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Hospital Readiness for the
Accountable Care Organization Model
Webinar, March 1st 2012
Anne-Marie J Audet, MD, MSc, FACP
VP, Health System Quality and Efficiency
The Commonwealth Fund
Delivery System and Payment Reforms Support
a High Performance Health System
ACO: Broad responsibility for quality
and cost of patient care, rewards for
quality, shared savings
•
Center on Medicare and Medicaid
Innovation
•
Primary Care and Medical Homes:
three new Medicare pilots, several
Medicaid initiatives; increased
payment for primary care
•
Bundled payments: Medicare pilots
for hospital and post-acute care,
Medicaid initiatives
•
Value-based purchasing
•
More transparency on quality and
cost
Payment and Delivery System Integration
Global
Budget
Pioneer
ACOs
Payment Integration
•
Comprehensive
Primary Care
Initiative
Medicare
Shared
Savings
Plan
FFS and DRGs
Small MD
practice;
unrelated
hospitals
Delivery System Integration
Source: The Commonwealth Fund, The New Wave of Innovation: How the Health Care System Is Reforming, (New York: Columbia
Journalism Review, November 2011); A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, Organizing the U.S.
Health Care Delivery System for High Performance (New York: The Commonwealth Fund, Aug. 2008); A. Dreyfus, The Alternative Quality
Contract and ACOs: Lessons for Policy-Makers, presentation to 2012 Bipartisan Congressional Health Policy Conference, January 22, 2012.
Integrated
delivery
system
Spread of Public and Private ACO Contracts
Today
2009
Private Sector
= Brookings-Dartmouth (3)
Public Sector
= Medicare Physician Group Practice Demo (10); Medicare
Health Care Quality Demos (2)
= AQC (8 in Massachusetts)
Private Sector
= Brookings-Dartmouth Pilots (5)
= Premier Implementation (23)
= CIGNA (12)
= AQC (9 in Massachusetts)
= AMGA Collaborative (16)
= Other private-sector ACOs
Public Sector
= Beacon Communities (13)
= PGP, MHCQ (13)
= Pioneer (32)
Source: E. Fisher, et al. ACO Formation: Leading the Transition to New Models of Care, Toward Accountable Care, (New York: The
Commonwealth Fund, January 2012).
Visit us at
www.commonwealthfund.org and
our Benchmarking and Quality
Improvement Site at
www.WhyNotTheBest.org
Additional Resources on ACOs
Commission on a High Performance Health System Report
• S. Guterman, S. C. Schoenbaum, K. Davis, C. Schoen, A.-M. J. Audet, K. Stremikis, and M. A. Zezza,
High Performance Accountable Care: Building on Success and Learning from Experience, The
Commonwealth Fund, April 2011
Case Studies
• A. D. Van Citters, B. K. Larson, K. L. Carluzzo et al., Four Health Care Organizations' Efforts to Improve
Patient Care and Reduce Costs, The Commonwealth Fund, January 2012.
• J. N. Gbemudu, B. K. Larson, A. D. Van Citters et al., HealthCare Partners: Building on a Foundation of
Global Risk Management to Achieve Accountable Care, The Commonwealth Fund, January 2012.
• K. L. Carluzzo, B. K. Larson, A. D. Van Citters et al., Monarch HealthCare: Leveraging Expertise in
Population Health Management, The Commonwealth Fund, January 2012.
• J. N. Gbemudu, B. K. Larson, A. D. Van Citters et al., Norton Healthcare: A Strong Payer–Provider
Partnership for the Journey to Accountable Care, The Commonwealth Fund, January 2012.
• K. L. Carluzzo, B. K. Larson, A. D. Van Citters et al., Tucson Medical Center: A Community Hospital
Aligning Stakeholders for Accountable Care, The Commonwealth Fund, January 2012.
Commonwealth Fund Blog Posts
• Accountable Care Organization Final Regulations Give Health Care Providers More Flexibility, M. Zezza
and S. Guterman,The Commonwealth Fund Blog, October 2011.
• Expanding the Options for Accountable Care Organizations: The Pioneer Model, Parts I and II, M.
Zezza and S. Guterman,The Commonwealth Fund Blog, October 2011.
• What Are the Characteristics of a Successful Shared Savings Program?, M. Zezza and S. Guterman, The
Commonwealth Fund Blog, April 2011.
© 2012, American Hospital Association
Accountable Care Organization
Survey Results
March 1, 2012
Maulik S. Joshi, Dr.P.H.
President, Health Research & Educational Trust
Senior Vice President, Research, American Hospital Association
Email: [email protected]
Office Phone: 312-422-2622
TRANSFORMING HEALTH CARE THROUGH RESEARCH AND EDUCATION
ACO Preparedness Survey Results
• Funded by The Commonwealth Fund
• Survey of the Field on Care Coordination Processes,
Financial Management Processes and Preparedness
to Becoming an Accountable Care Organization
• Survey conducted: May 2011 to September 2011
• 1,672 responses=34% response rate; 47% response
rate of hospitals 300+ beds
• 183 respondents (11% of the 1,672) completed section
2 – questions specific to being/becoming an ACO
• Average size of section 2 respondents: 318 beds
8
ACO Participation
ACO Participation
(n=1,672)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
9
75%
10%
2%
1%
Hospital has
established
an ACO
Hospital is
part of an
ACO
Hospital is Not exploring
actively
the ACO
working to
model
become an
ACO
12%
Do not
know/No
response
Care Coordination Practices
Processes for Facilitating Safe Transitions
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
73%
69%
64%
76%73%
67%
70%70%67%
72%
65%
61%
40%
33%30%
N=52 N=155 N=1192
N=53
N=158 N=1222 N=53 N=155
N=1211
N=52 N=157 N=1203 N=40 N=132
Identifying
Sharing clinical Providing patient Providing patient
patients who
information
discharge
discharge
transition between between settings summaries to
summaries to
settings of care
of care
primary care
other providers
providers
(e.g.,
rehabilitation
hospitals)
Participating in ACO
10
Preparing to Participate in ACO
N=917
Tracking the
status of
transitions,
including the
timing of
information
exchange
Not Exploring the ACO Model
Care Coordination Practices
Care Coordination Across Settings
42%
Telephonic outreach to discharged patients within 72 hours of
discharge
51%
62%
59%
85%
89%
Hospitalists for medical/surgical inpatients
18%
Disease management programs for one or more chronic care
conditions (e.g., asthma, diabetes, COPD)
33%
38%
13%
Nurse case managers whose primary job is to improve the
quality of outpatient care for patients with chronic diseases (e.g.,
asthma, CHF, depression, diabetes)
23%
22%
30%
32%
Arrangement of home visits by physicians, advanced practice
nurses, or other professionals for homebound and complex
patients for whom office visits constitute a physical hardship
11%
Post-hospital discharge continuity of care program with scaled
intensiveness based upon a severity or risk profile for adult
medical-surgical patients in defined diagnostic categories or…
Provision of visit summaries to patients as part of all outpatient
encounters and scheduling of follow-up visits and/or specialty
referrals at the time of the initial encounter
21%
23%
28%
24%
45%
41%
85%
90%
89%
Medication reconciliation as part of an established plan of care
24%
33%
38%
Assignment of case managers to patients at risk for hospital
admission or readmission for outpatient follow-up
0%
11
Not Exploring the ACO Model
10%
20%
30%
40%
Preparing to Participate in ACO
50%
60%
70%
80%
90% 100%
Participating in ACO
Current and Future Payment Mechanisms
Percentage of Net Patient Revenue by Payment
Mechanism
100%
80%
60%
40%
20%
0%
n=1,672
61.8%
TODAY-Percent of net patient revenue
57.1%
34.4%
TWO YEARS FROM NOW ESTIMATED-Percent of
net patient revenue
31.9%
9.7%
13.6%
4.2% 10.3%
5.4%
8.2%
Fee-for-service – Fee-for-service – per Fee-for-service plus Bundled payments Partial and global
shared savings
(inpatient plus
capitation payments
DRG
diem
physician)
Mean Percent of Net Patient Revenue Expected in 2 Years
by Payment Mechanism
100%
80%
60%
40%
20%
0%
57% 60% 56%
35%
14%
23%
Fee-for-Service -- Fee-for-Service DRG
Per Diem
Participating in ACO (n=53)
12
20% 13% 19%
9% 10% 13%
Fee-for-Service
Plus Shared
Savings
Bundled
Payments
Preparing to Participate in ACO (n=160)
21%
8% 12%
Partial and Global
Capitation
Payments
Not Exploring the ACO Model (1,255)
Bundled Payment Planning
Plans to Participate in Bundled Payment Arrangements
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
84%
48%
34%
34%
24% 21%
23%
9%
Considering
applying for a
bundled payment
pilot from CMS if
available
13
8% 8% 5%
3%
Currently in a
In negotiations with Not considering a
bundled payment
a private payer
bundled payment
arrangement
about a bundled
program for the
payment program next 12 months
in the next 12
months
Participating in ACO (n=50)
Preparing to Participate in ACO (n=143)
Not Exploring the ACO Model (n=1150)
CQI Training
Continuous Quality Improvement (CQI) Training
100%
90%
84%
85%
80%
70%
60%
54%
46%
50%
40%
30%
20%
16%
15%
10%
0%
No
14
Participating in ACO (n=51)
Preparing to Participate in ACO (154)
Not Exploring the ACO Model (n=1238)
Yes
Performance Data
Track and Share Performance Data
60%
50%
50%
42%
40%
46%
22%
46%
39%
36%
30%
30%
20%
44%
20%
15%
17%
18%
15%
10%
0%
Yes, provide performance
No,measures
but will
No, but will be
be able able to do so
to do so in the next
in the next
12 to 36 months
12 months
Participating in ACO (n=46)
15
Financial Utilization Patient Clinical
measures
measures bysatisfaction
quality measures
by each
each measures byby each
setting of caresetting setting of care
setting of care
of care
Preparing to Participate in ACO (n=103)
ACO Preparedness
Perceived Difficulty of Obstacles to Becoming an ACO
(1=No Challenge, 5=Extreme Challenge)
Reducing clinical variation
3.63
Aligning incentives to encourage provider productivity,
while minimizing unnecessary utilization of services
3.61
Developing and maintaining common culture
3.61
3.54
Reducing costs
Developing clinical and management information
systems
3.31
Increasing the size of the covered patient population
3.22
Motivating physicians to participate in the system
3.19
Resolving issues between primary care and specialty
physicians
3.16
Accessing capital and investing on a system wide basis
3.15
2.94
Developing physician leadership
2.87
Raising start-up capital
2.51
Developing a workable governance structure
16
0
1
2
3
n=183
4
5
The Accountable Care Alliance
Rita Potter, Director Managed Care
The Nebraska Medical Center
Why we are doing an ACO now with a competing
Health System?
• The community perception of these two organizations is both
systems have quality hospitals and physicians
• The partnering of two competing organizations evidences that our
objective is the improvement of the quality of health care and
reducing cost in our market
• The combining of resources and high quality providers will lead to
innovative ways to provide care and services
• The partnership may provide an attractive option for employers
relating to pay for performance and narrow networks
Structure
•
•
•
•
We formed a for-profit limited liability company
Each PHO has six directors on the Board
Each PHO chose five physicians and one hospital representative
There are two major committees in addition to the Executive
Committee:
• Credentialing
• Medical Management – meets monthly
 1 Quality officer from each system co-chairs the committee
Accountable Care Alliance Structure
Methodist
Health Partners
PHO
Nebraska
Health Partners
PHO
Accountable Care Alliance
Board of Directors
(12 Members)
Executive Committee
(4 Members)
Medical
Management
Committee
Credentialing
Committee
Physicians
• Physicians in the ACA must be a member of a system PHO
• Not all physicians on the PHO will be members of the ACA – it will
be physician choice as those physicians agree to be held to the
prescribed quality standards
Initial Objectives
CLINICAL PATHWAYS:
• We will utilize benchmarks for the evaluation of hospital and physician
performance, to identify opportunities for improved patient safety, clinical
efficiency, and patient outcomes.
• The ACA will serve as a venue for sharing metrics and processes for delivering
care (standard clinical protocols, QI project results).
• Each PHO will determine how it will address outlier results.
• Total Joint
• Pneumonia
• Reducing 30 day readmission
• Physicians sharing best practices with each other
• PQRI
• Medical home
Readmission Risk Assessment
Initial Identification Criteria
• Patients records were screened for existence
of the following criteria (32)
Initial Analysis
• Data was analyzed to determine which criteria more
successfully differentiated readmitted patients from notreadmitted patients
• Criteria with little to no differentiation were removed
from the study. Below are the remaining criteria. (16)
30 Day Readmission Rates
Improvement Plan Recommendation
Improvement Approach
Inpatient Stay
30 Days Post-Discharge
All HF, PN, & AMI Pts
Screened for Risk for
Readmission
IMPROVE
High
Risk
Admission
Inpt Care
Pts Case
Managed by an
RN
?Refocus Sr Assist
CMs & CV Svc Line
Resources?
APRN to round
and provide
intense follow up
?Contract w/
Methodist NP?
Discharge
Low
Risk
For High Risk AMI, PN, HF Pts:
(1) Face-to-face Med Rec with Pharm
b/f discharge
(2) Follow Up MD & Appt established
for w/in 7 days of DC
(3) Disease Specific Education
(4) Face-to-face interaction with Case
Mgr or MLP who will follow 30 d
post DC
Phone Call +
Single Point of
Contact for 30
days for issues
APRN to round
and provide
follow up
?Contract w/
Methodist NP?
Home
SNF
Home Health
TRU
Discharged to…
HF Readmissions
YTD Totals:
FY 2010
157 or 29.7%
FY 2011
FY 2012 to date
120 or 26.1%
38 or 22.9%
Hospital Readmissions:
• Developed shared savings / PFP program with 2 commercial
plans.
• Showing quarterly results at Medical Mgmt ACO Committee
• Grant proposal submitted with VNA (Coleman’s Care
Transition Model).
• APRN round 3X/week high volume skilled nursing facilities
Theme: Share best practices
on how to improve quality
• Medical Management Committee of ACO carries weight of
accomplishments
• High volume surgical DRG’s - continue developing clinical
pathways
• Total Joint, PCI, Large & Small Bowel Colon Procedures and
GABG
Community Health Assessment:
• Joint Assessment completed by Professional Research
Consultants – One study over multiple counties covered by
our 6 facilities
• Strategies being developed based on data analysis
• Measure residents’ access to healthcare, through phone
surveys to quantify preventative health needs, pinpoint
modifiable health risks that are unique to the community
Employee Plan Cooperation:
• Jointly reviewed new insurance plan options on renewals for
2012
• Adding each other as tier one benefits for missing services
(Urgent Care Clinics, pharmacy, palliative care)
• Both plans use Simply Well – Risk/Wellness
• Evaluating 3 year’s employee plan data with Pfizer for
patterns regarding diabetes, depression, ER usage, and pain
management.
Reviewing all CMS Proposals:
Jointly at ACO Board
• ACO Rules (submitted recommended changes to CMS on
proposed rules)
– If beneficiary does not opt out, data should be shared with ACO for
quality of care improvements
– Gain sharing only for first 3 years and future continuation would
require 2-sided option
– Increase maximum shared savings
• CMS Bundling Proposal
– Both submitting LOI: Intend to obtain CMS claims data for shared
learning on targets for specific DRG’s we have worked on at ACA level.
Dollars Saved through Collaboration:
• Dollars Saved through joint contracting on supplies, laboratory
services, property insurance and dialysis vendors $3,842,350
to date.
Next Steps
• ACO Credentialing standards developed
• Standardize peer review committee activities ACO/PHO level to
meet State protection laws
• Continue pathway work on high volume procedures
• Collaborative pharmacy services
Sharp HealthCare ACO
Hospital Readiness for
the Accountable Care Organization
March 1, 2012
Alison Fleury
Senior Vice President,
Business Development, and
Chief Executive Officer,
Sharp HealthCare ACO
36
Sharp HealthCare
• Not-for-profit serving 3.1 million residents of San Diego County
• Grew from one hospital in 1955 to an integrated health care delivery
system
– Fully integrated information technology systems and infrastructure
– Centralized system support services (business development, clinical effectiveness,
compliance, facilities development, contracting, finance, human resources,
information technology, internal audit, marketing and communications, risk
management, strategic planning, supply chain management, etc.)
– Over 25 years experience in managing care under a population-based payment
structure; over 280,000 individuals covered through population-based health plan
contracts alone
• Largest health care system in San Diego with highest market share
– 2 affiliated medical groups, 4 acute care hospitals, 3 specialty hospitals, 3 skilled
nursing facilities, a health plan, 21 outpatient clinics, 5 urgent care centers, home
health, hospice, and home infusion programs, etc.
– Only health system in San Diego to increase market share each of the past 11 years
• Largest private employer in San Diego
– 15,000 employees, 2,600 affiliated physicians (none employed), 2,000 volunteers
37
Sharp ACO Collaborations
• Commercial
• Commercial
• Pioneer ACO
PPO Patients
PPO Patients • Medicare Fee• Sharp
• SCMG and
for-Service
Community
Sharp ReesBeneficiaries
Medical Group
Stealy Medical • Sharp
(“SCMG”)
Group
HealthCare,
(“SRSMG”)
SCMG,
SRSMG
38
Goal of CMS ACO Program
CMS Shared Savings Program established
in the Patient Protection and Affordable Care
Act (“PPACA”) with the goal to provide:
1. Better care for individuals
ThreePart 2. Better health for populations
Aim 3. Lower growth in Medicare
expenditures
39
Pioneer ACO Program
• Offered by the Center for Medicare & Medicaid
Innovation (“CMMI”)
• Designed for health care organizations that are
already experienced in coordinating care for
patients across care settings
• Allows these provider groups to move more
rapidly from a shared savings payment model to
a population-based payment model
40
Pioneer ACO Process
160 Letters of Intent
80 Applications
55 Eligible
Applications
43 Interviews
36 Offered a Contract
32 Selected
41
Pioneer ACO Footprint
42
Sharp HealthCare ACO
• Began January 1, 2012
• Collaboration between Sharp
HealthCare, SCMG and
SRSMG
– All SRSMG physicians, most
SCMG physicians (includes
Graybill), and all Sharp
hospitals
• 32,000 aligned beneficiaries
– 74% with SCMG
– 26% with SRSMG
43
Beneficiary Alignment
• Patients aligned prospectively with the ACO based
on the plurality of outpatient evaluation and
management (“E&M”) billings
– Primary care activity and certain specialties activity
• Nephrology, Oncology, Rheumatology, Endocrinology,
Pulmonology, Neurology, and Cardiology
– Minimum requirement of 15,000 aligned beneficiaries
• 5,000 beneficiary minimum in rural areas
• Participating PCPs must be exclusive to one ACO
– Specialists are not required to be exclusive
44
Beneficiary Alignment
• Once a beneficiary is aligned to an ACO, they may
opt out of Medicare sharing data with the ACO
– Patients who opt out of information sharing are
included in an ACO’s quality and cost results
• Beneficiaries aligned prospectively
– Retrospective adjustments for decedents, patients
moving out-of-network, and patients who lose their
Medicare coverage or enroll in a Medicare
Advantage plan
• Patients retain unrestricted choice of providers
– No authorizations required for services
45
Milestones Thus Far
•
•
•
•
Signed Pioneer ACO Agreement on December 19, 2011
Established provider and supplier network
Published press and marketing materials
Mailed notification letters and data sharing forms
– Provided opt-out preference list to CMMI
• Created beneficiary engagement tools
– Web www.sharp.com/medicare-aco (includes Q&A)
– ACO Hotline 858-499-2666
• Established corporation, leadership team, subcommittee
structure and governing body
– Consumer and patient advocates on governing board
46
Subcommittee Structure
Care
Management
Information
Management/
Data
Exchange
Governing
Board
Patient and Consumer
Representation
Finance
Compliance
Performance
Management
Patient/
Consumer
Affairs
Network
Operations
47
Aim and Primary Drivers
Best Health, Best Care, Best Experience
Care Delivery Models
Care Coordination
Patient Engagement
Information Technology and Analytics
Alignment of Incentives
48
Years One and Two
Billing
Comparison
Bonus
Distribution
• Providers bill normally and receive standard
fee-for-service payments
• Total cost of care for ACO beneficiaries is
compared to a benchmark based on
historical costs of the aligned population
• If total expenses are less than target, and if
quality metrics are achieved, a portion of
the savings is returned to the ACO
• The ACO is responsible for dividing the
savings among ACO participants
49
Quality Measures
Patient/Caregiver
Experience
• 7 individual measures (6 composite)
based on CAHPS
Care Coordination/
Patient Safety
• 6 individual measures (EHR adoption
double weighted)
Preventive Health
• 8 measures (immunizations,
vaccinations, screenings, tobacco
cessation)
At Risk Population
• 12 measures (5 composite diabetes
measures and 2 composite coronary
artery disease measures)
50
Year Three
Payment
Option
• Must achieve quality targets as well as
a minimum 2% annual savings in years
one and two to receive populationbased payments in year three
CMMI’s AIM is that 100% of Pioneer ACOs
generate sufficient cost savings and quality
improvements to qualify for populationbased payments in year three
51
Change
Change has a considerable psychological
impact on the human mind. To the fearful it
is threatening because it means that things
may get worse. To the hopeful it is
encouraging because things may get better.
To the confident it is inspiring because the
challenge exists to make things better.
King Whitney Jr.
Executive Director
National Urban League
1961-1971
52
Sharp HealthCare ACO
53