Toward Accountable Care • Where Policy Meets Practice: Lessons from the CMS Physician Group Practice Demo • Nicholas Wolter, M.D. • Alliance for Health Reform Hill Briefing •
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Toward Accountable Care • Where Policy Meets Practice: Lessons from the CMS Physician Group Practice Demo • Nicholas Wolter, M.D. • Alliance for Health Reform Hill Briefing • Washington, D.C • May 10, 2010 ACO: Accountable Care Organization • Current use evolved from discussion between MedPAC Commissioners & Elliott Fisher on November 9, 2006 in effort to define ways to control healthcare costs in an environment of regional variation in utilization and a largely unorganized & fragmented delivery system • Further defined the following month in an article in Health Affairs [Health Affairs 26, no. 1 (2007): w44–w57 (published online 5 December 2006; 10.1377/hlthaff.26.1.w44)] • • • Onslaught of ACO conferences, white papers, consultant Power Points, RWJF Pilot in New Jersey, etc. Effect of Physician Group Practice demonstration on discussions with CMS, MedPAC, Congress Culmination in Health Reform bill (both HR and Senate versions) Program Environment: Billings Clinic • Group Practice • 240 Physicians, 65 midlevels, all employed • 29 (~50 sub-) specialties (Allergy to Vascular Surgery) • 8 clinic locations • 272 (220) bed tertiary hospital • Manage/support 6 CAHs • ~3500 Committed Employees • 3rd largest employer in Montana • Integrated Delivery System/ Medical Foundation • Board of Directors: community-based • Leadership Council (Internal Board): physician majority + senior administrators 10 Organizations Physician Group Practices Everett, WA – Everett Clinic Integrated Delivery Systems Marshfield, WI – Marshfield Clinic Springfield, MO – St Johns Danville, PA-Geisinger Academic & Network Middletown, CT – Integrated Org. Billings, MT-Billings Clinic Resources for Middlesex Area (IRMA) St. Louis Park, MN – Park Nicollet Ann Arbor, MI - University of Michigan Winston-Salem, NC-NovantForsyth Bedford, NH-Dartmouth Hitchcock Service Region Locations Lincoln Flathead Glacier Hill Toole Blaine Havre Kalispell Pondera Clinic Locations & Number of Providers Chouteau Cascade Billings Clinic - Columbus (2 MDs, 1 NP) Lewis & Clark Judith Basin Billings Clinic - Heights (4 MDs, 1 PA) Missoula Billings Clinic - Miles City (10 MDs, 3 PAs) Billings Clinic - West (8 MDs, 1 PA) Bow Bozeman OB/Gyn (6 MDs, 2 NPs, 1 PA) Affiliate Management Services Big Timber - Pioneer Medical Center Madison Garfield Petroleum Lewistown Roundup Forsyth Valley Gallatin Bozeman Livingston Park Billings Cody Colstrip - Colstrip Clinic Hardin Carbon Red Lodge Powell I-15 I-94 Custer Miles City Wibaux Fallon Colstrip Powder River Sheridan Bighorn Buffalo Hot Washakie Johnson Spring s Thermopolis Fremont Counties with Affiliate or Branch Clinic Scobey - Daniels Memorial Hospital Other Service Area Counties Adams Carter Sheridan Lovell Crook Gillette Worland Red Lodge - Beartooth Hospital Slope Baker Bowman Columbus - Stillwater Hospital Lovell - North Big Horn Hospital Dickinson Big Horn Greybull Park Livingston - Livingston Healthcare Stark Yellowstone Big TimberColumbu s Dillon Glendive Rosebud Musselshell Sweet Grass Dunn Prairie WheatlandGolden Jefferson Billings Clinic- Main (200 MD, 47 PA) Deer Lodge SilverButte Ravalli McCone McKenzie Dawson Meagher Billings Clinic - Red Lodge (4 MDs) Granite Williston Richland Sidney Fergus Great Falls Missoula Williams Wolf Point Glasgow Phillips Sheridan Roosevelt Valley HWY 2 Teton Lake1 PA) Billings Clinic - Cody (7 MDs, Sanders Divide Daniels Scobey Weston Campbell Natrona Riverton Casper I-25 I-90 Montana: 147,138 square miles and 922,002 people PGP Demo Concepts • Medicare Fee For Service continues as before – Business risk for the PGP • If PGP is able to reduce the rate of growth of Medicare spending for the cohort under its care compared to a local comparison, CMS will share part of its savings with PGP – Savings is a function of expenditure control and health status changes • Budget neutral project for CMS • Meeting Financial Target= “Gate” • Once “Open”, PGP’s portion dependent on meeting Quality Measures PGP Project Financial Model SAVINGS >2% 20% CMS 80% Performance Pay Q: Quality E: Efficiency Y1 Y2 Y3-5 0.3 Q 0.4 Q 0.5 Q 0.7 E 0.6 E 0.5E CMS PGP Quality Measures Outpatient Total 32 • Year 1: Diabetes • Year 2: Year 1 plus HF and CAD + flu and pneumonia • Year 3: Year 2 plus Hypertension and colorectal and breast cancer screenings vaccines PGP Quality Thresholds: Absolute or Relative Targets benchmarks or >10% improvement in gap (100%- baseline) Taken from the Doctor’s Office Quality measurement set in 1992. Thus some of the target measurements are not the current quantitative benchmark. The demonstration uses a total of 32 measures that focus on common chronic illnesses and preventive services Diabetes CHF CAD Preventive Care HbA1c Management Left Ventricular Function Assessment Antiplatelet Therapy Blood Pressure Screening HbA1c Control LV Ejection Fraction Testing Drug Therapy for Lowering LCL-C Blood Pressure Control BP Management Weight Management Beta-Blocker Therapy Prior MI Blood Pressure Control Plan of Care Lipid Measurement BP Screening Blood Pressure Breast Cancer Screen LDL Cholesterol Level Patient Education Lipid Profile Colorectal Cancer Screen Urine Protein Testing Beta-Blocker Therapy LDL Cholesterol Level Eye Exam Ace Inhibitor Therapy Ace Inhibitor Therapy Foot Exam Warfarin Therapy Influenza Vaccination Influenza Vaccination Pneumonia Vaccination Pneumonia Vaccination 10 Common Basis for Strategies among the PGP Groups 1. Focus: High Cost Areas Components of Medicare Expenditures For Billings Clinic (base year) 2. Focus: Chronic Care & Prevention • • • • • • • • Inpatient Hospital OP Part B SNF Home Health DME 40% 24% 22% 7% 3% 4% Reduce avoidable admissions, ER visits, etc • • High prevalence and high cost conditions Provider based chronic care management Care transitions Palliative care Financial Savings are INPATIENT driven. Quality Measures are OUTPATIENT driven. Interactive Telephone System with Web-enabled Data Tracking • Utilizes daily monitoring system for patients via Interactive Voice data collection Patients call daily between 4 AM and Noon • Data appears immediately on a web server • HF “Care Coaches” (RNs) call outliers • – Manage per HF protocols (diuretic ∆) – Refer to HF Clinic MD/NPP or PCP • • • Goal: coordinate care w/“Tx Physician” Validated, proven system that manages by exception Allows for 1 RN to follow 2-300 patients 12 35-43% reduction in hospitalizations ~80% Averted Admissions - All Payers Quarters Se pt 08 08 ch Ju ly- M ar pt Ja n- Se Ju ly- M ar 07 07 ch 06 pt Ja n- Se Ju ly- M ar ch 06 120.00 100.00 80.00 60.00 40.00 20.00 0.00 Ja n- Averted Admissions or ~ 5/100/month enrolled in TA Total: # 780 Medicare: Averted Admissions vs RTI Rate^^ Averted Admissions vs NonIntervention Group^^ 13 Advisory Board CMS-PGP Demonstration CMS PGP Objectives • Encourage coordination of Part A & Part B • Coordinate care for chronically ill and high cost beneficiaries in an efficient manner • Decrease the growth in Medicare spending over the next 3 years Timeline • Base Year: Calendar year 2004 • Performance Year 1: April 1, 2005 March 31, 2006 • Performance Year 2: April 1, 2006 March 31, 2007 • Performance Year 3: April 1, 2007 March 31, 2008 • Performance Year 4: April 1, 2008 – March 31, 2009 • Performance Year 5: April 1, 2009March 31, 2010 Accountable Care Organizations Key Features Key Design Components • Local Accountability • Organization well defined • Shared Savings • Scope of providers • Performance Measurement – PCP essential – Continuum of care • Spending and quality thresholds to ensure success • Distribution methodology for shared savings Brookings-Dartmouth ACO Learning Network https://xteam.brookings.edu/bdacoln/Pages/BackgroundInformationonACOs.aspx Advisory Board Accountable Care Organizations: A group of providers willing and capable of accepting accountability for the total cost and quality of care for a defined population. 7 Core Components 1. Providers 2. Payers 3. Management 4. Alignment Structure 5. Population IT/Data 6. Medical Home (PCMH) 7. Patients Providers • PCPs • Specialists • Hospital • LTC • Home Care • Pharmacy • Ancillary/DME • Alternative/Integrative • Hospice Scope of Accountability • Single Service/Episode • Bundled Payment/ETG • Disease Specific • P4P for outcome measures diabetes, etc. • Service Oriented • Medical Home payments • Segment by Illness • CMS Chronic Care demo • Total Population Care • Accountable Care Org (HF, Stuart Guterman, Karen Davis, Stephen Schoenbaum, and Anthony Shih, Using Medicare Payment Policy To Transform The Health System: A Framework For Improving Performance, Health Affairs, Vol 28, Issue 2, w238-250w Copyright ©2009 by Project HOPE, all rights reserved. Patient Protection and Affordable Care Act ACO Definitions • “Secretary (of HHS) shall establish” – • • • • • • • significant degree of discretion in rule making Starts “not later than” January 2012 Shared Savings Program Accountable for a population (>5,000 beneficiaries) Coordination of Medicare A&B Investment in infrastructure High quality and efficient delivery “groups of providers of services and suppliers meeting criteria” = ACO – – – – – Group practice arrangements Networks of practices JV between hospitals/providers Hospitals w/ employed providers Others? Patient Protection and Affordable Care Act ACO Requirements • • • • • • • Accountable for quality cost and overall care for assigned beneficiaries Agree to ≥ 3 year period Form legal structure to receive and disperse payments PCP enough for population (≥ 5K) Specify the providers in ACO Leadership for clinical and administration services Processes to ensure it – – – – • promotes EBM reports quality, cost, & utilization measures coordinates care (emphasizes technologies, care transitions) assesses patient and provider experience Engagement in PQRI, e-Rx, EHR (?meaningful use), possibly higher standards than general Medicare providers Patient Protection and Affordable Care Act ACO Methodologies • • • • • Assignment of FFS beneficiaries based on use of PC services – “appropriate method”; prospective vs. retrospective – Beneficiaries enrolled in A+ B, excludes Part C (Medicare Advantage) FFS payments continue + potential for shared savings payments Benchmark to determine shared savings – prior 3 year average per capita expenditure for assigned ACO population – updated by national growth trend (absolute amount, not rate) – risk adjustment methodology required but not defined by statute – updated each performance period Savings occurs if the average per capita expenditure is below a percentage of the benchmark that assures performance is not due to normal variation – ? 95% confidence interval, thus population dependent – Quality requirements must be met – Secretary to determine percentage & maximum amount of net savings shared Other features – Monitoring of risk avoidance by ACO – Termination possible if ACO not meeting quality standards DESIGN ISSUES • Attribution • Beneficiary Participation • Comparator Group • Rapid Performance Feedback • Risk Adjustment • Infrastructure Investment Requirements • Financial Design- 2% Threshold • Shared Savings as a Longterm Design Feature Other Thoughts • Focus on high volume/high cost • Continued need to refine FFS payment • Eliminate incentives driving fragmented behavior • Importance of some stick with the carrot • Relationship between delivery system organization and payment policy can be nonlinear • Importance of leadership/culture • Importance of collaborative learning • Rural healthcare providers can be players Collegiality is the Key “The key feature of the new integrated health care enterprise is not a balance of power, however, but the emergence of collegiality as the fundamental organizing principle. The essence of collegiality is tolerance and a sharing of common professional values. This trust and sharing of values is, in turn, the central precondition of the ability to share and successfully manage the economic risk of health costs.” Jeff Goldsmith Driving the Nitroglycerin Truck Healthcare Forum Journal March/April 1993 Culture of Quality and Safety: Billings Clinic • CMS PGP Demo • Early adopter CMS Core Measures • ICU Bundles(Pronovost) • MRSA reduction using positive deviance technique • Specialty Society Quality Data: STS, ACC, NSQP • Chronic Disease Registeries • PACE • Magnet/Beacon • Center Translational Research • Quest/Premier ACO Demo The past 50 years have been marked by advances in the science of medicine. The next 50 will be marked by improvements in the organization and teamwork of how healthcare is delivered. Charles Mayo, M.D. January, 1913 Thank You