View
7
Download
0
Category
Preview:
Citation preview
Practicing Medicine in the Era of Health Reform
Session 15
Accountable Care Organizations
Richard Lopez, MD
August 12, 2015
Tufts Health Care Institute1
Accountable Care Organizations
Richard Lopez, MD – Chief Medical OfficerAtrius HealthAugust 12, 2015
richard_lopez@atriushealth.org
2
Today’s Discussion
• Introductions• Health Care Crisis• Reactions to Rising Cost of Healthcare• ACO Concept as a Provider Solution• Global Payments in support of ACO’s• ACO Model: BCBSMA AQC• ACO Model: Pioneer ACO• ACO Results
3
4
Atrius Health
.
The Northeast’s largest nonprofit independent multi-specialty medical group. A national leader in delivering high-quality, patient-centered coordinated care.
Dedham Medical AssociatesGranite Medical GroupHarvard Vanguard Medical AssociatesVNA Care Network
Providing care for ~ 675,000 adult and pediatric patients with 750 physicians across more than 35 specialties
Atrius Health 2015. All rights reserved
Atrius Health Core Competencies
5
Corporate Data Warehouse integrates single platform, electronic health record data with multi-payer claims data
Widespread Extensive Population Health Management including disease-based and risk-based rosters, population managers
Long history with and majority of revenue under Global Payment across commercial and public payers
Sophisticated development and reporting of Quality and Performance Measures leading to high achievement
Patient-Centered Medical Home foundation, achieving level 3 NCQA across all primary care practices
© 2015 Atrius Health, Inc. All rights reserved. Not for distribution.Atrius Health 2015. All rights reserved
US Health Care Costs as Compared to Gross National Product
6
National Healthcare Perspective: Spending vs Life Expectancy
MA
9000
CT
8000
The U.S. is off the charts when it comes to health expenditures per capita, but this extensive spending is not performance-based and is not correlated to longer life expectancy.
7
Workers Are Paying a Greater Share of Health Care Premiums as Employers Strive to Reduce Their Costs
8
State Healthcare Perspective: Burden of Healthcare Expenditures
Massachusetts State Budget ($ Billions), FY 2001 vs. 2011
SOURCE: Massachusetts Budget and Policy Center
FY2011FY2001
+$5.1 B(+59%)
‐38% ‐33%
‐15%
‐23%
‐13%
‐50%
‐11%
-$4.0 B(-20%)
Health Care Coverage(State Employees/GIC;
Medicaid/Health Reform)
PublicHealth
MentalHealth
Education Infra-structure/Housing
HumanServices
LocalAid
PublicSafety
Growing healthcare expenditures are putting enormous pressure on state budgets throughout the country, forcing budget cuts in most other areas to make room for the growing healthcare component.
© 2013 Atrius Health, Inc. All rights reserved.
10
Response of Commercial Payers and Employers
• Consumer Driven Products (cost sharing)– High deductables– Higher copays– Defined contribution
• Tiered physician and hospital networks– GIC– Tufts Navigator– HPHC Independence
• Limited networks • Increased pre-authorization programs
– Imaging– High cost drugs– Sleep studies
• Increased risk sharing with providers (ACO)• Employers: Employee Wellness Programs
11
Response of Government – Part One
• Federal– Accountable Care Organizations
• Shared Savings Program (CMS)• Pioneer ACO Program (CMMI)• NexGen ACO (CMMI)
– Payment• Decreases for hospitals and physicians• Penalties for hospitals for re-admissions and “never
events”
– Bundled Payments• Bundle Payment for Care Improvement Initiative
12Atrius Health 2015Atrius Health 2015. All rights reserved
Response of Government – Part Two
• State– Chapter 224 passed in August 2012
• Limits rate of increase in health care costs to the State’s Gross Product
• Requires payers and providers to provide performance improvement plans if rates exceed SGP
• Regulates ACO’s• Requires transparency in pricing by both payers and
providers
– Municipalities• Conversion from traditional high cost BCBSMA plans to
lower cost Group Insurance Commission (GIC) plans with higher copays and deductibles
13Atrius Health 2015Atrius Health 2015. All rights reserved
Marketplace Response: Disruptive innovation?
• Limited service and retail clinics– CVS MinuteClinics and Walgreens Take Care Clinics– Doctors Express (franchise)– CareWell (in partnership with UMASS and Lahey)– MedSpring (in partnership with Partners Health Care
• Best Doctors – expert opinion program• Video visits, e.g. American Well, • Find a doctor when needed: ZocDoc• Potential use of out-of-state MDs for telemedicine • Employee wellness companies
14Atrius Health 2015Atrius Health 2015. All rights reserved
Response from Providers (Hospitals, Health Systems, Physician Groups)
• Heavy pressures on reimbursement rates are resulting in shifts towards accountable care and risk based contracting models
– Tighter network management of leakage across the spectrum – hospital, SNF, outpatient, specialty
– Stronger care management models- PCMH, High Risk Management• Healthcare delivery systems are integrating across the spectrum to optimize
care management– Hospitals acquiring physicians– Physician groups acquiring hospitals– Systems acquiring insurance companies– Insurance companies acquiring delivery systems
• Consolidation of health systems, with scale providing significant advantages– Access to capital– Efficiencies of scale both clinical and administrative– Opportunity for “white label” insurance products– Opportunity for direct-to-employer contracting
15Atrius Health 2015Atrius Health 2015. All rights reserved
The concept of an Accountable Care Organization is not new
“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”
Dr. Robert Ebert, Founder, Harvard Community Health Plan, 1967
© 2015 Atrius Health, Inc. All rights reserved
16Atrius Health 2015Atrius Health 2015. All rights reserved
Definitions of “Accountable Care Organization”
• Academic: Devers & Berenson in RWJ Brief: The ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care; The capability of prospectively planning budgets and resource needs; and Sufficient size to support comprehensive, valid, and reliable performance measurement.
• Federal Law: PPACA: an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.
• Certification: NCQA: provider-based organizations that take responsibility for meeting the health care needs of a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capita costs.
• MA State Law: Health Policy Commission will define ACO through its certification process and Model ACO certification
Providers
Migration Towards Accountable Care
CommercialPayors
Regulators
The act of providers assuming responsibility and
financial risk for the quality and total cost of care of a
defined population
This means a radical transformation from the perspective of providers, who will need to develop the capabilities to manage a population’s health, as well as payors, who will need to transition to risk-based contracting models.
18
From Fragmented Care Systems…
…Towards Integrated Care and Population Health Management
Implications for Providers
Managing a population’s health, and remaining financially viable in a risk-based contracting environment, requires healthcare delivery systems to be truly integrated across the spectrum of care.
Massachusetts is a Leader in Medicare ACOs
• Pioneer ACOs:– Atrius Health– BIDPO– MACIPA– Partners– Steward
– Of total 22 nationally
• Medicare Shared Savings:– Accountable Care Clinical Services– Accountable Care Org of NE– BMC Integrated Care Services– Cape Cod Health Network– Circle Health Alliance, LLC– Collaborative Health ACO– Emerald Physicians– Harbor Medical Associates, PC– Lahey clinical Performance ACO LLC– NEQCA Accountable Care– Physicians Accountable Care– Pioneer Valley Accountable Care– Southcoast ACO– UMASS Memorial ACO– Winchester Community ACO– Of total 404 nationally
20Atrius Health 2015Atrius Health 2015. All rights reserved
Impact of ACO’s: Consolidation
• The Massachusetts market is rapidly moving towards consolidation
• It is widely predicted that in 3-5 years, a large percentage of healthcare in the Commonwealth will be provided by 5-6 large health care systems:– Partners– Stewart– BIDCO– Atrius Health– UMass– ???
21Atrius Health 2015Atrius Health 2015. All rights reserved
First Year Results of Medicare Shared Savings ACO Program – the numbers
• Number ACO’s Participating: 114
• Number of ACO’s that saved money: 54
• Number of ACO’s that saved enough money to collect a bonus: 29
• Amount saved: $126M
22
Accountable Care is driving fundamental change in health delivery
• Increase in population management – registries, outreach• Increased use of data to manage cost and quality• Use of nurses to coordinate care for high-risk patients• Use of community health workers • Creation of preferred post-acute provider network (SNF and
VNA) • Connecting with local community elder service agencies to
provide community-based supports• Systematic ways to honor, across the care continuum, patients’
wishes around end of life care• Delivery of a proven post-discharge “bundle” of services to
prevent readmission• Increase in disease management programs• Patient engagement in shared decision making
23Atrius Health 2015Atrius Health 2015. All rights reserved
Global Payments provide financing model for an Accountable Care Organization• Infrastructure can be
– Planned and maintained without dependence on patient activity
– Provided even if not funded in under Fee-for-Service payment
• Provides stimulus for more efficient use of physician and office time with more convenience to the patient.
• Funds innovations such as e-portals, text messaging, phone calls and new roles necessary to “be with” the patient where life is actually being lived by the patient.
• Fosters use of diverse medical teams working at “top of license”
Atrius Health 2015Atrius Health 2015. All rights reserved
BCBSMA Alternative Quality Contract was Early Model for ACO
• Accountability for quality and resource use across full care continuum Long-term (5-years) Annual inflation tied to Consumer Price Index
• Improved quality, safety & outcomes as compared with traditional Pay-for-Performance
• Robust performance measure set (60+ measures) creates accountability for quality, safety & outcomes across continuum and over time
• Substantial financial incentives for high performance
Atrius Health 2015Atrius Health 2015. All rights reserved
Experience with AQC helped us step up our game
• Early adopter based on prior managed care experience
• Investments made to “retool factory” include Lean, Leadership Academy, Patient Centered Medical Home
• Quality framework provided focus and common language across Atrius Health groups
• Established strong precedent for joining Medicare Pioneer ACO Program
• Other Mass payers have followed suit
Atrius Health 2015Atrius Health 2015. All rights reserved
Lean is an important Foundation for our work
27
Why Participate in Pioneer ACO? “Reason for Action”
28
High quality, high –value care for allMedicare‐eligible patients across the care continuum with
spillover for commercial risk
Unique opportunity to be accountable for quality and costs for a PPO population
Further Atrius Health position as a market leader in payment reform, moving towards 100% global payment
Achieving Triple Aim Goals
.Atrius Health 2015Atrius Health 2015. All rights reserved
Three year contract effective January 2012 with two additional year options; accountable for all Medicare A and B benefits
Partnership with Center for Medicare and Medicaid Innovation (CMMI)
Medicare FFS beneficiaries aligned with ACO based on their historical claims data
Global budget: performance
measured against national
benchmark
Upside & downside risk sharing with
CMS
Incentives rewards to
achieve high quality
performancemeasurements
Accountable to Pioneer ACO Obligations
Key Features of Pioneer & Performance Measures
29Atrius Health 2015Atrius Health 2015. All rights reserved
Financial Measures: Shared saving/loss
BaselineBased on Actual Claim for ACO
population
BenchmarkThink Global Budget
Based on Growth Rate from National Matched Cohort
Atrius Health Goal:To beat the Benchmark
30Atrius Health 2015Atrius Health 2015. All rights reserved
Quality Measures: Key Features
33 Quality Measures:
many new, or with new features
• Patient/caregiver experience, measured by CG-CAHPS
• Care coordination/patient safety using claims data (eg. Readmission rates)
• At Risk Population, using EHR measures • Diabetes• IVD• CAD• Heart Failure• Hypertension
• Preventive Health
Atrius Health 2015. All rights reserved
Pioneer ACO Strategies Address Gaps
Quality & Safety
Internal Communication
& Structure
Regulatory
PATIENT‐CENTERED MEDICAL HOME
Data Analytics &Reporting
Hospital Strategy Geriatric Care Model
Care Management Strategy
Post-Acute Strategy
Electronic Health Records & Health
Information Exchange
Medicare/MedicaidDual Population
Strategy
Costs: Beat the TrendQuality:100% Reporting201290th Percentile2013
Atrius Health 2015Atrius Health 2015. All rights reserved
ACO = Medicare Population Health Strategy
33
Approximately 52,000 Medicare Beneficiaries in• Outcomes-Based Contracts with• Triple-Aim Accountability
30,000
21,000
1000
Pioneer Aligned
MedicareAdvantageDuals HMOs
Atrius Health 2015Atrius Health 2015. All rights reserved
Accountable Care = Population Management
• What is the target population? – How is the cohort defined?– How is accountability defined?
• What population outcomes do we want & how are they measured?
– What conceptual framework links potential care processes to target outcomes?– What are the overall key indicators? What are interim process/operational indicators?
• How do we support the key processes required to achieve outcomes?
– Which of these processes are most effective, efficient, and patient centered?– What infrastructure is required to ensure reliable frontline process execution?
34. Atrius Health 2015Atrius Health 2015. All rights reserved
Medicare Population Health Approach
• Close medical management at end of life • Tight coordination of 5% highest risk• Medical Management of chronic conditions • Preventative Care for “well” patients
» Local Implementation – Practices at different starting points.
» Central support to reach goals, manage CMS relationship and obligations.
35
Advanced Illness Management - Top 2%
Chronic Care Management -Next 15%
Population Management- Remaining 80%
Other High Risk/Acute - Another 3%
Atrius Health 2015Atrius Health 2015. All rights reserved
Focus One: High Risk Patients, High Cost Events
36
• Advance Care Planning• High Risk Roster Review • Care Transitions• Post Acute Episode Mgmt• CKD • Community Support for
Dual Eligibles
Advanced Illness Management - Top 2%
Chronic Care Management -Next 15%
Population Management- Remaining 80%
Other High Risk/Acute - Another 3%
Atrius Health 2015Atrius Health 2015. All rights reserved
Focus Two: Health Risk Prevention
37
• Falls Risk/Fractures• Depression Screening• Med Reconciliation
Advanced Illness Management - Top 2%
Chronic Care Management -Next 15%
Population Management- Remaining 80%
Other High Risk/Acute - Another 3%
Atrius Health 2015Atrius Health 2015. All rights reserved
Keep Working the Medicare Population Pyramid
38
2015 Focus:
• Custodial Nursing Home program
• Palliative Care/Hospice • Care Transitions• COPD• Expanded home tele-
monitoring• New ACO Quality
Measures
Advanced Illness Management - Top 2%
Chronic Care Management -Next 15%
Population Management- Remaining 80%
Other High Risk/Acute - Another 3%
Atrius Health 2015Atrius Health 2015. All rights reserved
The Triple Aim
ExperienceOf Care
Per Capita Cost
Population Health
Source: IHI.org
The root of the problem in health care is that the business models of almost all US health care organizations depend on keeping
these aims separate. Society on the other hand needs these three aims optimized (given appropriate weightings on the components)
simultaneously. Tom Nolan, PhD.
Atrius Health 201539
Atrius Health 2015. All rights reserved
40
TripleAim
Outputs: Population Health Initiatives
IdentifyGaps
DesignProgram
Develop Tools Implement
Track & Measures
Continuous Improvement
Inputs: Quality Measurement and Improvement, Data Analytics, Medical Management, Clinical Champions, Internal Best Practices,
External Peer AccomplishmentsAtrius Health 2015Atrius Health 2015. All rights reserved
Key ACO Initiatives: Our Investments
Acute/Post Acute Preferred Providers Strategies • Preferred SNF Network with service
standards/facility expectations• SNF Provider Expectations• Preferred Hospital strategy• Preferred ambulance strategy
Care Management (“Post Acute Home”)• VNACNH Integration• Local Elder Services Agencies• Programs for Dual-Eligibles• Shared standards and best practices
Geriatric Care Model • Patient Risk Stratification• Multidisciplinary Roster Reviews• Advance Care Planning• Chronic Kidney Disease
Data Analytics & Reporting• Ongoing Support for Workgroup
Initiatives• Trackers to monitor performance
against goals
Electronic Health Record and Health Information Exchange• Tools to Support ACO Quality
Metrics & Workflow
Quality & Safety• ACO Quality Metric Reporting• Performance Improvement/Best
Practices
41Atrius Health 2015. All rights reserved
Medicare High Risk Model:Patient Risk Stratification Tool
Using both claims and Electronic Health Records databases, the tool allows to identify members at risk of hospitalization, poor health outcomes, high costs
The model consists of five key factors:Likelihood of HospitalizationHospital admissions or ED visitsBehavioral Health diagnosisCHF or COPD>= 15 medications
42
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patients ACO TME
% DECEASED
% ALIVE H/VH Risk
% OTHERS
20% of patients
60% of costs
Proportions of High Cost (Atrius Health ACO) Patients & attributable to them Costs
(Aug 2012)
Factor Pts
DxCG Likelihood of Hospitalization Score (Model 71)
3
Hospital Admissions or ED Visits 3
Behavioral Health (Psychiatric, Substance Abuse, Dementia)
2
CHF or COPD or CKD 1
Poly-pharmacy (Excludes Topical & Supplies)
1
Maximum Score 10
Atrius Health 2015Atrius Health 2015. All rights reserved
High Risk Patient Roster Review
Confirm diagnoses Review medications Address quality measures
Confirm diagnoses Review medications Address quality measures
Social assessment Care needs assessment
Social assessment Care needs assessment
Advance directives Palliative care discussion
Advance directives Palliative care discussion
Care plan documentation & orders
Care plan documentation & orders
PCP-Led Team
PCP-Led Team
43. Atrius Health 2015Atrius Health 2015. All rights reserved
High Risk Roster Participants
“Each site may choose to have any number or combination of participants so long as the goals of high risk roster reviews are being met.”
Typical participants include:• PCP• Primary Nurse or Medical Assistant• Population Manager• Care Manager• Geriatric Champion or Palliative Care Specialist• Social Worker• VNA representative• Clinical Pharmacist
44.Atrius Health 2015Atrius Health 2015. All rights reserved
Geriatric Care Model: Multidisciplinary Roster Reviews
Review and confirm accuracy of diagnosis
Review appropriateness of medications
Perform a care needs assessment
Create a clinical summary of the patient
Perform a social assessment
Review applicable diseases related quality measures
Confirm existence and need for advance directives
Update the patient’s care plan and document next steps
Adopted common standards for High Risk Patient Roster Reviews
Early adopters of HRRR saw greater reductions in TME
45Atrius Health 2015. All rights reserved
Advance Care Planning Initiatives
46
Description: • Developed advance care planning (ACP) curriculum with CME/CEU credits.
• Established site‐based ACP champions to train and provide ongoing ACP support locally
• Developed new tools in Epic to track and document advance care planning
Expected Outcomes:• Improve PCP knowledge and comfort with ACP
• Increase end of life conversations and collection of patient’s care wishes, advance directives and proxy information
• Minimize use of aggressive curative care when not aligned with patient’s care wishes
82%86%
0%10%20%30%40%50%60%70%80%90%
100%
2013 ACP and 2014 MOLST Trainings
ACPMOLST
Atrius Health 2015Atrius Health 2015. All rights reserved
Advance Care Planning: Results
47
Implemented EMR checklist
Atrius Health 2015Atrius Health 2015. All rights reserved
Geriatric Care Model:Chronic Kidney Disease
ResultsIn first 5 months, 66% of patients with lab defined criteria were diagnosed with CKD triggering clinical interventions.
Description• Clinical guidelines• Provider education & training• Patient education and engagement• Keeping services in‐house when
appropriate• Expectations for outside nephrologists• Epic tools• Risk score modification
Expected Outcomes• Improve diagnosis• Slow progression of CKD
48Atrius Health 2015Atrius Health 2015. All rights reserved
49
Kidney International, Jan 2013; Supplement 3 KDIGO Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: 1 - 150Approved by the Atrius Health Accountable Care Organization’s Geriatric Care Model CKD Workgroup, which includes the Harvard Vanguard Chief of
Nephrology; February 2013
Stage (eGFR) Albuminuria? (≥30mg/g)
Serum eGFR and Urine
Microalbumin
Hgb, 25-OH Vit D, Phos, PTH, Lipids, Ca
Electrolytes
Initial Renal
Ultrasound
Nephrology Consult
Stage 3a (45-59) No Annually* Annually* Consider
Stage 3a; (45-59) Yes Q6 Month* Annually* Consider Recommend
Stage 3b; (30-44) No Q6 Month* Annually* Consider Recommend
Stage 3b; (30-44) Yes Q4-6 Month* Annually* Consider Recommend
Stage 4; (15-29) N/A Q3 Month* Annually* Consider Recommend
* Might require more frequent monitoring if abnormal and/or if undergoing changing treatment strategies
CKD: Clinical Guidelines
Atrius Health CKD Guidelines for Primary Care
.Atrius Health 2015Atrius Health 2015. All rights reserved
CKD Dashboard/Roster
50
Primary Care Dashboard: Merge of EPIC and Claims Data- Lab Result Based Total CKD Population- Laboratory Screening (Ca, Phos, CBC, UA, Vit D, PTH)- Clinical Outcomes (BP, LDL, HgA1c)- Referral to Nephrologist Specialist- Visit to Nephrologist
Atrius Health 2015Atrius Health 2015. All rights reserved
CKD: Impact
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patients w/EGFR<60
CKD Dx No CKD Dx
. 51Atrius Health 2015Atrius Health 2015. All rights reserved
Post-Acute Home Workgroup: Stronger Collaboration with VNACN
Developed Standard Work for referrals to and communication with VNACNH during episode of care.
Care plan transmitted to EPIC within 48 hours of admission, including: ‐ Advance care planning forms‐ Follow up appointment with PCP within 7 days of hospital discharge‐ Collection of ACO quality metrics
* Fall risk assessment * Medication review * Depression screen (PHQ) 2
© 2013 Atrius Health, Inc. All rights reserved.
We see a decrease in VNA $pmpm and a decrease in readmits during VNA episode 52
Atrius Health 2015. All rights reserved
PAH Tracker: By Medical Group
Post Acute Home (by Medical Group) YTDJan 2014 thru October 2014 YTD(Claims paid through December 2014)
VNACNF Episodes as % total HHA Episodes ‐ PION
VNACNF Episodes as % total HHA Episodes ‐
TMP
ED visit/K during VNACNF Episode ‐ PION
Readmit Rate during VNACNF Episode ‐ PION
% Patients with VNACNF
Episode with ACP in Epic ‐
PION% Duals Enrolled
DMA 53% 72% 84 17% 86% 15%GRN 40% 64% 92 20% 67% 15%HVMA 32% 65% 101 10% 67% 20%RMG 42% 68% 109 16% not available 50%SMG 35% 61% 288 18% 75% 22%
Atrius Health 2015Atrius Health 2015. All rights reserved
PAH 2015 Q1
TMP PIONA. ED Visit per 1000 during NON‐VNACNF episode/admission
NA 103 97
B. ED Visit per 1000 during VNACNF episode/admission
VNACNF lower than NON‐VNACNF 97 78
C. Readmit rate during NON‐VNACNF episode/admission
NA 22% 11%
D. Readmit rate during VNACNF episode/admission
VNACNF lower than NON‐VNACNF 17% 11%
E. VNACNF episodes/admissions as % of all home health episodes/admissions
37% 68% 37%
Quality% of patients admitted to VNACNF who have Falls Risk Assessment (FRA) scanned in EPIC within the episode/admission
94% 95% 88%
% of patients admitted to VNACNF who have Depression Screening scanned in EPIC within the episode/admission
94% 93% 87%
% of patients admitted to VNACNF who have ACP form (MOLST, Adv Dir, or HCP) in EPIC
watch until Q4 79% 75%
VNACNF Pre‐op Joint visits completed (all payers)
watch
% of total joint replacement discharges going home with VNA
Q1 watch 20% 37%
RPM Program (began May 2015 ‐ all payers)
a. # of referrals Q2 & Q3 watchb. accepted to program Q2 & Q3 watch
Acute hospital admissions during an RPM episode
Q2 & Q3 watch
VNACNF Patient ExperienceA. % of referrals with timely initiation of care
95% 94%
B. AH complaints ‐ % of investigations initiated within 48 hours
92%100% (12/12)75%(9/12)
53
0
Utilization 2015 PION Goal Atrius YTD thru PION YTD
65
C. AH complaints ‐ % resolved within 30 days
92%
2015 YTD thru May
Tracking VNA Performance
Atrius Health 2015. All rights reserved
Post-Acute Home Workgroup: Integrate Local Elder Services (ASAPs)
55Atrius Health 2015Atrius Health 2015. All rights reserved
Adapted from Slides presented by Robert Mechanic, Brandeis University, with permission
Variation in 2010 Medicare Average Length of Stay for Skilled Nursing Facilities
0
10
20
30
40
50
60
Quartile 1 Quartile 2 Quartile 3 Quartile 4
ALOS
Source: Adapted from Office of HHS Inspector General December 2010.
2929
3434
61
24
24
5
Difference Between Top & Bottom Quartile10 Days = $4,000
56
Adapted from Slides presented by Robert Mechanic, Brandeis University, with permission
Variation in 2009 Risk Adjusted Readmission Rates from Skilled Nursing Facilities
14.4%18.1%
22.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
25th Percentile Median 75th Percentile
Readmissions
Source: MedPAC Report to Congress, March 2012.57
58
Development of Preferred SNFs Network
Created preferred SNF network to enhance the delivery and
coordination of care
Meet service
standards
Atrius Health team
on‐site
History of positive
relationship
Geographic needs
Good metrics*
SNF willingness
to collaborate
*Good Metrics: Medicare Compare; State survey; Readmission during SNF stay; LOS
Atrius Health 2015Atrius Health 2015. All rights reserved
Managing SNF Events
Developed expectations and tools to manage length of stay
• Facility‐level expectations
• Provider‐level expectations
• Discharge workflow
• EHR documentation
• Monitoring & reporting
• Use of preferred discharge providers
↓2.0 LOS = $2M↓2% Readmit Rate = $.5M
59Atrius Health 2015. All rights reserved
Still Lots of Opportunity
PreferredNon-Preferred
60Atrius Health 2015Atrius Health 2015. All rights reserved
CHARTINGPatient ChecklistVisit InfoAllergiesVitals
Patient Care Checklist● Advance Care Planning documents are not on file● A Falls Risk Assessment has not been completed in the current calendar year● A PHQ-2 or PHQ-9 has not been completed in the current calendar year● Tobacco use has not been reviewed in the current calendar year● BMI has not been updated within the past 6 months
EHR tools to support ACO: Standard Checklist and Shared Workflows
Tools were developed to facilitate:• Advanced Care Planning• Fall Risk Assessment• Depression screening• Medication Reconciliation
61
Patient Care Checklist● Advance Care Planning documents on file● A Falls Risk Assessment has been completed in the current calendar year● A PHQ-2 or PHQ-9 has been completed in the current calendar year● Tobacco use has been reviewed in the current calendar year● BMI has been updated within the past 6 months
Atrius Health 2015. All rights reserved
Depression Screen & Fall Risk Assessment
Implemented EMR checklist
Reset FRA, PHQ Checklist
62Atrius Health 2015Atrius Health 2015. All rights reserved
Data Analytics and Reporting providesOngoing Support for Workgroup Initiatives
64
#1 ACO in New England; #2 Pioneer Nationally
Atrius Health 2015Atrius Health 2015. All rights reserved
First Year Pioneer Results: 2012 ACO Quality Metricswww.medicare.gov/physiciancompare/aco/search.html
Atrius Health compared to Pioneer ACO Range
• A1c = % of diabetic patient population with blood sugar (hgba1c) control < 8• BP = % of hypertensive patient population with blood pressure control <140/90• Tobacco = % of diabetic patient population who do not currently smoke• Aspirin = % of diabetics with ischemic vascular disease (IVD) who are currently taking aspirin• ACE/ARB = % of patients with coronary artery disease (CAD) who are also diabetics OR have left ventricular systolic dysfunction
(LVSD) and are on an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB)
65Atrius Health 2015Atrius Health 2015. All rights reserved
Independent “Near Market” Evaluation, May 2015
Association of Pioneer Accountable Care Organizations vs Traditional Medicare Fee for Service With Spending, Utilization, and Patient Experience
JAMA. 2015;313(21):2152-2161. doi:10.1001/jama.2015.4930.
• Pioneer ACOs saved $384M over two years– Atrius Health saved $36M compared to near market
• Ten of 32 Original Pioneers had statistically significant savings in both years– Atrius Health was one of the ten– Atrius Health noted as one of three Pioneers accounting for
70% of savings in 2013
66
Pioneer Financial Performance
2012 (PY1) = 1% loss, in the noise• Atrius Health expenditure $10,700 vs. • Massachusetts Pioneer Expenditure $12,000+
2013 (PY2) = 1% savings, in the noise* $3M saved for Medicare
2014 (PY3) = Projecting 1.4% savings, would be:* $4.5M saved for Medicare* $2.8M share to Atrius Health
Year over Year Improvement
67Atrius Health 2015Atrius Health 2015. All rights reserved
From the JAMA Article
68
Atri
us H
ealth
Par
tner
s
BID
CO M
AC
IPA
Ste
war
d
http://jama.jamanetwork.com/article.aspx?articleid=2290608
Side by Side Settlement: Beat the Trend
69.
Atrius Health 2015Atrius Health 2015. All rights reserved
Atrius Health 2015. All rights reserved
71
Keys to Success
Leadership and Facilitation • Create the data-based
hypothesis • Identify evidence-based best
practice• Develop standards & tools to
close gaps• Measure and track
Outcomes Fidelity to Process
Core Competencies• Small team with operational
credibility• Diverse clinical expertise • Share resources clustered
together (no silos)• Home for shared values • Exploratory mindset • Laser focus on triple aim
72Atrius Health 2015Atrius Health 2015. All rights reserved
Lessons Learned
Internal
• MD engagement key to driving change
• Wide adoption of Lean problem solving methodology created strong foundation for change
• “ One Model, One Contract” provided burning platform
• Making long-lasting change takes time
• Our ability to partner effectively is key
CMS
• More unknowns = more risk• It’s bigger than CMS - many
federal agencies have a stake• Engagement of other Pioneers
– big opportunity, but differing priorities
• CMS is moving up the learning curve too
Atrius Health 2015. All rights reserved
We will challenge “Simple rules”
“I am accountable” “We are accountable”This image cannot currently be displayed.
This image cannot currently be displayed.
From Accountable Care Organizations, Marc Bard and Mike Nugent, 2011
74
Two Kinds of Change
Technical• Problem is well-defined• Solution is known, can
be found• Implementation is clear
Adaptive• Challenge is complex• To solve requires
transforming long-standing habits and deeply held assumptions and values
• Involves feelings of loss, sacrifice (sometimes betrayal to values)
• Solutions requires learning and a new way of thinking, new relationships
From Jack Silversin, Amicus
75
Reflections…
“We shall not cease from exploration. And the end of all our exploring will be to arrive where we started and know that place for the first time.” T.S. Eliot
76
Charles HandyThe Age of Unreason
The future we predict today is not inevitable. We can influence it, if we know what we want it to be…
We can and should be in charge of our own destinies in a time of change.
Reflections…
77
Recommended