Pathways for Successful Accountable Care Organizations: Physician Engagement Thomas Kloos, MD Jim Barr, MD Atlantic ACO & Optimus Healthcare Partners ACO Helping providers Care Better for their patients. Helping patients Care Better for themselves. Helping people Care Better for each other.
Topics: Optimus and Atlantic ACO s Physician Engagement Models Performance Specialists Hospitals
Health Care Delivery Quality and Experience of Care Lack of evidence-based, comprehensive, coordinated care Lack of emphasis on prevention and healthy behaviors Health insurance affordability Chronic disease impact will increase Dysfunctional FFS Reimbursement System Lack of Physician/Provider Satisfaction & Engagement Lack of Patient Satisfaction & Activation
The Triple Aim Better care for individuals. Better health for populations. Reducing per-capita costs. Helping 4 providers Care Better for their patients. Helping patients Care Better for themselves. Helping people Care Better for each other.
Atlantic & Optimus Healthcare Partners ACO s
ACO Relationships
MSSP 2014 Preliminary Results 75% 0f 353 ACO s in PY2 did not achieve shared savings. 97 ACO s earned bonus of 422M on 833M of shared savings. More experienced ACO s tended to perform better Overall ratio of ACO s achieving savings similar to 2013 Pioneers: 11 paid bonus of 83M, 5 paid back 8M Helping physicians Care Better for their patients. Helping patients Care Better for themselves. Helping people Care Better for each other.
214 ACO s completed outcomes reporting nationally NJ ACO rankings in national results: Optimus 52 Hackensack 72 Advocare 81 Virtua 89 Atlantic ACO 102 Central Jersey 114 Meridian 119 Atlantic Care 128 ACO Health 130 Barnabas Health 167 2014 MSSP Quality Results for NJ AACO scored 50.8 points. 87.68% overall, a 7.4% increase from 2013 OHP scored 52.15 points. 90.46% overall, a 7.5% increase from 2013 Helping physicians Care Better for their patients. Helping patients Care Better for themselves. Helping people Care Better for each other.
2014 New Jersey ACO MSSP Participant Performance ACO Doing Business As (DBA) or Legal Business Name (LBN) States Where Beneficiaries Reside Agreement Start Date Total Assigned Beneficiarie s Expenditures as % of Total Benchmark Generated Savings Earned Shared Savings Payments Quality Score Optimus Healthcare Partners, LLC New Jersey 04/01/2012 23,542 3.98% 10,017,766 4,440,296 90.46% ACO Health Partners, LLC NJ, PA, FL 01/01/2013 12,703 4.35% 6,476,300 2,715,442 85.57% Hackensack Alliance ACO NJ, NY 04/01/2012 15,603 3.26% 6,464,895 2,832,988 89.43% Meridian AACO, LLC New Jersey 01/01/2013 41,202 1.84% - 86.45% RWJ Partners LLC New Jersey 01/01/2014 8,456.7% - P4R Central Jersey ACO LLC New Jersey 01/01/2013 20,014.63% - 86.84% LHS Health Network, LLC NJ, PA 01/01/2014 22,375.45% - P4R NEPA ACO Company, LLC New Jersey 01/01/2014 6,972.31% - P4R Partners In Care ACO, Inc. New Jersey 01/01/2014 6,843.26% - P4R Barnabas Health ACO-North, LLC New Jersey 07/01/2012 12,646 -.36% - 81.29% JFK Population Health Company New Jersey 01/01/2014 9,531-1.2% - P4R HNMC Hospital/Physician ACO New Jersey 01/01/2013 8,709-1.65% - 79.49% Atlantic ACO NJ PA 04/01/2012 70,550-1.82% - 87.68% NJ Physicians ACO New Jersey 01/01/2014 11,611-2.81% - P4R Advocare Well Network New Jersey 01/01/2013 15,121-4.28% - 88.75% Balance ACO NJ, NY 07/01/2012 8,165-10.22% - 79.34% VirtuaCare New Jersey 01/01/2013 15,837-11.71% - 88.19% AtlantiCare Health Solutions, Inc. New Jersey 01/01/2013 18,427-11.9% - 85.65%
What is a Value Based Contract? ACO s are in Value Based Contracts The ACO s do not negotiate fee for service rates with CMS or commercial payers ACO s are paid additional dollars based on a value equation Value = Quality/Cost Cost is our performance against our benchmark and market trend Quality is how we do against national averages on quality measures. Helping physicians Care Better for their patients. Helping patients Care Better for themselves. Helping people Care Better for each other.
Physician Engagement: The Time Problem Based on various analysis (for 2,500 patients): Time needed for chronic illness care = 10.6 hours per day Time needed for preventive care = 7.4 hours per day Time needed for acute care = 4.6 hours per day
Structure & Process Population Management Workflow Support
Quality and safety Patient-Centered Medical Home Model Personal provider Whole-person orientation Provider-directed team Office ACO Clinical Champions PCP & Spec: Population Management Activities Enhanced access ACO Coordinated Care: Complex Care Coordinators, COE, Community
Atlantic & Optimus ACO Services Data Aggregation/Management (CMS, payers, labs, EMR) Risk Stratification o o o Wellness access, patient engagement Rising Risk evidence-based care, care coordination High Risk complex care coordination, care transitions, readmission prevention, COE, PAC Quality Management enterprise-wide Patient Registry Cost Management analytics, efficiency indexes, innovation Provider Engagement & Practice Transformation Provider Performance Management (transparency, accountability) High Performance Network Development & Integration Community & Patient Activation
Population Risk Stratification Whole Person: risk stratify using risk factors, not just diseases Data Data - Data Analytics, Reports - Performance Metrics Tools & Interventions - Barriers - Incentives Physician Engagement & Patient Engagement Top 5% High Risk ACO Complex Care Coordinators, COE, Plan Case Managers 60-80% 15-35% (20% will become high risk each year) Rising Risk Low Risk ACO Population Care Managers, Practice Clinical Champions, PCMH model, Specialists Patient Portals, PHR, Apps
Data Sources & Aggregation Data Sources EMR & Paper Patient Charts Practice Management Systems Hospital (ADT s, lab, clinical) Claims, Lab, Pharmacy data Surveys, HRA s Data Aggregation Population Manager Risk Manager Lab, Pharma, Vendor Reports Payer Analytics
Team-Based Care: Staff Roles (PCC) VIP Management High & Rising Risk Identification Proactive Patient Care Plans Gaps in Care ER Management Care Transitions Medication Reconciliations Follow-up Visits Quality Reporting
> 50 points 50% of pmpm ACO 2015 Incentive Program > 65 points 75% of pmpm > 80 points 100% of pmpm MINIMUM REQUIREMENTS: 1) Quality data reporting 2) Communication with ACO (phone, text, e-mails) Quality IT Transformation Improvement Engagement Identification and management of high risk, rising risk & vulnerable patients within your practice 20 points Use of Cortext, Relay Health/NJ Health Connect, and McKesson Population Manager 20 points Population Management Office Roles, Responsibilities & Workflows 15 points Office Performance Improvement Process & Outcomes: Plan-Do-Study-Act (PDSA) 20 points Citizenship & Integration 25 points
PMPM Per Primary Care Physician Sample ACO Financial Proforma Practice Attribution Assumptions **CONFIDENTIAL** 2014 2015 Practice Potential Actual Potential Actual # Patients 60% Maximum Annual Paid Annual Paid Medicare 250 10% CMS PMPM Amount Amount Amount Amount Cigna 100 4% Performance Improvement PMPM Horizon 625 25% Shared Savings Horizon MA 25 1% Aetna FI 100 4% Cigna Aetna SI 200 8% Performance Improvement PMPM United 200 8% Horizon Others 1,000 40% Performance Improvement PMPM 2,500 Horizon Medicare Advantage PMPM Shared Savings Aetna Fully-Insured PIIP PMPM Self-Insured PIIP PMPM Shared Savings FI & SI United Performance Improvement PMPM Shared Savings Potential 2014 Actual 2014 Potential 2015 Actual 2015 **CONFIDENTIAL** Total PMPM Payments= Total Shared Savings= TOTAL 2014 TOTAL 2015
Shared Savings Distribution 30% ACO (operations and investment) 70% ACO Participants 5% Hospitals 95% Physicians o o 30% Specialists by episode volume 70% Primary Care Physicians 25% by attribution 25% by practice quality rating 50% by utilization performance & trend
Specialists PCMH-Neighbor Guidelines Centers of Excellence Clinical Integration (referral management) Shared Savings Distributions Bundled Payments / Episodes of Care
Reports Secure Access Full Transparency Performance Management Framework
ACO Provider Performance Efficiency Index
ACO Provider Performance KPI Atlantic ACO PCP - Allowed PMPM Period 4: January 1, 2014 - December 31, 2014 (4th Qtr, 2014) Data Sharing Members Only Period 2 Average # Members Risk Score Total Cost PMPM Total Prof PMPM Period 3 Period 4 Period 2 Period 3 AACO (Weighted Averages) 30,541 35,896 41,080 0.99 0.97 1.02 Period 4 Period 2 950 Period 3 953 Period 4 919 Period 2 367 Period 3 368 Period 4 356 Period 2 325 Facility PMPM Inpatient Period 3 324 Milliman Benchmarks - Moderately Well Managed 925 925 925 305 305 305 315 315 315 Milliman Benchmarks - Well Managed 680 680 680 220 220 220 214 214 214 Practice Name Average # Members Risk Score Total Cost PMPM Total Prof PMPM Period 4 315 Facility PMPM Inpatient Practice A 99 98 96 0.56 0.57 0.54 Practice B 79 81 84 0.92 0.86 0.81 54 52 51 0.97 0.90 1.14 90 95 98 1.01 1.01 0.92 356 402 444 0.98 1.07 1.23 380 381 381 0.56 0.55 0.63 206 215 222 1.13 1.10 1.21 182 180 177 1.58 1.54 1.62 1,065 679 1,230 1,198 1,043 1,207 1,009 944 807 681 1,088 1,057 1,029 1,101 1,073 917 761 753 1,071 961 974 996 960 832 436 310 363 475 331 517 277 251 412 333 357 419 306 487 287 248 418 346 338 401 272 426 254 239 446 149 546 379 371 357 473 460 211 107 419 351 406 297 485 428 150 122 494 299 427 292 435 375
ACO Provider Performance Integration
ACO Specialist Integration Detail Cardiologist A B C D E F G H
Episode Efficiency Episodes by Provider Case Mix Efficiency Index Specialty: Cardiovascular Disease PROVIDER # EPISODES AMT ALLOWED AMT CM EI EI STAT IMPACT ALLOWED/EPI SIGNIF A 1,744 1,020,142 585 1.06 1.09 Y 82,714 B 1,683 891,084 529 1.11 0.94 N (52,349) C 1,678 1,008,048 601 1.05 1.13 Y 113,600 D 1,434 468,957 327 0.65 0.99 N (3,546) E 1,347 750,372 557 1.06 1.03 N 24,994 F 1,219 563,405 462 0.97 0.94 N (35,648) G 1,125 723,941 644 1.16 1.10 Y 66,526 H 1,102 562,205 510 0.92 1.09 Y 48,212
Performance Management Framework If performance level is: <50% 50-59% 60-69% 70-79% 80-84% 85-89% >90% Improvement Needed By Next Reporting Period = 40% 15% 10% 6% 3% 0% 0% Examples: Base Compliance 9 mos 12 mos 18 mos 24 mos 30 mos 36 mos Practice "A" 50% 58% 66% 73% 77% 82% 84% Practice "B" 25% 35% 49% 69% 75% 80% >85% Practice "C" 80% 82% 85% 85% 85% 85% 85% Your Practice enter value calculate
Alignment & Collaboration Hospitals Payers Employers Unions IT Pharma Labs Medical Device / Vendors
Barriers Capitalization of PCMH and ACO models FFS vs Unfamiliar Compensation Model IT, Data and Analytics Predictive Modeling Management & Leadership Culture
Care Better Helping physicians Care Better for their patients Helping patients Care Better for themselves Helping people Care Better for each other
Thank You Q & A