Healthcare Financial Management Association October 13 th, 2016 Introduction to Accountable Care Organizations and Clinically Integrated Networks

Healthcare Financial Management Association October 13 th, 2016 Introduction to Accountable Care Organizations and Clinically Integrated Networks

Agenda Define ACO, CIN, and Coordinated Care Review ACO/CIN Activities in SC Basics of ACO/CIN Shared Savings Overview of Population Health Basics Introduction to Operational Considerations of Establishing an ACO/CIN

After this session Should be able to define and ACO/CIN and Coordinated Care and there relation to the Triple AIM. Describe Key Concepts of Shared Savings Models. Understand and describe the fundamental operational components to establish a ACO/CIN.

Triple AIM Institute for Healthcare Improvement Belief that new designs must be developed to simultaneously pursue Three Dimensions of: Improving Patient Experience (CG-CAPHS) Improving the Health of a Population Quality and Safety Reducing Per Capita Cost Source: IHI.org

What is an Accountable Care Organization (ACO)? Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. ACOs success can be measured by reporting quality metrics for defined populations of patients and spending health care dollars more wisely leading to lower costs. 6 Source: Healthcatalyst.com

CIN vs ACO Clinically Integrated Network (CIN) Network of otherwise independent physician who collectively commit to quality and cost improvement Multi-specialty in nature Quality and Cost goals established System to monitor performance Physician-led governance structure Contracting with commercial payers/employers Rule of Thumb generally refers to commercial based incentive programs/contracts (e.g. direct to employer contracts) Source: Advisory.com

CIN vs ACO Accountable Care Organization (ACO) CMS maintains specific definition and rules for ACOs participating in Medicare Shared Savings programs Broadly and ACO is: Group of providers potentially including physicians, hospitals, post-acute care providers who have collective responsibility for a patient population outcomes Rule of Thumb: Generally refer to programs that involve government based incentive programs/contracts (e.g. MSSP) Source: Advisory.com

PMCH, CINs & ACOs Generally Speaking ACO Multi-System Level Coordination (System Level) CIN Multi-Specialty Coordination (Group Level) PCMH Primary Care Coordination (Practice Level) Source: Advisory.com

Clinical Integration COLLECTION OF PRACTICES UNIFIED ENTERPRISE

ACO/CIN Activates in South Carolina MSSP Rural ACO

Move Toward Value Types of Value Contracts Today s Focus

Basic Types of Shared Savings Programs CMS Based Medicare Shared Savings Programs Multiple Tracks Track 1: One sided Track 2 & 3: Two sided risk Next Gen: Great risk & Capitated Options all-inclusive population based payments (AIBPB) CMS with Commercial Payer Medicare Advantage Programs Commercial Based Programs Various models, Total spend or per-patient models Typically up-side only, some double sided risk Networks generally start with their employees

How does a Shared Savings 1. Patient Pool Assigned Contract Work? 2. Fee for service payments continues 3. Cost Target Established (Key Concept) 4. Quality & Patient Satisfaction goals must be met 5. Network distributed savings to stakeholders (Supporting System and physicians)

Step 1: Patient Assignment Medicare Shared Savings (Track 1) Patients are attributed to Network through use of Primary Care Physicians Network must meet minimum Threshold of 5,000 patients to Initiate an MSSP program Patients are assigned based on Physicians they see MSSP Track 3 Patients are assigned prospectively Commercial Contract Plan Options may Assign patients prospectively Or through use (attribution)

Providers Get Standard Fee for Service Step 2: Billing

Step 3: Comparison Cost Based on Number of Beneficiaries CMS sets a Minimum Savings Rate (MSR) Quality Network must report Quality Performance data in year one Subsequent years Quality Performance tied to a threshold

MSSP Minimum Shared Rate (MSR)

Year 1: Report Year 2: Performance Quality Performance Patient Experience Care Coordination Preventive Health At-Risk Populations

Step 4 & 5: Bonus & Distributions

Shared Saving Example Mission Point Health Partners Tennessee Medicare Shared Savings Track 1 Attributed Lives: 23,711 Benchmark Expenditures: $276,551,602 Minimum Savings Rate: 2.46%

Shared Savings Example $276.5 M $269.7 M 2.46% $6.81 M $267.3 M 3.3% $9.22 M Achieved MSR Eligible for 50% of Savings $9.22 M X 50%= $4.51 M Benchmark Expenses Minimum Savings Rate Actual Performance Distributed To Participants

Risk Considerations Cost targets for Shared Savings are typically determined in two ways Medical loss ratio (MLR) Historic Cost Trends MSSP If risk is consider for target adjustments, typically age and sex are only risk considerations Other possible consideration: Commercial market rate inflation Cost inflation in various spend categories (Med vs. Rx) Is population assigned prospectively or through attribution?

Population Health Management Basics 1. Organize a Healthcare Delivery Network that can appropriately service the given populations needs. (e.g. Primary Care Physicians, Specialist, and Hospitals) 2. Clinically defining the populations of patients for which the organization anticipates assuming risk. 3. Developing a system for improving the quality of care for the given population and ensuring appropriate amount of care is delivered. 4. Developing a system to eliminate waste within care delivery process which ultimately reduces cost

Operational Considerations Governance & Executive Leadership Administrative Support Finance/Actuarial Support Information Technology Support Programmatic & Initiative Support

Governance & Leadership Governing Board membership Initial membership: 16 voting members (range 16-20) Two classes of members: IP = 8 Physicians (at least half PCPs) HS = 4 Physicians (at least half PCPs) 3 Health System Executives (at large) 1 Community member Total of 12 Physicians (at least half PCPs) P P P P P P P P P P P P H H H C Independent Physicians P Independent Physician P H C Health System Appointees Employed Physicians System Executives Community Member

ACO/CIN Generic Governance Structure Health System Board CIN Management Team ACO/CIN Board Payer Strategy & Contracting Quality / PI Professional Standards Primary Care Collaborative Transitions of Care (TOC)

Administration Support Business Operations Core Duties Finance Marketing Risk Assessment Contracting (Legal Support) Business Development Staff Executive Medical Director Business Operations Director Healthcare Administration Project Management Staff Analytic Staff Classic CIN/ACO Management Staff Clinical Operations Core Duties Clinical Integration Efforts High Risk Care Management Coordinating Performance Pilots Quality Improvement Efforts Staff Primary Care Director Clinical Operations Director Care Management Staff Quality Operations Staff **May exist in ACO/CIN or may exist at the practice or Health System Level**

Financial/Actuarial Support Core Duties Primarily Claims Based Review On going Financial Performance monitoring PMPM for Medical, Behavioral Health, & Prescription Discovery of Spend Category Variance Staff Where is the Spend relative to benchmark & where is the opportunity? Advanced Risk assessment expertise rare skill in typical health care network Actuary (Could be outsourced service) Risk assessment/benchmarking Finance & Operational Analyst Opportunity Discovery

Costs: Opportunities Systematic Breakdown

Cost: Opportunities Outpatient Expense: PMPM > median Example of Outpatient Spend By Category Relative to Actuarial Benchmark Preventive Radiology General Observation Cardiovascular Pathology/Lab Psychiatric Pharmacy Physical Therapy Other Alcohol & Drug Abuse Radiology - CT/MRI/PET Emergency Room Surgery $(1.69) $(1.52) $(0.77) $(0.60) $(0.54) $(0.52) $(0.51) $(0.25) $(0.03) $- $0.90 $3.86 High Use of Emergency Facilities when Alternate Low cost Channels are available $9.34 $(4.00) $(2.00) $- $2.00 $4.00 $6.00 $8.00 $10.00

Core Duties IT Support Aggregating Quality performance across a network Linking EMRs together (platform overlays) Consolidating EMR System Registry System for Disease States Link for Care Gap closures (Deficiency Reports) Software for Risk Stratification (High Risk Patients) Collaboration with Vendors for claims receipt Staff Intermediary typically need with commercial populations IT Project Manager IT Leadership

Programmatic & Initiative Examples Population Management Efforts Chronic Disease State Management Programs Formal assistance for stable chronic disease patients Need for commercial vs. government population may be different Commercial Diabetes, Weight Management Government COPD, HF Care Management Services Support service for patients with multiple chronic disease states Health Advocacy & Care Coordination Services in conjunction with disease education Prescription Trend Monitoring Monitoring for variations in prescribing habit Monitoring for changes in the market place New medication Rises in generic prescription costs

High Risk Patient Population Intensive Outpatient Care (IOCP) Critical High Risk (Category 1) Some How Managing (Category 2) Blended Targeting 1. Risk Score + 2. Utilization Trends + 3. Chart Review At least 2 ER or IP visits for chronic condition (high utilization) ~ Risk Score 5 ~Total Medical Spend >$25K 2+Chronic Conditions, Unstable Multiple Gaps Chronic Stable (Category 3) 1 ER or IP visit for chronic condition 2 + chronic conditions Chronic, unstable Multiple Gaps Missed appointments No needs identified (Category 4) Chronic condition currently stable No gaps identified or minimal gaps, connected with resources Consistent with appointments, prevention, & treatment plan Potential to become unstable No ER visits Schedule/planned IP stays only No chronic conditions identified (e.g. maternity, planned ortho only, etc) 2 chronic conditions which are stable and well-managed for 1 year Consistent with appointments, prevention, & treatment plan

Patients Reviewed High Risk Pt Population Advocacy or Disease program 350 300 250 Health Advocacy & Care Navigation Support Q2 IOCP Candidate Nursing Review Link Patient With Disease Support Programs or Resources Monitor Population Connect with PCP 289 207 200 173 150 100 Accessible & Approachable 95 Programs For Chronic Stable Patients Ex. Diabetes Program Weight Management 50 11 0 Critical (1) Some How Manageing (2) Chronic Stable (3) No Current Needs (4) No Current Information (5)

RISK Truven Risk Score 15 14.5 14 13.5 13 12.5 12 11.5 11 10.5 10 9.5 9 8.5 8 7.5 7 6.5 6 5.5 5 4.5 4 3.5 3 High Risk Patient Population-IOCP March 2016 IOCP List Truven Risk Score vs. Medical Allowable R. A. 48 yo Male CHF, DM, Multiple Admits & ER Visits Aug 2016 2.5 $- $5.00 $10.00 $15.00 $20.00 $25.00 $30.00 $35.00 $40.00 $45.00 $50.00 Medical Allowable (For Period in Thousands) Medical Spend R. A. 48 yo Male CHF, DM, Multiple Admits & ER Visits Jan 2016 Thousands

Cost Opportunities Q2 2016 Pt Assignments ER VISITS MODIFIABLE INPATIENT STAYS SURGICAL PLANNED VS. MEDICAL PREVENTABLE

Cost Opportunities Prescription Trend Monitoring DUEXIS Combination (Famotidine/Ibuprofen) Example New Combination Medications Total Cost for Plan Monthly= $1,300 to $1,800 Annual= $ 15,600 to $21,000 Short to Intermediate Therapy, but

Patient Impact Plan Impact Cost Opportunities Prescription Down Stream costs Opportunity for Network Based Ambulatory Formularies

Define ACO/CIN? Review Collective effort to improve Quality, Cost, & Patient Experience Rule of Thumb: ACO Gov CIN Commercial Key concept of Shared Saving Amount saved to be redistribute to network/md if savings rate & quality goals met Fundamental Operating Components of ACO/CIN Governance and Executive Leadership Admin Support (Business & Clinical) Financial/Actuarial (Claims) Technology (Clinical Tools) Programmatic and Initiative Support (Population Management Execution)

Questions?