Population Health in 2016: Know How to Move Forward

Population Health in 2016: Know How to

Move ForwardMike Maus

VP Enterprise Strategy

This event is live as of

We spend more on health care than Canada does…on everything.

United

State

s

Netherl

andsFra

nce

Switze

rland

German

yAu

stria

Denmark

Cana

da

Belgiu

mJap

an

New Zea

land

Swede

n

Portug

alSpa

in

Slove

nia

NorwayOEC

D

United

Kingdo

mGree

ce ItalyFin

land

Austr

alia

Icelan

dIre

land

Slova

k Rep

ublic

Hunga

ryKo

rea

Czech

Republi

cIsra

elCh

ile

Luxem

bourgPol

and

MexicoEst

oniaTur

key

0

2

4

6

8

10

12

14

16

18

Health expenditure as a share of GDP, public and private

Source: OECD Health Statistics 2014

3

Public Government Spend Private Spend

And we compete on quality of care with… Costa Rica.

Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insuranceand Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at:http://downloads.cms.gov/files/TR2013.pdf;

Projected Medicare Fee-for-service Payment Cuts per the ACA

2014 2015 2016 2017 2018 2019 2020

Projected number of Medicare beneficiaries

54M 56M 57M 59M 61M 63M 64M

-14B -21B -25B -32B -42B -53B -64B

Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf

2018: 90% of Medicare

payments tied to quality.

2020: 75% of commercial plans will be value-based.

Jan 2015. http://www.hhs.gov/news/press/2015pres/01/20150126a.html

7

Three types of bundled payment programs

Penalty-based

MUMeaningful Use

PQRSPhysician Quality Reporting System

VBMValue-Based

payment Modifier program

Incentive-based

CCMChronic Care Management

TCM Transitional Care

Management

PCMHPatient Centered

Medical Home

Risk-based

ACO, MSSP

Capitation

Bundles

8

Three types of bundled payment programs

Penalty-based

MUMeaningful Use

PQRSPhysician Quality Reporting System

VBMValue-Based

payment Modifier program

Incentive-based

CCMChronic Care Management

TCM Transitional Care

Management

PCMHPatient Centered

Medical Home

Risk-based

ACO, MSSP

Capitation

Bundles

MIPS(2018)

APMs(2018)

9

Three types of bundled payment programs

Penalty-based

MUMeaningful Use

PQRSPhysician Quality Reporting System

VBMValue-Based

payment Modifier program

Incentive-based

CCMChronic Care Management

TCM Transitional Care

Management

PCMHPatient Centered

Medical Home

Risk-based

ACO, MSSP

Capitation

Bundles

MIPS(2018)

APMs(2018)

10Pioneer ACO

2012 MSSP

2013 MSSP

2014 MSSP

Private ACO

23

114

106

123

240

742 ACOs Total

52%of US population lives near an ACO

14%of US population treated by an ACO

$342M shared savings payments✔$4M average shared savings payment✔

Only 26% of ACOs earned shared savings payments

✗11 ACOs failed to report✗94 ACOs hit the benchmark but received no savings

✗

Medicare Shared Savings Program (MSSP) Quick View

• No Downside Risk

• Retrospective Attribution

50%

• Upside and Downside Risk

• Retrospective Attribution

• Upside and Downside Risk

• Prospective Attribution

14

MSSP Shared Savings Bonus Payments

60%

75%

Track 1 Track 2 Track 3

Low Risk Patients

Rising Risk Patients

High Risk Patients

Near term high cost

Highly-automated, virtualized engagement

16

Focus on data management solutions….

17

…with little ability to realize value

and extract results

athenahealth’s Approach

++SOFTWARE KNOWLEDG

EWORK

RESULTS

Network services

Population health management

Patient access and care coordination

Inpatient services

Electronic health records

Revenue cycle

management

Ambulatory services

Revenue cycle management

Electronic health records

Population health management

22

Data SourcesCLINICAL SYSTEMSAllscriptsMeditech

EPICeClinicalWorksGE Centricity

CernerNextGen

PAYERS CIGNAAETNAAnthemUnitedCMS

BCBSMAHarvard Pilgrim AGGREGATED

PATIENTDATA

PHARMACY BENEFIT

MANAGEMENTCaremarkEnvision

ESI

REGIONAL LABSQuest Diagnostics

LabCorpConverge

Diagnostics

We aggregate data across multiple sources in the cloud

v

Network Data

Our population health services approach:

Over the past five years, athenahealth clients achieved strong results

24

45% Improvement in 1st year ACO33 quality scores

16% Increase in

network utilizationretention

63% of our MSSP clients

earned shared savings payment

55% Bend in medical

cost trend (lower spending

growth)

Our clients include some of the most forward-thinking provider

organizations

25

Our MSSP ACO GuaranteesYou’ll receive ACO Shared Savings. Pay us only if you do. Pay us nothing if you don’t

We will go at risk for our fee

Questions

27

Thank You