National ACO Summit. Fourth Annual. June 12 14, Follow us on Twitter and use #ACOsummit.

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1 Fourth Annual National ACO Summit June 12 14, 2013 Follow us on Twitter and use #ACOsummit. The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute

2 Track Three: Delivery System Reform and Clinical Transformation MANAGING THE PACE OF CHANGE IN CLINICAL TRANSFORMATION Jeffrey Epstein, MD, Medical Director: Quality, Case Management and Resource Utilization, Stamford Health Poonam Alaigh, MD, MSHCPM, FACP, Chief Executive Officer and President, Alaigh Care Associates LLC. Former New Jersey Commissioner of Health and Senior Services; Former Executive Director, Horizon Blue Cross Blue Shield of New Jersey Tom Cassels, Executive Director, Research & Insights, Advisory Board Company Seth Frazier, Chief Transformation Officer, Evolent Health Kimberly Kauffman, MA, Executive Director, Summit Medical Group

3 From Fee for Service to Value Based Healthcare Managing The Pace of Change in Clinical Transformation A Panel Discussion The Fourth Annual Accountable Care Organization Summit June 12 14, 2013 Hyatt Regency on Capitol Hill, Washington, DC

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6 500 Beds * 1 Billion Gross Revenue * $400 Million Medicare Revenue * 3% Profit Margin (All Payers) * $30 Million Profit per Year (All Payers) * $12 Million Dollar Profit on Medicare Patients Anytown Hospital Anytown, USA 08057

7 : Full Risk IHDS Global Payment for Defined Population 2013: VBP, Bundled Payments Readmission Reduction Penalty MSSP ACO

8 $400 Million in Medicare Revenue 2013: $4 Million 2014: $8 Million 2015: $12 Million

9 Hospital Readmission Reduction Penalty (HRRP) $400 Million in Medicare Revenue 2013: $4 Million 2014: $8 Million 2015: $12 Million

10 Bundled Payments

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12 EARN BACK YOUR MONEY ENHANCE REVENUE OPPORTUNITIES $12 Million Dollars $11 Million Dollars on Joints $12 Million Dollars $50 $150 Million Dollars

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14 Bundled Payments Revenue Opportunity Calculations Total Joint Surgery: Assume $28,500 for Episode of Care $7000 Hospital * $1500 Surgeon $2000 other Medical Expenses (Consults, Labs, Etc) $7000 SNF * $7000 Home Care * $4000 Implant Total: $28,500 Plan: Reduce SNF Spend to Zero if Possible: Send patient home with home PT If SNF needed, keep LOS optimized (7 days rather than 30 days) Reduce cost of implant. Savings: $2000 in implant and $5000 in SNF: $7000 per case profit $7000/$28,500 = 25% Profit Assume 1600 Total Joint Cases per Year. (1600 cases) x ($7000 profit/case) = $11.2 Million Dollar Profit Can we keep 100% of Savings How does SNF replace lost Revenue?

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16 ACO Revenue and Profit Opportunity ACO and Commercial Contracting IHDS with Contracting MSSP ACO which is 50% Shared Savings with No Downside 50,000 in population Current cost is $10,000 per member per year Total Yearly Spend on Population: $50,000 x 10,000 which is $500 Million per Year Reduce cost of care to $9000 per member per year Savings is ($10,000 PMPY x 50,000) ($9000 PMPY x 50,000) which is $50 Million per Year $50 Million per year on $500 Million per Year Gross Revenue is 10% margin For Baseline of $10,000 per member per year on population of 50,000 members: $9000 PMPY $50 Million Net Revenue $8000 PMPY $100 million Net Revenue $7000 PMPY $150 million Net Revenue Significant Dollar Opportunity in ACO program if we get to keep 100% of Savings

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18 Conclusions 2013: Value Based Care = $8 Million at Risk 1% of Gross Revenue and 27% of Profit $8 Million/$1 Billion in Revenue = 0.8% $8 Million/$30 in Profit = 27% of Profit at Risk 2020: Full Capitation and Full Risk $50 Million Dollar Opportunity for each 50,000 member population over 65 years of age

19 98% Fee For Service 1% Value Based Purchasing 1% Readmission Reduction Staged Quality Improvement Per Year Staging Populations to bring into Value Based System Full Risk, Global Capitation Payer/Provider Merge as One Population Health & Complex Case Management Incentives Aligned High Quality, High Value, High Patient Satisfaction Physician Designed Cost and Quality Data Feedback, Process Improvement

20 % Medicare 40% 40% 40% 40% 40% 40% 40% 40% 40% Commercial 40% 40% 40% 40% 40% 40% 40% 40% 10% Self Pay 10% 10% 10% 10% 10% 10% 10% 10% 10% Uncompensated Care 10% 10% 10% 10% 10% 10% 10% 10% Fee for Service 98% 96% 94% 78% 68% 58% 48% 0 Risk Sharing 2% 4% 6% 22% 32% 42% 52% 100% Fee For Service 98% 96% 94% 78% 68% 58% 48% 0% FFS plus Shared Savings (MMSP ACO) 10% 20% 30% 40% 100% Value Based Purchasing 1% 2% 3% 3% 3% 3% 3% Readmission Reduction 1% 2% 3% 3% 3% 3% 3% Bundled Payments 5% 5% 5% 5% Gainsharing Risk Sharing Commercial no no no no no no no yes Medicare no no no no no no no Self Pay no no no no no no no Self Funded (Employees) Yes Yes Yes Yes Yes Yes Populations at Risk: Uncompensated Care Yes Yes Yes Yes Yes Yes

21 ACO compared to the HMO HMO ACO $9 per month Capitation (not much money) $2 Co pay for Visit (Different Incentives for Provider and Patient) Incentive NOT to see Patient Data not complete, reliable or believable No Electronic Medical Records Payer and Provider at Odds Physician Engagement Poor Patient Engagement Poor Patient Education Poor Rules made by Managed Care Companies and Actuaries not Physicians Not many physicians in management in 1992 Physician Led with Robust Physician Engagement Robust Support Structures and Processes to assist Primary Care Electronic Medicare Records Fully Informed Care Robust Communication and Information Sharing Payer and Provider are Tight Partners Performance Improvement Systems Care Teams: Physician, Nurse Practitioner/Physician Assistant, Office Staff, Social Workers, Case Managers, Community Health Workers, Health Coaches

22 Track Three: Delivery System Reform and Clinical Transformation MANAGING THE PACE OF CHANGE IN CLINICAL TRANSFORMATION Jeffrey Epstein, MD, Medical Director: Quality, Case Management and Resource Utilization, Stamford Health Poonam Alaigh, MD, MSHCPM, FACP, Chief Executive Officer and President, Alaigh Care Associates LLC. Former New Jersey Commissioner of Health and Senior Services; Former Executive Director, Horizon Blue Cross Blue Shield of New Jersey Tom Cassels, Executive Director, Research & Insights, Advisory Board Company Seth Frazier, Chief Transformation Officer, Evolent Health Kimberly Kauffman, MA, Executive Director, Summit Medical Group

23 Track Three: Delivery System Reform and Clinical Transformation INNOVATIVE WORKFORCE SOLUTIONS IN AN ACCOUNTABLE CARE ENVIRONMENT Kavita Patel, MD, MSHS, Fellow and Managing Director, Clinical Transformation and Delivery Reform, Engelberg Center for Health Care Reform, The Brookings Institution Norma Ferdinand, MSN, RN, DNSS, Senior Vice President, Chief Quality Officer, Lancaster General Hospital Marcia Guida James, MBA, MS, CPC, Director, Provider Engagement, Humana Edward Salsberg, MPH, Director, National Center for Health Workforce Analysis, HRSA Tom Strong, MBA, Program Officer, The Hitachi Foundation

24 2013, The Brookings Institution Innovative Workforce Solutions in an Accountable Care Environment Kavita Patel, MD, MSHS Managing Director, Engelberg Center for Health Care Reform Fellow, Economic Studies The Brookings Institution Thursday, June 13 th, 2013

25 Frontline Workers in an Accountable Care Environment Frontline workers can help ACOs develop a number of critical capabilities and deliver on the promise of quality care at a lower cost. 2013, The Brookings Institution New Care Coordination Responsibilities Frontline workers can arrange for hospital admission/discharge, communicate between different sites of care, help with disease management reminder calls, connect patients with important community resources, obtain insurance preauthorization, etc. Health IT Capabilities Investing in health IT infrastructure implies not only the health systems, but the storage, servers, data security, and workforce needed to operate and run these systems. With the appropriate training, frontline workers can fill some of these new roles. Additional Clinical and Administrative Responsibilities (e.g., prevention and wellness, governance) Trained medical assistants can offer a substantial amount of clinical support (e.g., perform basic triage, measure vital signs, administer medications, draw blood, remove sutures) and administrative support (answering telephone calls, billing, updating patients medical records, scheduling appointments, authorizing drug refills). Delivering Patient centered Care Frontline workers are often viewed as trusted members of the community and, as a result, can better engage patients in his/her health care needs and facilitate sustainable behavior change. 25

26 2013, The Brookings Institution Health Coaches at the Special Care Center 26

27 2013, The Brookings Institution Medical Assistants at Arizona Connected Care 27

28 2013, The Brookings Institution Opportunities Moving Forward Opportunities to encourage widespread implementation include: Facilitating shared learning (e.g., job descriptions, basic templates for roles and responsibilities, training modules, metrics used, etc.) Expanding activities to new sites of care (e.g., hospitals and skilled nursing facilities) Involving payers Aligning workforce changes with other changes related to process redesign, health IT implementation, decision support tools, patient registries, etc. ACOs and other high performing delivery systems offer a unique opportunity to apply the lessons learned. ACOs have an environment for clinical transformation and team based care ACOs have a financing mechanism to benefit from reduced cost or gained efficiencies in productivity or workflow 28

29 Innovative Workforce Solutions in an Accountable Care Environment Edward Salsberg, MPA Director, National Center for Health Workforce Analysis Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions Accountable Care Organization Summit Washington DC June 13, 2013

30 The HRSA National Center for Health Workforce Analysis To support more informed public and private sector decision making related to the health workforce through expanded and improved health workforce data, projections and information. To promote the supply and distribution of wellprepared health workers to ensure access to high quality, efficient care for the nation. 30

31 HRSA Data Sources and Tools (1) The Area Resource File (ARF) Data from more than 50 sources on health workforce, health facilities, utilization, population and health status by county (and states by September) with excellent tool for comparison across counties and states Compendium of Federal Data Sources for Health Workforce Analysis ces.pdf 31

32 HRSA Data and Tools (2) Health Professions Minimum Data Set (MDS) Project Designation of Health Profession Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs) Issue briefs on NPs, PAs, dental hygienists, and pharmacists prepared by the National Governor s Association 32

33 NP Growth Growth in NP 1 Graduates, Graduates Year Source: American Association of Colleges of Nursing Annual Surveys 1 Counts include master s and post-master s NP and NP/CNS graduates, and Baccalaureate-to-DNP graduates. 33

34 PA Growth Newly Certified PAs, Newly Licensed PAs Source: Year National Commission on Certification of Physician Assistants Certified Physician Assistant Population Trends ; 2012 data from personal communication with NCCPA January 16,

35 National Center for Interprofessional Practice + Education (IPE) Overview: Five-year cooperative agreement Main site: University of Minnesota Aims: Provide unbiased, expert guidance on interprofessional practice and education Enhance the coordination and capacity building among health professions and particularly medically underserved areas Raise the visibility of high quality, coordinated, team-based care that is well-informed by interprofessional education and best practice models 35

36 Center for Medicare and Medicaid Services Health Care Innovation Awards Most approved projects include plans to use workers in new ways, including: Care coordinators and better management of patients; Use of inter-professional teams; Use of patient navigators; Use of community health workers; Use of advanced aides, assistants; Improved care transitions and in home services; and Greater use of telemedicine and Health Information Technology (HIT) 36

37 State Workforce Tools State colleges and universities Scholarships and loan repayment Workforce Investment Boards Payment policies (Medicaid, state employees, others) including for non-physician clinicians State scope of practice policies and regulations HRSA supported: State Primary Care Offices (PCOs), Area Health Education Centers (AHECs) and State Offices of Rural Health (SORH) 37

38 Contact Information Edward Salsberg, MPA Director, National Center for Health Workforce Analysis

39 Track Three: Delivery System Reform and Clinical Transformation INNOVATIVE WORKFORCE SOLUTIONS IN AN ACCOUNTABLE CARE ENVIRONMENT Kavita Patel, MD, MSHS, Fellow and Managing Director, Clinical Transformation and Delivery Reform, Engelberg Center for Health Care Reform, The Brookings Institution Norma Ferdinand, MSN, RN, DNSS, Senior Vice President, Chief Quality Officer, Lancaster General Hospital Marcia Guida James, MBA, MS, CPC, Director, Provider Engagement, Humana Edward Salsberg, MPH, Director, National Center for Health Workforce Analysis, HRSA Tom Strong, MBA, Program Officer, The Hitachi Foundation

40 Fourth Annual National ACO Summit June 12 14, 2013 Follow us on Twitter and use #ACOsummit. The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute