Session 15 Accountable Care Organizations Richard Lopez, MD August 12, 2015

Practicing Medicine in the Era of Health Reform Session 15 Accountable Care Organizations Richard Lopez, MD August 12, 2015 Tufts Health Care Institute 1

Accountable Care Organizations Richard Lopez, MD Chief Medical Officer Atrius Health August 12, 2015 richard_lopez@atriushealth.org 2

Today s Discussion Introductions Health Care Crisis Reactions to Rising Cost of Healthcare ACO Concept as a Provider Solution Global Payments in support of ACO s ACO Model: BCBSMA AQC ACO Model: Pioneer ACO ACO Results 3

Atrius Health The Northeast s largest nonprofit independent multi-specialty medical group. A national leader in delivering high-quality, patient-centered coordinated care. Dedham Medical Associates Granite Medical Group Harvard Vanguard Medical Associates VNA Care Network Providing care for ~ 675,000 adult and pediatric patients with 750 physicians across more than 35 specialties. 4

Atrius Health Core Competencies Corporate Data Warehouse integrates single platform, electronic health record data with multi-payer claims data Widespread Extensive Population Health Management including disease-based and risk-based rosters, population managers Long history with and majority of revenue under Global Payment across commercial and public payers Sophisticated development and reporting of Quality and Performance Measures leading to high achievement Patient-Centered Medical Home foundation, achieving level 3 NCQA across all primary care practices 5 2015 Atrius Health, Inc. All rights reserved. Not for distribution.

US Health Care Costs as Compared to Gross National Product 6

National Healthcare Perspective: Spending vs Life Expectancy The U.S. is off the charts when it comes to health expenditures per capita, but this extensive spending is not performance-based and is not correlated to longer life expectancy. CT MA 8000 9000 7

Workers Are Paying a Greater Share of Health Care Premiums as Employers Strive to Reduce Their Costs 8

State Healthcare Perspective: Burden of Healthcare Expenditures Growing healthcare expenditures are putting enormous pressure on state budgets throughout the country, forcing budget cuts in most other areas to make room for the growing healthcare component. Massachusetts State Budget ($ Billions), FY 2001 FY2001 FY2011 vs. 2011 +$5.1 B (+59%) -$4.0 B (-20%) 15% 38% 33% 23% 13% 50% 11% Health Care Coverage (State Employees/GIC; Medicaid/Health Reform) Public Health Mental Health Education Infrastructure/ Housing Human Services Local Aid Public Safety SOURCE: Massachusetts Budget and Policy Center 2013 Atrius Health, Inc. All rights reserved.

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Response of Commercial Payers and Employers Consumer Driven Products (cost sharing) High deductables Higher copays Defined contribution Tiered physician and hospital networks GIC Tufts Navigator HPHC Independence Limited networks Increased pre-authorization programs Imaging High cost drugs Sleep studies Increased risk sharing with providers (ACO) Employers: Employee Wellness Programs 11

Response of Government Part One Federal Accountable Care Organizations Shared Savings Program (CMS) Pioneer ACO Program (CMMI) NexGen ACO (CMMI) Payment Decreases for hospitals and physicians Penalties for hospitals for re-admissions and never events Bundled Payments Bundle Payment for Care Improvement Initiative 12

Response of Government Part Two State Chapter 224 passed in August 2012 Limits rate of increase in health care costs to the State s Gross Product Requires payers and providers to provide performance improvement plans if rates exceed SGP Regulates ACO s Requires transparency in pricing by both payers and providers Municipalities Conversion from traditional high cost BCBSMA plans to lower cost Group Insurance Commission (GIC) plans with higher copays and deductibles 13

Marketplace Response: Disruptive innovation? Limited service and retail clinics CVS MinuteClinics and Walgreens Take Care Clinics Doctors Express (franchise) CareWell (in partnership with UMASS and Lahey) MedSpring (in partnership with Partners Health Care Best Doctors expert opinion program Video visits, e.g. American Well, Find a doctor when needed: ZocDoc Potential use of out-of-state MDs for telemedicine Employee wellness companies 14

Response from Providers (Hospitals, Health Systems, Physician Groups) Heavy pressures on reimbursement rates are resulting in shifts towards accountable care and risk based contracting models Tighter network management of leakage across the spectrum hospital, SNF, outpatient, specialty Stronger care management models- PCMH, High Risk Management Healthcare delivery systems are integrating across the spectrum to optimize care management Hospitals acquiring physicians Physician groups acquiring hospitals Systems acquiring insurance companies Insurance companies acquiring delivery systems Consolidation of health systems, with scale providing significant advantages Access to capital Efficiencies of scale both clinical and administrative Opportunity for white label insurance products Opportunity for direct-to-employer contracting 15

The concept of an Accountable Care Organization is not new The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population. Dr. Robert Ebert, Founder, Harvard Community Health Plan, 1967 16 2015 Atrius Health, Inc. All rights reserved

Definitions of Accountable Care Organization Academic: Devers & Berenson in RWJ Brief: The ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care; The capability of prospectively planning budgets and resource needs; and Sufficient size to support comprehensive, valid, and reliable performance measurement. Federal Law: PPACA: an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-forservice program who are assigned to it. Certification: NCQA: provider-based organizations that take responsibility for meeting the health care needs of a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capita costs. MA State Law: Health Policy Commission will define ACO through its certification process and Model ACO certification

Migration Towards Accountable Care This means a radical transformation from the perspective of providers, who will need to develop the capabilities to manage a population s health, as well as payors, who will need to transition to risk-based contracting models. Commercial Payors Providers Regulators The act of providers assuming responsibility and financial risk for the quality and total cost of care of a defined population 18

Implications for Providers Managing a population s health, and remaining financially viable in a riskbased contracting environment, requires healthcare delivery systems to be truly integrated across the spectrum of care. From Fragmented Care Systems Towards Integrated Care and Population Health Management

Massachusetts is a Leader in Medicare ACOs Pioneer ACOs: Atrius Health BIDPO MACIPA Partners Steward Of total 22 nationally Medicare Shared Savings: Accountable Care Clinical Services Accountable Care Org of NE BMC Integrated Care Services Cape Cod Health Network Circle Health Alliance, LLC Collaborative Health ACO Emerald Physicians Harbor Medical Associates, PC Lahey clinical Performance ACO LLC NEQCA Accountable Care Physicians Accountable Care Pioneer Valley Accountable Care Southcoast ACO UMASS Memorial ACO Winchester Community ACO Of total 404 nationally 20

Impact of ACO s: Consolidation The Massachusetts market is rapidly moving towards consolidation It is widely predicted that in 3-5 years, a large percentage of healthcare in the Commonwealth will be provided by 5-6 large health care systems: Partners Stewart BIDCO Atrius Health UMass??? 21

First Year Results of Medicare Shared Savings ACO Program the numbers Number ACO s Participating: 114 Number of ACO s that saved money: 54 Number of ACO s that saved enough money to collect a bonus: 29 Amount saved: $126M 22

Accountable Care is driving fundamental change in health delivery Increase in population management registries, outreach Increased use of data to manage cost and quality Use of nurses to coordinate care for high-risk patients Use of community health workers Creation of preferred post-acute provider network (SNF and VNA) Connecting with local community elder service agencies to provide community-based supports Systematic ways to honor, across the care continuum, patients wishes around end of life care Delivery of a proven post-discharge bundle of services to prevent readmission Increase in disease management programs Patient engagement in shared decision making 23

Global Payments provide financing model for an Accountable Care Organization Infrastructure can be Planned and maintained without dependence on patient activity Provided even if not funded in under Fee-for-Service payment Provides stimulus for more efficient use of physician and office time with more convenience to the patient. Funds innovations such as e-portals, text messaging, phone calls and new roles necessary to be with the patient where life is actually being lived by the patient. Fosters use of diverse medical teams working at top of license

BCBSMA Alternative Quality Contract was Early Model for ACO Accountability for quality and resource use across full care continuum Long-term (5-years) Annual inflation tied to Consumer Price Index Improved quality, safety & outcomes as compared with traditional Pay-for-Performance Robust performance measure set (60+ measures) creates accountability for quality, safety & outcomes across continuum and over time Substantial financial incentives for high performance

Experience with AQC helped us step up our game Early adopter based on prior managed care experience Investments made to retool factory include Lean, Leadership Academy, Patient Centered Medical Home Quality framework provided focus and common language across Atrius Health groups Established strong precedent for joining Medicare Pioneer ACO Program Other Mass payers have followed suit

Lean is an important Foundation for our work 27

Why Participate in Pioneer ACO? Reason for Action High quality, high value care for all Medicare eligible patients across the care continuum with spillover for commercial risk Unique opportunity to be accountable for quality and costs for a PPO population Further Atrius Health position as a market leader in payment reform, moving towards 100% global payment Achieving Triple Aim Goals Ạtrius 28

Key Features of Pioneer & Performance Measures Three year contract effective January 2012 with two additional year options; accountable for all Medicare A and B benefits Partnership with Center for Medicare and Medicaid Innovation (CMMI) Medicare FFS beneficiaries aligned with ACO based on their historical claims data Global budget: performance measured against national benchmark Incentives rewards to achieve high quality performance measurements Upside & downside risk sharing with CMS Accountable to Pioneer ACO Obligations 29

Financial Measures: Shared saving/loss Atrius Health Goal: To beat the Benchmark Benchmark Think Global Budget Baseline Based on Actual Claim for ACO population Based on Growth Rate from National Matched Cohort 30

Quality Measures: Key Features Patient/caregiver experience, measured by CG-CAHPS 33 Quality Measures: many new, or with new features Care coordination/patient safety using claims data (eg. Readmission rates) At Risk Population, using EHR measures Diabetes IVD CAD Heart Failure Hypertension Preventive Health

Pioneer ACO Strategies Address Gaps Hospital Strategy Dual Population Medicare/Medicaid Strategy Geriatric Care Model Care Management Strategy Post-Acute Strategy PATIENT CENTERED MEDICAL HOME Costs: Beat the Trend Quality:100% Reporting 2012 90 th Percentile 2013 Quality & Safety Electronic Health Records & Health Information Exchange Data Analytics & Reporting Regulatory Internal Communication & Structure

ACO = Medicare Population Health Strategy Approximately 52,000 Medicare Beneficiaries in Outcomes-Based Contracts with Triple-Aim Accountability 1000 Pioneer Aligned 21,000 30,000 Medicare Advantage Duals HMOs 33

Accountable Care = Population Management What is the target population? How is the cohort defined? How is accountability defined? What population outcomes do we want & how are they measured? What conceptual framework links potential care processes to target outcomes? What are the overall key indicators? What are interim process/operational indicators? How do we support the key processes required to achieve outcomes? Which of these processes are most effective, efficient, and patient centered? What infrastructure is required to ensure reliable frontline process execution?. 34

Medicare Population Health Approach Close medical management at end of life Tight coordination of 5% highest risk Medical Management of chronic conditions Preventative Care for well patients Advanced Illness Management - Top 2% Other High Risk/Acute - Another 3% Chronic Care Management - Next 15% Population Management - Remaining 80%» Local Implementation Practices at different starting points.» Central support to reach goals, manage CMS relationship and obligations. Atrius Health 2015. All rights 35 reserved

Focus One: High Risk Patients, High Cost Events Advanced Illness Management - Top 2% Other High Risk/Acute - Another 3% Chronic Care Management - Next 15% Population Management - Remaining 80% Advance Care Planning High Risk Roster Review Care Transitions Post Acute Episode Mgmt CKD Community Support for Dual Eligibles 36

Focus Two: Health Risk Prevention Advanced Illness Management - Top 2% Other High Risk/Acute - Another 3% Chronic Care Management - Next 15% Population Management - Remaining 80% Falls Risk/Fractures Depression Screening Med Reconciliation 37

Keep Working the Medicare Population Pyramid Advanced Illness Management - Top 2% Other High Risk/Acute - Another 3% Chronic Care Management - Next 15% Population Management - Remaining 80% 2015 Focus: Custodial Nursing Home program Palliative Care/Hospice Care Transitions COPD Expanded home telemonitoring New ACO Quality Measures 38

The Triple Aim Population Health Per Capita Cost Experience Of Care The root of the problem in health care is that the business models of almost all US health care organizations depend on keeping these aims separate. Society on the other hand needs these three aims optimized (given appropriate weightings on the components) simultaneously. Tom Nolan, PhD. Source: IHI.org 39

Outputs: Population Health Initiatives Identify Gaps Design Program Develop Tools Implement Track & Measures Continuous Improvement Triple Aim Inputs: Quality Measurement and Improvement, Data Analytics, Medical Management, Clinical Champions, Internal Best Practices, External Peer Accomplishments 40

Key ACO Initiatives: Our Investments Geriatric Care Model Patient Risk Stratification Multidisciplinary Roster Reviews Advance Care Planning Chronic Kidney Disease Care Management ( Post Acute Home ) VNACNH Integration Local Elder Services Agencies Programs for Dual-Eligibles Shared standards and best practices Data Analytics & Reporting Ongoing Support for Workgroup Initiatives Trackers to monitor performance against goals Electronic Health Record and Health Information Exchange Tools to Support ACO Quality Metrics & Workflow Acute/Post Acute Preferred Providers Strategies Preferred SNF Network with service standards/facility expectations SNF Provider Expectations Preferred Hospital strategy Preferred ambulance strategy Quality & Safety ACO Quality Metric Reporting Performance Improvement/Best Practices 41

Medicare High Risk Model: Patient Risk Stratification Tool Using both claims and Electronic Health Records databases, the tool allows to identify members at risk of hospitalization, poor health outcomes, high costs Factor The model consists of five key factors: Likelihood of Hospitalization Hospital admissions or ED visits Behavioral Health diagnosis CHF or COPD >= 15 medications Pts DxCG Likelihood of Hospitalization Score 3 (Model 71) Hospital Admissions or ED Visits 3 Behavioral Health (Psychiatric, Substance 2 Abuse, Dementia) CHF or COPD or CKD 1 Poly-pharmacy (Excludes Topical & 1 Supplies) Maximum Score 10 Proportions of High Cost (Atrius Health ACO) Patients & attributable to them Costs (Aug 2012) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20% of patients Patients 60% of costs ACO TME % DECEASED % ALIVE H/VH Risk % OTHERS 42

High Risk Patient Roster Review Confirm diagnoses Review medications Address quality measures Social assessment Care needs assessment PCP-Led Team Advance directives Palliative care discussion Care plan documentation & orders. 43

High Risk Roster Participants Each site may choose to have any number or combination of participants so long as the goals of high risk roster reviews are being met. Typical participants include: PCP Primary Nurse or Medical Assistant Population Manager Care Manager Geriatric Champion or Palliative Care Specialist Social Worker VNA representative Clinical Pharmacist Atrius Health 2015.. All rights reserved 44

Geriatric Care Model: Multidisciplinary Roster Reviews Review and confirm accuracy of diagnosis Adopted common standards for High Risk Patient Roster Reviews Review appropriateness of medications Perform a care needs assessment Create a clinical summary of the patient Perform a social assessment Review applicable diseases related quality measures Confirm existence and need for advance directives Update the patient s care plan and document next steps Early adopters of HRRR saw greater reductions in TME 45

Advance Care Planning Initiatives Description: Developed advance care planning (ACP) curriculum with CME/CEU credits. Established site based ACP champions to train and provide ongoing ACP support locally Developed new tools in Epic to track and document advance care planning Expected Outcomes: Improve PCP knowledge and comfort with ACP Increase end of life conversations and collection of patient s care wishes, advance directives and proxy information Minimize use of aggressive curative care when not aligned with patient s care wishes 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 46 2013 ACP and 2014 MOLST Trainings ACP 82% MOLST 86%

Advance Care Planning: Results Implemented EMR checklist 47

Geriatric Care Model: Chronic Kidney Disease Description Clinical guidelines Provider education & training Patient education and engagement Keeping services in house when appropriate Expectations for outside nephrologists Epic tools Risk score modification Results In first 5 months, 66% of patients with lab defined criteria were diagnosed with CKD triggering clinical interventions. Expected Outcomes Improve diagnosis Slow progression of CKD 48

CKD: Clinical Guidelines Atrius Health CKD Guidelines for Primary Care Stage (egfr) Albuminuria? ( 30mg/g) Serum egfr and Urine Microalbumin Hgb, 25-OH Vit D, Phos, PTH, Lipids, Ca Electrolytes Initial Renal Ultrasound Nephrology Consult Stage 3a (45-59) No Annually* Annually* Consider Stage 3a; (45-59) Yes Q6 Month* Annually* Consider Recommend Stage 3b; (30-44) No Q6 Month* Annually* Consider Recommend Stage 3b; (30-44) Yes Q4-6 Month* Annually* Consider Recommend Stage 4; (15-29) N/A Q3 Month* Annually* Consider Recommend * Might require more frequent monitoring if abnormal and/or if undergoing changing treatment strategies Kidney International, Jan 2013; Supplement 3 KDIGO Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: 1-150 Approved by the Atrius Health Accountable Care Organization s Geriatric Care Model CKD Workgroup, which includes the Harvard Vanguard Chief of Nephrology; February 2013. 49

CKD Dashboard/Roster Primary Care Dashboard: Merge of EPIC and Claims Data - Lab Result Based Total CKD Population - Laboratory Screening (Ca, Phos, CBC, UA, Vit D, PTH) - Clinical Outcomes (BP, LDL, HgA1c) - Referral to Nephrologist Specialist - Visit to Nephrologist 50

CKD: Impact 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Patients w/egfr<60 CKD Dx No CKD Dx. 51

Post-Acute Home Workgroup: Stronger Collaboration with VNACN Developed Standard Work for referrals to and communication with VNACNH during episode of care. Care plan transmitted to EPIC within 48 hours of admission, including: Advance care planning forms Follow up appointment with PCP within 7 days of hospital discharge Collection of ACO quality metrics * Fall risk assessment * Medication review * Depression screen (PHQ) 2 We see a decrease in VNA $pmpm and a decrease in readmits during VNA episode 52 2013 Atrius Health, Inc. All rights reserved.

PAH Tracker: By Medical Group Post Acute Home (by Medical Group) YTD Jan 2014 thru October 2014 YTD (Claims paid through December 2014) VNACNF Episodes as % total HHA Episodes PION VNACNF Episodes as % total HHA Episodes TMP ED visit/k during VNACNF Episode PION Readmit Rate during VNACNF Episode PION % Patients with VNACNF Episode with ACP in Epic PION % Duals Enrolled DMA 53% 72% 84 17% 86% 15% GRN 40% 64% 92 20% 67% 15% HVMA 32% 65% 101 10% 67% 20% RMG 42% 68% 109 16% not available 50% SMG 35% 61% 288 18% 75% 22%

Tracking VNA Performance PAH 2015 Q1 Utilization A. ED Visit per 1000 during NON VNACNF episode/admission B. ED Visit per 1000 during VNACNF episode/admission C. Readmit rate during NON VNACNF episode/admission D. Readmit rate during VNACNF episode/admission E. VNACNF episodes/admissions as % of all home health episodes/admissions Quality % of patients admitted to VNACNF who have Falls Risk Assessment (FRA) scanned in EPIC within the episode/admission % of patients admitted to VNACNF who have Depression Screening scanned in EPIC within the episode/admission % of patients admitted to VNACNF who have ACP form (MOLST, Adv Dir, or HCP) in EPIC VNACNF Pre op Joint visits completed (all payers) % of total joint replacement discharges going home with VNA 2015 PION Goal Atrius YTD thru TMP PION NA 103 97 VNACNF lower than NON VNACNF 97 78 NA 22% 11% VNACNF lower than NON VNACNF 17% 11% 37% 68% 37% 94% 95% 88% 94% 93% 87% watch until Q4 79% 75% watch 65 Q1 watch 20% 37% PION YTD RPM Program (began May 2015 all payers) a. # of referrals Q2 & Q3 watch b. accepted to program Q2 & Q3 watch Acute hospital admissions during an RPM Q2 & Q3 watch episode VNACNF Patient Experience A. % of referrals with timely initiation of care 95% 94% B. AH complaints % of investigations initiated within 48 hours C. AH complaints % resolved within 30 days 92% 92% 2015 YTD thru 100% (12/12) 75% (9/12) May 5 3 0

Post-Acute Home Workgroup: Integrate Local Elder Services (ASAPs) 55

Variation in 2010 Medicare Average Length of Stay for Skilled Nursing Facilities 60 50 40 30 20 Difference Between Top & Bottom Quartile 10 Days = $4,000 24 29 24 34 29 61 34 10 0 5 Quartile 1 Quartile 2 Quartile 3 Quartile 4 ALOS Source: Adapted from Office of HHS Inspector General December 2010. 56 Adapted from Slides presented by Robert Mechanic, Brandeis University, with permission

Variation in 2009 Risk Adjusted Readmission Rates from Skilled Nursing Facilities 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 14.4% 18.1% 22.0% 0.0% 25th Percentile Median 75th Percentile Readmissions Source: MedPAC Report to Congress, March 2012. Adapted from Slides presented by Robert Mechanic, Brandeis University, with permission 57

Development of Preferred SNFs Network Meet service standards SNF willingness to collaborate Good metrics* Created preferred SNF network to enhance the delivery and coordination of care Atrius Health team on site History of positive relationship Geographic needs *Good Metrics: Medicare Compare; State survey; Readmission during SNF stay; LOS 58

Managing SNF Events Developed expectations and tools to manage length of stay Facility level expectations Provider level expectations Discharge workflow EHR documentation Monitoring & reporting Use of preferred discharge providers 2.0 LOS = $2M 2% Readmit Rate = $.5M 59

Still Lots of Opportunity Preferred Non-Preferred 60

EHR tools to support ACO: Standard Checklist and Shared Workflows Tools were developed to facilitate: Advanced Care Planning Fall Risk Assessment Depression screening Medication Reconciliation Patient Care Checklist Advance Care Planning documents are not on file A Falls Risk Assessment has not been completed in the current calendar year A PHQ-2 or PHQ-9 has not been completed in the current calendar year Tobacco use has not been reviewed in the current calendar year BMI has not been updated within the past 6 months CHARTING Patient Checklist Visit Info Allergies Vitals Patient Care Checklist Advance Care Planning documents on file A Falls Risk Assessment has been completed in the current calendar year A PHQ-2 or PHQ-9 has been completed in the current calendar year Tobacco use has been reviewed in the current calendar year BMI has been updated within the past 6 months 61

Depression Screen & Fall Risk Assessment Reset FRA, PHQ Checklist Implemented EMR checklist 62

Data Analytics and Reporting provides Ongoing Support for Workgroup Initiatives

#1 ACO in New England; #2 Pioneer Nationally 64

First Year Pioneer Results: 2012 ACO Quality Metrics www.medicare.gov/physiciancompare/aco/search.html Atrius Health compared to Pioneer ACO Range A1c = % of diabetic patient population with blood sugar (hgba1c) control < 8 BP = % of hypertensive patient population with blood pressure control <140/90 Tobacco = % of diabetic patient population who do not currently smoke Aspirin = % of diabetics with ischemic vascular disease (IVD) who are currently taking aspirin ACE/ARB = % of patients with coronary artery disease (CAD) who are also diabetics OR have left ventricular systolic dysfunction (LVSD) and are on an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) 65

Independent Near Market Evaluation, May 2015 Association of Pioneer Accountable Care Organizations vs Traditional Medicare Fee for Service With Spending, Utilization, and Patient Experience JAMA. 2015;313(21):2152-2161. doi:10.1001/jama.2015.4930. Pioneer ACOs saved $384M over two years Atrius Health saved $36M compared to near market Ten of 32 Original Pioneers had statistically significant savings in both years Atrius Health was one of the ten Atrius Health noted as one of three Pioneers accounting for 70% of savings in 2013 66

Pioneer Financial Performance Year over Year Improvement 2012 (PY1) = 1% loss, in the noise Atrius Health expenditure $10,700 vs. Massachusetts Pioneer Expenditure $12,000+ 2013 (PY2) = 1% savings, in the noise * $3M saved for Medicare 2014 (PY3) = Projecting 1.4% savings, would be: * $4.5M saved for Medicare * $2.8M share to Atrius Health 67

From the JAMA Article BIDCO MACIPA Steward Atrius Health Partners http://jama.jamanetwork.com/article.aspx?articleid=2290608 68

Side by Side Settlement: Beat the Trend. 69

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Keys to Success Leadership and Facilitation Create the data-based hypothesis Identify evidence-based best practice Develop standards & tools to close gaps Measure and track Outcomes Fidelity to Process Core Competencies Small team with operational credibility Diverse clinical expertise Share resources clustered together (no silos) Home for shared values Exploratory mindset Laser focus on triple aim 72

Lessons Learned Internal MD engagement key to driving change Wide adoption of Lean problem solving methodology created strong foundation for change One Model, One Contract provided burning platform Making long-lasting change takes time Our ability to partner effectively is key CMS More unknowns = more risk It s bigger than CMS - many federal agencies have a stake Engagement of other Pioneers big opportunity, but differing priorities CMS is moving up the learning curve too

This image cannot currently be displayed. This image cannot currently be displayed. We will challenge Simple rules I am accountable We are accountable From Accountable Care Organizations, Marc Bard and Mike Nugent, 2011 74

Two Kinds of Change Technical Problem is well-defined Solution is known, can be found Implementation is clear From Jack Silversin, Amicus Adaptive Challenge is complex To solve requires transforming longstanding habits and deeply held assumptions and values Involves feelings of loss, sacrifice (sometimes betrayal to values) Solutions requires learning and a new way of thinking, new relationships 75

Reflections We shall not cease from exploration. And the end of all our exploring will be to arrive where we started and know that place for the first time. T.S. Eliot 76

Reflections The future we predict today is not inevitable. We can influence it, if we know what we want it to be We can and should be in charge of our own destinies in a time of change. Charles Handy The Age of Unreason 77