ACO 101: Overview of Dartmouth-Hitchcock Health Pioneer ACO Model and OneCare Vermont ACO Models

ACO 101: Overview of Dartmouth-Hitchcock

Health Pioneer ACO Model and OneCare Vermont ACO Models

Lynn Guillette, CPA, MBAMay 3, 2014

2

The U.S. ranks last or next to last in five key areas¹:

Quality

Access

Efficiency

Equity

Healthy Lives

Structural Challenges

Fragmented delivery system with lack of primary care

Lack of evidence based care often drives variation in quality & patient safety

Misalignment of incentives

Transaction-based payment system

Lack of transparency

Limited focus on quality

The Health Care Ecosystem in 2014

¹The Commonwealth Fund – June 2010

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How Can Dartmouth-Hitchcock Health Address These Challenges?

Change the

Structure

Transform Payment System

from Transaction-

Based to Outcomes-Based

Transform Delivery System

to Patient-Centered Care

System

4

Who is Dartmouth-Hitchcock Health?

Dartmouth-Hitchcock Health

IvyMD

Dartmouth-Hitchcock Clinic

Mary Hitchcock Memorial Hospital

OneCare Vermont ACO,

LLC(50% owner)

New London Health

Association

New England Alliance for

Health

D-H

D-HH’s Work is Focused Into 7 Strategic DomainsUnder 3 Enterprise Core Strategies

Create A Sustainable Health System

Population Health Value-Based Care New Payment Models

Mission, Vision, Values

Improve Quality Outcomes Reduce Cost of Care

Improve Population

HealthInnovation

Leaders in

Value

Integrated Health System

FinanceDistinctive Education & Research

People

The strategic domains provide

additional focus for the D-H enterprise

core strategies

Performance Imperatives >

D-H Enterprise Core Strategies >

5

Creating A Sustainable Health System

VT NH

ME

MA

DHMC

D-H Concord

D-H Manchester

D-H NashuaD-H Keene

D-H Putnam

Population Health

NEAHBoston Children’sSo. NH & Seacoast

Value Based Care

HVHCMayo NNEACCDartmouth CollegeIndustry Partners

New Payment Models

Pioneer•OneCare VT Health Plan Partner

6-Confidential-

•••

• ••

•

Global Capitation

FullyIntegrated

Fee for Service

FragmentedDelivery

Payment Model

Care

Mod

el• Provide care and wellness services to 2+ million people

• Measurably improve population health

• Implement value-based care processes across D-H

• Participate to the fullest extent possible in payment models that recognize the value of care delivered

• Develop an integrated NNE healthcare network

• Refine and expand an integrated NNE support and management services infrastructure

• Enable more care and wellness to be delivered at community level and at home

• Align D-H workforce with enterprise strategies/objectives

• Align research and education to support achievement of a sustainable health system

• Establish innovative partnerships with government and industry that improve care and wellness

• D-H recognized as a national leader in creating value and implementing a sustainable health system

D-H

End-State Goals – Where Are We Heading?The D-H Strategic Operating Plan Matrix helps us to focus on a single year at a time. The 2015 plan will be designed to expand more on our medium to long-term strategic objectives, including:

7

8

To Transform the Payment System, We Need to Learn a New

Language

Accountable Care

Organization

Fee For Service

Pay for Performance

Shared Risk

Global Budget

Payment Model Continuum

Fee-For Service - is a payment model where services are unbundled and paid for separately by service

Pay-For-Performance - introduces quality and efficiency incentives, instead of solely rewarding quantity

Shared Risk - means distributing the cost of health care services across large numbers of participants - including people of various ages and health conditions

Global Budget / Capitation - is a payment arrangement for health care services that pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care

Fee-For-Service

Pay-for-Performance

Shared Risk

Global Budget

Capitation

VolumeFocused

ValueFocused

9

Accountable Care Organization (“ACO”) - is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients

10

More about ACOsDocto

rs, Hospitals,

Other Healthcare Providers

Payor(s)

AccountableCare

Organization

(“ACO”)

Providers in an ACO may all belong to the same health system, or may include multiple health systems, independent hospitals, physician groups/practices, and other types of healthcare providers

Providers work together with a payor to provide high quality coordinated care for patients

May include one or more payors

May include any one (or more) of the four payment methodologies outlined on slide 9

Quality performance is measured at the aggregate ACO level

The ACO would be rewarded for providing the ACO’s patients with a positive patient experience, better health outcomes, and reduction in the growth of total cost of care for the ACO patient population

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What Does D-H’s Payments Models Look Like Today?

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Dartmouth-Hitchcock Wellness Plus(Administered by Health Plans Inc.)

D-H Employee Health Benefit Plan(s)16,000 lives

Transformation to date at D-H(Directly Managing or Influencing 182,000+ lives)

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CMS Pioneer ACO Model• CMS Pioneer ACO Model: Medicare shared risk program that

incorporates the ACO concept; ACO has financial risk if actual costs exceed annual cost target but has financial reward opportunity if actual costs are less than annual cost target

• Through competitive application process, D-HH became one of thirty-two Pioneer ACOs in the country

D-HH ACO

Mary Hitchcock Memorial Hospital Dartmouth-Hitchcock Clinic17,536

attributed beneficiaries

Pioneer ACO

15,000 minimum attributed Medicare beneficiaries across entire ACO

Attribution refreshed annually

Two-stage attribution algorithm based on preponderance of qualifying E & M codes provided by primary care and 8 other

specialty types

Primary Care defined as: MDs, DOs, NPs, and PAs practicing in General Practice, Family Practice, Internal Medicine, Geriatric

Medicine

Pioneer ACO Model Attributed Population Requirements

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Algorithm:Uses a two-stage algorithm for attribution

New providers during performance year:Under Pioneer, the annual TIN/NPI roster may only be revised to reflect providers leaving the ACO during the year. New hires may only be added at time of the annual TIN/NPI roster submission.

8 Specialty Types for 2nd stage of attribution:NephrologyOncologyRheumatologyEndocrinologyPulmonologyNeurologyNeuropsychiatryCardiology

Nurse Practitioners & Physician Assistants: E & M codes billed under the name of a primary care Nurse Practitioner and primary care Physician Assistant “count” for attribution purposes

TIN Commitment:Once the TIN is committed to a Medicare ACO, that TIN is then limited to be a vendor/supplier to other Medicare ACOs.

Better Care for Individuals

Better Health for a

Population

Lower per Capita Costs

The Triple Aim

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• 7 measures• Possible Points per

Domain = 4• Domain Weight = 25%







Patient/ Caregiver

Experience

Care Coordination/ Patient Safety

At-Risk Population

Health Managemen

t

Preventative Health

Pioneer ACO Model – Quality Comes First in Achieving the Triple Aim4 Domains; 33 Individual Measures; 48 Possible Points in 2013

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D-HH Pioneer ACO Financial Model – For Illustrative Purposes Only

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Cost TargetExpected cost per beneficiary per year

times number of attributed beneficiaries$10,000 * 30,000 = $300,000,000

Minimum Savings Rate (MSR) Threshold

Cost Target times 1%$300,000,000 * 1% = $3,000,000

Actual Cost ExpendituresActual cost per beneficiary per year

times number of attributed beneficiaries$9,800 * 30,000 = $294,000,000

Gross SavingsCost Target less Actual Cost Expenditures

$300,000,000 -$294,000,000 = $6,000,000

If Gross Savings Rate > MSR

Gross Savings Rate Gross Savings divided by Cost

Target $6,000,000/$300,000,000 = 2%

ACO Shared SavingsGross Savings times 70%

$6,000,000 * 70%= $4,200,000If Gross Savings or Gross

Loss is 0% to 1%, CMS keeps total savings or

absorbs total loss

Gradient quality scores impact eligible shared savings

Quality Multiplier

Applied (0.00-

100.00)

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D-HH Pioneer ACO in 2013• For year two, expanded ACO

participation by adding one Critical Access Hospital and its employed physicians

• Criteria for adding NLHA:• D-H & NHLA affiliation discussions

were underway; ACO inclusion would foster continued clinical integration

• NLHA’s Chief Medical Officer was a former D-H physician who had championed accountable care, shared-decision making, evidence-based medicine, and shared the same care coordination philosophy

• NLHA’s patients generally used D-H for specialty care

D-HH ACO


Dartmouth-Hitchcock

Clinic

New London Hospital

Association

25,413 attributed

beneficiaries

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D-HH Pioneer Expansion in Year 3• D-H determined that it needed to expand Pioneer ACO

participants beyond D-H and NLHA

• Why?• To move closer to achieving our vision of creating a sustainable health

system with the healthiest population possible• To lead the transformation of health care in our region and to set the

standard for the nation

• How?• Create rigor and structure to the expansion identification, selection,

and implementation process• Adequately assess business risk to D-H and its ACO because of

changes in composition of ACO provider participation

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D-HH Pioneer ACO in 2014D-HH ACO


Dartmouth-

Hitchcock Clinic

New London Hospital

Association

Catholic Medical Center

Exeter Health

Resources/ Core

Physicians

St. Joseph Hospital

46,700 attributed

beneficiaries

Clinical Advisory Council Performance ReportingLeadership Council

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Medicare Shared Savings Program (“MSSP”) Model

• Medicare Shared Savings Program Model: Medicare shared savings program that incorporates the ACO concept; initial 3-year contract; ACO has no financial risk in any of the first 3 years if actual costs exceed annual cost target but has financial reward opportunity if actual costs are less than annual cost target in any of the first 3 years

• OneCare Vermont ACO, LLC was jointly formed by Fletcher Allen Health Care and Dartmouth-Hitchcock Health in summer of 2012

• Through application process, OneCare Vermont ACO became one of 218 MSSP ACOs in the country (# of ACOs has since grown to 341)

• Others in VT or NH:• Accountable Care Coalition of Green Mountains, LLC (Independent physician practice model in VT)• Community Health Accountable Care, LLC (FQHC-led model in VT and NH)• Concord Elliot ACO, LLC (Hospital system-led model in NH)• North Country ACO (FQHC-led advanced payment model in NH)

Fletcher Allen Health Care Dartmouth-Hitchcock Health

MSSP

5,000 minimum attributed Medicare beneficiaries across entire ACO

Attribution refreshed quarterly

Two-stage attribution algorithm based on preponderance of qualifying E & M codes provided by primary care and all other

specialty types

Primary Care defined as: MDs, and DOs, practicing in General Practice, Family Practice, Internal Medicine, Geriatric Medicine

MSSP Model Attributed Population Requirements

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Algorithm:Uses a two-stage algorithm for attribution but not the same one used for the Pioneer model

Nurse Practitioners & Physician Assistants: E & M codes billed under the name of a primary care Nurse Practitioner and primary care Physician Assistant DO NOT “count” for attribution purposes

TIN Commitment:Once the TIN is committed to a Medicare ACO, that TIN is then limited to be a vendor/supplier to other Medicare ACOs.









Patient/ Caregiver

Experience

Care Coordination/ Patient Safety

At-Risk Population

Health Managemen

t

Preventative Health

MSSP ACO Model – Quality Comes First in Achieving the Triple Aim4 Domains; 33 Individual Measures; 48 Possible Points in 2013

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OneCare Vermont ACO Board of Managers

Chief Executive Officer

Chief Compliance Officer

Chief Operating Officer

Administrative Directors/Staff

Executive Medical Director

Care Management & Quality Directors/Staff

Organizational StructureOCVT Board of Managers Composition (16 seat board): D-HH = 3 seats FAHC = 3 seats Gifford Medical Ctr = 1

seat Private/community

practice physician = 1 seat

Medicare beneficiary = 1 seat

CHS of Lamoille Valley = 1 seat

Southwestern VT Medical Ctr = 1 seat

Primary Care Health Partners = 1 seat

The Howard Center = 1 seat

The Pines at Rutland = 1 seat

Medicaid beneficiary = 1 seat (vacant)

Commercial Exchange consumer = 1 seat (vacant)

OneCare Vermont 2014 MSSP Network

Statewide ACO Provider Network• 2 Academic Medical Centers• 14 Community Hospitals• 1 Behavioral Health/Substance

Abuse Facility• 2 Federally Qualified Health

Centers• 5 Rural Health Clinics• 58 Private Practices

• 280 Primary Care Physicians across Network Participants

• Approximately 42,000 attributed Medicare beneficiaries

Hospitals with Employed Attributing Physicians

Significant Participation from Community Physicians

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OneCare Vermont ACO MSSP Model

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• NNEACC: Northern New England Accountable Care Collaborative

• Data Trust owned by Dartmouth College, Dartmouth-Hitchcock, Eastern Maine Health, Fletcher Allen Health Care, and MaineHealth

• Used by both D-HH Pioneer ACO and OneCare Vermont

• Proprietary software tools for:• Care Coordination/Management• Quality Management• Physician/Practice Administrator Management• User Help Desks

NNEACC

Beneficiaries Don’t Join the ACO?

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Providers and provider organizations join an ACO, not Medicare beneficiaries

Medicare Beneficiaries assigned to a Pioneer ACO or MSSP ACO: Still have traditional FFS Medicare as primary payor Can’t be in a Medicare Advantage Plan Must have Part A and Part B Medicare coverage Can choose any provider or provider organization that accepts

Medicare – are not locked into seeing only ACO participating providers

Medicare beneficiary ID card does not indicate or reference ACO assignment

Do the Beneficiaries Know They’ve Been Assigned to the ACO?

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Beneficiaries get a one-time notice in the year that they are first assigned to a Pioneer or MSSP ACO

NOTICE TO BENEFICIARIES LETTER: Your Doctor is Participating in an Accountable Care Organization <BENEFICIARY FULL NAME><ADDRESS> <file creation date><CITY STATE ZIP> ACOs: A Way to Better Coordinate Your Health CareYour doctor or primary care provider has chosen to participate in Dartmouth-Hitchcock Health, our Medicare Accountable Care Organization (ACO). An ACO is a group of doctors, hospitals, and health care providers working together with Medicare to give you more coordinated service and care.

We’re Working to Improve Your CareThe goal of an ACO is for your doctors or primary care providers to communicate closely with your other health care providers, so they can deliver high-quality care that meets your individual needs and preferences. ACOs may be rewarded for providing you with high quality, more coordinated care.

Excerpt of

notice

Can the Beneficiaries Opt-Out of ACO Assignment?

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Beneficiaries cannot opt-out of being assigned to a Pioneer ACO or MSSP ACO, but they can opt-out of allowing CMS to share their personal health information with us

Decline to Consent to Share Information “opt-out” forms mailed out with the Notice to Beneficiaries Letter

If they opt-out, they are still assigned to ACO but ACO will not receive any claims or clinical data from CMS for services provided to these beneficiaries

All Medicare Beneficiaries are automatically opted-out of sharing alcohol & substance abuse dataDate: January 28, 2013

Declining to Share Personal Health Information

Please sign this form if you do NOT want Medicare to share information about care you have received from other healthcare providers with the Dartmouth-Hitchcock Health ACO for use in coordinating your care. You can also call 1-800 MEDICARE (1-800-633-4227) instead of completing this form. TTY users should call 1-877-486-2048. Your decision not to share this personal health information with the Dartmouth-Hitchcock Health ACO will remain in effect until you tell us that you have changed your preference. You may change your decision not to share your personal information at any time. Your request will take effect in approximately 60 business days. Note: Even if you don’t want to share your personal information with the Dartmouth-Hitchcock Health ACO for use in coordinating your care, Medicare will still need to use your information for some purposes, including certain financial calculations and determining the quality of care provided by the Dartmouth-Hitchcock Health ACO. Also, Medicare may share some of your personal health information with the Dartmouth-Hitchcock Health ACO as part of assessing the quality of care your healthcare providers at the Dartmouth-Hitchcock ACO are providing.

Excerpt of form

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• Development of “Anchor Specialists” and “Medical Neighbors”• Special expertise/focus to support PCP ‘s management of chronic care conditions (e.g. heart failure “expert” within cardiology;

Vascular support from Surgery)

• Need for rapid consult access• Special clinics for commonly encountered problems• Special focus on fragile patients at risk for hospital care• Are bookable office hours per week available to meet this demand?

• Assess OR Efficiency in order to support ACO Hospital• Are case start times inconsistent?• Are block times altered for low volume days?• Are surgeons returning to office on low case OR days?• Are supplies and high-cost implants standardized?

• Do current clinical “standard protocols” need to be revised to be more attractive in ACO environment?• Diagnostic work-ups• Use of shared-decision making• Location of surgery (inpatient, hospital outpatient, ASC, other?)

• Greater emphasis/involvement in post-acute care planning• Use of SNFs/rehab facilities vs. home health services• Encouraging “pre-hab” prior to surgery to potentially reduce post-acute care recovery times and increase patient functional

restoration

What can Specialists do to impact ACO models?

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• Coordinate care with primary care providers• Encourage beneficiaries to see their primary care provider for annual Medicare Wellness

preventative care visit

• Collaboration between primary care coordinators and specialty care staff/nurses/care coordinators for complex patients (e.g. chronic kidney disease, oncology) and those with rare diseases (e.g. hemophilia)

• Enhance patient satisfaction; what patients think about their specialty care visits matter

• Assist in closing gaps in care

• Emphasis on more precise coding and medical record documentation

• Focus on quality performance measures that could be applicable to specialists

What can Specialists do to impact ACO models?

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APPENDIX – Pioneer ACO’s 33 Quality

Measures

ACO #

Domain Measure Title NQF Measure#/Measure Steward

Method of Data Submission

P4P Phase-In PY1

P4P Phase-In PY2

P4PPhase-In PY3

1. Patient/Caregiver Experience

CAHPS: Getting Timely Care, Appointments and Information

NQF #5, AHRQ

Survey R P P


CAHPS: How Well Your Doctors Communicate NQF #5, AHRQ

Survey R P P


CAHPS: Patients’ Rating of Doctor NQF #5, AHRQ

Survey R P P


CAHPS: Access to Specialists NQF #5, AHRQ

Survey R P P


CAHPS: Health Promotion and Education NQF #5, AHRQ

Survey R P P


CAHPS: Shared Decision Making NQF #5, AHRQ

Survey R P P


CAHPS: Getting Timely Care, Appointments and Information

NQF #6, AHRQ

Survey R R R

8. Care Coordination/ Patient Safety

Risk-Standardized, All Condition Readmission CMS Claims R R P


Ambulatory Sensitive Conditions Admissions: COPD or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5)

NQF #275, AHRQ

Claims R P P


Ambulatory Sensitive Conditions Admissions: CHF (AHRQ Prevention Quality Indicator (PQI) #8)

NQF #277, AHRQ

Claims R P P


Percent of Primary Care Physicians who Successfully Qualify for an EHR Program Incentive Payment

CMS EHR Incentive Program Reporting

R P P

Pioneer ACO Quality Performance Standards MeasuresAIM: Better Care for Individuals

Note: NQF = National Quality Forum; P4P = pay for performance; P = performance; R = reporting

ACO #



P4P Phase-In PY1

P4P Phase-In PY2

P4PPhase-In PY3


Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility

NQF #97, AMA-PCPI/NCQA

GPRO Web Interface

R P P


Falls: Screening for Fall Risk NCQA #101, NCQA

GPRO Web Interface

R P P

Pioneer ACO Quality Performance Standards MeasuresAIM: Better Care for Individuals


AIM: Better Health for PopulationsACO #



P4P Phase-In PY1

P4P Phase-In PY2

P4PPhase-In PY3

14. Preventative Health

Influenza Immunization NQF #41, AMA-PCPI

GPRO Web Interface

R P P


Pneumococcal Vaccination NQF #43, NCQA

GPRO Web Interface

R P P


Adult Weight Screening and Follow-up NQF #421, CMS

GPRO Web Interface

R P P


Tobacco Use Assessment and Tobacco Cessation Intervention

NQF #28, AMA-PCPI

GPRO Web Interface

R P P


Depression Screening NQF #418, CMS

GPRO Web Interface

R P P


Colorectal Cancer Screening NQF #34, NCQA

GPRO Web Interface

R R P


Mammography Screening NQF #31, NCQA

GPRO Web Interface

R R P

ACO #



P4P Phase-In PY1

P4P Phase-In PY2

P4PPhase-In PY3


Screening for High Blood Pressure CMS GPRO Web Interface

R R P

22. At Risk Population - Diabetes

Diabetes Composite (All or Nothing scoring): Hemoglobin A1C Control (<8 percent)

NQF #729, MN Community Measurement

GPRO Web Interface

R P P


Diabetes Composite (All or Nothing scoring): Low Density Lipoprotein (< 100)


GPRO Web Interface

R P P


Diabetes Composite (All or Nothing scoring): Blood Pressure (< 140/90)


GPRO Web Interface

R P P


Diabetes Composite (All or Nothing scoring): Tobacco Non-Use


GPRO Web Interface

R P P


Diabetes Composite (All or Nothing scoring): Aspirin Use


GPRO Web Interface

R P P


Diabetes Mellitus: Hemoglobin A1C Poor Control (>9 percent)

NQF #59, NCQA

GPRO Web Interface

R P P

28. At Risk Population - Hypertension

Hypertension (HTN): Controlling High Blood Pressure

NQF #18, NCQA

GPRO Web Interface

R P P

29. At Risk Population – Ischemic Vascular Disease

Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control (<100 mg/dL)

NQF #75, NCQA

GPRO Web Interface

R P P


Ambulatory Sensitive Conditions Admissions: CHF (AHRQ Prevention Quality Indicator (PQI) #8)

NQF #277, AHRQ

GPRO Web Interface

R P P

Pioneer ACO Quality Performance Standards MeasuresAIM: Better Health for Populations


ACO #



P4P Phase-In PY1

P4P Phase-In PY2

P4PPhase-In PY3

30. At Risk Population – Ischemic Vascular Disease

Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

NQF #68, NCQA

GPRO Web Interface

R P P

31. At Risk Population – Heart Failure

Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

NQF #83, AMI-PCPI

GPRO Web Interface

R R P

32. At Risk Population – Coronary Artery Disease

Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Drug Therapy for Lowering LDL-Cholesterol

NQF #74, CMS (Composite) /AMA-PCPI (individual component)

GPRO Web Interface

R R P

33. At Risk Population – Coronary Artery Disease

Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD)

NQF #66, CMS (Composite) /AMA-PCPI (individual component)

GPRO Web Interface

R R P

Pioneer ACO Quality Performance Standards MeasuresAIM: Better Health for Populations


Documents

ACO 101: Overview of Dartmouth-Hitchcock Health Pioneer ACO Model and OneCare Vermont ACO Models