How to Thrive as an Independent

Group in the ACO Era

Cameron Buck, MD, FACEP

UW Valley Medical Center

The Journey of an Independent Emergency Medicine group in the ACN world

New Healthcare environment

ACOs and ACNs

Integrated ED group

Partnership /Alignment with Hospital

IT integration and analytics

Innovation

Participation in Integrated delivery network(IDN) and Physician Compacts

MACCRA and MIPS –CMS migration to value based healthcare

Why should we be concerned?

National Health Expenditureshas

grown to $3 trillion andactually more than $10,000 per person.

Serious healthcare challenges extend far beyond the walls of our hospitals and emergency departments .

THE RESULT

$750 Billion In Inefficient Health Care

Spending

• With physicians, hospital

administrators and insurance companies on often diverging

building plans, the idea that the health care system could fall apart

like a badly built house is not

surprising. - Kaiser Health News

Assumption – FFS going away Fee-for-service healthcare will be no-profit zones. Salvation will lie

in risk.

We will no longer be asking, “should we accept risk?” but rather “how much and how fast?”

Effects of Health Care Payment

Models on Physician Practice in the

United States – 2015 “Multiple practice leaders and market interviewees reported that their own practices or others in their markets were changing their organizational models—predominantly by affiliating or merging with other physician practices or aligning with or becoming owned by hospitals—in response to new payment models.

…the most prominent payment model–related reasons for these mergers were to enhance practices’ ability to make the capital investments required to succeed in certain alternative payment models, to negotiate contracts with health plans (including which performance measures and targets would be included), and to gain a sense of “safety in numbers.”

Let’s look into the

crystal ball…

America’s healthcare system will

do more with less.

Hospitalizations will decline considerably.

Care will shift to the outpatient

arena with great staffing demands.

Evolving leadership will drive health care

delivery, care coordination and

population health management.

CHANGE “WILL” to “IS.”

Different way of thinking about a process

We cannot solve the problems of today with the same thinking used to create

them. -Albert Einstein

Paradigm Shift

What drove margin in a volume world becomes cost in the accountable world

OLD PARADIGM -- Patient comes to ED– address their acute problem,

rule out life threats, treat and street/refer or admit

Value = appropriateness, quality, price, outcomes, utilization, patient experience

What is the Real Value Proposition? STRATEGIC VISION:

develop a comprehensive strategy for aligning and engaging providers

and serving patients in an exemplary manner that optimizes quality

outcomes, improves patient/family experiences, boosts practice

efficiency and significantly increases remuneration for the hospital and

providers (both employed and independent).

New Model of Care

Accountable Care Networks

(ACOs) (ACNs)

a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending. At the heart of each patient's care is a primary care physician

ACOs

More affordable healthcare

Meets each patient’s unique needs

Trusted relationship with a skilled primary care provider.

Access -full team of specialists

ACOs ?

In 2014, the 20 ACOs in the Medicare Pioneer Program and 333 in the Medicare Shared Savings generated $411 million in total savings but after paying bonuses, the program resulted in a net loss of $2.6 million to the Medicare trust fund.

UW Medicine Accountable Care Network

• A dedicated phone number for scheduling

• Same or next day appointments for primary care

• A 24-hour nurse care line

• Access to specialists within three days for urgent needs

• A concierge service available by phone, email or web to help patients access the health resources

• Proactive support for preventive care and chronic disease management

ACN – reduce inappropriate ED

utilization

Maintaining processes to educate the ACO Participant, at the point of service, regarding the most appropriate setting, and to direct the ACO Participant to that setting

Maintaining a care management program with a system to track and reduce inappropriate emergency department visits in general, and specifically for ACO Participants at high risk of visiting a hospital emergency department

Within two days of being made aware of an emergency department visit by an ACO Participant, UW will encourage the ACO Participant to make a timely visit to a Primary Care Physician, or other appropriate physician, within seven (7) calendar days.

EP roles in the ACN and P4P programs : Cost

Total cost of care and spending per beneficiary = cost component.

ED utilization and Admission reports regularly generated

Admissions : ED does not have control over patients coming into the ED. But have some control over whether or not they are admitted.

Standardizing pathways and admission criteria (i.e COPD)

Consultative role – How to provide / input into strategies to avoid ED visits

The perfect independent ED group in the ACN environment --

Cares about the triple aim and actively looks for ways to deliver on

it.

Prioritizes metrics quality outcomes and patient experience

Addresses Admissions and RE-admissions -Collaborates to ensure appropriateness

Care Pathways –partners to create acute care pathways

Imaging Utilization – prioritizes and utilizes high cost imaging appropriately

CARE MANAGEMENT -- understands and embraces

Accountability for Outcomes

Accountable Care Program (ACPs)

Report on a broad set quality measures (Washington State Core Measures Set) in the following clinical domains:

Chronic conditions (e.g. diabetes, hypertension)

Behavioral health management (depression)

Patient experience

Medical screenings and immunizations (BMI measurement; childhood

immunizations)

C-section rates

Quality improvement Plans that

Implement Bree Collaborative

recommendations:

Potentially avoidable readmissions

Obstetrics outcomes

Joint replacements

Spine surgery (fusions)

Cardiology

Low back pain

End of life care

Addiction and dependence treatment

Accountable Care Program

(PEBB and Boeing)

Providers are accountable

Clinical quality

Patient experience

ACN contracts

Requires absolute decrease in cost on PMPM basis before success of

quality measures comes into play

ACN FINANCIAL OBJECTIVES for the

HEALTH SYSTEM

Monitor and reduce per capita spending

Understand the financial investment required to support the transition to value-based payment models

Contracts with providers that align with the aims of a value-based health system

Contracts with payers that align with the aims of a value-based health system

Value of the Clinician

Assumption – Emergency Medicine is

well positioned

We can deliver care at a lower cost and be high performing

Deliver high-quality, cost-effective health

care

Opportunities – Where will EP fit in ?

Service Integration

organization and participation in health systems so that people get the care they need

Shared savings

payment strategy that offers incentives for providers to reduce healthcare spending for a defined patient population by offering them a percentage of net savings realized as a result of their efforts.

Transitions of Care

The movement patients make between healthcare providers and settings as their condition an care needs change during the course of a chronic or acute illness.

Virtual Care

encompasses a broad variety of technologies and tactics to deliver a wide range of care and management

Partnership --A new impetus for working together

Silos must fall

Hospitals, physicians, nurses, social workers, case managers, behaviorists, and ancillary care providers must improve working as effective teams

Be Part of a new Pardigm High-Performing Health System

Ensure “readiness” for optimizing performance under value-based payment models;

High Performing Health Systems

Have the patient receive the right care at right time at the right place

Assist with both the cost and experience components.

Cost component - Help manage the total cost of care

EP in the

Accountable Care Network

ADMISSIONS and RE-ADMISSIONS

Developing processes to support safe alternate to admissions

Consistent decision making

CARE PATHWAYS

Standardizing patient care pathways for certain populations – COPD , CHF , CAD, Diabetes, Pneumonia)

PER CAPITA COST

Understanding and Reducing the Per capita cost for certain populations

Medicare spending per beneficiary

Attributed or Designated ACN patients (PMPM – per member per month)

IMAGING UTILIZATION

Reduce unnecessary imaging

Evidence based decision making

ELEMENTS of STRATEGIC DESIGN QUALITY and VALUE

IT INTEGRATION AND ANALYTICS

CARE COORDINATION

INNOVATION

CONTINUOUS CARE PATHWAYS

Makes your quality measure reporting more efficient.

Identify practice variation within an ED

Essential in ED quality reporting

TJC Ongoing Professional Practice Evaluation (OPPE)/ Focused

Professional Practice Evaluation (FPPE) compliance

Increased Medicare and potentially increased private payer revenue –

will allow completion of MIPS reporting

Continuous quality improvement

3 “S’s”

Stroke

Sepsis

STEMI

STROKE OUTCOMES

Part of the Center for Medicare & Medicaid Innovation’s (CMMI) Transforming Clinical Practice Initiative (TCPI).

enroll over 2,200 EDs across the country

participate in 8 month learning collaboratives to

disseminate best practices

benchmark emergency care sepsis performance

support emergency clinicians in meeting educational and regulatory needs of ABEM, CMS and others.

WHAT IS

EQUAL

Network?

Three learning

collaboratives

Improving outcomes for patients with sepsis

Reducing avoidable imaging in low risk patients through implementation of ACEP’s Choosing Wisely recommendations

Improving the value of ED chest pain evaluation by reducing avoidable admissions in low risk patients with chest pain

Benefits

Supporting quality improvement efforts

Meet new CMS MIPS requirements for Clinical Practice Improvement Activities

Submit and receive benchmarking data

ED commitment to quality improvement

Financial subsidies for rural EDs

JOIN E-QUAL

For more information on how to join the E-QUAL Network

email equal@acep.org

visit : www.acep.org/equal

Coming to your local hospital July 2017…

Quality

The training wheels are off! CARDIAC BUNDLES – JULY 2017 The admitting hospital for a heart attack or bypass surgery will be accountable for the cost and quality of care provided to Medicare FFS beneficiaries during the inpatient stay and for 90 days after discharge.

• Participating hospitals will be paid a fixed target price for each care episode, with hospitals that deliver higher-quality care receiving a higher target price.

• At the end of a model performance year, actual spending for the episode will be compared to the target price that reflects episode quality for the responsible hospital.

• Hospitals that work with physicians and other providers to deliver the needed care for less than the quality-adjusted target price, while meeting or exceeding quality standards, will be paid the savings achieved.

IT INTEGRATION AND ANALYTICS

Data integration and reporting is critical.

Analytics in real-time – Dashboards

Balanced provider report cards

Advanced reporting

• ACTIONABLE DATA IS ONE OF THE KEYS TO ACHIEVING OUTCOMES.

• A FULLY INTEGRATED ANALYTICS PLATFORM WILL ENHANCE THE COLLABORATION PAYER AND PROVIDER

Tableau

Analytics and Data

Quickly analyze, visualize and share information

Create custom dashboard and reports

Unique views of your data

subscribe to Healthcare intelligence

Make TRANSPARENCY part of the culture

Set group expectations for performance.

Efficiency + Transparency = Effectiveness

Imaging Utilization (CT)

Value – assessing group average and outliers

Decreasing inappropriate utilization

Challenges : CT usage variable by site and patient mix

no standard for the “right” number

Measure – imaging utilization for evidence based situations

Pediatric head CT in isolated closed head injury

CT KUB / CT abd-pelvis

Lends itself better to a quality improvement project

•Timely data to inform care decisions

Data

•Clear roles and responsibilities

•Trust

•Respect

Teams •Define “the

best” and achieve it

Outcomes

Core Components for Success

To what extent does the health

system use clinical quality

measures for performance

management or process

improvement?

Percentage of Discharges that Re-

visit (within 48 hours)

Percent of Discharges that are

admitted on Return visit

Process and performance

improvement

Dedicated EHR (EPIC) Analyst

IT clinical champion / analyst Dyad

Participate in the development of new workflows

Efficient builds

Change management - Rapid turnaround on IT service

requests

Participate in Operational meetings

Ability to provide 1 on 1 clinician support

Create reports on the fly when needed quickly

Assist in reporting and EHR process improvements

Special projects - Behavioral Health pathway

Behavioral Health metric tracking

Behavioral Health Metrics

CARE COORDINATION and MANAGEMENT

We need to be population manager for own cohort

Integrate care management team in the ED

Use and educate about “transitions of care “ connections within the community

Identify patients who are at high risk for returning to ED and enrolling them in care management services – connect to services

Care Management Utilization

Information exchange

EDIE (Emergency Department Information Exchange)

Highly utilizers

Effectiveness and Impact ?

Information sharing – better decision making

Get to something more quickly / changes decision making

Resource utilization

EDIE utilization

Track department usage

Transitions of Care

The ED as effective (pivot) point – connecting the patient back to the clinic system and outpatient resources

Previous – unorganized patient referrals

Current – organized and automated follow up

Patient resource center routing – integrated – warm handoff for follow up

Improves compliance for navigation

Integrated Care Management

ED High Utilizer program – recognize and target

EMS – Mobile Integrated Healthcare

Works with police and EMS

Sobering Center pilot – alternate destination for alcohol intoxication patients

Care pathways and Clinical

practice guidelines

Multi-disciplinary collaboration

Disease or symptom specific pathways (i.e COPD, chest pain)

Evidence-based care guidelines to manage patients classified as at-risk

Value - Patient centered care

Decrease variance

Collaboration

Workgroup on Admissions

Streamline admissions (transitions safer, efficient and effective)

Improve handoffs

Collaborate on transitional order sets

Patients pulled from ED

Decrease boarding

Track and report boarding measures

Care Model Re-design

Survival will require

that we innovate

NEW CLINICAL PARADIGM = VALUE

RECOGNIZE SYSTEMS OF CARE

Recognizing Avoidable ED visits

Participating in chronic disease management / transitions of care

Case management -Identifying and managing High

Utilizers

High level Collaborating with Hospitals and Systems

Expand circle of influence

Mobile Integrated Healthcare

Innovative Alignment and Transitions of Care between EMS and Health Systems

MIH program –EMS 3.0

Value

Improve patient health outcomes per dollar spent

Improve operational efficiencies of 911 response model

Reduce unnecessary 911 calls

Expanded services

Navigation and alternate transportation

Referral and connection to community health/social services

Chronic disease management and support -proactive visits

Inter-Organizational Support AND

Community Partners

NEMS response model

Improving System Operational Efficiency

Opportunity for EPs to be involved

Telemedicine Opportunity to improve economics of

healthcare delivery

Expected savings gained from reducing the number of physical transfers between Emergency departments through telemedicine easily could cover the costs of equipping all U.S. emergency rooms with telemedicine capabilities

The costs to outfit a nursing home with telemedicine technologies would be more than offset by reducing the costs of transporting patients to emergency rooms and physician offices when issues arise that can be handled remotely.

Telemedicine

ACN implementation

use telemedicine to help reduce costs and increase

savings.

Quality metrics — including patient satisfaction —improved with telemedicine services

The Path Forward

Adoption will be incremental and transformative.

Will follow cost pressures and consumer demand

Dependent on regulatory environment

COMPENSATION ALIGNMENT Increased Value based compensation

Increased quality and risk based contracting

Pay for performance elements

Away from Fee-for service

Future contracting will be more collaborative (work with commercial insurers and hospitals/systems)

ACN contracts – risk tied to quality and overall cost

Value based contracting- contracts pay out on a risk adjusted basis compared to other health systems (bonus for quality and shared savings)

Option for groups / entities to "Gain share” / Improve the Medical loss ratio:

Drive down costs and participate in the savings

If you can cut down ratio from 89%- 85% - receive 50% of savings

VMC TRANSFORMATIONAL STEPS

1. ESTABLISH A COLLABORATIVE HEALTHCARE TRANSFORMATION COUNCIL (HTC) WITH ADMINISTRATIVE AND PHYSICIAN LEADERS

2. BUILD A CONSENSUS FOR A DRAFT VMC QUALITY PERFORMANCE PACT

3. DEVELOP A QUALITY MATRIX FOR EACH HEALTH PLAN THAT INCLUDES BOTH BENCHMARKS AND TARGETS, AND BUILD A COMPREHENSIVE PROVIDER CONTRACT.

PROVIDER COMMITMENT

1. resolve to attain top-tier quality performance

across all payors.

2. High level practice engagement and support

for centralized quality initiatives.

3. Peer-to-peer benchmarking and

maintenance of accountability.

4. A radical shift in team-based culture,

cooperation and interoffice support.

INSTITUTIONAL COMMITMENT

1. Board and executive level support for

facilitating top-tier performance.

2. Centralized care coordination support

for at risk patients.

3. IT infrastructure support for optimizing

data aggregation and reporting.

4. Integration of hospital/provider

leadership in risk-based contracting.

QUALITY PERFORMANCE PACT

Emergency Physicians • Lead rather than follow!

• Set high standards for peer-to-peer improvement

• Establish top tier –MIPS benchmark performance as imperative

• Work together with systems rather than independently on quality

performance and risk based contracting / programs

Opportunities • FOCUSING ON THE ESSENTIAL ELEMENTS OF OPTIMIZED

SYSTEMS OF CARE

• QUALITY IMPROVEMENT IN AN UNPRECEDENTED

MANNER.

• ENHANCING GAIN SHARING AND REDUCING RISK.

• EFFECTIVELY DEALING WITH THE ELEMENTS THAT WE DO

NOT PRESENTLY CONTROL.

• PROMOTING COLLECTIVE PROVIDER ENGAGEMENT

AND PRACTICE TRANSFORMATION.

• ASSUMING RISK AT THE RIGHT TIME.