A Clinically Integrated Network R.W. Chip Watkins, MD, MPH, FAAFP Independent Affinity Group 3 March 2015
HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.
This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments
Alternative Payment Models Panel Evaluates New Payment Models, Offers Fresh Ideas Brookings Institution Briefing - February 05, 2015 Panelists focused on one state that is moving rapidly away from the traditional fee-for-service model. Since 2009, physicians in Michigan's Blue Cross Blue Shield (BCBS) plan have been ineligible for a fee increase unless they participate in an alternative payment system, such as a medical home. Instead, they are paid on a tiered fee structure that ranges from 100 to 130 percent of their base fee. Michigan has 4,400 primary care physicians participating in medical homes -- 70 percent of all the state's primary care physicians. Hospital admission rates have fallen 27 percent, according to Thomas Simmer, M.D., senior vice president and chief medical officer for Michigan BCBS.
How Will Your Practice Prepare? Falling Reimbursements Extra Paperwork Expensive EHR Systems Billing/ICD-10 Quality Initiatives/Requirements PCMH Recognition HR/Month End Contracting Increased Complexity/Regulations
A Clinically Integrated Network
Clinically Integrated Network Defined A network of physicians working collaboratively to improve the quality and efficiency of patient care led by physicians and supported by a population health management infrastructure (CCNC). To be the health care delivery solution for all systems by demonstrating value and quality of care. Physicians are the leaders in the development of all facets of the program. Facilitating the delivery and coordination of patient care across conditions, providers, settings and time. Focusing on patient populations.
Vision and Principles Several provider organizations, in an effort to better serve the needs of their members, have requested that CCNC help support the development of a Clinically Integrated Network (CIN) demonstrating enhanced quality, efficiency and access to health care services. Participating providers must demonstrate commitment to improving the quality of care for their patients. Starting with primary care providers but will add aligned specialists and hospitals interested in improving health outcomes and moving towards a value-based model.
Vision and Principles CPNC will be positioned to work with other clinically integrated efforts. It is not an exclusive model and will look for opportunities to partner with other initiatives that have aligned quality and cost performance metrics: Participate as a Medicaid ACO, if appropriate in Medicaid reform Partner with hospitals to serve as their primary and specialty care network for ACO activity virtual network Partner/Contract with hospitals to enable them to expand their primary care footprint
Vision and Principles CPNC can create a win-win-win for the patient, the primary care provider and the health care system: Work together to avoid unnecessary hospital readmissions and achieve other desired outcomes Enhance patient and caregiver engagement, compliance and satisfaction across systems of care Create and implement strong health care teams working in medical neighborhoods
Independent Practices Serving the Medicaid Population in North Carolina
Unenrolled 355,413 Other (RHC, LHD, other) 96,226 FQHC 100,800 Established Provider-led ACO s 73,887 CCNC Medical Home Network: Where are Medicaid Beneficiaries Seen? Independents 644,602 Other Hospital Owned 120,869 Large Health System Owned 344,655 *Numbers represent estimated number of members enrolled in each type of practice (total member months divided by 10). 12
CCNC Provider Network: Practice Landscape A majority of practices have < 500 Medicaid patients Smaller practices have higher case mix index (patients are sicker) Number of Practices by Size of Medicaid Patient Population <50, 137 3.5 Average Case Mix Index Across Practices of Different Sizes 500+, 515 50-99, 91 100-199, 163 3 2.5 2 1.5 1 0.5 200-499, 303 0 <50 50-99 100-199 200-499 500+ 13
Quality Measures in Healthcare System Owned vs. Independent Practices Condition Diabetes Asthma Prevention and Management of Cardiovascular Disease Heart Failure Measure Healthcare System Owned/Managed Independent CCNC A1C Control < 8.0% 61.5% 60.4% 60.9% A1C Control > 9.0%* 27.0% 30.1% 28.4% Blood Pressure Control < 140/90 67.7% 68.9% 66.9% LDL Cholesterol Control < 100 48.5% 46.7% 47.0% LDL Cholesterol Control > 130* 34.8% 37.1% 36.3% Foot Exam 84.1% 75.7% 80.7% Continued Care Visit w Assessment 77.8% 77.3% 76.9% Assessment of Triggers 81.5% 80.9% 80.5% Action Plan 37.7% 46.8% 42.2% Approp Pharm Tx w Persistent Asthma 97.3% 97.0% 97.2% Blood Pressure Control < 140/90 64.6% 66.3% 64.5% Aspirin Use 87.9% 84.8% 86.1% LDL Cholesterol Screening 79.6% 80.4% 79.3% LDL Cholesterol Control < 100 48.6% 46.5% 46.8% Smoking Status and Cessation Advice 90.9% 88.6% 89.6% LVEF Documented in PCP Chart 89.2% 83.1% 86.0% ACE/ARB Use 84.2% 85.9% 84.7% Beta Blocker Use 93.8% 94.5% 93.2% 14qq1111`111
The Way You Get Paid is About to Change Dramatically To Stay Financially Solvent Smaller and Independent Practices Must: Adopt Cost Sharing and Cost Savings Strategies Make the switch from financial rewards focused on value, not volume.
The Way You Get Paid is About to Change Dramatically Are you ready for reimbursement that revolves around Pay-for-Performance plans, Bundled Payments and Episodes of Care? Is yours a small practice, particularly in a rural or underserved area? Do you have the electronic infrastructure needed to share risk and reward with other types of providers? Do you have the data to manage a population effectively? Is there an ACO in your area that is ready to take on collective accountability for quality and cost?
Community Physicians of North Carolina Update on Formation
Initial Governing Board Identified Dr. Kerry Willis - Chair Dr. Joe Ponzi - Treasurer Dr. Stephen Hsieh - Secretary Dr. Deborah L. Ainsworth, FAAP Mr. Charles. T. Frock, MHA Mr. E. Benjamin Money, Jr., MPH Dr. Thomas R. White
Governance & Committees Board of Directors Management and Staff Potential Committees Bylaws / Governance Nominating / Membership Quality Performance / Medical Advisory Contracting / Finance Others (e.g. Pharmacy, Credentialing, etc.)
Additional Decisions to be made Define performance improvement goals Define how performance will be measured Define criteria for selecting quality initiatives Define payment innovations that will strengthen performance improvement Define how patient data can be easily accessed to facilitate transitions across providers and care settings
Define Program Support Local? Central? Care management/transitional care of complex patients Practice support for population management QI Support PCMH Support 24/7 nurse line, etc. Medication management Data, analytics and reporting Quality Metrics Population stratification Contract development/credentialing medical home network for Medicaid, other payers, etc. HR Support for Front/Back Office Personnel or Billing Group Purchasing
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By Sticking Together We Can Build a new approach to running our businesses and caring for our patients. We will be stronger in an aligned network focused on the delivery of primary care. We will be ready to seize opportunities to engage and partner with interested specialists, hospitals and other healthcare entities as reform unfolds in North Carolina and beyond.
Next Steps Provider Relations and Recruitment Effort Read through Marketing Material Sign Letter of Intent (Non-Binding) - Tonight Participation Agreement Will Be Forthcoming Shortly Can decide if want to participate at that point Have your Legal Department take a look if you would like Think about what Committees you would be willing to serve on Get signed up with NC-HIE NOW!
NC-HIE Continues to Move Forward
A Clinically Integrated Network R.W. Chip Watkins, MD, MPH, FAAFP Independent Affinity Group 3 March 2015