An ACO Participation Framework Rod Piechowski, Senior Director, HIMSS
Conflict of Interest Rod Piechowski, MA Has no real or apparent conflicts of interest to report.
Conflict of Interest Rod Piechowski, MA Salary: Royalty: Receipt of Intellectual Property Rights/Patent Holder: Consulting Fees (e.g., advisory boards): Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g., speakers bureau): Contracted Research: Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds): Other:
Agenda Welcome Value Suite New Payment Models ACO Navigator
Learning Objectives Identify the requirement to participate in an ACO as a provider Describe the hierarchy and vocabulary of the requirements Apply framework to strategic planning
Health IT & Value Suite
Patient Satisfaction Improved Quality of Life Improved Accessibility of Records Reduction in Readmissions Increased Information Sharing Among Providers Improved Patient Compliance Better Chronic Care Management Overall Improvement in Prevention Improved Workflow Overall Operational Savings More Efficient Resource Usage
New Payment Models
New Payment Models Goal #1: 30% of Medicare payments are tied to quality or value through alternative payment models (i.e. ACO, medical homes, bundled payments, comprehensive primary care initiatives, pioneer ACOs) by the end of 2016, and 50% by the end of 2018. Goal #2: 85% of all Medicare fee-for-service payments are tied to quality or value (same as goal #1, plus hospital value-based purchasing, physician value based modifier, readmission/hospital acquired conditions reduction program) by the end of 2016, and 90% by the end of 2018.
New Payment Models In 2014, 20 Pioneer and 333 Shared Savings Program ACOs generated more than $411 million in savings, which includes all ACOs savings and losses. In the third performance year, Pioneer ACOs showed improvements in 28 of 33 quality measures and experienced average improvements of 3.6% across all quality measures. Shared Savings Program ACOs that reported quality measures in 2013 and 2014 improved on 27 of 33 quality measures. More than 420 Medicare ACOs have been established, serving more than 7.8 million Americans with Original Medicare as of January 1, 2015.
New Payment Models
MACRA & MU - What's coming? Merit-based Incentive Payment System (MIPS) The MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program based on: Quality Resource use Clinical practice improvement Meaningful use of certified EHR technology
MACRA Alternative Payment Models (APMs) ACOs, patient centered medical homes and bundled payment models. APMs give us new ways to pay health care providers for the care they give Medicare beneficiaries. For example: From 2019-2024, pay some participating health care providers a lump-sum incentive payment. Increased transparency of physician-focused payment models. Starting in 2026, offers some participating health care providers higher annual payments.
New Payment Models - Payers
UnitedHealth Group Payments tied to value have tripled the last 3 years to $36B in 2015 and expect that number to rise to $65B by the end of 2018
Anthem Value-based spending will rise from $38 billion in 2014 to $65 billion in 2018. Currently, about 30% of its total health providers approximately 40,000 are involved in value-based payment contracts.
Aetna Has approximately $20 billion about 30.6 percent of its total spending tied to value-based contracts, with a goal to achieve 75% by the end of the decade
Cigna Agrees to the goals set by HHS, including 90 percent of payments in value-based arrangements and 50 percent of payments in alternative payment models by 2018
Humana In 2014, Humana paid $76.8 million to physicians participating in the program (Accountable Care Continuum Program), in addition to their normal reimbursements. That is a 28 percent increase from the $60 million paid to physicians in 2013.
BCBS Blue Distinction Total Care estimated savings were > $840 million over traditional payment models on an annual basis. Payments represent approximately 20 percent of BCBS medical claims and serve more than 25 million members nationwide
ACO Navigator The content in this section was derived from materials previously developed by CCHIT.
ACO Navigator http://www.himss.org/value-suite/
Pillars
Care Coordination Access real time health insurance coverage information Establish payer relationships Establish provider relationships Share clinical data during transitions of care Identify best setting for care Identify social and community supports Manage referrals Patient-centric medication management and reconciliation Clinical information reconciliation
Cohort Management Identify desired cohorts of patients from within entire population Monitor individual patients Patient engagement within cohort Engage preferred providers and clinicians in care teams Shared care management plan Interventions Follow up Monitor cohort
Patient & Caregiver Relationship Management Informational services Administrative simplification for patients Patient educational services Patient communication Patient engagement in their own care Patient willingness and confidence to assume appropriate responsibility for care Monitor individual patients Patient experience of care surveys
Clinician Engagement User friendly, timely and actionable Clinical Decision Support (CDS) Standardized clinical assessment tools Well defined patient specific care teams Communication tool used within the organization or on the patient care team Communication tool for use in settings outside of accountable organization Administrative simplification for providers Usability of clinical information technology Clinical education at point of care Access to information about community based resources Access to public health information Access to information on research protocols
Financial Management Administrative simplifications for operations Normalized and integrated data Assessment of the health of the organizations population of patients Assignation of patients to a particular clinical or practice Performance reports Risk sharing analytics Payer contract management Cost accounting Reimbursement systems for all forms of payment types Billing for revenue outside of contracts Provider contract management
Reporting Retrieve data specific to quality metrics Store data specific to quality metrics Calculate quality metrics Report quality metrics for internal use Reporting quality metrics to external designated entities Public health reporting syndromic surveillance Registry reporting Report on resource usage, costs and patient feedback at all managerial levels Reporting of adverse events to patient safety organizations
Knowledge Management Clinical Decision Support (CDS) Personalized presentation of information that is specific to a given patient Create and share clinical knowledge Create and share process improvement knowledge Support comparative effectiveness research
Deep Dive Cohort Management
Cohort Management Identify desired cohorts of patients from within entire population Monitor individual patients Patient engagement within cohort Engage preferred providers and clinicians in care teams Shared care management plan Interventions Follow up Monitor cohort
Cohort Management
Value of HIT in ACOs Greater Rochester Independent Practice Association: reduced wait times: increased Satisfaction Marshfield Clinic: reduced drug errors: Treatment/Clinical University of Iowa Hospitals: improved quality reporting: Electronic Secure Data Lone Star Circle of Care: increased screenings: Population Management U of I Hospitals: reduced length of stay: Savings, Treatment/Clinical, Satisfaction
Questions Rod Piechowski, MA Senior Director, Health Information Systems HIMSS North America Office 312.915.9550 Mobile 312.909.3918 33 West Monroe Street Suite 1700 Chicago, Illinois 60603 Twitter: @RodP_HealthIT