TKG Health Systems Advisory Panel Meeting Healthcare in 2017: Trends & Hot Topics Tuesday, March 24 th, 2017 Gaylord Texan Resort, Grapevine, TX
Executive Summary Key Trends The transition to value-based care remains challenging for health systems and medical groups. Issues that are currently top-of-mind for health systems and medical groups: Addressing the value-delivery catch-22: Reducing admissions and readmissions also destroys demand and reduces revenue. Health systems are offsetting these losses by focusing on the Medicare segment and working to grow market share. Moving the culture to a value mindset: Having value discussions that clearly break down the details of value-based contracts, the details of such value-based contracts as bundled payments that can help ensure all care team members are going in the same direction. Using extended care teams to improve the patient experience while reducing unnecessary costs: Pilot programs using teams that include physicians, care managers, behavioral health specialists, and pharmacists, with a focus on closing gaps in medication reconciliation, have been successful in reducing readmission rates and increasing patient adherence. Taking a more holistic approach to formulary decision-making: Formulary decisions now hinge on long-term value rather than on short-term costs, and pharmacists and specialists are becoming more involved in the decision-making process to ensure that both patient experience and total care costs are being evaluated. Addressing the physician shortage: Medical groups and health systems with value-based contracts find it difficult to attract primary care physicians and specialists, and to structure compensation such that these providers are rewarded for achieving. Moving out of the Merit-Based Incentive Payment System (MIPS) and into alternative payment models (APMS) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): Provider groups, including specialists, are interested in moving into APMs, but are frustrated by the limited number of qualifying APMs. To address this, some provider groups have collaborated to develop and propose additional bundled payment models for as many as 113 acute and chronic episodes of care. Impact for Pharma Demonstrating the value of medications via Return on Investment (ROI) to payer and provider leadership is critical to gaining formulary placement and ensuring access. Higher price points can be justified if the medication is shown to reduce readmissions or ER visits, demonstrate improved efficacy and/or improve overall patient experience. Generic options will trump branded rebates 80% of the time. Personalized medicine will be a game changer that transcends the value equation. Partnerships between pharma, payers, and providers can help targeted patient populations receive better access to care and improve their adherence to treatment. Providing educational resources for patients and providers, and increasing access to devices and medications, positions pharma as a valued partner. More bundled payments are forcing payers and providers to assume increased risk. They want pharma to have skin in the game as well, particularly since medication costs can account for a significant percentage of the cost of an episode of care. 1
Success In Delivering Value-Based Care Can Negatively Impact The Bottom Line You have to be in value-based contracts; otherwise, you re investing in all this infrastructure (eg, population health technology, a care management team), and you re not getting paid for it on the other end due to demand destruction. - Large IDN, Northeast Successfully moving to a value-based care model, which emphasizes outpatient care over inpatient treatment creates a catch-22 for integrated health systems: by reducing admissions and readmissions, they are also destroying demand and reducing revenue. (For medical groups, there is less downside of demand destruction.) Health systems must weigh the ROI of costly requirements associated with value-based care (eg, Information Technology (IT) infrastructure and additional staffing). Revenue tied to value-based contracts must be sufficient to offset the investment. There are multiple opportunities for hospitals and health systems to offset the revenue loss resulting from reducing readmissions. A growing market share presents opportunity for recouping revenue. In addition, moving to outpatient care yields more revenue opportunity in the Medicare segment. [After] your interventions, you see your admissions drop very quickly and you have to manage that with market share expansion. We ve expanded from 3 to 5 counties and grown 2% in market share. For a hospital, 1% change is huge. Mid-sized ACO, Midwest Gaining Buy-In From Care Team Members, Especially Specialists, Is A Critical Success Factor In Transitioning To Value-Based Care Models The real fight within a multispecialty group is how you split up the money. Primary care doctors are doing all the work, but specialists are used to making more. Large Multi-Specialty Group, Northeast Care coordination can help reduce costs, but all care team members need to be on board. Specialists in particular want to know how their interests will be protected. Discussions around the opportunities and challenges connected with value-based care can help break down silos. Once you show a provider what a bundle looks like, they will never practice medicine the same way ever again. It is that powerful. Large IDN, South Central 2
Value Discussions Are Critical To Pharmacy and Therapeutics (P&T) Decisions You have to show what the value stream looks like for that patient experience. Good oldfashioned lidocaine is a good example. Surgeons inject it into incisions and patients go home 2 days earlier because they have no incision pain. The pharmacy cost looks awful, but when you look at episode costs, it looks fantastic. Large IDN, South Central Hospital stakeholders, health plan stakeholders, and pharmacy decision-makers have traditionally operated in silos, making decisions without seeing the whole picture. To be successful in value-based care models, stakeholders will need to adopt a holistic view considering both patient experience and total cost of care. Further complicating therapeutic decisions is the fact that health systems carry distinct contracts with different payers thereby creating conflicts. One risk model might drive you to drug A, but another, because of the discounts, drives you to drug B. It s very, very difficult to explain to two patients why they re getting two different drugs. Mid-sized ACO, Midwest Stakeholders need to collaborate on formulary decisions, taking the big picture into account. Pharmacists and specialists must be included in conversations since they can help determine the relative efficacy and cost-effectiveness of treatment choices for particular patient groups. Including the cost of medications in value-based contracts a component that was not included in the past can help mitigate risk. I only have one vital sign it s called total cost of care. Large IDN, South Central Probably 80% of the time, it s about generic; the other 20% of the time we need a medicine that s not generic that has a particular benefit that s above and beyond what a generic will do. Large ACO, Northeast Once a formulary decision has been made, technology and traditional methods can help ensure the uptake of cost-effective options. One health system has set up pop-ups in their electronic health records (EHRs) that show generic options, and when a medication becomes available that matches the efficacy of existing drugs but reduces costs, that information is disseminated to physician groups who are asked to use the new option. To retain margin, some health systems have even begun to blur the lines between payers and providers. Ochsner Health System, for instance, now has 10 retail pharmacies, has launched its own specialty pharmacy, and anticipates launching its own pharmacy benefits manager (PBM). Impact For Pharma Demonstrating the value of medications to payers and providers will be critical to ensuring access. The placement of products on formulary will require conversations between pharma and internal leadership, and even then generics will trump branded rebates 80% of the time. Gaining formulary positioning for new, more costly medications will be especially challenging among customers who are in value-based contracts. In addition to proving that these medications are efficacious, pharma will need to demonstrate that their higher price points can be justified by a strong ROI. Personalized medicine will be an exception to this rule since it s a game changer that transcends the value equation. One particular medication showed a definite decrease in readmission rate and efficacy, but came out at a price point that was so high it didn t actually prove an ROI. But if I were a patient, I would want to be on that medication for sure. Large IDN, Northeast I don t want to buy drugs; I want to buy value. I don t really care what the price is. Show me how it s creating value. Show me that somebody is not going to be in the hospital or the ER. Show me that the quality of life is going to be better. Large IDN, South Central 3
Extended Care Teams Can Improve Management Of Patients With Chronic Conditions We re taking on the whole concept of comprehensive medication management by embedding pharmacists within the practice as part of the team, along with behavioral health providers, physicians, and extenders. Large ACO, Northeast Under value-based care models, health systems have to find innovative solutions for problems like improving patient adherence and managing high-risk populations with extensive health care services needs. Gaps in medication reconciliation contribute to low adherence and high readmissions rates. Care management is a critical component of value-based care. Care managers help ensure that patients get their medications and follow treatment plans. Cornerstone piloted two programs that demonstrated the results of effective care management. The first pilot program used extended care teams, that included physicians, behavioral health providers, and pharmacists, to manage heart failure, oncology, and chronic care patients. A key element of the program was medication management via a pharmacy hub. Pharmacists worked both with providers and directly with the patients themselves, particularly when more complex medication issues were a concern. The approach reduced costs by 20%. In collaboration with pharma, Cornerstone also launched a pilot program aimed at increasing adherence among chronic obstructive pulmonary disease (COPD) patients. Together they developed a care model which incorporated specific care pathways and utilized respiratory therapists in an extended role that included going to patients homes. The hospital s readmission rate, which had started at 15%, went down to 6% after implementing the program. Impact For Pharma Partnerships between health systems and pharma companies can improve access and adherence for certain patient populations. Providing educational resources for patients and providers, along with services that increase access to devices and medications, positions pharma as a valued partner in patient care. Love partnerships with pharma, but they have to be extraordinarily transparent so that the prescriber (physician, nurse practitioner, etc.) can understand for that patient why that s the right product. Mid-sized ACO, Midwest 4
Now That MACRA Has Gone Into Effect, Providers Are Interested In Moving From MIPS To APMs There s a lot of interest in MACRA and how to get out of MIPS by getting into APMs, and the focus is coming out of specialty work as opposed to primary care. Large ACO, Northeast The Medicare Access & CHIP Reauthorization Act (MACRA), which went into effect in January 2017, offers two participation tracks: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). Most providers are participating via MIPS, but are interested in moving into APMs, these are higher risk/reward opportunities and would exempt them from reporting on measures and activities for MIPS. However, qualifying APMs are limited in number and scope. Provider groups, including specialist groups, can request the evaluation of alternative payment models, along with recommendations for their implementation. For instance, the American College of Surgeons is the Physician-Focused Payment Model Technical Advisory Committee (PTAC), with a proposal offering bundled payment options for as many as 113 acute and chronic episodes of care. Impact For Pharma Medication costs can account for a significant portion of episode of care costs, so there s a need for pharma to partner with payers and providers who are implementing bundled payment models in ways that are helpful, creative, and innovative while also meeting regulatory standards. Payers and providers currently bear the risk and believe that, for partnerships to be successful, pharma must have skin in the game as well. Payers like Aetna and Horizon have expressed willingness to partner with pharma on creative solutions for episodes of care. You have to change your whole way of marketing and partnering. Large Multi-Specialty Group, Northeast 5
The Physician Shortage Makes It Difficult To Attract Talent The physician shortage has made it difficult to recruit primary care physicians and specialists. Many residency programs have tried to solve the problem by hiring young doctors, who lack necessary experience. Once hospitals and medical groups have succeeded in attracting primary care physicians and specialists, they are then faced with the additional challenge of determining how to structure their compensation to align with value-based care goals. Further compounding the problem is the fact that young physicians want to live in cities, making recruitment more difficult outside of urban settings and affecting access for patients. Medical groups that have been unable to recruit specialists because of market conditions have collaborated with hospitals to recruit indirectly. Since a hospital may be able to offer additional resources or a more desirable location, leasing a specialist to sign a 3-year contract, When the contract ends, they would then have the option of moving to the medical group s independent model. Some health systems find that it makes sense to use mid-level providers in Medicaid clinics and use intensivists in chronic care clinics. TKG is a strategy and execution consultancy that empowers life sciences companies to effectively engage with health system and payer customers by developing strategies and real-world solutions that result in improved relationships and market access. Our work includes strategic development, marketing program planning, account manager training, and pull-through execution. Through our direct work with health systems and payers to implement value-based delivery models for identified patient populations, TKG has an unsurpassed knowledge of key drivers and areas of shared priority that are applied to our work with life sciences clients. Our deep health systems experience, and the valuable perspective it offers, creates breakthrough value for our life sciences clientele. 6
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