Embed Size (px)
Citation preview
Risk Evolution Task ForceSeptember 2019
We know that asking clinicians to take on this risk and shoulder the burden of America’s health is not easy.
The Risk Evolution Task Force was formed to ensure APG members and the wider physician communities have access to the education, support, and resources necessary to both be successful in current risk models and prepare for the next iteration of risk models to come.
RETF Leadership
Melanie Matthews Niyum Gandhi Aneesh Chopra Valinda Rutledge
AgendaWelcome and Introductions from RETF Co-Chairs
Niyum Gandhi, EVP and Chief Population Health Officer, Mount Sinai Health System
Melanie Matthews, CEO, Physicians of Southwest Washington
Status of the New Benchmarking DataAneesh Chopra, President, CareJourney
Best Practices and Shared Successes in Inpatient CareDr. Ryan Jones, Primary Care Senior Medical Director, USMD
Dr. Peter Tilkemeier, Chairman, Department of Internal Medicine, Prisma Health UpstateKim Roberts, Executive Director, Prisma Health Upstate Network
Update on What’s Happening at CMSValinda Rutledge, SVP, Federal Affairs, APGMelanie Matthews, CEO, Physicians of Southwest Washington
Status of the 2018 Updated Data
Data Metrics & Benchmarking Purpose: To provide benchmarking to APG members across a core set of quality &
utilization measures that align with risk model success
Current Established Measures: • PMPY by category (IP, OP, Part B, SNF, HH)• IP admits per 1k and % of IP admits that come in
through the ED• % of avoidable ED visits• SNF stays per 1k and average length of stay• Part B spend across subcategories
Current benchmark cohort includes 24 Medicare ACOs
Preview: 2018 Benchmark Reports
Releasing Benchmarking Reports: 10/15
Facilitating a Discussion on MA Data
Adopting CMS Data @ the Point of Care
Best Practices Speakers
Dr. Peter Tilkemeier is the chair of the Department
of Medicine at Prisma and a professor at the
University of South Carolina School of Medicine
Greenville and the Clemson University School of
Health Research. He serves as the Chair of the
Quality Care and Delivery committee for Prisma
Health – Upstate Network and as a member of the
network and clinical strategy councils for Prisma
Health.
Ryan Jones, MD, serves as senior medical director of primary care at USMD Health System. She attended medical school at University of Texas Health Science Center at Houston and completed her residency in internal medicine at Baylor University Medical
Center in Dallas.
As Executive Director of Prisma Health Upstate Network, Ms. Roberts leads the overall strategic direction of the network ,developing the network, including building its governing body, operations, and securing their first MSSP contract that included 60,000 beneficiaries with three consecutive years in shared savings.
© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed. 12
USMD MSSP Inpatient Admissions
Ryan Fiedler Jones, MDSenior Medical Director
Primary Care
13© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
Meet Caryl….
14© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
USMD At A Glance
• Nearly 50 physician clinic locations, many of
which are multispecialty
• Nearly 20 different specialties
• Two hospitals –Arlington and Fort Worth
• One cancer treatment center –Arlington
• Imaging and diagnostic services
• More than 200 Physicians including:• Nearly 100 primary care physicians
• Nearly 100 specialists
• More than 50 Associate Practitioners (NPs and PAs)
• More than 250,000 patients under primary care
In 2018, USMD had 917,314 patient encounters and saw 237,584 unique
patients.
USMD Health System
15© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
USMD Population
1) Commercial -----CATALYST
1) BCBS, Cigna, and United plans
2) 45,477 patients
2) Medicare ---Medicare Shared Savings Plan---MSSP
1) Traditional Medicare FFS patients
2) 17,743 patients
3) Medicare Advantage– Full Risk
1) AARP WNI + Humana Gold= 15,012 USMD
*Total patients USMD= 1,717,076
15
16© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
Results- IP
17© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
Call us first
17
18© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
Caryl continued….
19© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
19
The Contingency Plan
20© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
Every Patient, Every Time
• Call Us First
20
21© WellMed Medical Management, Inc. , Optum® and OptumCare® are trademarks of Optum, Inc. All rights reserved. Confidential property of WellMed.
Thank You
Kim Roberts, Executive Director
Peter Tilkemeier, MD Chair Department of Medicine, Prisma Health - Upstate
Chair, Quality and Care Delivery
Mission and Vision
Mission:
Transform care.
Promote Value.
Enrich the patient experience.
Vision:
Enhance the quality of life for every patient.
Prisma Health Upstate Network Confidential and Proprietary Information. Copyright 2019. All Rights Reserved.
Network Footprint
Prisma Health Upstate Network Confidential and Proprietary Information. Copyright 2019. All Rights Reserved.
13 Counties
14 Hospitals
2,843 Providers
622 Primary Care
2,151 Specialists
70 Post Acute
At-Risk Lives # Members
MSSP Track 1 + 60,000
Direct-to-Employer 49,300
Humana MA 10,200
Total 2019 119,500
MSSP Success
Prisma Health Upstate Network Confidential and Proprietary Information. Copyright 2019. All Rights Reserved.
Inpatient Spend & Utilization Decrease
$3,586.68
$3,379.16
$3,981.70
3,000.00
3,200.00
3,400.00
3,600.00
3,800.00
4,000.00
4,200.00
Inpatient PMPY
Inpatient Spend per Member per Year
CY 2017 CY 2018 2018 Cohort Benchmark
198.2
169.54
207.96
0
50
100
150
200
250
Inpatient Admits / 1,000
Inpatient Admits per 1,000
CY 2017 CY 2018 2018 Cohort Benchmark
Complex Care & Condition Management Programs
Risk Stratification
Workflow Management Tool
Patient Assessment
Care Management Interventions
Health Coaching
Care Transitions
Post-Acute Care
Measures of Success
Key Components for Success
Complex Care & Condition Management Programs
Risk Stratification
Workflow Management Tool
Patient Assessment
Care Management Interventions
Health Coaching
Care Transitions
Post-Acute Care
Measures of Success
Key Components for Success
Complex Care & Condition Management Programs
Risk Stratification
Workflow Management Tool
Patient Assessment
Care Management Interventions
Health Coaching
Care Transitions
Post-Acute Care
Measures of Success
Key Components for Success
Complex Care & Condition Management Programs
Risk Stratification
Workflow Management Tool
Patient Assessment
Care Management Interventions
Health Coaching
Care Transitions
Post-Acute Care
Measures of Success
Key Components for Success
Rethinking the Care Team
Care Transformation
• Integrated Care Teams− RN Care Managers (Complex Care Management)− Health Coaches (Condition Management)− Social Workers− Support Specialists− Transitions of Care Nurses
• Connected to Delivery Systems− Hospital Case Management− Specialized Clinical Programs and Navigation− Community Health Programs (non-traditional)
• Subject Matter Expertise− Care Model Design− Post Acute − Value-based Care− Evidence-based Guidelines
• Medical and Behavioral Health Physician Advisors
The New Care Team
Team-Based Model
Prisma Health Upstate Network Confidential and Proprietary Information. Copyright 2019. All Rights Reserved.
• Integrated teams lead by Registered Nurse (RN) and
supported by:
• Health Coaches (HC)
• Social Worker (SW)
• Transitions of Care Nurse (TOC)
• Community Health
• Allows for focus on rising-risk patients for Health Coaches
(HC) for condition management
• Regionally-based instead of embedded in certain practices
• Structure permits:
• Scalability
• Deployment of the right resource based on patients’
current health status
• Earlier intervention with a rising-risk patient
Complex Care & Condition Management Programs
Risk Stratification
Workflow Management Tool
Patient Assessment
Care Management Interventions
Health Coaching
Care Transitions
Post-Acute Care
Measures of Success
Key Components for Success
Complex Care & Condition Management Programs
Risk Stratification
Workflow Management Tool
Patient Assessment
Care Management Interventions
Health Coaching
Care Transitions
Post-Acute Care
Measures of Success
Key Components for Success
CHF Spend, ED Utilization and Readmissions
14%
9%
15%
37%
18%
40%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Total Graduated Did Not Graduate
COPD
30 Day Read 90 Day Read
Transitional Care ProgramBPCI Readmissions
Source: BPCI Claims Data for MS-DRG 190, 191, and 202Use: Measure Performance of Transitional Care ProgramData Timeframe: Go-live December through October 2018
ED/Readmission rates: Total number of ED/Readmissions divided by the total number of episodes. This measure helps to quantify how often readmissions are occurring and measures the impact of episodes that may have multiple readmissions during the episode.
Ave
rage
Rat
e
CHF Spend, ED Utilization and Readmissions
9%0%
10%
19%
9%
21%
14%
9%
15%
37%
18%
40%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Total Graduated Did Not Graduate
COPD
30 Day ED 90 Day ED 30 Day Read 90 Day Read
Transitional Care ProgramBPCI ED Utilization and Readmissions
Source: BPCI Claims Data for MS-DRG 190, 191, and 202Use: Measure Performance of Transitional Care ProgramData Timeframe: Go-live December through October 2018
ED/Readmission rates: Total number of ED/Readmissions divided by the total number of episodes. This measure helps to quantify how often readmissions are occurring and measures the impact of episodes that may have multiple readmissions during the episode.
Ave
rage
Rat
e
CHF Spend, ED Utilization and Readmissions
$14,983
$12,565
$15,374
$5,018$3,766
$5,220
$3,993
$2,597
$4,219
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
$18,000
0%
10%
20%
30%
40%
50%
Total Graduated Did Not Graduate
Avera
ge E
pis
ode S
pend
COPD
30 Day ED 90 Day ED 30 Day Read90 Day Read Average Total Spend Post-Acute 30 Day Spend
Transitional Care ProgramBPCI Spend, ED Utilization and Readmissions
Source: BPCI Claims Data for MS-DRG 190, 191, and 202Use: Measure Performance of Transitional Care ProgramData Timeframe: Go-live December through October 2018
ED/Readmission rates: Total number of ED/Readmissions divided by the total number of episodes. This measure helps to quantify how often readmissions are occurring and measures the impact of episodes that may have multiple readmissions during the episode. Average Episode Spend: Total episode spend divided by the number of episodes. It is a measure of central tendency that is influenced by outliers.
Ave
rage
Rat
e
Transitional Care ProgramBPCI Graduated vs. Other Readmissions
9% 0%
15%17%18%
33%38%
42%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Graduated TCM Visit w/PCP E&M Visit w/PCP No Follow-Up
Avera
ge R
ate
COPD
30 Day Read 90 Day Read
Source: BPCI Claims Data for MS-DRG 190, 191, and 202Use: Measure Performance of Transitional Care ProgramData Timeframe: Go-live December through October 2018
ED/Readmission rates: Total number of ED/Readmissions divided by the total number of episodes. This measure helps to quantify how often readmissions are occurring and measures the impact of episodes that may have multiple readmissions during the episode.
Transitional Care ProgramBPCI Graduated vs. Other ED Utilization & Readmissions
0% 0% 8%
14%
9% 0%
19%
25%
9% 0%
15%17%
18%
33%
38%42%
0%
10%
20%
30%
40%
50%
Graduated TCM Visit w/PCP E&M Visit w/PCP No Follow-Up
COPD
30 Day ED 90 Day ED 30 Day Read 90 Day Read
Source: BPCI Claims Data for MS-DRG 190, 191, and 202Use: Measure Performance of Transitional Care Program Data Timeframe: Go-live December through October 2018
ED/Readmission rates: Total number of ED/Readmissions divided by the total number of episodes. This measure helps to quantify how often readmissions are occurring and measures the impact of episodes that may have multiple readmissions during the episode.
Ave
rage
Rat
e
Transitional Care ProgramBPCI Graduated vs. Other Spend, ED Utilization & Readmissions
$12,564$13,102
$10,669
$19,151
$3,766
$2,658 $2,031
$7,951
$2,597
$4,733$2,758
$5,189
$0
$5,000
$10,000
$15,000
$20,000
$25,000
0%
10%
20%
30%
40%
50%
Graduated TCM Visit w/PCP E&M Visit w/PCP No Follow-Up
Avera
ge E
pis
ode S
pend
COPD
30 Day ED 90 Day ED
30 Day Read 90 Day Read
Source: BPCI Claims Data for MS-DRG 190, 191, and 202Use: Measure Performance of Transitional Care ProgramData Timeframe: Go-live December through October 2018
ED/Readmission rates: Total number of ED/Readmissions divided by the total number of episodes. This measure helps to quantify how often readmissions are occurring and measures the impact of episodes that may have multiple readmissions during the episode.Average Episode Spend: Total episode spend divided by the number of episodes. It is a measure of central tendency that is influenced by outliers.
Ave
rage
Rat
e
Complex Care & Condition Management Programs
Risk Stratification
Workflow Management Tool
Patient Assessment
Care Management Interventions
Health Coaching
Care Transitions
Post-Acute Care
Measures of Success
Key Components for Success
Post Acute Care
• Transitional Care Program
• Transitions of Care tracking by practice
• Partnerships with Skilled Nursing Facilities• Chronic care patients• Post-acute rehab
• Hospital at home
Complex Care & Condition Management Programs
Risk Stratification
Workflow Management Tool
Patient Assessment
Care Management Interventions
Health Coaching
Care Transitions
Post-Acute Care
Measures of Success
Key Components for Success
Questions?
October 15 DC
Meeting (9-4:30)
• Update on the Benchmarking for MA
• Status Update on the Data Point of Care
Amy Gleason, White House
• CMMI Listening Session on Direct Contracting
Dr Michael Lipp, CMO CMMI
• CMS Listening Session on MSSP
John Pilotte. Director of MSSP Models
***Email Shelley if you are attending!
What’s Happening
at CMS
• Valinda
– MSSP
– Primary Care First
– Direct Contracting
– New CMMI Director
• Melanie
– Next Gen
Questions?
• Kim Roberts | [email protected]
• Dr Peter Tilkemeier | [email protected]
• Dr Ryan Jones | [email protected]
• Aneesh Chopra | [email protected]
• Valinda Rutledge | [email protected]
• Anu Murthy| [email protected]
