Population Health & ACOs What is or is not working? 4 th Annual Texas Primary Care & Health Home Summit Presented by Christie Lawrence VP, Sales/Business Development KPN Health, Inc.
Objectives Population Health via the Medicare MSSP ACO Model Growth of Medicare MSSP ACOs MSSP ACO Tracks How MSSP ACOs Get Paid Overview of the Winners & Losers 2014 MSSP ACO Results What is Working? What is Not Working? Considerations for Your Organization Summary Questions & Answers 2
Value-Based Reimbursement The HHS Goal: The Dept. of Health and Human Services has set a goal of moving 50% of payments toward alternative models by 2018 and 90% linked to quality performance. 3
Total Number of Medicare ACOs Number of Medicare ACOs as of January 1, 2016 477 CMS ACOs participating in 1 of 4 models 8.9 million lives, up from 7.3 million in April 2015 Seven (7) Pioneer ACOs and 8 MSSP ACOs became Next Generation ACOs 100 new MSSP ACOs, but 70 ACOs did NOT renew Source: Medicare ACOs Announced: What Happened and Why it Matters., Leavitt Partners, January 2016.. 4
Projected ACO Growth Leavitt Partners estimated the number of ACO-covered lives (Commercial & Medicare) will quadruple, increasing from 23 million to 105 million in 2020 = 1/3 of Americans! Currently 8.9 million Medicare ACO lives, up from 7.3 million in April 2015 Source: Projected Growth of Accountable Care Organizations, Leavitt Partners, December 2015. 5
MSSP ACO Tracks CMS refined the MSSP ACO rules to encourage continued and enhanced stakeholder participation; and in 2016, twenty-two (22) percent now have riskbearing arrangements. Key rule changes include: - Track 1 ACOs can renew for another 3 yrs in Track 1 - Added Track 3 with up to 75% sharing rate - Previously terminated Track 1 ACOs can reapply 1: 50% Sharing Rate No risk UP to 50% of savings but no penalty for higher costs 94.93 % (412) MSSP ACOs in Track 1 * MSR Minimum Savings Rate * MLR Minimum Loss Rate 2: 60% Sharing Rate ACO shares the risk UP to 60% of savings Several symmetrical MSR/MLR* options 1.38% (6) MSSP ACOs in Track 2 3: 75% Sharing Rate ACO shares the risk UP to 75% of savings Opportunity for waiver of 3-day inpatient stay SNF rule Several symmetrical MSR/MLR* options 3.69% (16) MSSP ACOs in Track 3 * Only track 2 & 3 are projected to be an Alternative Payment Model (APM) in MIPS Source: Medicare ACOs Announced: What Happened and Why it Matters,, Leavitt Partners, January 2016 6
Final 2016 MSSP ACO Rules CMS issued a FINAL MSSP rule on 6-6-16 to incorporate regional FFS expenditures into the methodology for establishing, adjusting, and updating the benchmarks of MSSP ACOs after an initial 3-year period. Highlights of the rule changes include: 1 st agreement period benchmarking methodology will use assignable Medicare FFS beneficiaries instead of all FFS beneficiaries (all licensed MSSP ACOs) 2 nd agreement period benchmarking methodology will include: Use of regional trend factors instead of national in order to determine if an ACO delivers high-quality care at a lower cost compared to regional peers Phased approach to regional being weighted more than national, ultimately regional will be weight at 70% Annual update the rebased benchmark to account for regional spend changes Calculate the ESRD spend at a state level rather than by county Pending the ability for ACOs to renew in Track 1 for a 4 th year with a deferred rebasing of the ACO s benchmark, but ACO MUST transition to Track 2 or 3 in its fifth year. (beginning with 2017 ACOs) CMS will release annual data files containing county-level expenditure and risk score data Source: www.cms.gov, June 6, 2016 press release 7
How do MSSP ACOs get Shared Savings? Reduce costs below the ACO s benchmark set by CMS Reporting on 34 quality measures (32 individual measures and 1 composite measure that includes 2 individual component measures) CAPHS survey reporting patient satisfaction MSSP ACO Track 1 No Risk Year 1 Year 2 Year 3 Data Reporting Only Data Reporting & Outcomes Data Reporting & Outcomes Pay for Performance Measures 0 20 30 Pay for Reporting Measures 33 13 3 TOTAL 33 33 33 Metrics really matter in year 2 & 3! 8
Health Determinants & Spending Healthy behaviors are the biggest impact influencing a person s health; yet only 4% is spent on prevention something has got to change! 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Health Behaviors 50% Environment 20% Genetics 20% Access to Care 10% Factors Influencing Health 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Prevention 4% Medical Services 96% National Health Expenditures Lambrew JM. A Wellness Trust to Prioritize Disease Prevention. The Hamilton Project, Brookings Institution. 2007. discussion paper 2007-04: 1-36. University of California at San Francisco, Institute of the Future, 2000 9
MSSP ACO Quality Domains 8 10 Patient/ Caregiver Experience Preventative Health Care Coordination / Patient Safety At Risk Populations - Diabetes - Hypertension - Ischemic Vascular Disease - Heart Failure - Coronary Artery Disease - Depression 9 7 ACOs must meet minimum attainment of 30 th percentile benchmark on at least 1 P4P measure in each domain to be eligible for savings, and the EHR measure is double-weighted (4 pts). 10
Are MSSP ACOs Succeeding? MSSP ACOs total net savings in 2014 to Medicare Trust Funds was $465 M. 2014 Performance Year Results for 333 MSSP ACOs Reduced spending enough to earn shared savings * Had these ACOs achieved the 90% quality score, they would have received $41 million more! Reduced spending enough to earn shared savings, but failed to satisfactorily report quality metrics Reduced spending ($168 million), but not enough to earn shared savings *Did not meet minimum savings threshold 86-25.82% saved $777 million and earned $341 million in shared savings. 6-2.72% - small ACOs - Left $941,236 to $10.62 million on table 89-26.72% Costs exceeded their benchmark spending target 152-45.66% One-sided risk ACOs with losses of 2% relative to their benchmark. 87-26.12% - 1-sided has no risk. * 2013 Results: 24% of MSSP ACOs earned shared savings Source: go.cms.gov/media/2015-8-25 11
10 Key Takeaways for MSSP ACOs Leavitt Partners identified 10 key takeaways from the MSSP ACO program which they published in April 2016. 1. ACOs in high-costs markets were more likely to earn shared savings. 2. Physician groups out performed hospital-only ACOs both in savings and quality. 3. ACOs with more contracts had higher quality, but not greater savings. 4. More experienced ACOs earned more savings over time. 5. 26% of ACOs earned shared savings, but a handful of ACOs had the bulk of the savings. 6. More covered lives does NOT equal more shared savings, but larger ACOs did have better quality scores. 7. Top 10 ACOs had higher quality scores and Medicare cost benchmarks. 8. High performers averaged higher quality scores, but higher quality did not correlate with shared savings. 9. 35% of all quality losses came from three (3) metrics. 10. Geography does matter regarding shared savings and quality. Source: Leavitt Partners, April 2016 12
Average ACO Savings by States Geographic Division States Covered # of ACOs Covered % that Earned Shared Savings Average Savings % that Saved (actual spending < benchmark) Average Quality Score East N. Central IL, IN, OH, WI, MI 57 28.1% 1.2 M 54.4% 76.6 East S. Central AL, KY, MS, TN 27 44.4% 1.4 M 66.7% 74.4 Middle Atlantic NJ, NY, PA 50 16.0% 645 K 46.0% 75.1 Mountain New England AZ, CO, ID, MT, NM, NV, UT, WY CT, MA, ME, NH, RI, VT 26 15.4% 361 K 27.0% 73.5 29 24.1% 993 K 55.2% 81.2 Pacific AK, CA, HI, OR, WA 35 5.7% 999 K 37.1% 68.4 South Atlantic West N. Central DC, DE, FL, GA, MD, NC, SC< VA, WV IA, KS, ND, NE, MN, MO, SD 98 32.7% 1.1 M 62.2% 72.6 24 16.7% 375 K 54.2% 78.2 West S. Central AR, LA, OK, TX 38 47.4% 2.4 M 60.5% 71.6 Top 1/3 Middle 1/3 Bottom 1/3 Source: Early Takeaways from MSSP ACO Program, Leavitt Partners, April 2016 13
2014 Avg. ACO Savings by State Source: Leavitt Partners, April 2016 14
Average Savings By Medicare Costs Medicare Cost Highest 20% * 42% earned savings Benchmarked Cost per Beneficiary $14,364 Fourth 20% $10,937 ACOs in the highest cost quintile earned an average of $2.1M vs the lowest quintile at $357K. 40% of ACOs in the most expensive markets did NOT earn shared savings. Third 20% $9,615 Second 20% $8,732 Lowest 20% * 18% earned savings $7,729 AL $ 9,718 AR $ 8,949 LA $11,700 MS $10,667 NM $ 8,120 OK $10,000 TN $10,024 TX $11,479 Source: Leavitt Partners, Ten Early Takeaways from MSSP ACOs, April 2016 15
Shared Savings by # of Lives Large ACOs generally did not have an advantage in financial performance ACOs < 6,500 attributed lives had a higher average savings rate of 1.5% 1.5% Physician-based ACOs (33% earned savings) and those with rural health clinics or FQHCs performed better than hospital-based ACOs (21% earned savings). 0.62% 0.53% 0.50% - 0.31.% <6,500 <6,500 9,000 9,000 13,000 13,000 20,000 + 20,000 Source: Healthaffairs.org/blog/2015/11/4 16
ACO Quality Score vs Percent Savings % Savings Relative to Financial Benchmark There continues to be almost NO correlation between overall quality scores and savings, and NO clear or automatic relationship between higher quality and lower spending. * Avg. quality score was 83 %. Quality Score Source: Healthaffairs.org/blog/2015/11/4 17
2014 Avg. ACO Quality by State Source: Leavitt Partners, April 2016 18
TOP MSSP ACO Savings * These 10 earned 30% of ALL earned shared savings! ACO Name Type ST Shared Savings Raw Quality %ile (high = good) Avg. Med. Spend %ile (high = costly) 1. Memorial Hermann ACO ** Hospital TX $22.7 M 79 52 2. Palm Beach ACO ** Physician FL $14.5 M 86 97 3. Physician Org. of Michigan Both MI $12.1 M 83 90 4. Oakwood Both MI $815 K 73 90 5. ProHealth Med Group ** Physician NY $802 K 90 72 6. ProCare Med Both FL $798 K 87 90 7. RGV Providers ** Physician TX $753 K 87 99 8. Qualuable Med Physician TN $741 K 85 70 9. Delaware Val. Hospital PA $657 K 64 74 10. Mercy Select Hospital OH $652 K 77 75 ** Were in top 10 last year Source: CMS.gov 19
Tips From #1 Memorial Hermann ACO Geography We were in Texas, thus there was great opportunity for cost reduction. # of Lives We had a large number (44,000) attributed lives and more opportunity for savings. Post-Acute Transitions Our goal was to have discharged patients see their PCP within 7 days, preferred 3-4 days. Also had nurse practitioners going into the home. PCMH Transformation Had ACO staff in physician offices at least every other week sharing actionable data and helping with PCMH transformation. Every quarter, staff gave and reviewed these lists with doctors: Top 20 chronic disease patients Top 20 frequent ER fliers Top 20 high cost ESRD patients List of patients arriving by ambulance Ronda Gage - Former Director of Medical Home for Memorial Hermann ACO during their 2013 and 2014 #1 performance years. - Currently, Executive Director ACO for a Next Generation ACO run by Collaborative Health Systems Source: Leavitt Partners, April 2016 20
Continuous Improvement Counts Efficiency and continuous improvement are critical to long term ACO success according to MHMD (Memorial Hermann Physician Network), the #1 ranked MSSP ACO based upon 2014 outcomes. Improvement 12.18% 9.36% 9.32% 37.5% 25.38% 21
What Did Winning ACOs Do? Care Management o Transition of Care coordination with hospital discharge planners and ACO care managers o Home assessments and interventions very effective One ACO uses EMTs for these home assessments o Non-Medical Interventions (i.e., transportation, meals, HVAC, housing, literacy, and finances) had surprising positive impact on reducing cost and stabilizing chronic patients o Reduced Re-admission Rates and Length of Stay Rates o 7-day Post-Acute follow-up visit with PCP o Focused efforts on high-cost areas (i.e., Cardiac, COPD, Home Health, Hospice, Palliative Care and SNFs) o High-risk patients given PA or Provider s cell phone # to call before they go to the ER 22
What Did Winning ACOs Do? - Continued Provider / Staff Education & Engagement o Educated providers / staff on quality measures & cost reduction Monthly lists of high-risk patients, ER visits, inpatient admissions and discharges o Got engagement from physicians / staff collaborative team mindset o Helped practices achieve PCMH recognition by providing training, handson-assistance, and clinical decision support tools o Communicated metrics in a way that was not perceived as punitive IT Infrastructure o Negotiated discount for practices to purchase or switch to an approved EMR o Provided clinical decision support tool, Point of Care Report, that identified gaps in care o Found way to capture and report required GPRO data o Analyzed their claims data to identify key expenses and to identify high-risk and high-cost patients 23
Care Management & Coordination Keeping people healthy & managing high risk patients is key. Multiple Chronic Conditions & Complex Patients 24
Lessons Learned From Methodist ACO Shannon Huggins, VP of Managed Care for Methodist Patient-Centered ACO, shared insights on their success (#13 nationwide). Know Your Data: Get your CMS data and identify where your expenses are. We identified our post-acute costs were 3x the national average; so, we partnered with home health and skilled nursing. Vendor report cards issued 2x year! * Some ACOs didn t request to have their data sent until a year later big mistake! Physician Leadership: A strong physician leader is key to getting your physicians engaged. Hospital Leadership Support: Having hospital leadership on board helped with capital investment and hospital / ACO collaboration. Higher Benchmark: Greater opportunity for savings due to a high Medicare cost benchmark. IT Infrastructure: Need clinical and financial data, but it doesn t happen overnight! Took the 1 st six months just to figure out who our patients were. Community Resources: Large % of dual eligible; therefore, we used non-medical (dieticians / social workers) and community resources (food banks, transportation, pharma assistance and evening housing). 25
MPCACO Navigator Program 26
MPCACO Success to Date Performance Year #1 (2012 2013) $12,717,281 savings 78% aggregate quality score #13 in the nation 220 providers 13,000 lives - Net $11,492,369 to Methodist Health System (MHS) - $4,063,320 shared with physician practices Performance Year #2 (2014) $12,612,997 savings 85.12% aggregate quality score 330 providers 14,700 lives Performance Year #3 (2015) 430+ providers 70,000 lives Commercial contracts with Cigna, Partnerships with Baylor (Aetna), Catalyst Health Network (BCBS, UHC) 27
Lessons Learned: Triad HealthCare Network Triad HealthCare Network ACO in Greensboro, NC achieved Top 10 status in 2013, receiving $10.5 million in shared savings and also ranked in the 86 th percentile for 2014. * Now one of 21 Next Generation ACOs. Software Products & Services Implemented: Connected to 25+ different EHRs, including EPIC Point of Care clinical decision support to all PCPs and select specialties Data extracted and aggregated in Enterprise Data Warehouse from claims, hospital ADT, health plans, reference lags, and other disparate data sources Providers / care managers have access to ALL patient data via KPN Optimize, a web-based platform GPRO portal for data collection from practices without an EMR 28
A Sample Point of Care Report Labs, Calculations and Diagnostic Procedures pertinent to the Action Items are displayed for easy reference Diagnoses and Meds are prioritized to highlight chronic conditions Goals Not Met are highlighted for quick reference and visibility Targeted reminders for nursing staff allow better leverage of provider time and more efficient workflow 29
A Sample Quality Benchmarking Report PQRS and quality metric performance graphs allow drill-down capabilities on measures at the enterprise, Tax ID, location and by provider level. Dr. A Dr. B Dr. C Dr. D Source: Triad HealthCare Network 30
A Sample Enterprise Quality Metrics Dashboard PQRS and quality metric performance graph shows performance on specific quality metrics by organization and by Tax ID, including identification of the number of patients needed to reach goal. Source: Triad HealthCare Network 31
A Sample Transitions of Care Dashboard A web-based product that identifies patients upon admittance or discharge from the hospital or program related setting; Identifies critical timing requirements for discharges; Displays data elements which improve the beneficiaries transition process, quality of care and attempt to reduce readmissions for high-risk beneficiaries. Source: Triad HealthCare Network 32
Lessons Learned: Importance of Home Assessments Patient referred to Triad Pharmacist for medication reconciliation and to help determine a way to afford medications CHF, DM, COPD, anxiety, HTN, depression, MVA resulting in chronic headaches Upon questioning about migraines, he brought out a bag of medications Total of 9 bags of expired OTC and prescription medications Source: Triad HealthCare Network 33
What Caused ACOs to Lose? Care Management o Inability to reduce the cost of care below the CMS benchmark o High leakage rate to non-aco partners / specialists o Not following their patients / knowing where they are o Lack of SNF & Palliative Care programs o Top heavy with RN care managers not always need an RN Provider / Staff Education & Engagement o Did not require practices to change / transform it s optional mindset o Did not communicate with or educate providers / staff especially on quality metrics o No support given to practices for PCMH (Patient-centered Medical Home) recognition IT Infrastructure o Spent all the money on the IT infrastructure no reinvestment o No or poor documentation; therefore, didn t have data for GPRO reporting o Underestimated time involved or complexity of GPRO reporting process o Relied only on claims data 3 months behind care spend Administrative o o Not prepared for running ACO and its complexities Not enough capital 34
Key Metrics Leading to Quality Losses Thirty-five (35) percent of all MSSP quality losses came from three metrics: 1) Heart Failure Admissions, 2) % of PCPs who qualified for EMR incentive payment, and 3) COPD/Asthma related admissions. Source: Leavitt Partners, April 2016 35
Lessons Learned: Summary Saving Money: Lowering cost/saving money is more difficult than it would seem. Care Management: Managing Transitions of Care, home assessments / interventions and selecting post-acute partners have been most effective. Most Surprising: The impact of non-medical drivers on cost. Transportation, meals on wheels, HVAC, housing, literacy, and finances. Most Frustrating: Lack of ability to influence beneficiary behavior through benefit design or other incentives. Focus: Limit your initiatives and focus on key areas. Data: Accurate data is imperative. Leakage Has Negative Impact: You must identify and utilize the established preferred partner network. We have a lot to learn! 36
Considerations for Your Organization Factors driving an ACO performance in the MSSP model: Historical Trend During Benchmark Setting Years High regional trend creates an additional hurdle to overcome with a flat national trend Low regional trend, and in may cases, negative regional trend helps ACOs Relative Benchmark Payment Levels Higher benchmark payment levels reflects more opportunities to improve efficient care delivery Lower benchmark payments either suggest under-delivery of care or historically more efficient markets Attribution High rates of churn impact ability to get credit for care coordination on final population High rates of churn also have indicated healthier populations leaving ACO attribution lists Rule of thumb CMS attribution averages 1/3 of the lives you think you have Care Coordination Groups with history of managing populations under Medicare Advantage tend to do better than those without Engagement level of providers and beneficiaries impacts the continuously attributed population results Source: Collaborative Health Systems 37
Considerations for Your Organization Some things to consider regarding participation in an MSSP ACO: Commercial Model: Commercial ACOs are less onerous and a good place to start Capital: NAACOS study - $1.5 million a year average ACO management costs Leadership: You will need strong ACO physician leadership as well as ACO administration Data/Analytics: Data really matters because it is hard to monitor what you can t measure, and you must report your data to Medicare Restrict EMRs: Pick 5-6 EMRs and require all ACO providers to switch negotiate a discounted rate and/or provide $$ to help providers make the switch Be Selective: Kick providers out if they are non-compliant Partnerships: Limit your network partners! Next Generation Model: Consider going Next Generation ACO model if you are already efficient and taking risk 38
Questions & Answers Thank you for your time and interest! Please let me know if you have any additional questions. Christie Lawrence VP, Sales / Business Development KPN Health, Inc. Dallas, TX W: 214-593-6926 C: 214-681-2987 Christie.Lawrence@kpnhealth.com www.kpnhealth.com To learn more about how KPN Health s tools drive quality performance improvement and generate additional revenue, please contact me and/or visit our website at www.kpnhealth.com FREE 2016 PQRS Toolkit available for download www.kpnhealth.com 39