Marshfield Clinic Health System MSSP Track I ACO Experience Narayana S Murali MD FACP EVP Care Delivery & Chief Clinical Strategy Officer, MCHS President/CEO MCHS Hospitals Inc. Executive Director, Marshfield Clinic
Who are we Marshfield Clinic is founded 1971 Greater Marshfield Community Health Plan is created (now Security Health Plan) 2002 Partners with Family Health Center to provide health, dental services to rural communities 2008 Lakeview Medical Center, Rice Lake, is integrated with Clinic 2015 Comfort and recovery suites open in Marshfield, Wausau and Eau Claire 2017 St. Joseph s Hospital becomes a part of the MCHS family and is renamed Marshfield Medical Center 1916 2012 1959 Marshfield Medical Research and Education Foundation is established 1972, 76 Establishes Joint Venture Lab; begins regional system 2007 With a sophisticated electronic health record, converts to chartless medical environment Marshfield Clinic Health System is incorporated 2016 Launches Hospital at Home partnership with Contessa; announces hospital construction in Eau Claire FUTURE Acute care expansion 1916 Marshfield Clinic begins as a group practice in Marshfield with six founding physicians TODAY MCHS has about 1,250 physicians and health professionals and 9,000 employees in 50+ locations
Our reach around Wisconsin Security Health Plan Coverage Area
Snapshot of MCHS Today
MISSION & VISION We enrich lives We enrich lives to create healthy communities through accessible, affordable, compassionate health care. We will innovate We will continue to innovate and define the future of health care for generations. We will be the consumer s first choicefor health care.
CMS PGP version 1 ~ $56M over five years Exceeded 130 of 133 quality metrics over 5 years Single handedly led to we can do it & eventual formation of ACO
MCHS as part of MSSP ACO program Over 30,000 Medicare members in MSSP ACO o 15% less costly than the average of ACO s participating in MSSP o Gap maintained during PGP, Transition Demo and ACO participation (awaiting data for year 5) Our Value Based Journey 2006-2010 2011-12 2013-15 2016-18 PGP Transition MSSP Round 1 MSSP Round 2
MSSP Track I Model o No downside risk shared-savings model o 50/50 split on savings generated over threshold that is prorated upon quality performance o The Threshold is re-benchmarked every ACO cycle o Quality metrics are dictated with thresholds for scoring set by CMS o Receive claims data to understand opportunities for improvement
Top Notch Quality Scores CMS Medicare Shared Savings Program (MSSP) Quality Results Marshfield Clinic ranks in top 5% (#18 out of 432 participants) Consistent improvement in scores Entity Score Marshfield Clinic 98.5% Baylor Scott & White 98.4% Cleveland Clinic 96.3% Johns Hopkins 92.4% UCLA 89.9% 100 98 96 94 92 90 88 86 84 98.5% 94.9% 88.9% 2014 2015 2016 9 Source: https://data.cms.gov
Other Quality Metric Results Colorectal Cancer Screening 49% 77.9% May-18 2004 Breast Cancer Screening Diabetic Foot Exam Pneumococcal Vaccination HTN Blood Pressure Control 49.8% 60.8% N/A 57.4% 81.4% 77.7% 87.7% 84.5% 0 10 20 30 40 50 60 70 80 90 100
Improved HTN Control Impact Why is this important? o Additional 5,250 medical home patients at goal with their BP o Additional myocardial infarctions averted over 5 years - 200! o Additional strokes averted over 5 years 50! o Savings in direct medical costs over $13M o Enriches our communities - more healthy and vibrant o Sense of accomplishment by care teams o Improved performance in metrics for HTN reported publicly
Skills/Infrastructure needed to be successful
Skills/Infrastructure needed to be successful o Strong Data and Analytics team o Central coordinating structure attentive to enormous administrative work required by CMS within specific timelines o Feedback mechanism (Population Health Dashboards) Quality of care Outcome metrics Process metrics Patient experience Utilization
Dashboards BP at Goal Performance Initiative 87% of patients at goal
Skills/Infrastructure needed to be successful o Coordination of care to reduce redundant services Interconnectivity of EMR s or Integrated single EMR HIE capabilities are beneficial Referral management Model focused on wellness & Rx of chronic disease o Strong primary care base/pcmh practice model o Care management capabilities HF COPD & other chronic illness Transitions of care Anticoagulation
Care Management Program Heart Failure care management: Compared to traditional management REDUCED Mortality by 39% Hospitalization by 11.4% Readmissions by 12.6% ED visits by 12.8% COPD care management reducing hospitalizations & readmissions Transition care management
Focus on right care, right time, right place Anticoagulation care management program o All ACO patients on warfarin o Time in therapeutic range near 80% o Improved outcomes with less major adverse events such as thrombosis or bleeding 24/7 RN triage - patient care advice & protocol driven Rx o 50%+ patients receive home care advice o Lowest ED triage rate in national comparison group o Assists in appointing when needed o Coordinates with other care management programs Telehealth
Strengths No downside risk, shared-savings model prorated to quality Receive claims data to understand opportunities for improvement Qualifies as an APM but NOT as an A-APM (MACRA) o No additional quality reporting to qualify as APM o No utilization metrics in MIPS o Points awarded for Clinical Practice Improvement in MIPS
Weaknesses Shared savings has no reward for cost containment Claims data is difficult to manipulate/analyze Quality reporting platform is unstable and CMS support is often not responsive to issues All Quality metrics automatically used for MACRA. Other Non-ACO s get to choose their metrics and maximize performance
Weaknesses 2 ACO cycles and then exit or switch o Baseline performance benchmarking disadvantages high performing systems that are already well below the national and regional spend o Re-benchmark after every cycle of ACO - no revenue stream to support infrastructure or maintain performance o Does not allow use of the 3 day SNF waiver o Up-front costs for preventative services count against you now o One may not generate savings until years later
What can be done to strengthen the MSSP I program? Rework the benchmarking methodology o o CMS calculates expected spend adjusted on demographic and risk/burden of illness nationally or regional If you more efficiently than expected (adjusted for quality of care), then continuously reward for achieving these outcomes regardless of the baseline performance Allow non-risk ACO s to be part of the A-APM model o o As long as one reduces cost of care relative to expected spend Stop prohibiting CPC+ withholds, regional restrictions etc. Allow use the 3 day SNF waiver Allow continued participation in no-downside model after 2 ACO cycles