Value Proposition: The Building Blocks Needed To Transition ......Value Proposition: The Building Blocks Needed To Transition To New Care Models A Webinar/TweetChat Combo from healthsystemCIO.com

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Value Proposition: The Building Blocks Needed To Transition To New Care Models

A Webinar/TweetChat Combo from healthsystemCIO.com

Sponsored by Optum

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http://healthsystemcio.com/presentation/vbc-trans-webinar.pdf



Housekeeping

• Webinar Moderated by Anthony Guerra, editor-in-chief, healthsystemCIO.com

• Simultaneous TweetChat Hosted by Kate Gamble, Managing Editor & Director of Social Media, healthsystemCIO.com (@khgamble) • Participate in separate browser or on your phone by using #HSCIOchat

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• Deck @ http://healthsystemcio.com/presentation/new-models-webinar.pdf


http://healthsystemcio.com/presentation/hipaa-bcp-webinar.pdf



Agenda

• 25 minutes: Renee Broadbent, AVP, Population Health Information Technology and Strategy, UMass Memorial Healthcare

• 15 minutes: Erik Johnson, VP, Health Management Consulting, Optum

• 10 minutes: Q&A w/Renee & Erik




Value Proposition: The Building Blocks Needed To Transition To

New Care ModelsRenee Broadbent, AVP, Population Health Information Technology and

Strategy, UMass Memorial Healthcare




Goals

• Population Health Framework

• Programs supporting population health and Value Based Care

• Industry readiness survey

• Administration changes - Impact




Who We Are • Largest Health care system in Central Massachusetts

• Clinical partner with U-Mass Medical school, with access to latest technology, clinical trials and research

• Locations:

• Worcester (UmassMemorial Medical Center)

• Clinton Hospital (Clinton)

• Health Alliance Hospital (Leominster and Fitchburg)

• Marlborough Hospital (Marlborough)

• 1,600 Physicians on active medical staff

• 3,000 Registered Nurses

• 12,000 total employees

• 1,125 hospital beds




Who We Are • We provide a variety of services by staff who are nationally

acclaimed in several areas:• Heart and Vascular

• Orthopedics• Cancer • Surgery

• NICU• Children's & Women’s services

• Emergency and Trauma

• New:• First Academic Medical Center to join Dana Faber

Cancer Collaborative




Population Health Management Organization

• Internal organization within the health system• Sits at the system level, by that I mean we have

responsibility for the entire organization as the drivers of population health

• Manage multiple programs (MSSP, Bundles, Commercial, Medicaid Pilot)

• Staff of 45 consisting of Administration, Care Management, Data Analytics & Reporting, Account Management for Network support and development

• 1700+ participating providers in Central MA and to the east and west

• Total beneficiary member count across programs: 160,000




Definition

• Value-Based Care (VBC) is described as the transition from a fee for service model to one that provides reimbursement tying payment for quality to the delivery of care: often referred to as shifting from volume to value




Slide Courtesy Of U.S. Department of Health and Human Services




Transitioning• Transitioning isn’t easy

• Time is important: change doesn’t happen overnight

• Must have support from the most senior level teams

• It must be system level, not one offs

• Need appetite for increasing risk

• Complicated by changing regulatory landscape, administrative changes

• Uncertainty

• It can be accomplished




Strategy• Given the complexity, the number of programs (instruments),

regulatory ‘opportunities,’ a carefully crafted strategy needs to be created

• It needs to be vetted thoroughly• Address all components• Remain flexible; as things changes modifications will likely be

needed• It needs to have the basic components of VBC including:

• Care Management• Data Analytics & Reporting• A patient-centered approach• Network strength• Data – meaningful data, useful data, data integrated from a

variety of sources




Visual Framework –Building the House

• Framework establishes the path to VBC

• Each functional block has many tasks and subtasks associated with it

• Information Technology and Data Infrastructure are the foundation




Components• Technology: While true interoperability has not been achieved, it’s vastly

improved. Ensuring that data access and timely delivery is available to care givers is critical to achieving VBC. Integrating claims, clinical data and other data sources is critical. Telehealth strategies that align physicians with patients enhance care delivery and help avoid unnecessary costs.

• Care Management: You need comprehensive care management programs that are robust and can deliver and manage the care necessary to the populations at risk, especially high-risk patients and rising risk patients. Having a robust, post-acute care network and process is critical.

• Data and Analytics: Robust information, data analytics and predictive analysis are all necessary so that you can understand which patients are likely to get sick in the coming year and need management

• Network strength and the alignment of physician incentives to help with the transition are important. Create a value proposition.




Conceptual Model

• XXXXX

• Data is a key part of the VBC strategy

• Conceptual model demonstrates the data sources and process

• It fuels the processes and programs in the VBC model

• It must remain flexible• Many layers of integration• Production of robust

analytics




Value-Based Programs• Accountable Care Organizations: Accountable Care Organizations (ACO), allow

organizations and groups of physicians to form an entity that will help focus on improving the quality of care delivered to patients. ACOs, governed through CMS offer several tracks with increasing amount of risk to be taken on by the entity. Many utilize a track one Medicare Shared Savings Program (MSSP) which has no downside risk, only the potential for share savings. ACOs who are more advanced and who may have been participating successfully in track one may decide to move to another track with increasing risk, for example track 3, MSSP +1 or the Next Generation ACO. To date however, most hospital and physician groups in an ACO remain in track one (95%).

• Bundle Payments: Bundle Payment programs ‘bundle’ a service together where the reimbursements are set for the entire continuum of treatment. The most prevalent is the Comprehensive Joint Replacement (CJR). This program and other bundle programs offer organizations the ability to manage both the care and the cost of those patients through a specified period, with the goal of improved care while overall reducing the cost of that care.

• Medicaid ACOs: Medicaid ACOs are similar in construct to the Medicare ACO and present other opportunities for organizations to manage a specific population.




Value-Based Programs• Patient-Center Medical Homes (PCMH): PCMH focus on primary care

that is patient centered, comprehensive, team based, coordinated, accessible and focused on quality and safety.

• Self-Insured’s: Management of an organization’s self-insured population represents a low-risk approach to improving the quality of care while managing the cost.

• Direct to Employer strategy. Once and entity establishes a proven track record for management and network strength it can become a value proposition to area employers.

• Medicare Advantage plans: Focused on enhancing the quality of care delivery while controlling and managing the cost of that delivery and offering additional benefits to plan members to help them manage costs and remain healthy.




As organizations decide which clinicians should pursue which path, they often consider the following:

Choosing the right path at the right time: MIPS and APM

• The financial upside and downside of MIPS and APMs may differ significantly, particularly in the 2017 transition year. Financial impact is driven by a number of variables at the individual clinician and TIN level.

• Many of the tools required to be successful in APMs will also support MIPS performance. This allows for organizations to invest in the short and long term simultaneously

• CMS designed MIPS to simulate APM participation which will help organizations to evaluate provider readiness for APMs based on MIPS performance

• The incentive structure in MIPS and APMs are vastly different than traditional fee for service. Support for and commitment to making the necessary changes must exist among both leadership and clinicians in order to be successful

Key Components

Financial Implications Necessary IT Infrastructure

Provider Readiness Cultural Readiness

Slide Courtesy of Deliotte, 2017




MACRA – Most significant transformation in health care payment since the creation of Medicare• What does MACRA do?

Repeals Sustainable Growth Rate (SGR) adjustments to Physician Fee Schedule (Part B payments)

Establishes the Quality Payment Program to incent transition from volume to value

1. Creates two payment tracks: Advanced Alternative Payment Models (Advanced APMs) and “MIPS,” Merit-Based Incentive Payment System

2. “Streamlines and consolidates” current Medicare quality reporting and performance incentive programs into one reporting structure (MIPS).

3. Not likely to go away under the new administration




Quality Payment Program

Payment Tracks

Advanced APMs

(+/- risk)

MSSP

Tracks 2 & 3

Next Generation

ACOOther APMs

MIPS

MSSP Track

1FFS

Bundled Payment Models

Incremental increases in +/-annual adjustment based on MIPS Composite Score

5% lump sum annual incentive payment

Downside Risk Programs

Not in downside risk programs

New option in 2018

MSSP Track 1 +




Market Overview • Many

organizations starting down the VBC road

• Few thinking they are ‘very strong’

• Majority are somewhat or weak

• Reasons: No strategy, market uncertainty

Slides Courtesy of Health Leaders Media, July 2016




Slides Courtesy of Health Leaders Media, July 2016




Future Considerations •Administration Changes:• Don’t Panic

• Stay the course; stick with basic foundations of :• Care Management, Data Aggregation, Patient Centered Focus, Reporting

and Analytics

• Identify Programs that make sense, including those with increasing risk (APMs)

• Remain flexible in process; you may have to change direction to be compliant• Ensure you remain current on what changes are

forthcoming as there is uncertainty and mixed messaging


MACRA for

Successful

Value-based care

A Review of the Short

and Long Term Impact

Erik N. JohnsonVice President, Health Management Consulting

Medicare Access and CHIP Reauthorization Act of 2015

25

Payment and Delivery ReformsMeasurement

Regimes

Incentive for

Infrastructure Development

CMS has been driving innovation for over a decade

MACRA is intended to help accelerate the transformation to value based care

2006 20092008 2010 2011 2012 2013 2014

Physician Quality Reporting System

CMS Ceases Paying for Hospital Acquired

Conditions

Health Information Technology for

Economic and Clinical Health Act

Affordable Care Act

Meaningful use incentives

First generation of Medicare Shared Savings Program

Hospital Value-Based Purchasing and

readmission penalties

Physician value-based modifier

Merit based incentive payment systemand alternative

payment models

2015

First performance year for MACRA

payments

2017

Setting the foundation…

…Evolution continues

Hospital Inpatient Quality

Reporting (IQR)

2003

26

MACRA gives physicians a choice

Merit-based incentive payment system (MIPS)

• Measurement-based regime, replacing PQRS, VBP modifier and MU and creating single reporting framework for physicians

• Four domains: quality, clinical practice

improvement, advancement of care, resource utilization

• Physician discretion in selecting metrics to report to CMS

• Increasing upside/downside risk, depending on relative performance

Advanced alternate payment models (APMs)

• Demonstration of preponderance of patients/revenue in value-based care models, most of which must include 2-sided risk

• Includes MSSP Tracks 2 & 3, Next

Generation ACO, Comp ESRD (2 sided), and CPC+ programs

• Upside bonus of 5% and enhanced fee schedule increases if meet risk requirements

CMS has also created an option for APMs that do not qualify for advanced status (MIPS APM). Benefits include significantly reduced reporting burden and preferential scoring against MIPS only peers.

PQRS =Physician Quality Reporting System

VBP =Value-based Payment

MU =Meaningful Use

MSSP = Medicare Shared Savings Plan

ESRD = Comprehensive End-stage Renal Disease

CPC = Comprehensive Primary Care

27

MIPS vs. APM: Financial fee schedule implications

• MIPS positive adjustments have the potential for a 3X adjustment (i.e. +12% for 2019 up to +27% for 2022+).

• For 2019-2024, exceptional performers (top 25th percentile) are eligible for additional payment up to 10% ($500M funding per year).

2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 & On

Medicare

Fee Schedule

Advanced APM =

Adv. Alternative Payment Model (QP)

+0.25

or 0.75%

+0.5% each year No Change

+5% bonus

Excluded from MIPS

MIPS =

Merit basedIncentive System

Max Adjustment

(+/-)

4 5 7 9 9 9 9

28

MIPS is a stand-alone, temporary approach to VBC

Medical Center Physician Groups SNF Partner(s)

Provider collaboration to meet demands of:• Medicare VBC models (ACOs, bundles)• Medicaid reform (Medicaid ACOs and

managed care)• Commercial ACOs (employer-based, MA)

Physician Groups

Advanced APMs Meet Market NeedsMIPS as Stand-Alone Model

• MIPS stands apart from market trends

• Re-sets annually with no guarantee that past performance will drive future success

29

Incentive payments are tied to provider risk

Global Payment

Shared Risk

Shared Savings

Degre

e o

f risk Bundle Payment

Pay For Performance

Quality Performance

Based Contracts

Fee For Service

MIPS

Advanced APMs• Comprehensive ESRD Care

• Comprehensive Primary Care Plus

• Next Generation ACO Model

• Shared Savings Program Track 2&3

• Medicare ACO Track 1+ Model

Payment model maturity

APM

30

AAPMs – providing greater long term value

Medicare Fee-for-

Service Model

Value-Based Care models premised on two objectives:

1. Create broader financial risk for episodes and populations2. Facilitate, foster, or require collaboration across multiple providers

• Readmission penalties

• Resource utilization measures

• Mandatory bundles

Required

Collaboration

• Physician-hospital

• Hospital-post-acute care

• Physician-pharmacy

• Provider - community

Consistency and

Discipline

• Parameters around best

clinical delivery

• Consistent measurement over

time to measure improvement

• Models reward year-over-year

improvement

AAPMs:- Reward these

expected behaviors- Reward the scale

required to achieve these results

- Reward year-over-year improvement

- Dovetail more closely with emergent commercial models than reporting models

31

Assembling the necessary capabilities for MACRA success

High-performance network management

Population health management & quality

Data management Analytics & reporting

Enabling technology

Enterprise risk & financial management

Org

aniza

tional c

hange &

tale

nt a

ccele

ratio

n

Business operations excellence

Pro

duct

leaders

hip

Consumerengagement

Value-based care strategyGrowth channels | Value-based entity | Strategic blueprint | Road map | Leadership & governance | Financial pro forma

1

2 3 4

56

7

8

9

10 11

Thank youErik N. Johnson

Vice President, Health Management Consulting

[email protected]

Conf idential property of Optum. Do not distribute or reproduce without express permission from Optum.



Audience Q&A

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Thank You!

• Please take a moment to answer our post-event survey.

• Thanks to our speakers: • Renee Broadbent • Erik Johnson

• Thanks to our sponsor: Optum!

• Continuing Education • CHIME CHCIO Credits – Attending our Webinars = 1 CEU• Certificate of attendance: See final slide

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Certificate of Attendance

This bearer of this certificate has attended the healthsystemCIO.com-Produced Web Seminar,

entitled, “Value Proposition: The Building Blocks Needed To Transition To New Care

Models” on 2/9/17

Contacts:

Anthony Guerra, Editor-in-Chief, healthsystemCIO.com

Nancy Wilcox, Director of Sales and Marketing, healthsystemCIO.com


Documents

Value Proposition: The Building Blocks Needed To Transition ......Value Proposition: The Building Blocks Needed To Transition To New Care Models A Webinar/TweetChat Combo from healthsystemCIO.com