Transcript Negotiating Pharmacy's Role From a Position of Strength

Engaging the C-suite to Advance
Pharmacy Practice
Providing quality patient care through
progressive pharmacy practice
Negotiating Pharmacy's Role
From a Position of Strength
Objectives
• Define Accountable Care Organizations
(ACO)
• Define Pioneer ACO
• Define Transitions of Care
• Determine the Opportunities for
implementation of the Pharmacy Practice
Model Initiative in an ACO setting
What are the core elements of ACO’s?
• Accountable for health, quality, and costs of care
over the full continuum of their patients’ care
• Collaborate, share information and manage patient
health for a population of patients (physicians, acute
care hospitals, wellness, home care, long term care,
pharmacies, et al)
• Focus on improving health and reducing overall
costs for a population of patients
• Able to measure and report improvements in patient
health and overall costs
• Integrate financially to accept and distribute bundled
payments and incentive payments or penalty
retractions
Health Care Reform formalizes the Accountable
Care Organization (ACO) model
• Beginning 1/1/2012, hospitals-physician entities may provide ACO
services
• Beginning in 2013, Voluntary bundled payment pilot programs
• FTC expected to waive restrictions that prohibit effective formation
of ACOs.
• 5 guiding principles:
– ACOs have a strong foundation of primary care
– ACOs report reliable measures to support quality improvement and
eliminate waste and inefficiencies to reduce cost
– ACOs are committed to improving quality, improving patient
experience and reducing per capita costs
– ACOs work cooperatively towards these goals with stakeholders in a
community
– ACOs create and support a sustainable workforce
Accountable Care Objectives
• Create efficient teams of hospitals,
primary care physicians and specialists
• Reduce or eliminate duplication of
services and fragmented care
• Reduce costs – Shared savings
• Improve quality
• Bundle payments
Care Transitions Infrastructure
P
U
B
L
I
C
Figure 1: Care Transitions Infrastructure
COA
Senior Center
Faith-based Org
Home Health
Agencies
Health Plans
Insurers
Emergency
Department
LTAC or
Rehab Hospital
Acute
Hospital
Patient and
Family
SNF
Hospice
Retail
Pharmacy
ADRC
ASAP
EMS
LTC Medical
Home: NH, AL
MH, DDS
Outpatient
Rehab
H
E
A
L
T
H
Are you on the Road to Accountable Care ?
Accountable Payment at Risk
a. ACO Pioneer
b. Commercial ACO
c. Don’t know
Efficient Delivery System Transformation
Synchronizing change
Inadequate physician alignment.
High cost pathways.
Poor analytics for measurement
Care Delivery
Lower unnecessary utilization for
the ACO population.
Have sufficient ACO population.
Careful not to undermine nonACO revenues.
Financial
Care Transformation
Some Elements of Care Common to
Most of the Transitions Models
• Medication Management
• Assessing Patient's Understanding/Ability to Follow
Care Plan
• Discharge Support
• Coaching for Primary Care Physician Visit
• Use of Home Visits Screening for cognitive ability
• Use of Centralized Health Record
• Involving Family and other Caregivers
• Arranging Community-Based Support Services
From: The Lewin Group, December 16, 2009 Care Transitions Workgroup and ASHP Ambulatory Practice Group
What is the Pioneer Program?
• Patient Protection and Affordable Care Act
(2010)
– Center for Medicare and Medicaid Innovation
(CMMI)
– Separate from Medicare Shared Savings Program
– Accountable Care Organizations (ACO)
• Triple Aim
• Quality and cost efficiency = value
• Steward’s community care model is considered an ACO
What is the Pioneer Program? (cont’d.)
• Pioneer ACOs will be held financially
accountable for the care provided to their
aligned beneficiaries
• The Pioneer program begins on January 1,
2012 and continues for three, one-year
performance years. There is an option to
extend for two additional years.
• 60-day termination provision and no settlement
if effective within first 6 months of performance
year
Engaging the C-suite to Advance
Pharmacy Practice
Providing quality patient care through
progressive pharmacy practice
Engaging the C-suite to Advance
Pharmacy Practice
Providing quality patient care through
progressive pharmacy practice
Engaging the C-suite to Advance
Pharmacy Practice
Providing quality patient care through
progressive pharmacy practice
ACO Pioneer Project
• Demonstration project for certain entities to
start Pioneer ACO in 2012
• More flexibility than traditional ACO program
– Assignment of patients, for example
• Quality reporting measures similar to ACO
• CMS named 30 Pioneers – 5 in Massachusetts
Institution A as a Pioneer
Accountable Care Organization
• Health Care Reform (Insurance Reform)
– Treat patients in best location
– Avoid unnecessary admissions
– Requires physician groups and hospitals to
collaborate
– Focus on chronic care
– Focus on preventative care
– Refer internally
– Experience with transitions of care model
– Reduces cost and adds value
Institution A as a
Pioneer ACO - Infrastructure
• Physician groups and hospital are in the same pool
together for all risk contracts
– Institution A - 10 hospitals (1,980 beds)
– Institution A - 149 physician sites (2,200 physicians)
– Institution A
• Owned physicians
– Institution A
• Non – owned, affiliated physicians
– Treat 1.2 million Patients Annually
Commercial ACO Model Contracts
• Blue Cross Blue Shield (BCBS) 66,000 members
choosing Steward - BCBS AQC – Since 2009
– 5 year AQC design based on total costs
– Member opt in
– Quality Measures
• X Health Plan 30,000 members that choose a PCP –
Since 2012
– Based on PMPM
– Quality Measures
• XX Health Care 38,000 members that choose a PCP –
Since 2012
– Based on PMPM
– Quality Measures
Institution A’s Business Strategy
Where We
Are Today
7 - 10
5-6
4th year
Utilization
Per Unit Cost
Infrastructure
•
Value: Quality, Access and Costs (TME –Time & Materials Estimate)
•
•
•
Coordinate care and keep it “in the community”
•
•
•
Improve quality, enhance patient experience
Keep cost trend low, affordable
Build scale: enhance services, apply efficiencies across entire delivery system
•
•
•
Lower annual rate of TME (unit price and utilization)
Drive provider efficiency
Create better value for patients and employers
Creative disruptions in the market, where needed
Budget as Medical Loss Ratio
Redefine
“Health
Care”
&
shift the
focus to
VALUE
Value: keep care in right place, at
right time, at right cost
•
•
•
•
Academic / Tertiary / Quaternary
Community Hospital
Physician office / Clinic
Home
There is a 20% -25% drop in cost
as you move
care from high
cost, to low cost
settings
19
Community Care Model:
The Role of Payment Reform
• Value is the new paradigm
– Keep appropriate care local
• Payment Reform is a tool not the goal
– Move away from FFS (volume)
• Alignment of Key Stakeholders: CI and FI
–
–
–
–
–
Value
Hospitals, LTAC*s, Rehab, FQCHC
Providers
Payers
Employers
Consumers / Patients
• The role of risk contracts
– Commercial: BCBS, THP, HPHC all risk contracts
– Pioneer
– Avoids mixed mode and aligns key stakeholders
*LTAC Long Term Acute Care
Access
Key Strategies for Success: Population Health
Management
Population
Identification and
Stratification
• Analyze population to identify patients health status and
drive the most appropriate and effective care
interventions
Deliver Care
Interventions
• Evidence based clinical pathways and protocols to define
and deliver the most appropriate intervention for all
patients based on their identified health status
Optimize Care &
Physician
Communication
• IT and communication infrastructure to enable improved
care delivery
Measure & Track
Performance
• Improve ability to measure population health to the patient
level, disease/condition level and physician level
Community & Patient
Engagement
• Primary prevention initiatives including cultural
compatibility and community education outreach
Distribution of Complexity and
Costs
• Biggest opportunity is managing medical costs
for complex and complex prevention categories
Focus Area: Patients with Heart
Failure And Its Co-morbidities
TOP 10% Most Costly Members
HF
COPD
6,357
2,873
$16,252
$15,546
$16,120
Avg. Acute IP Admits
4.1
4.6
4.2
4.2
4.8
Avg. All IP Admissions
5.2
6.0
5.3
5.4
6.0
1.6
1.9
1.7
1.7
2.3
Members with HF and at least
the Condition
Avg. Cost PMPM
Avg. ER Visits
* CAD is the most prevalent Disease Management co-morbid condition
* Diabetes is the most expensive
CAD
Diabetes
Asthma
4,008
924
$15,791
Initial Analysis and Identification
Population is analyzed to identify
patients and group by health status:
Population
Identification and
Stratification
•High Risk($) Impactable
• Facility based care, re-admissions,
etc
• Active, high current claims
•At Risk Patients
• Diabetes, CHF, CAD, COPD, IVD, HBP etc.
•All Beneficiaries
• Quality, wellness, prevention
•Palliative Care and/or End of Life Care
Key Strategies for Success
• Quality
– Pioneer ACOs who fail to achieve certain minimal quality
standards may be terminated from the program
– High quality scores can mitigate potential losses and maximize
sharing in successful performance years.
– The Quality Score is based on 33 measures comprising four
domains, weighted equally at 25% each
• ACOs must meet minimum attainment level of the 30th percentile
or 30 percent to earn points on given quality measure
• ACOs not eligible for savings unless achieve the quality
performance standard on at least 70% of measures within each
domain
– Exception: Meeting the EHR measure is required in order to be
eligible
Pioneer Quality Measures (N=33):
Four Domains
•
•
Patient/Caregiver Experience
Care Coordination/Patient Safety
(N=7)
(N=6)
– Includes meaningful use of Electronic Health Record
•
•
Preventive Health
At-Risk Populations
–
–
–
–
–
(N=8)
(N=12, 5 are “all-or-nothing”)
Diabetes
Hypertension
Ischemic Vascular disease
Heart Failure
Coronary Artery disease
Year
Pay-for-Performance
Pay-for-Reporting
PY1 (2012)
0
33
PY2 (2013)
25
8
PY3 (2014)
32
1
• Top Down and
• Bottom Up
Approach to
Readmission
Prevention
CHF Care map
Percentage Re-admission Rates - Medicare
Percentage Re-admission Rates –All Payers
Percentage Re-admission Rates -AMI
Re-admits
by MSDRG
Pay For
Performance
Pay For
Performance
HCAHP’s Inpatient Hospital
HCAHP’s Inpatient Hospital
Pharmacist
Role
STAAR Initiative
Effective Interventions to Prevent Readmissions
• RED – Re-Engineered Discharge
– Education, Discharge Follow-up, Med plan
• Transitional Care Model
– Pre, post discharge coordinated care for high risk – Steward
Healthy Transitions
• Care Transitions Program
– Self management skills training – “Red Zones”
• Evercare™ - Care Model
– Aimed at LTC, Chronic conditions, hospice, palliative care
– Care in home setting
– Phone follow-up
Patient Discharge Information
in Nine Languages
Conclusions
• Evaluation of ACO readiness is critical
• ACO organizations must have sufficient
numbers of risk patients
• Value proposition of ACO differs from FFS
• Pharmacists are part of the care team
• Pharmacist reimbursement for services is part
of the bundle not FFS
• Pharmacists have a role in the success of the
ACO in both inpatient and outpatient settings
Appendix
•
•
•
•
•
Readiness as an ACO
Strategies for Success
Re-Admission Prevention
Care Maps
Data collection
Barriers to Effective Care Transitions
•
Structural
– Lack of integrated
care systems
– Lack of longitudinal
responsibility
– Lack of
standardized forms
and processes
– Incompatible
information systems
– Lack of care
coordination and
team-based training
– Lack of established
community links
•
Procedural
– Ineffective
communication
– Failure to recognize
cultural, educational
or language
differences
– Processes are not
patient-centered nor
longitudinal
•
Performance
Measurement and
Alignment
– Underuse of
measures to
indicate optimal
transitions
– Compensation and
performance
incentives not
aligned with care
coordination and
transitions
– Payment is for
volume of services
rather than
outcomes
Initial Analysis and Identification
Population is analyzed to identify patients
and group by health status:
Population
Identification and
Stratification
•High Risk($) Impactable
• Facility based care, re-admissions, etc.
• Active, high current claims
•At Risk Patients
• Diabetes, CHF, CAD, COPD, IVD, HBP, etc.
•All Beneficiaries
• Quality, wellness, prevention
•Palliative Care and/or End of Life Care
Key Strategies for Success
• Population Health Management (cont’d.)
– Develop a real-time understanding of physicians
who are managing the populations effectively in
terms of quality and cost efficiency
– Cluster patients with chronic disease and comorbidities with physicians and care teams who
demonstrate expertise in management
– Team based care and practice redesign
– Care management tool enables the development
and delivery of evidence based clinical pathways
and protocols based on the health status of all
patients
Key Strategies for Success
• Ambulatory-driven care management program
– Improve care coordination and care management through
disease management for complex and chronic conditions, ER
readmissions, homecare VNAs, SNFs, hospice and palliative
care programs
– Since the ACO is responsible for the total cost of care of
aligned beneficiaries, it is essential that Steward look to
improve coordination along the entire continuum of care
– One of the largest opportunities for achieving shared savings
arises from enhanced post-acute care that reduces
readmissions
– Medically complex beneficiaries also offer significant
opportunities to improve care coordination and realize
immediate savings
– Telephonic and embedded case management
Readmissions
Pneumonia Care Map
Pneumonia Care Map
Institution A
Readmissions Summary
October 2009 – December 2011
Percentage Re-admission Rates –
All Cause
Percentage Re-admission Rates - Pneumonia
Percentage Re-admission Rates – HF – All Cause