Understanding Payment Models in a World of Valuebased Care Under MACRA Mark Schafer, MD Chief Executive Officer MemorialCare Medical Foundation March 23, 2017
Capitation and Medicare Advantage 2
Agenda 1. Overview of MemorialCare Health System 2. Our Journey into Value-based Care 3. Keys to success with Capitation & Medicare Advantage 4. Questions 3
A Few Facts About MemorialCare Health System Revenue $2.4 Billion Bond Rating AA- stable Hospitals Patient Discharges 69,000 MemorialCare Medical Foundation Patients 730,000 At-risk Lives 265,000 Workforce Employees 11,200 Affiliated Physicians 3,300
MemorialCare Hospitals
MemorialCare Medical Foundation 261 Employed Providers 170 PCP s 50 Specialists 41 Advanced Health Practitioners 1500+ contracted Specialists Independent Practice Association 170 PCPs 900 Specialists 17 Employed Primary Care Physicians
Growing Outpatient Presence 360 PCPs, 2,200 Specialists >50 PCP Health Centers 12 Urgent Care Centers 10 Imaging Centers 9 Surgery Centers 13 Dialysis Centers 265,000 At-Risk Lives 148,000 HMO Lives 107,000 ACO Lives
Journey in Value Based Care 9
Capitation versus FFS Living in two worlds at the same time is challenging
The ACO Bandwagon0 32,900 18,000 27,000 NEXT GENERATION 20,900 8,600 11
400 PCP s >2000 Specialists 9 Hospitals 10 Surgery Centers 19 Imaging Centers 22 Dialysis Centers Boeing Preferred Partnership
Reasons for ACO Shift Commercial HMO membership is flat Protect and grow new membership (Boeing, other employers) Marketing and branding opportunity that plays to our strengths Potential financial upside Physician alignment Catalyst for transformation CA HMO Commercial Enrollment
HMO vs PPO Cost 2010-2016 14
15
In California.. Capitation is 16
Benefits of Capitation Upfront Cash Flow Ability to invest in infrastructure and care model redesign Aligns incentives (away from volume) Facilitates physician incentives Creates risk environment 17
Keys to Success 18
6 Keys to Success with Capitation Data Analytics Robust Medical Management Infrastructure Information at the Point of Care Physician Alignment and Leadership Risk Adjustment Ambulatory Shift 19
Data Analytics Modeling and understanding cost trends Risk stratification Identify candidates for: Care management Chronic disease management Special clinics 20
Sample Cost Trend Analytics
Sample Risk Stratification 22
Sample Patient Drill Down **No PHI used not a real patient 23
Robust Medical Management Infrastructure Case Management & Care Coordination Special Clinics Discharge Clinics Intensive Outpatient High Risk/Diabetes Provider Contracting & Network Management Sub-capitation of specialists Education of network physicians 24
Information at the Point of Care Risk adjustment LYNTY Box Gaps in care Prevention Chronic diseases Identification of network specialists HMO, Boeing, Next Generation, etc 25
Sample LYNTY Box 26
Sample HCC Gaps 27
Physician Alignment & Leadership Network of engaged physicians specialists and PCP s Mechanism to align physicians Panels Risk Adjustment Quality Strong physician leaders Variations in care 28
Risk Adjustment Critical to Medicare Advantage capitation Physician Champion Educating physicians Tweaking the EMR Coders/Auditors Ensure appropriate documentation Reward risk level 29
Ambulatory Shift Site of service 10 Imaging Centers 9 ASC s 13 Dialysis Centers 12 Urgent Care s Avoidance of admission ED to SNF Focused partnerships (eg. Dialysis)
6 Keys to Success with Capitation Data Analytics Robust Medical Management Infrastructure Information at the Point of Care Physician Alignment and Leadership Risk Adjustment Ambulatory Shift 31
Questions? Mark Schafer, MD mschafer@memorialcare.org 32