Embed Size (px)
Citation preview
FletcherAllen.org
Successful Switch Hitting in a Combined Volume and Value Environment
J. Churchill Hindes PhD (Iowa 1977)
Chief Operating Officer, OneCare Vermont ACOVice President for Accountable Care, Fletcher Allen Health Care
Clinical Associate Professor of Medicine, University of Vermont
HEALTH CARE IN VERMONT
Vermont superlatives: Small, pretty, rural & healthyFirst or second “Healthiest State” in the USA625,000 population (equals Denver or Milwaukee)Low number of uninsured—6.8% (before exchange)Low to average health care spend per personHealth care is nearly 20% of state economy
2
HEALTH CARE IN VERMONT
2 academic health systems (University of Vermont and nearby Dartmouth)
14 hospitals (8 are Critical Access)1,900 physicians (65% are hospital employed)Two commercial health insurers dominate marketAll major players are non-profitsLargely non-competitive provider model
3
HEALTH CARE IN VERMONT
Aggressive state reform agendaCommitted to “Single Payer” by 2017 Fueled by SIM funding—Most per capita in USAExchange required for individuals and business <100One dominant, liberal political partyClosely regulated health care systemProviders and public sector closely engaged
HEALTH CARE IN VERMONT
University of Vermont (UVM, in Burlington) is:• 90 minutes south of Montreal Canada• 6 hours north of New York• 4 hours north of Boston
Dartmouth and UVM on opposite state bordersVT & NH among smallest states with Med Schools
FletcherAllen.org
6
Top 10 University HospitalUniversity HealthSystem Consortium (UHC) ranked University of Vermont / Fletcher Allen Health Care:
1st in the nation for patient safety for 20147th for overall quality of care
Vermont’s Reform Legacy• Northern New England Medical Compact (1958)• Cooperative Health Information Center of Vermont (1970)• John Wennberg’s small area variations (1970)• CON controls (since 1979); Hospital budget reviews (since 1983)• State public controls after Reagan era relaxation (1987)• Vermont Program for Quality in Health Care (1988)• Medicaid expansion (1987…)• Health insurance reforms (1991…)• Creation of statewide Health Care Authority (1992)• Howard Dean’s unsuccessful universal access attempt (1992-94)
7
Vermont’s Reform Legacy• Blueprint for Health—Chronic disease and PCMH’s (2003)• Choices for Care long term care reforms (2004)• Statewide HIE mandate (2005)• Catamount Health Plan (2007)• Contribution to and capitalization on PPACA (2010 to present)• William Hsiao Report on 3 Single Payer opportunities (2011)• “Single Payer” mandate (2011)• Green Mountain Care Board (2011)• OneCare Vermont first statewide Medicare ACO (2013)• Medicaid and Commercial ACO programs (2014)• Physician Assisted Dying legislation (2014)
8
FletcherAllen.org
9
Health Care Reform Path 2011-2017
2010-2011Legislative Action
National: PPACAVermont: Act 48
2011-2012 Early Implementation
National: MSSP ACO Program; Age 26; Exchange PlanningVermont: GMCB seated; VT
exchange legislation; Hospital NR growth limits, payment
reform pilots
2012-2014Becoming Real
National: ACA benefit plans, exchanges,
Medicaid expansion Vermont: SIM Grant, VT Health Connect, Multi-
Payer ACOs; population-based SSP on top of FFS
2014-2016Redesign and Results National: MSSP ACO risk; stabilize ACA and national
exchangeVermont: ACO Multi-Payer;
GMC Funding design; continued provider
consolidation; Start move to non-FFS
2010 2011 201420132012 20172015 2016
2017+Future Model
National: Refined national model and/or
state innovation; Medicare/Medicaid funding challenges
Vermont: GMC as right of citizenship; new
funding and provider revenue model(s)
onecarevt.org
10
Vermont Public Reforms Primary public agenda elements
• “Act 48”>Commitment to “Single Payer” reforms>Public financing of system (taxes replace premiums)
• State Innovation Model grant program (SIM)>Payment reforms away from fee-for-service
• Vermont Health Connect (PPACA insurance exchange)> To become single payer enrollment tool> To access to federal exchange premium subsidies
• Insurance market changes >Individuals, most employers must purchase via exchange
10
FletcherAllen.org
11
Key Public Priorities
PAYMENT REFORMS
COST CONTROLS
PUBLIC R.R.
PUBLICALLY FINANCED
SINGLE PAYERHIE
UNIVERSAL ACCESS
onecarevt.org
12
Vermont’s Private Reforms Primary private elements include
• Capitalize on federal and state legislative opportunities
• Explore payment reform alternatives to fee for service>shared savings > bundled payments>global budgets > pay for performance
• Explore Accountable Care Organizations and
ACO programs (Medicare, Medicaid, Commercial)
• Integrate Vermont Blueprint for Health PCMH initiative
• Structural changes (UVM Network, OneCare Vermont ACO)
• Eliminate cost shift
• Eliminate premium hikes at multiples of GDP rates
12
FletcherAllen.org
13
Key Provider Priorities
TEMPERED COST GROWTH
WELL POPULATIONS AND COMMUNITIES
SUSTAINABLE REFORMS
PROVIDER R.R.
HEALTHIER PATIENTS
BETTER QUALIITY MORE PATIENT ENGAGEMENT
FletcherAllen.org
14
Vermont’s Reform Landscape
THE VOCAL "CON"
"THE COALITION OF THE WILLING"
MENTAL HEALTH SUBSTANCE ABUSE
DLTSS
POST-ACUTE PROVIDERS
INSURED EMPLOYERS
SELF FUNDED EMPLOYERS
DARTMOUTH HITCHCOCK
ONECARE ACOUNIV OF VERMONT
FLETCHER ALLENVERMONT
BLUE CROSS
COMMUNITY HOSPITALS &
EMPLOYED MDs
INDEPENDENT PHYSICIANS
VERMONT STATEWIDE HIE
THE VOCAL "PRO"
VERMONT HOUSECOURTS
GOVERNORVERMONT SENATE
VERMONT SIM PROGRAM
GREEN MOUNTAIN CARE BOARD
VERMONT MEDICAID
VERMONT INSURANCE EXCHANGE
FletcherAllen.org
15
Who Should Focus on What?
PUBLIC SECTOR (FEDERAL AND STATE) ADVANTAGESTATUTORY AUTHORITYREGULATION OF PAYERSCONTROL OVER PREMIUMSCONTROL OVER PLAN DESIGNWAIVER OF RESTRICTIVE LAW (FTC, CMS...)SENSITIVITY TO BUSINESS, CITIZEN INTERESTS
`
PRIVATE SECTOR (PROVIDERS, PAYERS) ADVANTAGEPAYMENT SYSTEMS EXPERTISEDEPTH OF SYSTEMS UNDERSTANDINGNIMBLENESSFLEXIBITYCOALITION BUILDINGSENSITIVITY TO PROVIDER, PAYER INTERESTS
THE GRAND DESIGN: CAPITALIZE ON LAW OF RELATIVE ADVANTAGE
PROVIDERSTO
INFLOWSREVENUE
OUTFLOWSCAPITAL TO INVEST IN DESIGNING REFORM
SIM FUNDS TO INVEST IN DESIGNING REFORM
FletcherAllen.org
16
Both Pulling Together
TEMPERED COST GROWTH
PAYMENT REFORMS
COST CONTROLS
SUSTAINABLE REFORMS
PUBLIC R.R. PROVIDER R.R.
HIE
BETTER QUALIITY MORE PATIENT ENGAGEMENT
HEALTHIER PATIENTS
WELL POPULATIONS AND COMMUNITIES
UNIVERSAL ACCESS
PUBLICALLY FINANCED
SINGLE PAYER
FletcherAllen.org
17
Filling the Funnel
OTHER STREAMS CURRENT PAYMENT SOURCES
PAY FOR NON-RESIDENTS' CARE
COMMERCIAL - SELF FUNDED * ORWORKERS COMP
TRICARE etc.
INFLOWS
OUTFLOWSTO
NO PREMIUMS, PUBLIC $'s ONLY BLEND OF PREMIUMS & PUBLIC $'s
* SOME COMMERCIAL SELF-FUNDED OPT IN, OTHERS DO NOT
PROVIDERS
"PURE" SINGLE PAYER "MODIFIED" SINGLE PAYER
NEW PAYROLL, EARNINGS TAX COMMERCIAL - FULLY INSURED
COMMERCIAL - SELF FUNDED *
MEDICARE VIA ALL PAYER WAIVER
MEDICAID VIA 1115 WAIVER
MEDICARE VIA 1332 WAIVER
FED SUBSIDIES VIA 1332 WAIVERMEDICAID VIA 1115 WAIVER
REVENUE
FletcherAllen.org
18
Filling the Funnel (detail)
OTHER STREAMS CURRENT PAYMENT SOURCES
PAY FOR NON-RESIDENTS' CARE
COMMERCIAL - SELF FUNDED * OR
WORKERS COMP
TRICARE etc.
INFLOWS
NO PREMIUMS, PUBLIC $'s ONLY BLEND OF PREMIUMS & PUBLIC $'s
* SOME COMMERCIAL SELF-FUNDED OPT IN, OTHERS DO NOT
"PURE" SINGLE PAYER "MODIFIED" SINGLE PAYER
NEW PAYROLL, EARNINGS TAX COMMERCIAL - FULLY INSURED
COMMERCIAL - SELF FUNDED *
MEDICARE VIA ALL PAYER WAIVER
MEDICAID VIA 1115 WAIVER
MEDICARE VIA 1332 WAIVER
FED SUBSIDIES VIA 1332 WAIVER
MEDICAID VIA 1115 WAIVER
REVENUE
FletcherAllen.org
19
Flowing to Providers
OTHER STREAMS CURRENT PAYMENT SOURCESPAY FOR NON-RESIDENTS' CARE
COMMERCIAL - SELF FUNDED * OR
WORKERS COMP
TRICARE etc.
FOR ALL LIVES
NON-POPULATION-BASED:
POSSIBLE ALL PAYER WAIVER
POSSIBLE GLOBAL BUDGETS
POSSIBLE COMMON FFS
AS NEGOTIATED OR BY LAW
"PURE" SINGLE PAYER "MODIFIED" SINGLE PAYER
NEW PAYROLL, EARNINGS TAX COMMERCIAL - FULLY INSURED
FED SUBSIDIES VIA 1332 WAIVER COMMERCIAL - SELF FUNDED *
OUTFLOWS
MEDICAID VIA 1115 WAIVER MEDICAID VIA 1115 WAIVER
MEDICARE VIA 1332 WAIVER MEDICARE VIA ALL PAYER WAIVER
SINGLE STREAM
NO PREMIUMS, PUBLIC $'s ONLY BLEND OF PREMIUMS & PUBLIC $'s
* SOME COMMERCIAL SELF-FUNDED OPT IN, OTHERS DO NOT
INCENTIVE PAYMENT: SELECT PROVIDERS
FOR THEIR ATTRIBUTED LIVES
TRANSITION PAYMENT: SELECT PROVIDERS
PREDOMINANTLY POPULATION-BASED:
PMPM: HOSPITALS, EE'd MDs, PCPs
COMMON FFS: ALL OTHERS
CAPACITY PAYMENT: SELECT PROVIDERS
REVENUEINFLOWS
TOPROVIDERS
FOR THEIR NON-ATTRIBUTED LIVES
NON-POPULATION-BASED:
POSSIBLE ALL PAYER WAIVER
POSSIBLE GLOBAL BUDGETS
POSSIBLE COMMON FFS
FletcherAllen.org
20
Flowing to Providers (detail)
FOR ALL LIVES
NON-POPULATION-BASED:
POSSIBLE ALL PAYER WAIVER
POSSIBLE GLOBAL BUDGETS
POSSIBLE COMMON FFS
AS NEGOTIATED OR BY LAW
OUTFLOWS
INCENTIVE PAYMENT: SELECT PROVIDERS
FOR THEIR ATTRIBUTED LIVES
TRANSITION PAYMENT: SELECT PROVIDERS
PREDOMINANTLY POPULATION-BASED:
PMPM: HOSPITALS, EE'd MDs, PCPs
COMMON FFS: ALL OTHERS
CAPACITY PAYMENT: SELECT PROVIDERS
TOPROVIDERS
FOR THEIR NON-ATTRIBUTED LIVES
NON-POPULATION-BASED:
POSSIBLE ALL PAYER WAIVER
POSSIBLE GLOBAL BUDGETS
POSSIBLE COMMON FFS
BLENDED VALUE AND VOLUME BASED REVENUE MODEL FOR ALL VERMONT HOSPITALS
PMPM FOR HSA-ATTRIBUTED LIVES
DERIVED FROM STANDARDIZED FEE FOR SERVICE
EQUIVLENT PAYMENTS
STANDARDIZED FEE FOR SERVICE FOR
CARE TO NON-ATTRIBUTED VERMONT LIVES
REVENUE FOR NON-VERMONTER CARE
REVENUE FOR NON-VERMONTER CARE
NEGOTIATED BASELINE AND INFLATOR
PLANNING SCENARIO
QUALITY & COST INCENTIVES
REMAINDER = DIMINISHING TRANSITION PAYMENT
ESSENTIAL SERVICES CAPACITY PAYMENT
CURRENT SOURCES OF PATIENT REVENUE
(CARE FOR VERMONT RESIDENTS)
FletcherAllen.org
22
Enter the OneCare Vermont ACO
OneCare Vermont ACO
Began in 2012 as joint venture between Dartmouth and University of Vermont’s Academic Health System to:
• Explore potential for further collaboration
• Attempt a broad statewide population health strategy
• Present a unified front in politics of Vermont reforms
Structured as a Medicare SSP track one ACO
FletcherAllen.org
23
Enter the OneCare Vermont ACO
OneCare Vermont ACO
“Discovered” by Vermont public reform authority• Adopted as a SIM program payment reform pilot
• Asked to co-design Medicaid and Commercial ACO dealsAgnostic to revenue sources including tax fundingNow providers’ lead vehicle in Vermont reform efforts Commissioned to design “flow from bottom of the funnel”Goal is a design that is
• Collaborative, cohesive and consistent
• Sustainable with reasonable growth rates
FletcherAllen.org
24
Center Place in the Landscape
THE VOCAL "CON"
"THE COALITION OF THE WILLING"
MENTAL HEALTH SUBSTANCE ABUSE
DLTSS
POST-ACUTE PROVIDERS
INSURED EMPLOYERS
SELF FUNDED EMPLOYERS
DARTMOUTH HITCHCOCK
ONECARE ACOUNIV OF VERMONT
FLETCHER ALLENVERMONT
BLUE CROSS
COMMUNITY HOSPITALS &
EMPLOYED MDs
INDEPENDENT PHYSICIANS
VERMONT STATEWIDE HIE
THE VOCAL "PRO"
VERMONT HOUSECOURTS
GOVERNORVERMONT SENATE
VERMONT SIM PROGRAM
GREEN MOUNTAIN CARE BOARD
VERMONT MEDICAID
VERMONT INSURANCE EXCHANGE
FletcherAllen.org
25
Vermont is a bit different…
Across the nation, ACO’s are typically business arrangements between groups of providers and one or more payers. Providers see ACO as a way to maybe make a little extra money.
In Vermont, ACOs are business arrangements between groups of providers and multiple payers. Providers see ACO as a way to maybe make a little extra money…
AND, the ACOs (particularly the OneCare ACO) are high profile leaders for statewide health care reform—private provider led efforts that complement the public sector led initiatives
FletcherAllen.org
26
ACOs as a “platform” for reform
ACOs as a “Health Care Reform Trifecta”
Structure a broad network of linked providersContract voluntarily to mutual performance agreementsCommit to better understand community status & needsCommit to test and add new ideas into daily practiceStrive to achieve slower cost growth
(While improving clinical quality and patient satisfaction)Collaborate with insurers (Medicare, Medicaid, Blue’s)Willing to be paid differentlyWilling to assume more financial risk
onecarevt.org
27
Provider-Led, Population-Based Coordination, Alignment, and Support
•Forum for Delivery System Design/Optimization
•Payment Reform Leadership•Revenue Model Design•Incentive Programs
•Care Management Design and Support•Primary Care/PCMH Alignment•HIE Facilitation•Population-Based Clinical and Analytic Systems•Quality Measurement
ACOACO
Regulator(s)
Payer(s)
Legislators
Physicians
Hospitals
Other Providers
OneCare Vermont Roles
FletcherAllen.org
28
OneCare Vermont
Multi-payer, private/public collaboration
•Credentialed by Vermont reform authority as a SIM payment reform program
•100,000 attributed beneficiaries (16% of statewide population)•$750,000,000 accountable spend (17% of statewide health care spending)
•MSSP began January 2013•Medicaid (VMSSP) began January 2014•Commercial (XSSP) began January 2014
•Quality measures: CMS-33 plus others for Medicaid and Commercial ACO programs
•Preparing for two-sided risk starting in 2016
OneCare Vermont
Statewide ACO Provider Network
•Two Academic Medical Centers (University of Vermont and Dartmouth)
•Every hospital in the state
•550 Primary Care clinicians 90% are NCQA medical home practices•1,400 Specialist physicians
•4 Federally Qualified Health Centers•5 Rural Health Clinics
•Broad network model:Nearly every VNA, Hospice, SNF and Community Mental Health and Substance Abuse agency statewide
•Links to other large ACOs in upstate New York, New Hampshire and MaineHospitals with Employed Attributing Physicians
Significant Attribution from Community Physicians29
Some OneCare Notable Notes
• Central role in Vermont statewide health care system reform • Credentialed by state regulators as payment reform program• One of very few statewide ACOs in nation• One of few ACOs sponsored by two academic health centers• One of largest rural ACO’s—now at over100,000 attributed lives • Now accountable for $750,000,000 in health care costs and growing• One of relatively few multi-payer ACOs • Unusually broad-spectrum provider network strategy• Linked to ACOs from St Lawrence valley in New York to coastal Maine• Close collaboration with Vermont ‘s statewide medical home model• Designed to be compatible with Vermont’s plans for “Single Payer”
FletcherAllen.org
31
The Future of Vermont Reforms
Opportunities• Providers are engaged and collaborative
>Population-based approach is being widely embraced
• Broad physician alignment>65% of MDs work for hospitals or FQHCs>All hospitals and FQHCs are in multipayer ACOs
• Data infrastructure is approaching maturity>Statewide HIE>All-payer claims databases>Northern New England Accountable Care Collaborative
• OneCare provides statewide framework for real change
FletcherAllen.org
32
The Future of Vermont Reforms
Challenges• How do you improve on our high-performing system?• Ongoing tension about who should lead reform
>Best public-private balance?>Best locus for public leadership—political or policy centric>Best roles for providers / payers / ACOs / state agencies?
• Providers’ concerns about their future sustainability • Wariness about Vermont state intensions• Wariness about Dartmouth and UVM intensions• The heaviest lifting has yet to come
FletcherAllen.org
33
Some Key Unknowns
Will Vermont receive its required federal waivers?
Will the Vermont legislature approve public financing? “The largest tax increase in state history” “Substituting payroll taxes for private insurer premiums”
Where will “Single Payer” risk be held?
Will state or providers control key reform infrastructure?
What role will commercial payers continue to play?
Will ERISA plan employers successfully sue Vermont?
FletcherAllen.org
34
Some Key Unknowns
How will Vermont reforms impact out of state providers?
(Dartmouth Hitchcock, Boston Children’s…)
Will the reforms adversely impact the state economy?
Will Vermont’s high performing system be maintained?
What will the changes mean for Vermont providers?
Will changes result from the Nov 4 Vermont elections? Will changes result from the Nov 4 federal elections?
FletcherAllen.org
35
A Closing note—Then…and now!
Then: C. Rufus Rorem
visited us at Iowa and spoke
about his work on the CCMC
1969 -1925 = It was 44 years ago!
“None of us were born then!”
“What an old codger!”
Now: J. Churchill Hindes came to
Iowa in 1969, back speaking today
2014 -1969 = It’s been 45 years!
“None of us were born then!”
“OMG! Who? Me? Old?!”
Questions and Discussion
802-847-6249
36
37
