Examining the Differences Between Commercial and Medicare ACO Models Michelle Copenhaver December 10, 2015
Agenda 1 Understanding Accountable Care Organizations 2 Moving to Accountable Care: Enhancing the patient experience, lowering costs, and improving quality What you need to know and things to consider 3 Learnings from CMS Program Experience 2
Understanding Accountable Care Organizations (ACOs) A number of different value-based models exist, and share the same fundamental purpose and goals. An ACO is a group of health care providers who agree to share responsibility for the quality, cost, and coordination of care for a defined population of patients 1. Pioneer ACO Model and the Medicare Shared Savings Program (MSSP) Commercial Payer Value-Based Contract Medicare Advantage (MA) Value-Based Contract Common Goals: Focused on achieving the Triple Aim Designed to empower the primary care physician (PCP) and patient Dependent on increased transparency and data sharing, improved communication, and enhanced engagement with all involved parties Rewarded for quality and cost improvements 1 http://www.aafp.org/practice-management/payment/acos.html 3
Moving to Accountable Care
Providing the Appropriate Level of Interaction Understanding each patient s health status and how to engage with them effectively. Intensity of Service Integrated Care Management Intensive Care Sick + Telemedicine + Home visits + Intensive Care Management Chronic Disease Management + Telephonic Care Management Wellness and Prevention + Automated Care Management Healthy 5
Improving the Patient Experience with Collaboration An ACO infrastructure requires shifting away from the traditional fee-for-service mentality. ACO Initiative Care and Disease Management Outreach Follow-up Care Duplication Care Coordination Member Out-of- Pocket Costs Access Data Analytics/ Reporting EHR/ HIE Benefits with Accountable Care.. Core capabilities enhanced via point-of-care data, doctor-patient relationship, and outreach Proactive outreach by providers and informed by data Consistent follow-up with patients and providers Reduced through interconnectivity across ACO Highly coordinated between physicians, plus gains from data sharing Reduced, due to improvements in efficiency and quality Enhanced access to care with an extended care team, after-hours care, patient portals, and other initiatives Creating actionable information through risk-stratification, predictive modeling, workflow analysis, and financial analysis Improved information exchange 6
Lowering Employer Costs while Improving Quality ACOs are designed to better manage populations, in turn improving the health of employees. ACO Initiative High-Quality Select Network Primary Care Care Coordination (CC) Clinical Integration Analytics Cost Reduction Employee Satisfaction Wellness What It Offers Complete physician Hospital Post-acute care network Excellent geographic and specialty capacity Increased preventive care and superior disease management Fully developed CC/ disease management structure coordinated between PCP and specialists Integrated team Committed delivery network Common protocols Pathways Communication EHR Interoperability Analytic tools Proven predictive models Risk stratification Intense focus on top 5% who drive 50% of the cost ACO at risk for performance or no reward Patient feedback surveys Biometric screening and other wellness resources with PCP encounters 7
Aligning Incentives with Quality and Efficiency Metrics Accountable care provides incentives to doctors to improve quality and meet efficiency metrics. Accountable Care Metrics Preventive Care Managing Chronic Conditions Efficiency Cancer Screenings: Colorectal, Cervical, Breast Diabetes LDL-C screening, HbHA1c, neuropathy prevention/care Asthma medication adherence for children and adults Heart disease LDL-C screening and beta blockers after MI Hospital Admissions and Readmissions Emergency Room Usage Generic Prescribing Rates 8
Engaging Patients is Critical to Success Patient engagement is critical for any provider organization, and it is especially vital for those making the move to a value-based model. Doctor s Office Care Tools Hospital An (AARP) study showed patients who were active in their care were less likely to be readmitted to the hospital (12% vs. 28%) or experience a medical error (20% vs. 35%). 1 Patient Patient-Centered care is a team effort. To succeed, we must take responsibility for care delivered to the patient between office and hospital visits. 1 Kropp, MD, MBA, CHIT, B., & Lenhart, J. (2015). 8 Steps to Patient-centered Care. Group Practice Journal. 9
Moving Toward Patient-Centered Care 8 Steps Before providers can achieve the Triple Aim, they must first develop a clear strategy for activating patients and engaging them in their care. 1. Start with provider teams 2. Offer variety and convenience 3. Meet patients where they are 4. Be a coach 5. Make it simple 6. Expand your team 7. Extend your reach Patient-Centered Care 8. Define and measure success 1 Kropp, MD, MBA, CHIT, B., & Lenhart, J. (2015). 8 Steps to Patient-centered Care. Group Practice Journal. 10
Comparing ACO Programs and Contracts Although the overall ACO objectives remain the same, details and requirements can vary widely between managed populations. Overview Population Under Management Pioneer ACO Model/MSSP Commercial Medicare Advantage Incentive programs run by the Centers for Medicare & Medicaid Services (CMS) Medicare fee-for-service patients (must have at least 5,000 attributed patients) Value-based care model collaborations with third-party payers Commercial members, including those who self-select an ACO benefit plan Value-based care model collaborations with third-party payers MA members Getting Started Formal application and approval Contract negotiations Contract negotiations Contract Length Minimum of 3 years Varies by payer Varies by payer Data-Sharing Reporting Marketing/Growth Payment Structure Raw claims data provided if patient has not declined to share information 33 quality measures: Data collection and GPRO reporting, claims-based reporting, CAHPS for ACOs survey Patient marketing and communications highly regulated Gain-sharing and risk-sharing options: must meet minimum savings rate and quality requirements in order to receive shared savings Actionable data provided in the form of organized reports: reports vary by payer Claims-based reporting: quality measures vary by payer and contract type Marketing to change patient behavior encouraged Bonus payments, gain-sharing and risk-sharing options: payment structure varies by payer and contract type Actionable data provided in the form of organized reports: reports vary by payer Claims-based reporting: quality measures vary by payer and contract type Patient marketing and communications highly regulated Bonus payments, gain-sharing and risk-sharing options: payment structure varies by payer and contract type 11
Managing Multiple Populations Considerations Providing enhanced care for patients while meeting requirements for all ACO contracts is key. CMS programs have less flexibility than commercial contracts. As value increases, so does the potential risk. Data is only good when you can use it. Populations differ in age, complexity, aversion to technology and engagement levels. Physician engagement and buy-in is essential. 12
Learnings from CMS Program Experience
Learning from Experience Participation in Pioneer ACO and MSSP Programs resulted in many learnings for medical group leaders. Pioneer ACO Sharp HealthCare, CA Pioneer ACO Atrius Health, MA Favorable utilization and quality performance Financial model concerns Dropped out of the Pioneer program Approached entire population the same way: single model of care Team focused on population health strategy Shared best practices for care delivery Financial accountability concerns Not used to relying heavily on Medicare for data 1 Hagland, M. (2014, September 29). Evolution and Revolution: What Medical Group Leaders Are Learning through their Federal ACO Participation. Healthcare Informatics 14
Learning from Experience Participation in Pioneer ACO and MSSP Programs resulted in many learnings for medical group leaders. MSSP ACO Family Health ACO, NY Pioneer ACO Banner Health Network, AZ Alliance of 3 federally qualified health centers Small Medicare population struggling with attribution requirements Cannot seek out lost patients only receiving data for those who are attributed Centralized support and resources Physicians are much more open to data-driven care delivery improvements Challenges integrating disparate data sources and getting timely information from Medicare 1 Hagland, M. (2014, September 29). Evolution and Revolution: What Medical Group Leaders Are Learning through their Federal ACO Participation. Healthcare Informatics 15
Learning from Experience What they are learning is how to truly implement team-based care. And that involves figuring who should do what, and what information they need in order to do that, he says. The old days of, we ll just take the claims data, do some analysis, and produce some reports, are over. You have to get the right data and information to the right people at the right moments. You have to do this in a population health context, to figure out which services you ll provide to which patients, at which levels. Jerry Penso, MD, chief medical and quality officer, American Medical Group Association (AMGA) 16
Q & A 17