2/5/2018

Alternative Payment Models

for Chronic Pain and

Substance Abuse

2/5/2018

1. Empower Patients to be Partners

2. Drive Delivery System Improvements

3. Shift to Population-Based Payments

4. Incentives Should Reach Providers

5. Payment Models & Quality

6. Motivate Providers

7. Dominant Form of Payment

8. Examples in the Framework

Key Principles

2/5/2018

APM Framework

2/5/2018

APM Goals

2/5/2018

• Traditional FFS payments

– No infrastructure investments, provider

reporting of quality data, nor provider

performance on cost and quality metrics

– Includes DRGs unless linked to quality or value

Category 1

2/5/2018

• Traditional FFS payments PLUS payments for:– Infrastructure investments to improve care or

clinical services

– Providers reporting quality data

– How well providers perform on cost and quality metrics.

• Can drive the development and expansion of health information technology (HIT)

• Should be used to smooth the transition into Category 3 and 4 APMs

Category 2

2/5/2018

• Payments are based on cost performance

against a target

• Structured to encourage providers to deliver

effective and efficient care

• Must hold providers accountable for

performance on measures of “appropriate

care”

Category 3

2/5/2018

• Avoids wasteful tests and procedures that provide no benefit to patients

• Involves a high degree of care coordination to ensure efficient delivery

• Encompasses everything patients need to achieve their personal goals

• Essential to ensure that providers are only incentivized to reduce/eliminate care that is wasteful and potentially harmful for patients

Measures of “Appropriate

Care”

2/5/2018

• Prospective, population-based payments

• Structured to encourage providers to deliver

well-coordinated, high-quality, person-

centric care

• Must hold providers accountable for

performance on measures of “appropriate

care”

Category 4

2/5/2018

Begin with the end in mind

2/5/2018

If you can’t measure it,

you can’t improve it

2/5/2018

• Align incentives to drive toward common

goal

• May include process measures initially

• Consider NQF endorsed measures

• Best determined in collaboration

• Need very clear baseline and benchmarks

• KISS

Quality Measures

2/5/2018

Who’s gonna get you

there?

2/5/2018

Who are the people in your

neighborhood?

2/5/2018

• PCP

• Specialist

• Hospital (both ED and inpatient)

• Pharmacy

• PT/Chiro/Yoga

• CBT/EMDR

• Peer Support

• Lab

• Health Plan

Medical Neighborhood

2/5/2018

• Project ECHO

• eConsults

• Telemedicine

• Telehealth

What’s missing?

2/5/2018

Who’s your quarterback?

2/5/2018

You need a coordinator

2/5/2018

• Traditional FFS payments PLUS payments

for infrastructure investments to improve

care or clinical services

– Used for care coordination

– Used for non-capitated services like yoga

– Can be used in conjunction with shared savings

or shared risk

Option 1

2/5/2018

• Traditional FFS payments PLUS payments

for high performance on clinical quality

measures (Pay for Performance)

– Same measures could be used in conjunction

with shared savings or shared risk

– Could incentivize multiple ”neighbors” to align

goals

Option 2

2/5/2018

• Total Cost of Care Shared Savings/Risk

– PCP or Specialist

• Chronic Episode of Care Shared

Savings/Risk

– PCP or Specialist

Option 3

2/5/2018

• Cost performance compared to a target

(“budget”)

– Any APM with “neighbor” counted toward cost

• Percent of savings shared back

• Higher risk = greater upside

• Always tied to quality

TCC SS/SR

2/5/2018

2/1/2018 Glenn Wood PA - Dashboard

https://www.treoservices.net/portal/dashboard.aspx?personaViewID=network&userPkey=ntwk&userPkeyValue=48&entranceToken=ProspectiveEntrance&clientAcce… 1/1

Glenn Wood PA (Claims paid through 3/31/2017)

Total Cost of Care

Potentially Preventable Events

Utilization

Value Index Scores (VIS) ­ Percentile

Budget Basis

Base risk score 0.4

Current risk score 0.4

Base budget $101.

Current budget $106.

VIS Target 37.

Population Data04/2016­03/2017

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Reports

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Supporting Resources

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Rolling 12 months01/2016­12/2016

Program YTD01/2016­12/2016

N/A ($5.87)

$100.42 $100.42

N/A $0.17

N/A ($3.64)

N/A $2.48

N/A ($4.25)

Key Performance Measure

Variance from Budget (PMPM $)

Allowed (PMPM $)

Variance IP Allowed (PMPM $)

Variance OP Allowed (PMPM $)

Variance PR Allowed (PMPM $)

Variance RX Allowed (PMPM $)

Rolling 12 months01/2016­12/2016

Program YTD01/2016­12/2016

$17.84 $17.84

0.3 0.3 Member List

(1.5) (1.5) Member List

(143.1) (143.1) Member List

97.4 97.4 Member List

Key Performance Measure

Allowed Preventable (PMPM $)

Variance PPR Admits PKPY

Variance PPA Admits PKPY

Variance PPV Visits PKPY

Variance PPS PKPY

Rolling 12 months01/2016­12/2016

Program YTD01/2016­12/2016

7.2 7.2 Member List

(104.9) (104.9) Member List

(327.5) (327.5) Member List

74.23 % 74.23 % Member List

Key Performance Measure

Variance IP Admits PKPY

Variance ER Visits PKPY

Variance Rx Scripts PKPY

% Rx Generic Scripts

Rolling 12 months01/2016­12/2016

61.0

57.7

54.4

51.5

79.1

51.6

28.7

Key Performance Measure

Value Index Score ­ Percentile

Primary and Secondary Prevention ­ Percentile

Tertiary Prevention ­ Percentile

Panel Health Status Change ­ Percentile

Continuity of Care ­ Percentile

Chronic & Follow­up Care ­ Percentile

Efficiency ­ Percentile

© 2018 3M Company All Rights Reserved. 3M Company 575 Murray Blvd | Murray, UT 84123    1 518 426 4315

Data Updated : 5/30/2017 LoHelp

Home Dashboard

David Harmon

Example

2/1/2018 Glenn Wood PA - Dashboard

https://www.treoservices.net/portal/dashboard.aspx?personaViewID=network&userPkey=ntwk&userPkeyValue=48&entranceToken=ProspectiveEntrance&clientAcce… 1/1

Glenn Wood PA (Claims paid through 3/31/2017)

Total Cost of Care

Potentially Preventable Events

Utilization

Value Index Scores (VIS) ­ Percentile

Budget Basis

Base risk score 0.4

Current risk score 0.4

Base budget $101.

Current budget $106.

VIS Target 37.

Population Data04/2016­03/2017

Loading...

Reports

Loading...

Supporting Resources

Loading...

Rolling 12 months01/2016­12/2016

Program YTD01/2016­12/2016

N/A ($5.87)

$100.42 $100.42

N/A $0.17

N/A ($3.64)

N/A $2.48

N/A ($4.25)

Key Performance Measure

Variance from Budget (PMPM $)

Allowed (PMPM $)

Variance IP Allowed (PMPM $)

Variance OP Allowed (PMPM $)

Variance PR Allowed (PMPM $)

Variance RX Allowed (PMPM $)

Rolling 12 months01/2016­12/2016

Program YTD01/2016­12/2016

$17.84 $17.84

0.3 0.3 Member List

(1.5) (1.5) Member List

(143.1) (143.1) Member List

97.4 97.4 Member List

Key Performance Measure

Allowed Preventable (PMPM $)

Variance PPR Admits PKPY

Variance PPA Admits PKPY

Variance PPV Visits PKPY

Variance PPS PKPY

Rolling 12 months01/2016­12/2016

Program YTD01/2016­12/2016

7.2 7.2 Member List

(104.9) (104.9) Member List

(327.5) (327.5) Member List

74.23 % 74.23 % Member List

Key Performance Measure

Variance IP Admits PKPY

Variance ER Visits PKPY

Variance Rx Scripts PKPY

% Rx Generic Scripts

Rolling 12 months01/2016­12/2016

61.0

57.7

54.4

51.5

79.1

51.6

28.7

Key Performance Measure

Value Index Score ­ Percentile

Primary and Secondary Prevention ­ Percentile

Tertiary Prevention ­ Percentile

Panel Health Status Change ­ Percentile

Continuity of Care ­ Percentile

Chronic & Follow­up Care ­ Percentile

Efficiency ­ Percentile

© 2018 3M Company All Rights Reserved. 3M Company 575 Murray Blvd | Murray, UT 84123    1 518 426 4315

Data Updated : 5/30/2017 LoHelp

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David Harmon

2/5/2018

• Risk adjusted budget for all assigned

patients

– Traditional FFS structure

– Project ECHO payments count toward budget

– Infrastructure payments count toward budget

– Incentives to “neighbors” count toward budget

• Percent savings paid tied to quality

benchmarks

PCP Attribution

2/5/2018

• Risk adjusted budget for all attributed members

– Traditional FFS structure

– Infrastructure payments count toward budget

– Attributed members removed from PCP budget

– Incentives to PCP count toward budget

– Incentives to “neighbors” count toward budget

• Percent savings paid tied to quality benchmarks

Specialist Attribution

2/5/2018

• Cost performance compared to a target

(“budget”)

– Might be counted toward TCC SS/SR

• Percent of savings shared back

• Higher risk = greater upside

• Always tied to quality

Chronic EOC SS/SR

2/5/2018

Episode Template

2/5/2018

Episode Example

2/5/2018

• Prospective, population based payment

• Full risk

• Always tied to quality

Option 4

2/5/2018

• Chronic EOC triggered by diagnosis and

attributed to specialist (quarterback)

• No pre-trigger services

• Post-trigger services measured for 6 months

– Includes PMPM for infrastructure

– Includes incentive payments to “neighbors”

• Episode Cost compared to “budget” with

shared savings/risk contingent on quality

Hypothetical Urban

2/5/2018

• TCC SS/SR attributed to assigned PCP

(quarterback)

– Includes PMPM for infrastructure

– Includes Project ECHO

– Includes incentive payments to “neighbors”

• Actual costs compared to budget with

shared savings/risk contingent on quality

Hypothetical Rural

2/5/2018

The common enemy