Leading Change in Primary Care Delivery: Transitioning Beyond Medical Homes to ACOs

March 26, 2014

Agenda

I. Objectives II. Changes in the Role of Primary Care PhysiciansIII. PCMHs and ACOs: Concepts and ResultsIV. Adirondack Health Institute: The Evolution from PCMH to ACOV. Questions and Discussion

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Objectives

• Review challenges and successes of patient-centered medical homes (PCMHs), highlighting Adirondack Health Institute

• Describe the transformation of health care delivery from PCMH to a more clinically integrated network

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CHANGES IN THE ROLE OF PRIMARY CARE PHYSICIANS

Traditional Role of the Primary Care Practice

One-to-one patient care

Managed care interaction and contract negotiation

Supervising staff

Payment per unit of service5

Evolving Practice Approaches Beyond of the Patient-Centered Medical Home (PCMH)

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Example Requirements

Access

Population health management

Care coordination

Wellness

Outcomes

Example Models and Approaches

Group visits

Patient empowerment

Telemedicine

Team care

PCP Role (Patient Care)

Other Practice Innovations in the Transition to ACOs and Other Models • Concierge practice• Patient portals • Patient registries • Patient empowerment • Chronic care approaches • Unsponsored patient care management• Dedicated house calls• Dedicated nursing homes• Other (?)

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PCMHs AND ACOs: CONCEPTS AND RESULTS

Patient-Centered Medical Home Concept

• Four essential functions of a PCMH– First contact access– Patient-focused care over time– Comprehensive care– Coordinated (integrated) care

• Three corollary functions of a PCMH– Family orientation– Community orientation– Cultural competence

9Source: COGME 20th Report: Advancing Primary Care, January 2011.

Patient-Centered Primary Care Collaborative Report, January 2014• 90+ commercial and not-for-profit plans are using the PCMH concept• Early evidence showing many consistent, positive outcomes• Research also showing the foundational role of PCMHs in other

delivery models such as ACOs, with high-performing ACOs embracing their strong PCMH components

• Substantial improvements demonstrated in cost, utilization, population health management, prevention, access to care, and patient satisfaction

10Source: The Patient-Centered Medical Home’s Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013, The Patient-Centered Primary Care Collaborative, January 2014.

Latest Findings on PCMH Results

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TotalStudies

CostReductions

Fewer ED Visits

Fewer Inpatient

AdmissionsFewer

Readmissions

Improvementin Population

HealthImprovedAccess

Increase in Preventive Services

Improvement in Satisfaction

Reportedoutcomes (n = 13) 61%

(n = 8)61%(n = 8)

31%(n = 4)

13%(n = 1)

31%(n = 4)

31%(n = 4)

31%(n = 4)

23%(n = 3)

Reported outcomes (n = 7) 57%

(n = 4)57%(n = 4)

57%(n = 4)

29%(n = 2)

29%(n = 2)

14%(n = 1)

29%(n = 2)

14%(n = 1)

Peer-Review/Academia

Industry Reports

S+

Source: The Patient-Centered Medical Home’s Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013, The Patient-Centered Primary Care Collaborative, January 2014.

Individual PCMH Results

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40% fewer inpatient stays37% fewer ER visits250% increase in primary care visits18% lower health care claims costs

39% lower ER visits40% lower readmission ratesReduced appointment wait time from 26 to 1 day129% increase in optimal diabetes care

15% fewer hospital readmissions15% fewer inpatient hospital stays50% fewer inpatient stays of 20 days or moreOverall health care cost savings of $15.5 million

13.5% and 10% fewer ED visits among children and adults7.5% lower use of high-tech radiology17% lower ambulatory-care sensitive inpatient admissions6% lower readmission rates60% better access to care for practices open 24/7

BCBS of California ACO Pilot

Capital Health Plan

BCBS of Michigan

Health Partners

Source: www.pcpcc.org/guide/benefits-implementing-primary-care-medical-home, accessed January 2014

Individual PCMH Results (continued)

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25% lower hospital admissions50% lower readmissions following dischargeLonger exposure to medical homes reduces health care costs:

14.7% lower inpatient hospital days25.9% fewer ED visits6.5% lower per member per month medical and pharmacy costs

10% lower per member per month costs26% fewer ED visits25% fewer hospital readmissions21% fewer inpatient admissions

BCBS of New Jersey (Horizon BCBSNJ)

BCBS of South Carolina 2012

Geisinger Health System

Source: www.pcpcc.org/guide/benefits-implementing-primary-care-medical-home, accessed January 2014

Accountable Care Organization (ACO) Concept

• An ACO can be defined as a set of health care providers —including primary care physicians, specialists, and hospitals — that work together collaboratively and accept collective accountability for the cost and quality of care delivered to a population of patients

14Source: www.accountablecarefacts.org, accessed January 2014.

Evolution of Accountable Care Organizations

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2006 2007 2008 2009 2010 2011 2012 2013 2014PRE 2000’s

Physician-hospital partnerships for efficient care

CONCEPT

“Extended hospital medical staff” to lower cost and improve quality

1990s principles

of managed

care

Key publications develop ACO concept and model; organizational competencies include:– Relationships with other providers– IT infrastructure for care coordination and

population management– Infrastructure to monitor and report quality– Ability to receive and distribute savings

PATIENT PROTECTION ANDAFFORDABLE CARE ACT

Section 3021: CMMI establishedSection 3022: Medicare Shared Savings Program

ACO RULE(S)

PROPOSED: APRIL2011

FINAL: NOVEMBER 2011

Pioneer Model ACOs

launched

Major commercial payor ACO-like arrangements

developed

Medicare Shared Savings (and Advance

Payment) ACOs launch(es)

2012: APRIL, JULY2013: JANUARY2014: JANUARY

Sources: Creating Accountable Care Organizations: The Extended Hospital Medical Staff, Health Affairs, January 2007. Accountable Care Organizations, AHA Research Synthesis Report, American Hospital Association Committee on Research, June 2010.

Accountable Care Organizations: The Basics

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What they are…

What they are…

• CMS/CMMI-developed payment and delivery model pilots

• Commercial payor arrangements organized in a structure similar to CMS/CMMI structures

• Group of payors, physicians, hospitals, and other providers that collaborate (legal entity) to provide efficient, high-quality, and coordinated care to assigned patient population(s) across a range of care settings

• If providers reduce costs and/or improve established quality metrics in a given time frame, they are eligible to share in associated savings with payors/at risk with payors

What they are not…

What they are not…

• “Health care reform” and/or “population health management”

• Patient-centered medical home

• Value-based purchasing

• Bundled payments

• Clinical integrated networks

Fast factsFast facts

• Physician groups lead the greatest proportion of ACOs, followed by health systems

• 52% of Americans live in a service area with at least one ACO

• Medicare ACOs represent 52% of all ACOs

• ACOs cover approximately 40 million patients, with nearly 500 health care entities practicing accountable care

• ACOs are projected to save Medicare up to $940 million in the first four years

Sources: Growth and Dispersion of Accountable Care Organizations, Leavitt Partners, June 2012.ACO Manifesto: 50 Things to Know About Accountable Care Organizations, Becker’s Hospital Review, September 2013.

Medicare and Commercial ACO Models

17Note: 33 quality of care metrics across four areas (patient/caregiver experience; care coordinate/patient safety; preventive health; and at-risk population, which includes diabetes, hypertension, CHF, CAD) must be met for shared savings. Source: ACO Manifesto: 50 Things to Know About Accountable Care Organizations, Becker’s Hospital Review, September 2013.

1 MEDICARE SHARED SAVINGS PROGRAM • 220 ACOs participating nationally; two three-year options

• Minimum patient population of 5,000 • Additional (third Medicare) model - Advanced Payment Model

– 35 participants (small practices and rural providers)– Receive advance payment that will be repaid from future

savings earned

2 PIONEER ACO MODEL (CMS/CMMI)• 32 participants nationally; three-year agreement with CMS• Designed for organizations already experienced with coordinated care delivery models• Includes provisions for shared risk and higher potential shared savings than MSSP model• Minimum patient population of 15,000 (5,000 in rural communities)

• Commercial insurers set quality metrics; utilization metrics can be included

• Plan to drastically increase (double or more) the number of accountable care contracts over the next four years

3 COMMERCIAL

ACO Example Results to Date

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First year results for 32 Pioneer ACOs reported by CMS

250 organizations participated in Pioneer ACO Models and Medicare Shared Savings Program

Pluses Minuses • Program saved Medicare $88M prior to

bonus distribution • Pioneer ACOs earned over $76M• Cut rate of Medicare spending by 0.5%• Savings were achieved largely by

reductions in admissions and readmissions

• Four participants generated 2/3 of savings • Seven participants that did not produce

savings are intending to move to shared savings program

• Two intend to exit the program• Criticism about lack of savings sharing with

patients

TBD:• Will these levels of cost savings be deemed sufficient?• Will the Adirondack ACO, of which AHI is a member, achieve similar results?

Source: The Health Care Blog, August 13, 2013, “Pioneer ACO’s Disappointing First Year”, Jeff Goldsmith.

ADIRONDACK HEALTH INSTITUTE

Adirondack Health Institute

Adirondack Medical Home Pilot

Providers

97 physicians and 127 MLPs spanning

33 individual practices

Hospitals

5 hospitals and health systems

Patients

Population 200,000105,000 patients

attributed

Payers

All 7 commercial payors, Medicare, Medicaid

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Connect Primary Care to Population Health

Plan, facilitate, and coordinate activities required for successful transformation of the health care system

• Performance measurement• Payment and delivery system reform• Training and assistance in performance improvement• Patient education and engagement• Strategic planning and coordination• Prepare workforce

Regional Health Improvement Collaborative

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Adirondack Medical Home Pilot• Five-year pilot to generate

health care value in Adirondacks

• Key objective is to transform physician practices into NCQA recognized medical homes

• Launched in January 2010

• Three operational “pod” support structures covering over 8,000 square miles

Source: http://www.adkmedicalhome.org.22

Evolution of the PCMH to an ACO – AHI’s Participation in Other Regional Initiatives 1. Health Home2. Practice Innovations3. Care Transitions Program4. Health Foundation Initiative5. Health Innovation Plan6. Health Systems Redesign Commission

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• Health Home: roots in Affordable Care Act

• Health Home model expands on the medical home model to build linkages to other community and social supports, and to enhance coordination of medical and behavioral health care, with the main focus on the needs of persons with multiple chronic illnesses.

Health Home

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#1

Source: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/federal_requirements.htm.

At least two chronic conditions, one chronic condition and at risk for another, or one serious and persistent mental health condition

Chronic Conditions:• Mental health condition

(SED excluded initially)

• Substance abuse disorder• Asthma • Diabetes• Heart disease • BMI over 25 • HIV/AIDS• Hypertension

Broad Criteria for Health Home: Integration

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Health Home Network PartnersPrimary Care

Specialty Care

Hospitals

RHIO

Care Management

Home Health Care

Payors

Behavioral Health Providers

Substance Abuse Treatment Providers

Psychiatric Hospitals

Housing

Transportation

Other Social Services & Community Supports

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Health Home Services Provider Qualifications Standards

1. Comprehensive care management2. Care coordination and health promotion3. Comprehensive transitional care4. Patient and family support5. Referral to community and social support

services6. Use of health information technology to link

services

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Prioritize Care Manager Activity Based On Potential for Impact

Chronic disease management

• Primary care visit 5-7 days post discharge• Medication reconciliation• Early warning sign awareness• Caregiver/Home Health/DME in place

• Education & counseling• Care plan creation

Care transition to home

• Continuity of care to post-acute care facility• Communication of care plan

ED diversion programs• Ensure primary care access• Optimize urgent care access• Leverage ED diversion program

Care transition to post acute careCare Managers

Practice Innovations: Deploying Population Health Management Resources

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#2

Consortium of six community-based organizations and 10 hospitals serving over 100,000 FFS Medicare beneficiaries in a 10-county region

AHI will coordinate the care transitions intervention discharge process at three partner hospitals

North Eastern NY Community-Based Care Transitions Program (CMS)

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#3

“Using Data to Improve Care, Reduce Cost, and Sustain the Model in the Adirondacks”

Overall goals:

1) Ensure that we have optimized the investments made to date by our payors to improve the health outcomes of the residents of the Adirondack region, especially those with chronic conditions like diabetes and heart disease

2) Secure payment models that will help us reinvest potential cost savings into continuous quality improvement efforts and allow us to align incentives that yield high value care

New York State Health Foundation Initiative Pay for Value Not Volume3

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#4

New York State of Health“Marketplace”

Enrollment Assistance Services and Education (EASE)

• Education and outreach specialists are presently dispersed through the region offering training programs to community members about the Marketplace.

• Enrollment specialists offer one-on-one, in-person assistance to individuals, sole proprietors, and small business owners at numerous convenient locations to “ease” them through the online health insurance enrollment process

Access to Care

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HEALTH HOME Builds on HEAL 10

Payer Data Warehouse

Treo

Health Plans

HospitalsPrimary Care PracticesPODs

Claims portal

Clinical Quality & Care Management Portal

Clinical careportal

ADT, Meds, Lab/rad/departmental reports(HL7 content)

Claims data flow

Access to web viewerWeb application

Clinical summary info (C32 content)

Specialty Providers Health Plans

GFH Specialty Practices

EHR Data Warehouse

(QDC)

Clinical Transaction Content

Health Home Service Providers

Crimson Care

Registry

Health Home Service

Providers

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• Health care delivery systems are being transformed based on patient needs and workforce availability

• Issues considered:– New models of care, like the PCMH– Collaborations across providers– Effective strategies for chronic disease management– Innovative staffing configurations– Worker flexibility

• Evaluate outcomes and adjust as needed

“Business as Usual” Is Not Sustainable

Source: http://chws.albany.edu.33

• Improved patient and physician satisfaction

• Stabilized primary care system• Achieved specific gains in quality

indicators• Lowered cost by reductions in ER

visits and inpatient stays

Accomplishments

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• Continued threat of physician and primary care provider shortages

• Fragmented, widely dispersed services

• Need to transition medical, behavioral, and long-term care services to outpatient settings

• ADK Medical Home Pilot ends 2014

Today’s Challenges

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• Build upon the experience of regional health care innovation models including those of AHI (Adirondack Medical Home Pilot, Health Home) that have made significant contributions toward achieving the “triple aim” for all New Yorkers

• Empower regional entities that are best equipped to set local priorities, convene local stakeholders, and support mechanisms of regional implementation to lead plan implementation

New York State Health Innovation Plan

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#5

There are five strategic pillars • Improving access to care for all New Yorkers, without disparity• Integrating care to meet consumer needs seamlessly• Making health care cost and quality transparent to enhance consumer decision

making• Paying for value, not volume• Strengthening linkages among primary care, community resources, and policies for

health improvement

There are three enablers that are foundational to all strategies• Health care workforce strategy• Health information technology• Measurement and evaluation

New York State Health Innovation Plan

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• Collaborative relationships for the improvement of health in the Adirondack Region and New York State

• Resources for our community partners as they expand coverage to this underserved region while also addressing rapid changes in the health care system

• Programs designed to help communities make their neighborhoods healthy places to live and work

Relationships, Resources, and Expertise

38Source: www.adirondackhealthinstitute.org.

North Country Health Systems Redesign Commission (NCHSRC)

• Assessing the total scope of care in the North Country• Assessing the regional population's health care needs and the system's ability to meet them• Recommending ways in which to ensure that essential providers survive or that appropriate

capacity is developed to replace failing providers• Identifying opportunities for merger, affiliation, and/or partnership among providers that will

maintain or improve access, quality, and financial viability, and promote integrated care• Making specific recommendations to improve access, coordination, outcomes and quality of

care, and population health• Developing recommendations for the distribution of re-investment grants

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The goal is to create an effective, integrated health care delivery system for preventative, medical, behavioral, and long-term care services to all communities throughout New York's North Country. Its tasks include:

#6

Clinical Integration (CI)• Pilot serves as an active and ongoing program to evaluate and modify practice

patterns by physician participants and create a high degree of interdependence and cooperation among physicians to control costs and ensure quality in health care

• Quality measures include process compliance, clinical outcomes, and satisfaction• Payment reform to reward value rather than volume

AHI provides the critical tools for CI and ACO success• Health information technology• Data analytics• Care management• Physician leadership

Pilot & AHI and Other Regional Initiatives = ACO Building Blocks

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Accountable Care Organization (ACO)A voluntary group of physicians, hospitals, and other health care providers willing to assume responsibility for the care of a clearly defined population of beneficiaries and have a mechanism of shared governance that provides appropriate control over the ACO’s decision-making process. ACOs that meet specified quality performance standards are eligible to receive payments for shared savings if they can reduce spending growth below target amounts.

• Medicare Shared Savings Program (MSSP) is an ACO with at least 5,000 Medicare beneficiaries attributed to them on the basis of patients’ use of primary care services

• May also go “multi-payer” through programs with other payers

Pilot & AHI = ACO Building Blocks

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New York Accountable Care Strategy – ACO Design

Hudson Headwaters 

Health Networks

CVPH

Glens Falls Hospital

Physician GroupEntity (PGE)

Adirondack Health/AMC

Governance

Corporate Membership(Ownership)

Operations and Technology(in early visioning)

Provider Participants

FAHC

Required Members

Adirondacks Accountable Care Organization LLC

Fletcher Allen Partners

Fletcher Allen Partners

All above plus other invitees (list and timing TBD)

2 Seats(Both Class P and S)

2 Seats(Class P)

2 Seats(Class S)

6 Seats(Class M)

2 Seats 4 Seats

Irongate Family Practice

1 Seat

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Update on New Developments

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QUESTIONS AND DISCUSSION

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BIBLIOGRAPHY

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Bibliography/Additional Reading

• Goldsmith, Jeff. (2013). “Pioneer ACO’s Disappointing First Year.” The Health Care Blog.

• Ness, Debra, Kramer, William. (2013). “The First-Year Pioneer ACO Results: Predictable Bumps In The Road.” Health Affairs Blog.

• Nielsen, Ph.D., M.P.H, Marci, Langner, Ph.D., Barbara, Zema, Ph.D., Carla, et. al. (2012). “Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results.” Patient-Centered Primary Care Collaborative.

• Clark, Megan. (2014). “Five Steps to Build the Advanced Medical Home.” The Advisory Board Company.

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PRESENTER BIOS

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Presenter Profile

• Craig E. Holm, FACHE, is senior vice president with Health Strategies & Solutions, Inc., and one of the nation’s leading experts on physician-hospital affiliations. With over 30 years of health care administration and consulting experience, he is an expert in primary care strategy, physician-hospital alignment, medical staff planning, and ambulatory care planning. His ability to understand the key issues facing providers has enabled him to evaluate and develop numerous successful physician-hospital alliances including joint ventures that create value for physicians and the sponsoring hospital or system. Craig has also helped hospitals and medical staff organizations develop incentives for active physician participation and facilitate thriving referral relationships, and he is skilled at identifying and implementing revenue enhancement and operations improvement opportunities. Craig is a frequent speaker for national and state health care associations and societies. He has authored two books on the topic of physician-hospital alignment, as well as several articles for leading health care journals and publications.

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Presenter Profile

• John Rugge, M.D., president & CEO, Hudson Headwaters Health Network, is a family physician and founding chief executive Officer of Hudson Headwaters Health Network, which operates 14 community health centers delivering primary and specialty care in upstate New York. Over the years, Dr. Rugge has served on numerous health policy councils in Albany, New York and Washington, D.C. He is currently board director of the New York State Primary Care Association and chair of the Health Planning Committee for the New York State Public Health and Health Planning Council. For the last several years, Dr. Rugge has been co-organizer of the Adirondack Region Medical Home Pilot, one of the nation’s few all-payer demonstrations of the medical home model. Dr. Rugge received his AB from Williams College, his MTS from the Harvard University Divinity School, and his MD from Yale University Medical School.

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