & Staff Models) ACO, PCMH, PHO, IPA To Employ or Not? Physician Involvement/Leadership Aligned Incentives Clinical Team Approach Case Management Disease Management Wellness Coaching 18

19 Clinical & Financial Integration RAF Score Expertise Data Longitudinal View (the Continuum of Care) Past & Present Integration Analytics Population Health (Global & Granular) Data Warehousing Actuarial & Predictive Modeling Descriptive vs Predictive vs Prescriptive 19

20 Accountable Care: Emerging Risks & Exposures 20

21 Accountable Care & Emerging Risk/Exposures Provider Stop Loss Got Capitation? Managed Care/Errors & Omissions Network Development Clinical Guidelines Utilization Review Financial Incentives Claims for Health Plan Benefits Management of Health Care Plans Directors & Officers 21

22 Accountable Care & Emerging Risk/Exposures MPL & the Standard of Care Is it evolving? Provider Shield Laws Historical Perspective Is Usual & Customary changing? Care Plans Vicarious Liability The ACO or ACE entity Physician oversight of allied health professionals Clinical Decision Making versus Utilization Pressures Credentialing 22

23 Accountable Care & Emerging Risk/Exposures Physician Patient Ratios Enterprise Accountability Medical Director Cyber Regulatory & Billing E&O 23

24 Accountable Care Alignment with the MPL Industry 24

25 Alignment of Accountable Care & MPL Industry Renewed Prominence of Quality & Patient Safety Medicare s Goals The Triple Aim The 4 Domains Patient/Caregiver Experience Care Coordination/Patient Safety Preventative Health At Risk Populations 25

26 Alignment of Accountable Care & MPL Industry HIT Minimize Variation Manage Variation Analytics Alignment: The New MPL Imperative Descriptive Predictive Prescriptive 26

27 The Industry Migration 27

28 Alignment of Accountable Care & MPL Industry Reform s Imperatives = Risk Management Fundamentals Improve Integration of Care Improve Coordination of Care Minimize Clinical Variation Patient Centered Care 28

29 Summary Depth & Breadth of Change Historical Perspective When Will This End? MA Chapter 224 Managing Healthcare Risk The MPL Role 29