SUCCESS IN A VALUE - BASED PAYMENT ARRANGMENT October 3 rd, 2017 David Evangelista MediSys Health Network 1
Who is MediSys? Jamaica Hospital is a 431-bed not-for profit teaching hospital. Jamaica is a Level 1 Trauma Center and Stroke Center. It has one of the busiest Emergency Departments in the US, with almost 130,000 patients treated each year. Flushing Hospital is a 293-bed not-for-profit teaching hospital. Flushing services one of the most one of the most ethnically diverse populations in the United States. Employ 500+ physicians, and have relationships with community physicians as well as large community based IPA s. Employ ~ 100 staff members in a value based care management role. We bet the farm on Value Based Reimbursement! MediSys takes full capitated risk on 133,000 lives and has 15,000 lives in other Value Based Reimbursement contracts Shared Savings/Shared Risk. Majority of the lives are in a Managed Medicaid product. Looking to grow this number. 45% of our patient revenue comes through value based reimbursement. Administration has been in leadership roles at MediSys for 40+ years each. Part of Advocate Community Partners (ACP) PPS for DSRIP. This is the only physician-led PPS in New York State. MediSys Health Network serves as the safety net for the surrounding community. MediSys includes a state of the art Skilled Nursing Facility known as the Trump Pavilion, a large ambulatory care network, a free standing mental health clinic with two locations, and are integrated into the NYC 911 EMS system with our hospital based ambulances. MediSys also offers physical rehabilitation, psychiatric and chemical dependency services. 2
Medisys Health Network 45% of our organizations revenues are from Value- Based Payments 133,000 fully capitated lives that we take full risk for 750,000 Ambulatory care visits 165,000 Emergency department visits 5,500 Newborn deliveries 6,000 employees 3
Hospital Market Queens County Most culturally diverse county of the 3,000 counties in United States Over 135 spoken languages 4
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MediSys Health Network Payer Mix Medicaid - 60% Medicare - 20% Self pay - 5% Commercial - 15% 6
Organizational Priority High quality + Low cost = Value 7
Healthcare Reimbursement Shift from volume based payment to value based payment. Hospitals and physicians that provide patient-centered, high quality, low cost healthcare will be the leaders. Hospitals and physicians will be rewarded for meeting quality objectives for their entire patient population, not just those patients actively seeking care. 8
Critical Issues to be Addressed Success on Risk Contracts is essential to overall MediSys success We developed a contracting plan to successfully manage the contracts Many services are delivered at provider locations other than MediSys Increase the proportion of hospital services provided by MediSys by ten percent. Achieve through physician education, PCP connectivity and effective Care Management. 9 We needed data infrastructure to manage this size risk population Worked with our IT Dept on data development and claims data tools. MCO needed to increase reporting and data sharing.
Critical Issues to be Addressed Many MediSys staff are involved with managing the risk contracts, but no one is fully devoted to it. We didn t set up a dedicated department but rather created a team of multi-disciplinary staff, including Administration. Our CEO and CFO are involved in every aspect of our risk agreements. It takes a village Significant downside risk, so one bad year could be very harmful. Get it right the first time as we can t be wrong. Track early indicators for advance warning of negative results. Physicians not fully engaged in shift to Value Based Payment. Collaborate w. employed and independent physicians to drive improvement on value based arrangements. Takes a while to change culture. 10
Key Findings The most costly 5% of all patients account for 70% of costs The 5% became our focus. Throw out the outliers and care management focused on the remainder to reduce the total cost of care. Identify your high cost beneficiaries, both today and tomorrow. Two-thirds of IP care goes out of network (based on costs). Higher for behavioral health services. Utilize care management programs as a differentiator. Focus on services you provide, not ones you do not. PCP connectivity. 11 ED utilization for Medicaid beneficiaries was high compared to benchmarks DSRIP initiatives helped. Flagged members in EPIC to connect members back to PCP. Care Management initiatives assisted.
12 Value-Based Contracts (VBC) How ready is your organization, your physicians, and the key players you have contracts with for VBC? Neighborhood Health Providers (NHP) HealthFirst Depending on type of value-based arrangement, performance is measured differently. Full risk Shared risk Shared savings
What are the goals? Population Health Minimize the cost of care. Enhance the overall health status of a given population. Provide care at the earliest practical point, not treating disease at the acute care level. Minimize expensive interventions, i.e. hospitalizations, emergency room visits, or expensive diagnostic testing. 13
Where to begin Before you start any meaningful population management, you need to have information to analyze. This itself is challenging because you need information about services performed inside and outside your network to get the full picture. Data has been more forthcoming and advancements such as DSRIP, risk arrangements and Health Information Exchanges should supply a lot of this data going forward. 14
Care Management Even with somewhat limited external data, we made our first step at Care Management by identifying high cost high frequency patients. Within that cohort, identifying those than can be potentially impacted by intervention. These actions will likely provide the biggest bang for the buck, as a relatively small number of members make up an extraordinary portion of the cost. 5% of the patients represent 70% of the cost. 15
Care Management Following at-risk patients to prevent 30 day readmissions. Engagement with patients in house at the hospital. Initiatives to reach out to members discharged from other facilities, something we were not always comfortable doing. Readmission rates have been historically higher for our members discharged from other facilities. 16
Care Management Goals & Focus Improve the health of our community Reduce/avoid unnecessary hospitalizations Close gaps in care 17
Top Members by Utilization Frequently Admitted Members Currently Engaged in CM Program Top 50 Members by Dx Diagnosis Count Diagnosis Count Sickle Cell 6 CHF & Asthma 1 Alcohol Abuse & Dependence 5 ESRD 1 CHF 4 CHF & Chest Pain 1 Alcohol & Drug Dependence, Psych 2 Intracranial Hemorrhage 1 COPD 2 CHF & Diabetes 1 Drug & Alcohol Abuse 1 Nephritis & Nephrosis 1 Pneumonia 1 CHF, Cirrhosis & Alcoholic Hepatitis 1 Myocardial Infarction, Respiratory Failure 1 Pancreas Disorder 1 Bronchiolitis & Pneumonia 1 Cirrhosis & Alcoholic Hepatitis 1 Seizures 1 Psychoses 1 Cancer 1 Asthma 1 Hepatic Coma 1 Schizophrenia 1 Chest Pain, Anxiety 1 Type 1 Diabetes 1 Opioid Abuse & Dependence 1 Septicemia 1 Chest Pain, Circulatory 1 Diabetes 1 Renal Failure 1 Digestive Malignancy 1 Alcohol & Drug Dependence 1 Alcohol & Drug Dependence 1 Asthma & Interstitial Lung Disease 1 Coronary Atherosclerosis 1 18 Grand Total 50 Cost Savings $4,509,269
Care Management Results Top Members by Utilization Frequently Admitted Members Currently Enaged in CM Program Spend Comparison Member Name Member Diagnoses Spend Before Engagement Baseline Monthly Medical Costs Spend Since Engagement Post Engagement Monthly Medical Costs Monthly Savings Post Engaement Annual Savings Post Engagement Patient 1 Alcohol & Drug Dependence $46,501.00 $82,060.59 $30,626.00 $8,834.42 $73,226.17 $878,713.98 Patient 2 Sickle Cell $356,668.00 $54,314.92 $0.00 $0.00 $54,314.92 $651,779.09 Patient 3 Sickle Cell $73,393.00 $68,805.94 $50,676.00 $17,677.67 $51,128.26 $613,539.16 Patient 4 Chest Pain, Anxiety $323,507.00 $46,885.07 $8,362.00 $1,334.36 $45,550.71 $546,608.53 Patient 5 Myocardial Infarct, Resp Failure $418,896.00 $41,750.43 $2,997.00 $956.49 $40,793.94 $489,527.31 Patient 6 CHF, Cirrhosis & Alcoholic Hepatitis $123,637.00 $19,521.63 $0.00 $0.00 $19,521.63 $234,259.58 19
Value-Based Contract Successes Care Management programs reduced cost by $4.5M annually. Membership growth to 133,000 fully capitated lives. 143% growth since 2014. Consistently positive excess medical revenue. Top Rankings in quality ratings. Substantial quality incentive payments annually. Reduction in out of our network services. 20
21 Quality Incentive Payments
Excess Medical Revenue EMR (All Product Lines) EMR (All Product Lines) 22 2011 2012 2013 2014 2015 2016
23 Covered Lives in Global Risk
24 Importance of PCP Connectivity
Importance of PCP Connectivity 25 Relationship is the link in the value based arrangement 5% churn within membership The PCP relationship is also what can drive more in network utilization, preventative care, disease management, etc. Our efforts in that regard have been to focus on new member outreach from Day 1, to contact members with gaps in care, and constantly try to connect patient back to PCP after an inpatient or ED visit.
Goals to Managing Value-Based Arrangements Improve patient care and group profitability Maximize premiums through risk adjustment activities Increase patient/pcp connectivity, especially with chronic or acute care management Resolve patient care gaps (i.e. Quality and HCC chronic care) Review Financial and Membership trends Review Clinical Trends and Integration 26
Goals to Managing Value-Based Arrangements There have been extraordinary increases in Pharmacy related costs. Determine if Pharmacy is to be included in the arrangement. Market price increases are out of control. A single Hep-C fill can cost over $25K. Linking patients to in-network OB s is important because deliveries can lead to costly out of network NICU spend. Select a few things to concentrate on first, then build on success. 27
28 HEDIS/QARR Team Effort Managed Care Department Sorts monthly missing services list by site-pcp-member-missing services, adds members with missing services to bottom of previous list and distributes Analyzes performance trends and provides reports to Coordinating team Site Management Review missing services list and address at point of service Managers oversee Patient Navigators at their site to ensure work is completed Patient Navigators Scrubs list for providers they are assigned to and recall patients with missing services Care management Quarterback for HIV and Post Partum exam measures Home visits to complete Post Partum exam and other missing services Performance Improvement Review Age out Measures Review documentation deficiencies Submit encounter files to MCO MCO Provides MMS data Provides consultative support Receives and processes Lab and Encounter file submissions
Team Effort Ambulatory Care Managers Administration Care Management Physician Leadership HEDIS/QARR Coordinating Committee Navigators Call Center Quality Department 29 Finance MCO Managed Care
HEDIS/QARR Improvement Process Monthly MMS Reports Recall Patients Sorting and Distribution Submit corrections Scrubbing Medical Records 30
31 Process for most measures Managed Care Department (MCD) obtains Monthly Missing Member Services (MMS) report from Managed Care Organization (MCO) MCD sorts and distribute MMS by Site and Physician to Patient Navigators and Site Manager Patient Navigators and/or site Managers scrub MMS records to identify services already received Missing services found during scrub submitted to Performance Improvement group which reviews and sends back to MCO to update MCO database Patient Navigators recall patients Home visits by Care Management Department as needed Mailings to non-utilizers (one-time mailing) Phone calls to members missing services Members advised about incentive program Teams authorized to arrange livery transportation Process repeats each month
32 Advances In Technology Internal MCO Quality Database - Monthly MMS is loaded into Database and numerator hits are automatically flagged - Data can be grouped by site to measure performance - Helps to avoid duplication of efforts Internal MCO Claims Application - Monthly raw claims data file uploaded from MCO - Monthly member roster uploaded - App used to identify high cost members - Helpful in monitoring out-of-network utilization Flagging of Value Based Contract members in Epic
Challenges Locating patients Patient compliance with appointments Data integrity Patients using providers outside of the MediSys system and documentation of services 33