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traveling together for better care
The 5 Pillars of Value-based Care
Lynn Barr, CEO, Caravan HealthMay 15, 2018
5 Value-based Care Pillars• Wellness & Population Health Strategies
• Performance Improvement & Quality Initiatives
• Clinical Integration & Physician Engagement
• Data Integration & HCC Coding
• Scale and Strategy
The healthcare industry is moving from Fee-for-Service to
Value-based Payments.
CMS is driving this change through highly-complex programs.
Providers need expert help to qualify, participate, and succeed.
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Agenda
3
Helping Providers Navigate the Challenges of Value-Based Payments
CPC+MACRA
§ Founded in 2013
§ 38 Accountable Care Organizations
§ >14,000 Providers
§ >1,000,000 Patient Lives
§ Results (cms.data.gov)
§ 95%- 97% Quality Scores
§ >10x National Average of Shared Savings
ACOs Practice Transformation
About Caravan Health
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Wellness & Population Health Strategies
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Current thinking and efforts create a disproportionate focus on existing chronic patients.
A better approach is to monitor all patients, healthy and chronically ill.
Chronic Care Managementis only ONE focus.
What’s Different About an Effective Population Health Strategy for Value-based Payment Models?
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Empower Your Nurses
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Build your primary care capacity.Utilize nurses and medical assistants to meet patient needs and provide additional support to providers.
Medicare allows important preventive services to be billed under provider supervision.
Physicians get more time to attend acute patient needs, and patients benefit from more attention overall.
Population Health Nurses Generate Income
Population Health Nurse
Wellness Visits
($118/yr)
Chronic Care
Management ($45-$90/mo)
Advanced Care
Planning ($86/yr)
Behavioral Health
Integration ($126/mo)
Cognitive Assessment & Planning ($238/yr)
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8
Trained Nurses Excel at PreventionNo AWV
(n=15,232)AWV done by MD/NP
(n=446)AWV done by QMnurse (n=2,863)
Men up to date on AAA screen 70.1% 77.7% 83.8%
Women up to date on mammogram 42.2% 61.1% 74.0%
Women up to date on bone density 45.3% 63.5% 75.1%
Up to date on PCV-23 vaccine 33.4% 57.6% 58.4%
Up to date on depression screening 1.9% 3.4% 94.9%Up to date on Health Risk Assessment 1.9% 2.0% 94.3%Up to date on Fall Risk Screening 1.9% 2.0% 94.3%
Up to date on ADL Assessment 1.9% 2.0% 94.3%
Up to date on Smoking Cessation screen 1.9% 2.0% 94.3%
Up to date on End of Life Plan screen 1.9% 2.0% 93.8%
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Source: Hattiesburg Clinic
Performance Improvement & Quality Initiatives
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Have a Plan to Execute
Focus on executionDon’t just have a plan – focus on the end result.
Identify new resourcesDedicate new resources and technologies to project planning, management and tracking above and beyond clinical staff and technology investments.
Adapt to New ProcessesEven if you are a high-performing health system, you might have to do something different to produce extraordinary results as an ACO.
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Build on Performance
Teach
Expertise & Compliance
Practice Transformation
Clinical Excellence
Intelligence & Analytics
Guidance through the complex regulatory environment and governance procedures
Drive clinical and non-clinical transformation initiatives
Lead the physician engagement aspects of value-based care
Healthcare data experts delivering mission-critical insights
Improve
Implement1
4
2
Report 3
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Keep ScorePracticeABC
Category Metric PointsPointsPossible
RNCareCoordinatorinplace ✓ 6 6PhysicianLeaderinplace ✓ 6 6LightbeamInterfaceStatusasofX/X/XXXXdate InDev. 4 6#ActiveMedicareAWVCases-Claims+EHRInterfaceDataQ12017 300 0%ofpatientswithAWV-fullcreditforover50% 41.0% 4 6#ActiveMedicareCCMCases-SelfReportedQ12017 140 0%ofpatientsinCCM-fullcreditforover10% 17.0% 6 6#ActiveMedicareTCMCases-SelfReportedQ12017 170 0%ofpatientsinTCM-fullcreditforover10% 8.0% 4 6BillingAWV ✓ 4 4BillingCCM ✓ 4 4BillingTCM ✓ 4 4BillingAdvanceCarePlanning(ACP) X 0 4PatientSatisfactionTabletUtilizationRate 27.0% 6 6Qualityscore 100.0% 6 6TotalCost-fullcreditforreductionbeyondstatisticalthreshold -3.2% 6 6EDutilization-fullcreditforreductionbeyondstatisticalthreshold -2.5% 2 2SNFutilization-fullcreditforreductionbeyondstatisticalthreshold 3.0% 0 2IPutilization-fullcreditforreductionbeyondstatisticalthreshold -1.0% 2 2RepresentativeatBoardMeeting ✓ 4 4ACOChampionatRoadMapCall ✓ 2 2PracticeManageratRoadMapCall ✓ 2 2CareCoordinatoratRoadMapCall ✓ 2 2AttendQIW ✓ 4 4AttendCareCoordinatorCohortCalls ✓ 4 4AttendQuarterlySteeringCommitteeMeeting ✓ 3 3AttendCohortCalls ✓ 3 3
TOTALSCORE 88 100
ACOBOARDSCORECARDADDITIONS/ADJUSTMENTSAttendEBMWebinars X 0 2AttendCohortCalls ✓ 2 2AttendPhysicianLeaderCohortCalls ✓ 2 2
Status
PhysicianLead
ACOMedicalDirector
KeyBillingIndicators
CareCoordination
Outcomes
LeadingIndicators
StaffEngagement
Use a scorecard to keep focused on goals and pinpoint areas of weakness.
Metrics should be based on efforts towards goals such as AWV percentage rate or cohort meeting participation.
13
Detailed Roadmap Keeps you on Track Theme
January February March April May June3 July August September October November December
In3Person3Meetings ACO3Launch3333333333333Annual3Wellness3Visit3
Workshop
Chronic3Care3
Management3(CCM)3
Workshop
Annual3Symposium3333
Advanced3Care3
Management3Training
Population3Heath3
Nurse3Cohort3Call
Pop.3Health3Nurse3and3
Practice3Managers3
Cohort3call
Physician3Leader3
Cohort3CallPopulation3Health3
Nurse3Cohort3Call
Pop.3Health3Nurse3and3
Practice3Managers3
Cohort3call
Physician3Leader3
Cohort3Call3
Population3Heath3
Nurse3Cohort3Call
Pop.3Health3Nurse3and3
Practice3Managers3
Cohort3call
Physician3Leader3
Cohort3Call3
Population3Heath3Nurse3
Cohort3Call
Pop.3Health3Nurse3and3
Practice3Managers3
Cohort3call
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
Pop.3Health3Nurse3Office3
Hours
ACO3Medical3Director3
Cohort3Calls3
ACO3Medical3Director3
EBM3Committee3
ACO3Medical3Director3
Cohort3Calls3
ACO3Medical3Director3
EBM3Committee3
ACO3Medical3Director3
Cohort3Calls3
ACO3Medical3Director3
EBM3Committee3
ACO3Medical3Director3
Cohort3Calls3
Community3Provider33
Meeting3
Community3Provider33
Meeting3
Community3Provider33
Meeting3
ACO3Champions Steering3Committee3Prep Steering3Committee3Prep Steering3Committee3Prep
Executive3Director3
Meetings
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Monthly3ED3Cohort3
Calls3
Compliance Compliance3Meeting Poster3Audit Compliance3Meeting SelfMAssessment Compliance3Meeting Compiance3Meeting
Board3and3Steering3
Committee3MeetingsBoard3Chair3Prep Board3Meeting
Steering3Committee3
Board3Chair3PrepBoard3Meeting
Steering3Committee3
Board3Chair3PrepBoard3Meeting
Steering3Committee3
Board3Chair3PrepBoard3Meeting
Lightbeam3Users Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting Lightbeam3User3Meeting
20183Performance3Year3
Quality3Reporting33
Webinar
Quality3Reporting3
Webinar
Quality3Reporting3
Webinar
Quality3Reporting3
Webinar
Quality3Reporting3
Webinar
Quality3Reporting3
Webinar
Quality3Reporting3
Webinar
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
Weekly3MIPS3Office3
hours
3Road3Map3Call 3Road3Map3Call Road3Map3Call
Workshop3
(Recommended)3or3
Road3Map3Call
Road3Map3Call Road3Map3Call
Workshop3
(Recommended)3or3
Road3Map3Call
3Road3Map3Call 33Road3Map3Call 3Road3Map3Call Road3Map3Call
IT3Interface3KickMoff3
Meeting3
IT3Interface3KickMoff3
Meeting3
IT3Interface3KickMoff3
Meeting3
Initial3Claims3Feed3and3
LB3Access33
Monthly3Claim3Feeds3
Updates
Monthly3Claim3Feeds3
Updates3and3Attribution3
Updates
Monthly3Claim3Feeds3
Updates
Monthly3Claim3Feeds3
Updates
Monthly3Claim3Feeds3
Updates3and3Attribution3
Updates
Monthly3Claim3Feeds3
Updates
Monthly3Claim3Feeds3
Updates
Monthly3Claim3Feeds3
Updates3and3Attribution3
Updates
Monthly3Claim3Feeds3
Updates
Monthly3Claim3Feeds3
Updates
Monthly3Claim3Feeds3
Updates3and3Attribution3
Updates
Analysts
Performance3and3Planning Wellness3and3Prevention Care3Management3 Continuous3Improvement
Clinical3Meetings
90MDay3Advancing3Care3Information3(Recommended) ACOMCAHPS
Quality3Team
Practice3Team
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20162017
Caravan Health ACOs
2016 2017
PREV-12 30th 50th 31.65 57.25
MH-1 * * 3.4 6.06
DM-2 * * 16.78 9.49
CARE-2 60th 80th 53.7 75.69
DM-7 * * 39.61 45.71
PREV-8 60th 70th 66.57 73.36
PREV-6 50th 60th 59.85 64.98
PREV-5 60th 60th 62.69 67.81
PREV-9 60th 60th 64.84 68.76
PREV-13 * * 77.78 80.34
PREV-7 70th 70th 71.6 73.27
PREV-10 90th 90th 92.97 94.57
IVD-2 90th 90th 90.85 92.15
HTN-2 60th 60th 69.47 67.82
CARE-1 * * * 75.87Medication Reconciliation Post-Discharge * *
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet 90th 1.43%
Controlling High Blood Pressure 60th -2.37%
Preventive Care and Screening: Influenza Immunization 70th 2.33%
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 90th 1.72%
Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 60th 6.04%
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease * 3.29%
Colorectal Cancer Screening 60th 8.56%
Breast Cancer Screening 60th 8.17%
Diabetes: Eye Exam * 15.40%
Pneumonia Vaccination Status for Older Adults 70th 10.21%
Diabetes: Hemoglobin A1c Poor Control * 43.45%
Falls: Screening for Future Fall Risk 80th 40.95%
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan 50th 80.89%
Depression Remission at Twelve Months * 78.34%
2017 Quality Measures Year to Year Comparison: Caravan Health
Benchmarks Measure RatesMeasure
2017 2016 to 2017 % Change
Clinical Integration and Physician Engagement
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16
Everyone Needs to Join a Team
Do You Want to be the Chef or the
Lunch?
Value-Based ContractsReward Clinical Integration• PCPs are the heart of the network• Hospitals are the soul (and usually the sole source of funds)• Specialists are the frosting on the cake
Your Network MayAlready Be Under Attack• Privia• Aledade• Competing health systems
If You Lose Your Network,You Lose…• Communication across providers• Referrals• Reputation• Contracting opportunities
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Solidify Provider Relationships
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Ensure your physician contracts encourage a
collaborative work environment
Establish a level of trust between providers to leverage each other’s
strengths
Keep an open line of communication so PCPs,
specialists and facilities can most effectively work
together
18
ACOs Meet All CIN Requirements
ACO/CIN
Physician Leadership
Participation Criteria
Performance
Improvement
Information Technology
Payor Contracting
Legal Entity and
Waivers
Flow of Funds
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Maintain Independence and Control
Every community of providers operate independently and are paid on their own performance.
Independent providers can fully participate in value-based payments while retaining their autonomy.
All health care decisions are kept local.
Data Integration & HCC Coding
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Maximize Power of Claims and EHR Data
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Analyze your population to understand prevalence of chronic illness, hospitalizations and related costs.
Prioritize areas for improvement and identify where you need additional resources based on which population has the most clinical and financial risk.
Plan early for in-house and outsourced expertise.Ingesting claims data and drawing meaningful reports takes time.
Gain a Deep Understanding of Your Patients
Source: Margaret Mary Health Community Hospital
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Patient ID Provider 12 Mo Costs ATI ScoreER Visit Count
Chronic Conditions
Prob. High Total Cost
Predictive Risk
ScorePatient 1 RHC $11,953 8.16 21 12 0.02 0.645Patient 2 Provider 7 $16,823 8.25 15 15 0.39 3.856Patient 3 Provider 8 $13,016 9.37 13 15 0.2 2.641Patient 4 Provider 1 $56,295 9.36 11 17 0.21 2.744Patient 5 Provider 6 $21,167 9.45 9 16 0.1 1.914Patient 6 Provider 1 $7,856 9.36 9 15 0.35 3.619Patient 7 Provider 2 $8,432 8.82 9 4 0.05 1.331Patient 9 Provider 5 $16,011 9.61 8 15 0.21 2.716Patient 10 Provider 5 $19,744 9.53 8 11 0.11 1.975Patient 12 Provider 1 $7,111 9.46 8 10 0.08 1.648
Analytics Provide New Insight into Old Problems
Rehab /Care Center #1 Rehab /Care Center #2 Rehab /Care Center #3
AverageCost per Day
$399.94 $468.80 $329.35
Risk Adjusted AverageCost per Day $189.18 $219.41 $66.53
Admissions 52 20 4
Nursing Home Compare Score
5 out of 5 stars 4 out of 5 stars 3 out of 5 stars
23
Source: Tri-state Memorial Hospital
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Get Your Coding in Order
Ensure you receive credit for the sicker patients you treat• Your benchmark cannot go up from
better identification of sick patients, but it can go down.
• Numerous ACOs have found that inattention to HCC-coding workflows has been the difference between collecting shared savings and falling below the minimum savings rate.
• Integrating coding best practices into your workflow can help you get credit for caring for sicker patients without driving your clinicians crazy.
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© 2017 Lightbeam Health Solutions | All rights reserved. | Confidential. Please do not copy or forward.
HCC Correct Coding – MA
Optimize RAF Scores
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Scale and Strategy
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The Future of Population Health Depends on Scale
Participants need to form collaborative ACOs with more than 100,000 lives to minimize impact of statistical variance and administrative burden
Greater likelihood of predictable shared savings through:• Lower minimum
savings rates • Better link between
effort and outcome
Be fully prepared for future risk models, payer and employer contracting and provider based health plans, which also need scale
28
In Most Cases Savings Are Modest
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Caravan ACOs consistently save 1% per year
Caravan ACOsMSSP National Average
$107$126
$222
Year 1 Year 1 Year 2*
n=52,925
On average, ACOs savings and losses fall between -0.2% and 0.5%
2015 Starts
2016 Starts
2016 Starts
Savings Per Beneficiary Per Year
n=221,262($4) ($4)
$25 $3
($29)
$54
$16 $31
($22)Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Year 1 Year 2 Year 1
2013 Starts
2014 Starts
2015 Starts
2016 Starts
Unpredictable Results are Unsustainable
• Small ACOs experience savings and losses plus or minus 10-20% simply due to statistical variation in health care spend and in HCC coding in performance and benchmark years
• 73% of MSSP ACOs have fewer than 20,000 lives
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Savings and Losses by Size of ACO
-20%
-15%
-10%
-5%
0%
5%
10%
15%
20%
0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,0002013 2014 2015 2016
Wild Swings in Performance are Common
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Year over Year Changes in ACO Savings and Losses by ACO Size
-20%
-15%
-10%
-5%
0%
5%
10%
15%
20%
0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000
2013/2014 2014/2015 2015/2016
Impact of Random Winnings and Losses on Organizational Culture
Failure is an orphan…. • Losing while you’re trying
hard is deflating. • Finger-pointing and blame
break out
• Dis-engagement creeps in• Is it you or is it bad luck?
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While success has many fathers…• Winning breeds deeper
engagement and re-investment• New initiatives become easier
to sell internally • But did you really deliver
excellence or did you get lucky?
Scale and Strategy
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Where Does the ACO Program Stand Today?
• About 1/3 of all hospitals and clinicians participate in the program.• Under the Track 1 model CMS pays random earnings by chance.• MSSP will mature into downside risk to remain sustainable for Medicare.• Under risk models, providers will pay CMS random losses by chance.
Secretary of Health and Human Services Alex Azar talks tough to hospitals…
“…make no mistake: we will use these tools to drive real change in our system. Simply put, I don’t intend to spend the next several years tinkering with how to build the very best joint-replacement bundle — we want to look at bold measures that will fundamentally reorient how Medicare and Medicaid pay for care ….
….As just one example, we are looking at our efforts regarding Accountable Care Organizations. The program was intended to give providers three years to learn how to accept risk and share savings, but the results have been lackluster.….
….as costs continue to skyrocket, the current system simply cannot last.”
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Basics of ACOs
1 Centers for Medicare and Medicaid, Fast Facts
Provides opportunities to learnto effectively manage population health while avoiding unnecessary penalties.
All existing reimbursement does not change.
Established by the Affordable Care Act to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs.
ACOs are groups of Medicare providers that work together to coordinate care for the Medicare fee-for-service patients they serve. The goal is to deliver seamless, high-
quality care for these beneficiaries, rather than the fragmented care that often results
from a fee-for-service payment system.
Participants are in an Advanced Payment Model. If they take downside risk, they are in a qualifying advanced payment model, eligible for the 5% MACRA bonus and are exempt from MIPS.
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Forming an ACO
Multiple models (physician-led, hospital-led); if an ACO is formed by more than one provider, then the ACO must be a separate legal entity.
• ACO professionals in grouppractice arrangements
• Networks of individual practices of ACO professionals
• Partnerships or joint venture arrangements between hospitals and ACO professionals
• Hospitals employing ACO professionals
• Federally qualified health centers
• Rural health clinics
Must serve at least 5,000 Medicare fee-for-service patients.
Agree to participate for at least 3 years, meet other program requirements such as a governing body, processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost measures and coordinate care.
Eligible entities
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Medicare Shared Savings ProgramThe Medicare Shared Savings Program rewards ACOsthat lower their growth in health care costs while meeting performance standards on quality of care and puttingpatients first.To participate, eligible providers must form or join a Medicare ACO, then the ACO must apply to CMS.
April 2018 May 1–31 Jul 1–312018
December2018
January 1, 2019
Form corporation, obtain EIN and open bank account.
Notice of Intent to Apply submission period.
Application submission period.
Application approval or denial decision.
Begin first ACO performance year.
Estimated Application Process Deadlines
• Develop strategy.• Engage
Physicians.• Recruit
independents.• Seat Initial Board.• Approve Pre-
Participation Waivers.
Now – March 2018
ApplicationProcess Deadlines
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Shared Governance: Shared Accountability, Local Control
Two types of participants: Principal Participants & Participants. A principal participant is the entity that loans the MSO fees to the ACO on behalf of itself and the participants in its community.
If shared savings are earned, the principal participant recovers its fees before shared savings are paid to the participants. If shared savings are not earned, the ACO has no obligation to repay the fees and the loan is forgiven.
Each Principal Participant in the Caravan Collaborative ACO has one vote.
All participants will be required to promote wellness, prevention and chronic care management and consistently document chronic conditions for HCC coding purposes. They will be required to report quality measures and comply with program regulations. If in Track 1, they must also report Advancing Care Information.
Membership. Flow of funds.
Voting. Expectations.
Shared Savings Distribution
• Based on 2015, 2016 and 2017 data, we expect that the Collaborative ACO will save 1% in the first year, 2% in the second year and 3% in the third year.
• The ACO will ultimately determine the sharing distribution, but Caravan Health recommends the following based on its experience:o Principal participant loaned amounts are repaid, and Caravan Health
receives 10%, with the remainder distributed as:a. 40% based on share of attributed lives.b. 40% based on quality as measured by the MSSP program, with 20%
divided among all practices who meet the threshold and 20% going to the top half of the quality score distribution, based on attributed lives.
c. 20% based on special initiatives specific to the ACO, informed by Caravan Health recommendations. The first year will be focused on chronic care management.
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Won’t Those Other Participants Lower My Cost and Quality Performance?
• The model requires mutual accountability and transparency to work.• Non-performing participants WILL be removed annually if they do
not remediate.• ACO participants generally perform very well on quality.• Caravan Health ACO Participants score >95% in quality.
NO PARTICIPANT CAN HURT YOU MORE THAN STATISTICAL ERROR!
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Why Take Risk?
• New MIPs delay will reduce maximum performance adjustment to 2-3% of Part B payments – and only if you have a perfect score.
• ACO participants taking risk will get 5% lump sum payments that are not counted in shared savings – making your specialists happier and more attractive to others in value-based payments.
• CMS is steadily increasing incentives for risk-takers• Higher rewards for MSSP performance• Reduce risk corridor to 0.5% or lower• Direct admissions to SNFs• Telehealth to patients homes as a billable visit• Exempt from MIPS and Meaningful Use• 0.5% higher annual increases in Part B starting in 2026• More to come….
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41
Caravan Health Creates Results
Revenue Quality
Shared SavingsMIPS
For 2014 starts, average inpatient revenue is up by 7% and outpatient revenue by 17%. For the 2015 starts, average gross inpatient revenue is up by 4%, and outpatient gross revenue by 15%.
Within one year of ACO participation, Caravan
Health hospitals increased their overall quality score by 15%.
In 2016, Caravan Health ACOs generated savings
greater than 10x the national average.
All Caravan Health ACO partners are projected to score 87% or higher under MIPS and are expected to get an upward adjustment of Part B payments in 2019.
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Next Steps• Continue to invest in primary care.• Join a Practice Transformation Network to get FREE technical
support and bring immediate value to your community • www.nationalruralaco.com• Others listed at https://innovation.cms.gov/initiatives/Transforming-
Clinical-Practices/
• Consider joining an ACO to improve care to your community, accelerate your transformation and prepare for whatever comes next.
• Local initiatives• State-based initiatives• National initiatives
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Thank Youtraveling together for better care
www.caravanhealth.com | [email protected] | 916.542.4582
Lynn BarrCell: 925-876-5315