Why do we care about ACO?

Why do we care about ACO? 1 Integrating Occupational Medicine practice into the Accountable Care Organization Fred Fung, MD, MS, JD, Esq. Medical Director Occupational Medicine Department & Employee Health Services Sharp Rees-Stealy & Sharp HealthCare 2 3

Content Attestation I, Fred Fung, hereby declare that the content for this activity, including any presentation of therapeutic options, is well balanced, unbiased, and to the extent possible, evidence-based. 4 Conflict of Interest Disclosure I have no financial relationships with commercial entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients relevant to the content I am planning, developing, presenting, or evaluating. 5 Disclaimer gets you off just about any legal problems! 6

Learning objectives- able to Objective 1: recognize basic model of ACO (what is ACO?) Objective 2: differentiate ACO from HMO (how to compare ACO with HMO?) Objective 3: integrate basic elements of ACO into occupational medicine practice (how to take advantage of ACO?) 7 Define accountable ac count a ble /əәˈkountəәbəәl/adjective 1.(of a person, organization, or institution) Required or expected to justify actions or decisions; responsible. 8 A basic definition of ACO A legal entity (contracts) composed of a group of health care providers that assumes responsibility (accountable) to manage and coordinate care for a defined group of patients (population) in an efficient (quality, timely) and effective (cost, outcome) manner. 9

Triple aim of ACO do better/more for less Experience (improve) Quality (improve) Cost (decrease) 10 Major elements Has legal authority to contract with payers and administer care thorough providers Is governed by participating providers Is responsible for the total care of a group of patients (population health*) Able to measure quality and efficiency of care delivered during the contractual time frame Payments are aligned to quality and effectiveness of care delivered 11 A new payment scheme: shared savings (or penalties) Based upon the extent that care expenditure of ACO on defined population compares to an established expenditure benchmark Benchmark is composed of risk adjusted estimated expenditures by payer on defined population as if ACO wasn t in existence Quality threshold (33 quality measures) as a gate to additional payments (P4P)- Big Data! 12

Doctor-specific Medicare Data AMA, hospitals, medical groups all oppose release claims data citing privacy concerns Fed Dist Ct: Permanent injunction on releasing doctors data lifted as of 5/31/13 (i.e. gov t may now release physician practice data; health plans want them for quality and cost analysis) Physicians' privacy no longer outweighs the public interest to see Medicare data Government to run entire medical practice? 13 Solution for healthcare mess? 14 2 payment models for ACO Pioneer ACO Track 2 or 2-sided model where the ACO may take up to 80% of shared savings off the table but assumes downside risk (i.e. ACO risks losses and penalties if it does not meet its perbeneficiary benchmarks) 15

ACO payment models (2) Medicare Shared Savings Program (MSSP) Track 1 or 1-sided model under which there are no downside risks for losses incurred when actual per-beneficiary costs exceed per-beneficiary benchmarks (but shared savings are much lower) 16 Why Pioneer ACO? Pioneer ACO that generates a minimum average annual savings over performance years 1 and 2, will transition to population-based payment in year 3 ; may extend 2 more years The population-based payment is defined as per-beneficiary per month (PBPM) payment amount intended to replace a significant portion of the ACO s FFS with a prospective payment ($$$). This is not capitation! 17 What happen to the original Pioneer ACOs? 32 original Pioneer ACOs were granted 2011 2 ACOs intend to leave the program completely by 2014; 7 ACOs intend to switch over to MSSP Combined savings are about 1.1% or $33 Million for all ACOs combined 18

HMO v ACO (gov t) Managed Care v Hybrid of MC and FFS Commercial, Medicare, Medicaid paid by capitation v Medicare FFS PBPM$ Full risk, may include pharmaceuticals v Shared savings Stay w/n network v Free to move among Medicare FFS providers ~ work comp MPN Large publicly traded corporations v Physician-led entity 19 Sharp HealthCare ACO Not-for-profit healthcare organization with five acute care hospitals, Sharp Rees-Stealy Medical Group and Sharp Community Medical Group of combined 600 primary care and specialty care physicians serving the Greater San Diego area (~1500 Sharp affil d IPA physicians are not included) 20 Current initiatives at SHC (1) Integrated EHR with frequent updates such as ICD-10, practice guidelines & drug alerts (2) Incentives on hospital readmission rate (3) Improve access to both primary care and specialty care services based on both patient perception & actual appointments- MLP SDA (4) Explore Telemedicine to better serve patients and primary care providers in satellite clinics and to capture codes not generally paid under Medicare 21

Sharp ACO experience Culture of teamwork: most important element Primary care physicians have equal footing as specialists Robust Health Information Technology/data Adequate & equitable financial incentives (each dept to demonstrate contribution) ereferral (rational triage v timely access) e-prescribing & generic drug use 22 Sharp Occ Med experience to integrate current practice into ACO Unique non clinical skills (communication skills, customer service mentality) Telephonic skills and experience dealing with WC adjusters and employers Utilization review experience (ACOEM Practice Guidelines v Health Plans ) Med-legal knowledge (K free from prior auth/pre-approved, other admin burdens, grace period dispute, malpractice, GINA) 23 Hot occ med clinical skills Musculoskeletal (MSK) spine/sports medicine as treater (intermediary b/w PCP and specialists) Clinical preventive medicine/vaccines as screener (USPSTF rating A & B services) Clinical wellness program (integrating primary prevention with disease management) as advisor 24

Impact of ACO on Occupational Medicine practice Level the playing field to encourage more collaboration between primary physicians, specialty physicians and hospitals, joint K Employers demand physicians to provide quality and cost effective care and receive value-based payments Care integration between providers and healthcare facilities require newer tools of information technology such as user friendly Electronic Health Records system, redesign medical office/workflow 25 My take Hate it or love it, we need to learn it To physicians: Learn the language of ACO- participate or abdicate Keep up your clinical skills and certification (especially younger occ med physicians) Where do we go from here? Uncharted waters- gov t ACO (?) as roadmap but commercial ACO will flourish 26 Summary ACO is an incentive and quality driven government program that is likely to replace other forms of healthcare delivery system ACO-like models including commercial ACO will be set up by employers or insurance carriers to impose quality, access and cost-control to care delivery Autonomy ( I ) v Unity ( We ) 27

Additional Resources: American Bar Association: Health Law esource http://www.americanbar.org/groups/health_law.html http://www.americanbar.org/content/newsletter/ publications/aba_health_esource_home/ aba_health_law_esource_2011_april_volume_7_aco.html American Health Lawyers Association: Health Law http://www.healthlawyers.org/pages/default.aspx 28 In conclusion (for now ) 29