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Strategies for Commercial ACO Development
Sam Nussbaum, M.D.Executive Vice President, Clinical Health Policy and Chief Medical Officer
Second National Accountable Care Organization Congress
November 2, 2011Los Angeles, CA
2
Health Expenditures
16.0%
16.5%
17.0%
17.5%
18.0%
18.5%
19.0%
19.5%
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Billion
s % GDP
$2.57 Trillion17.3% GDP
$4.48 Trillion19.3% GDP
2008 version of the National Health Expenditures (NHE) released in January 2010 Kaiser/HRET Survey of Employer‐Sponsored Health Benefits, 2001‐2011.
Average Annual Health Insurance Premiums and Worker Contributions for Family Coverage,
2001–2011
3
Healthcare Costs are Concentrated
23 Million Beneficiaries•Spending $1,130 each•Total Spending = 5%
($26 B)
16.1 Million Beneficiaries•Spending $6,150 each•Total Spending = 20%
($104 B)
7 Million Beneficiaries•Spending $55,000 each•Total Spending = 75%
($391 B)
4
Payment Innovation
Payment Reform ModelsPayment Reform Models
Fee-for-ServiceEnhancement
Episode-Based Payment (Bundled Payments)
Population-Based Payments
• Payment for quality (Q-HIP®) • Patient Centered Medical
Homes• Centers of Excellence• Enhanced payment for
immunization, urgent care
• Chronic illness risk adjusted (diabetes, heart disease)
• Surgical services• Transplant/cancer
• Accountable Care Organizations
• Capitation• Gain sharing• Global budgets
Performance Recognition Programs Reward Quality Outcomes (P4P)Performance Recognition Programs Reward Quality Outcomes (P4P)
5
Current Program Landscape
Fully Integrated
Early Integration
Fee-for-Service
Payment for Value
Anthem Models in Markets
Integration of Care Delivery
Valu
e-B
ased
R
eim
burs
emen
t
Physician P4P: Programs in 13 markets, 70k+ physiciansHospital P4P: Q-HIP programs in all markets, with 560 hospitals (approx. 55% of admissions)
PCMH currently in CA, CO, CT, ME, NH, NY, OHIncludes over 170k members
Bundled payments currently in MO, CO, ME, and NVExpansion underway in WI, CA, MO, GA and others
ACOs in CA and NH; over 90k membersExpansion underway in CA, IN, NY, OH
6
ACOs: The Race to Value-Based Care
Finish:Finish:ValueValue--Based CareBased Care
Concerns Along the Way:•Attribution•Overuse of supply sensitive care increases revenue; optimized FFS revenue model•Payment shifting to private sector; will gain sharing overpower FFS•Acquisition of specialty practices
Key Principles for the Race: •Primary Care is central•Commit to evidence-based medicine•Information at the point of care•Focus on health, prevention, risk reduction for chronic illness•Coordination of care
Start:Start:Fee For ServiceFee For Service
7
Membership• Defined by attribution for PPO and
member selection for HMO • All lines of Business including Senior,
Commercial (Small and Large Group, Local and National), and State Sponsored
Funding Types• Fully Insured• ASO (phased in)
Information Exchange• Core report set on quality and efficiency• Risk stratified population reports• Care gap population reports
Communications• Member, Employer, Broker
Payment Methodology• Fee For Service• Care management fee• Shared savings
Medical Managment•Traditional UM shifts to point of care •CM/DM shifts to physicians
Metrics – Quality & Resource• Facility• Physician
Anthem ACO Model
8
Dartmouth-Hitchcock ACO
Membership• Year 1 - ~12,000 Fully Insured
• Year 2 – Projecting ~15,000+ Fully Insured and PPO members
Cost • Year 1 Risk Adjusted costs
have declined 2.4% from the benchmark
Integrated Delivery System
Academic Medical Center
>1200 PCP’s and specialists
9
Pay For QualityProspective
Payment Prospective
Payment
Payment MethodologyPayment MethodologyPayment Methodology
NCQA’sPPC Recognition:
•Care Coordination•Process Redesign
•HIT
Evaluate Levels of Achievement
ClinicalProcess and Outcomes
Resource Use/Cost of Care
Satisfaction and Service
FFSFFS
For services currently recognized
through Medicare RBRVS system;
potential for additional services
Patient-Centered Medical Home
10
WellPoint PCMH Pilots
MA
MT
AK
HI
ME
V T
RINY
PA NJOH
W V
MD
VA
NC
SC
GA
F L
KS MOKY
TNAR
LA
MS AL
IA
IL IN
MNWI
MI
ND
SD
NEWY
CO
OKNM
TX
AZ
NVUTCA
M T
WA
OR
ID
D C
CTD E
NV
ID
N H
Colorado:•Convener: Health Team Works
Maine:Maine:•Convener: Quality Counts
New Hampshire:•Convener: NH Citizen’s Initiative
New York:•Convener: THINC RHIO (Hudson Valley)
•Convener: Hudson Headwaters (Adirondacks)
•Convener: EMPIRE (New York City)
Ohio:•Convener: Greater Cincinnati Health Improvement Collaborative
•Convener: Access Health - Columbus
Connecticut:•Convener: State of Connecticut Employer Group
11
COLORADO
• Quality improvement in nearly all diabetes measures
• 3.6% decrease in acute IP admissions per 1000 per year
• 6.1% decrease in total ER visits per 1000 per year
• 2% decrease in specialist visits per 1000 per year
• 1.3% increase in persistent medication usage
NEW HAMPSHIRE
NEW YORK
• IP rate per 1000 between 12% - 23% lower for PCMH providers
• ER rate per 1000 between 11% - 17% lower for PCMH providers
• Total medical and Rx cost for PCMH members was 14.5% lower than for members seeing non-PCMH providers
Highlights of PCMH Results
12
Improving Primary Care: Comprehensive Primary Care Initiative
• CMS led private-public initiative testing a primary care service delivery and payment model in 5-7 locations
• Service delivery model:
Risk-stratified Care Management
Access and Continuity
Planned Care for Chronic conditions and Preventive Care
Patient and Caregiver Engagement
Coordination of Care
• Payment Model: monthly care management fee to primary care practices for FFS Medicare beneficiaries; potential to share savings in 2-4 years
• Aligned payment from private insurers
13
Contractual Innovation: Improving Value and Affordability
New Model: Rate increases tied only to quality, safety, and value
Old Model: Rate increases not tied
to value
14
Hospital Quality: Q-HIP® Hospital Quality Program
Q-HIP® Hospital Pay-for-Performance rewards quality, safety, outcomes, and patient satisfaction
Patient Safety Section (35% of total Q-HIP® Score)
• Joint Commission National Patient Safety Goals
• Computerized Physician Order Entry (CPOE) System
• ICU Physician Staffing (IPS) Standards
• NQF Recommended Safe Practices
• IHI 5 Million Lives Campaign – ADE Medication Reconciliation and WHO Surgical Safety Checklist
• CDC/APIC Flu and Pneumonia Vaccine Guidelines
• NQF Perinatal Measures
Member Satisfaction Section (10% of Total Q-HIP® Score)
• H-CAHPS Survey Results
Patient Health Outcomes Section (55% of total Q-HIP® Score)
PCI Indicators• 5 ACC-NCDR/Indicators for Cardiac
Catheterization/PCI
Joint Commission/CMS Nat’l Hospital Quality Measures• Acute Myocardial Infarction (AMI) Indicators• Heart Failure (HF) Indicators• Pneumonia (PN) Indicators• Surgical Care Improvement Project (SCIP)
NSC Indicators• 4 JC/NQF Nursing Sensitive Care Indicators
CABG Indicators• 5 STS Coronary Artery Bypass Graft (CABG)
Measures
15
CareMore’s Model: Community Providers and CareMore Care Centers
Primary Care Physicians
CareMore Extensivists
Non-Frail Population Frail & Chronically Ill Population
The CareMore Model
CareMoreCare Centers
Extensivists
Provider Relations
Continuous Frailty Assessment Tools
Member Services
Case Managers
Primary Care Physicians
Specialists
Home Based Services
CareMore Care Centers
16
CareMore: Care Innovation
• Care Centers provide a “Healthy Start” initial evaluation and integrated care that combines wellness and medical supervision and offers personalized health planning
• Specialists intensively manage chronically ill members: approximately 20% of members that account for 60% of medical costs
• Biometric monitoring applied to care management
17
Improved Outcomes for Chronic Diseases
Diabetes End Stage Renal Disease Congestive Heart Failure
Result Result Result
7.08 average HbA1c for those attending
diabetes clinic
50% reduction in hospital admission
rate in 5 months
56% reduction in hospital admission
rate in 3 months