Health Care Transformation FEE FOR SERVICE TO FEE FOR VALUE Valley Office Practice Forum 6/13/17
Agenda Unsustainable Trends in Health Care Payment Reform: Value Based Payment Models Defining Population Health VHS Population Health Strategies Core Competencies Clinically Integrated Network
Unsustainable Trends Rising Costs and Lower Quality
Two Major Challenges of US Healthcare Combine to Yield Lower Value Rising Healthcare Costs Unsustainable for Employers and CMS. ($3.2 Trillion Total Health Care Spend/17.8% of GDP More than twice the average per capita costs of other developed countries) US ranked last among other developing countries in Quality of healthcare. (Commonwealth Fund in their latest report Mirror, Mirror On The Wall 2014 Update )
CMS Sets Aggressive Goals to Create Value SETTING THE TRENDS FOR ALL PAYERS Transition To Risk FFS Tied To Value 50% 90% 20% 30% 80% 85% 2015 2016 2018 Tied To Risk Models ALTERNATIVE PAYMENT MODELS MSSP ACOs Bundled Payments CPC+ 2015 2016 2018 Tied To Quality Hospital: Value Based Purchasing Program Hospital Acquired Condition Reduction (HACs) Hospital Readmission Reduction Program (HRR) Physician: Merit Based Incentive Program
Payment Reform Transition to Value Based Payments
Current CMS Payment Programs INCREASING RISK TO PROVIDERS OF CARE Pay/Penalty for Performance Bundled Payments Shared Savings Shared Risk Full Risk Pay for Performance Readmission Penalties Mandatory (2017) Merit Based Incentive Program or Imposed Value Base Payment Program Bundled Payments Bundled Payment for Care Payments Improvement (BPCI) Comprehensive Care for Joint Replacement Model (CCJR) Episode Payment Models (EPMs) Shared Savings Shared Risk Full Risk MSSP Track#1 (50% sharing) Increasing Risk MSSP Track #2 (60%) MSSP Track #3 (75%) Next Generation (80 85%) Next Gen Full Risk Medicare Advantage
Bundles/Episodes of Care THE TYPICAL MODEL Discrete DRG/Dx Episode usually begins with acute care admission Usually ends after 90 days Accountability for cost and quality (HCAHPS/Risk Adjusted Complications) Includes costs from both Part A&B Retrospective reconciliation of actual vs. target costs If < X (~2%) savings the payor recoups payments Gain sharing distributed to hospital/providers based on predetermined matrix
Bundles/Episodes of Care TRENDS An increasing cost containment methodology FFS to FFV Increasing risk shifted to provider side Increasing downside risk Increasing number of mandatory CMS programs Gain sharing opportunities Forcing collaboration Financial pressure Inclusion of quality metrics
Accountable Care Organizations THE TYPICAL SHARED SAVINGS MODEL A group of providers contract with a payor Predetermined attribution methodology Base rates unchanged Baseline costs are measured Potential gain sharing if the total cost of care (PMPM) reduced below a predefined threshold ACOs have varying downside risk (0% 100% Full Risk) Gain sharing % based on predefined quality performance thresholds
Medicare Advantage Competing Model NOT THE FIRST STEP: REQUIRES TAKING ON FULL RISK Regionally Disparate Penetration: NJ ~15% MA Is this a Threat/Opportunity? MA Enrollment to Double By 2025 Millions 35 30 25 20 15 10 5 0 (40%) (30%) (13%) 2005 2015 2025
Defining Population Health Management POPULATION HEALTH MANAGEMENT Taking accountability for, and managing the health of an attributed population with the objective of improving the health outcomes, lowering the cost of care, and improving the patient s experience.
VHS Population Health Strategies A HIGH LEVEL OVERVIEW
50% of Healthcare Spend 20% 40% 5% Rising Risk Patients 18% Conversion At Risk Patients Success Factor #1:Segmentation APPROPRIATE INTERVENTION AT RIGHT TIME FOR THE RIGHT PATIENT High Cost Patients Centralized Complex Care Management Disease Management Centers CHF Center HTN Initiatives CKD Programs COPD Clinic Multiple Hospitalizations/Terminal Multiple Chronic Dz/Uncontrolled Dz Pre-Dx/Controlled Chronic Dz Office Care Team (PCMH) 35% Healthy Patients Clinical Risk Social Risk Behavioral Risk No Current Illness/ Risk Patient Engagement Methodologies Patient Portal Gaps in Care Management Wellness Programs Preventive Health Outreach
Success Factor #2: Leveraging the System A HOLISTIC APPROACH TO AN ORGANIZATIONAL PIVOT Provider Network Expansion The integrated network defining market share Innovative Payment Models Increasing levels of risk Upfront Investments Backend Payments (ROI) FFV CMS & Commercial Contracts Transformational Integration & Coordination Employed & Voluntary Payer Engagement Systemness Population Health Enhanced Physician Leadership Competitive Consumer Pricing High Reliability Organization A System Wide Goal of Zero Harm Access & Experience Consumerism Cost and Service (Value) Transitions in Care Coordination throughout the Continuum of Care Home Care Extensivist Dz Management Timely Accurate Actionable Information Information Technology System Wide Interoperability 15 I
Population Health Department COMPLEX CARE MANAGEMENT/TRANSITIONS IN CARE Opened 1/1/16, internally resourced Now coordinating care for all VMG patients Functions: Coordinate follow up visits Arrange for appropriate services Medication Reconciliation Communication with providers Over 4,000 patients managed to date Rolling readmission rate is significantly reduced Post Acute Navigators: Reducing LOS/Readmissions from Post Acute facilities Gaps In Care Resolution Goals: Reduce unnecessary readmissions Increase quality of care Improved patient experience
Geriatric Services: Medical Director, Dr. Bennett Leifer Additional Geriatrician/Two APNs Transition In Care Program IMPROVING CONTINUITY OF CARE Director of Palliative Care, Dr. Puneeta Sharma Physiatry/Rehab Services: Medical Director, Dr. Ryan Murphy Recruiting for Rehab Physiatry APN Collaborating with Dr. Girardi s group Post acute Transition in Care Navigators Functions: Inpatient consultation services Coordinate with Care Management team Continuous care in preferred post acute facilities Goals: Decrease ALOS and hospital readmissions Increase quality of care Improved patient experience
Illustrative Example: CHF MR. STARLING Mr. Starling is an 86 year old widowed man who suffers from Congestive Heart Failure for the past 5 years (mortality 50%). He also has Type II Diabetes, Hypertension, Vascular Insufficiency with foot ulcers and numbness. His shortness of breath has worsened and his primary care provider asked him to call the ambulance and go to the ED.
Mr. Starling No Elements of Population Health Seen in ED and admitted to the Hospitalist service. Cardiologist/Vascular Surgeon consultations. The Cardiologist uses diuretics and an ACE Inhibitor to remove the fluid on his lungs. The Vascular Surgeon recommends wound care. After 4 days the discharge team is consulted and plans are made for Mr. Starling to be transferred to a post acute facility to regain his strength. He is discharged on Day #6 to his home (ALOS 6 days) He was not seen by his cardiologist since his hospital discharge, gets worsening shortness of breath and along with his foot ulcers falls and fractures his hip (Mortality ~ 20%)
Mr. Starling Population Health Management Seen in ED and admitted to Hospitalist Service Transition In Care Physicians consulted: CHF, Geriatric and Physiatry services The CHF Service uses EBM protocols. The geriatric team identifies a fall risk due to foot numbness and vascular ulcerations. They recommend a wound care consultation and home fall risk assessment upon discharge. The Transition in Care Coordinator (TOC) is notified of Mr. Starling s admission (Day #2) and speaks with the hospitalist and home care with regard to discharge planning. TOC assigns Mr. Starling to a Complex Care Manager (CCM) who arranges for Home Care, Geriatric Home Assessment, home PT and wound care (Continuity of Care). He is discharged to home on Day #4 (readmission risk 7.8%) The CCM reconciles all medications, calls Mr. Starling as needed over 30-90 days keeping all his providers updated.
Formation of Clinically Integrated Network A Clinically Integrated Care Organization is a physician led, professionally managed organization centered around a common clinical program to reduce clinical variation, improve quality and drive down cost of care Providers aligned through collaborative care Network is inclusive of both independent and system employed providers All CI providers agree upon an enhanced clinical quality program The Network is allowed to collectively negotiate with payers Supporting infrastructure enabling value based initiatives Supports CIN initiatives and provides the back office administrative and IT support for the network Has the ability to scale population health capabilities Clinically Integrated Network Population Health Infrastructure At a high level, Clinical Integration (CI) is a strategy in which physicians partnership with a health system (Physician Alignment) make a significant, collective commitment to performance improvement and an investment in infrastructure to see significant returns through these quality and efficiency gains
Why a Advantages of a VHS Clinically Integrated Network Partnering with Providers to Improve Quality of Care Alignment: Employed/Independent Reduced Variation in Care Self governance of physicians Potential for Enhanced Reimbursement Furthering the goal of Zero Harm Reduce CMS penalties Shared Savings contracts Gainsharing in Bundled Payments Inclusion in High Quality Network Overall greater negotiating leverage Enhanced keepage in network referrals High level of clinical integration Avoidance of Narrow Network exclusion
23 Picture of Board POCof Managers/VHS Administrative Support 2016 Advisory Board All Rights Reserved advisory.com
Closing Comments QUESTIONS