The Alphabet Soup of Change

• SIM• CPCI• TCPI• ENSW• ACC/RCCO• MU 1-2-3• MIPS• APM

Forget the Acronyms

• Colorado Health Extension Service:– One souce of

information.

– Clarity about who, what, where, when and how.

– Ongoing and improving as it does.

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• Better Care. Smarter Spending. Healthier People

HHS Announcement

We can receive better care. We can spend our health dollars more wisely. We can have healthier communities, a healthier economy, and a healthier country.

In three words, our vision for improving health delivery is about better, smarter, healthier.If we find better ways to pay providers, deliver care, and distribute information:

Incentives

Focus Areas Description

Care Delivery

Information

Encourage the integration and coordination of clinical care services Improve population health Promote patient engagement through shared decision making

Create transparency on cost and quality information Bring electronic health information to the point of care for meaningful use

Promote value-based payment systems – Test new alternative payment models– Increase linkage of Medicaid, Medicare FFS, and other payments to value

Bring proven payment models to scale

Source: CMS

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Target percentage of Medicare FFS payments linked to quality and alternative payment models

All Medicare FFS (Categories 1-4)FFS linked to quality (Categories 2-4)Alternative payment models (Categories 3-4)

2016 2018

85%

30% 50%

90%

Source: CMS

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CMS Payment Reform – 4 Categories

Category 1: Fee for Service—No Link to Quality

Category 2: Fee for Service—

Link to Quality

Category 3: Alternative Payment Models Built on

Fee-for-Service Architecture

Category 4: Population-Based Payment

Description

Payments are based on volume of services and not linked to quality or efficiency

At least a portion of payments vary based on the quality or efficiency of health care delivery

Some payment is linked to the effective management of a population or an episode of care. Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk

Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (i.e., >1 year)

Medicare FFS

Limited in Medicare fee-for-service

Majority of Medicare payments now are linked to quality

Hospital value-based purchasing

Physician Value-Based Modifier

Readmissions/Hospital Acquired Condition Reduction Program

Accountable care organizations Medical homes Bundled payments Comprehensive primary care

initiative Comprehensive ESRD Medicare-Medicaid Financial

Alignment Initiative Fee-For-Service Model

Eligible Pioneer accountable care organizations in years 3-5

Source: CMS

ANTHEM PROPRIETARY AND CONFIDENTIAL

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Current Law and SGR reform timeline

Sunset of existing quality value penalties under PQRS, VBM, EHR 12/31/2018

Permanent repeal of SGR

APM participating providers exempt from MIPS; receive annual 5% bonus (2019-2024)

Trac

k 1

Curr

ent

Law 2018

4%

Physician Quality Reporting System Penalty2015-1.5%

2016 & beyond-2.0%

Value-based Payment Modifier penalty (up to %)2015-1.0%

2016-2.0%

2017 -4.0%

Merit-Based Incentive Payment System (MIPS) adjustments 2019+/-4%

2020+/- 5%

2021+/- 7%

2022 & beyond+/- 9%

MIPS exceptional performance adjustment; Up to 10% annually (2019-2024)

Updates in physician payments 0.5% (7/2015-2019) 0% (2020-2025) 0.25%

(2026 )

Meaningful Use Penalty (up to %)2015-1.0%

2016-2.0%

2018-4.0%?

2019 & beyond-5.0%?

2017 -3.0%

2018 & beyond ???%

Trac

k 2

0.75% update (2026 )

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Source: Premiere

“Change Concepts”: 10 Building Blocks

• Demonstrating value & performance (continuous commitment to and skill at ongoing measurement of quality, costs, patient experience, organizational performance)

• Access (acute/urgent care appointments, non-traditional hours, telehealth, someone on the care team who has patient information 24/7, interoperable EHR)

• Process to include patients as partners (in quality improvement, care design, patient and family engagement, evaluation, peer support)

• Population health management (empanelment, risk stratification, data-driven technology, evidence-based care guidelines, social determinants, health literacy, shared care planning)

• Organized teams provide comprehensive care to include behavioral health support, health coaching, care coordination, shared decision making

• Organizational Culture Change (leadership commitment, leadership skill in change management, coaching and developing the team, satisfied patients and staff, operational efficiency)

http://www.annfammed.org/content/12/2/166.full

Bodenheimer et al (2014)

"Change concepts" are general ideas/directions for transforming a practice to stimulate specific, actionable steps that lead to improvement. (Wagner et al, 2012; Commonwealth Fund)

Insights from PCPCC Accredidation Work Group

The Care Model

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Medical Practice vs. Leadership Practice(Gordon Barnhart, O’Brien Group)

Physician1. Prescribe and expect compliance2. Immediate and short term focus and results3. Procedures and/or episodes4. Relatively well-defined problems5. Consistently effective solutions, protocols, best

practices, processes6. Increasing focus on specialization7. Focus on patient’s interests8. Working with a person or family9. Being “the” expert10. Relating primarily to the physical being11. Relating to sick/injured people12. Working solo or with small teams13. Receiving lots of thanks14. Respect and trust of colleagues

Leader1. Lead, influence and collaborate2. Short, medium and long term focus and results3. Complex processes over time4. Ill-defined and messy problems5. Frequent environmental shifts requiring

complementary changes in solutions, processes, best practices, style and approaches

6. Increasing need for comprehensive and integrated approach

7. Focus on patients’ interests8. Working with many diverse stakeholders9. Being one of many experts10. Relating to whole beings11. Relating to healthy people12. Working with larger teams and complex networks13. Encountering lots of resistance14. Suspicion of being “a suit”

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• Physician– Self-sacrifice– Physician-driven care– Individual hero– Ownership: “my patient”– Full control– Lone expert

• Team– Building relationships– Collaborative health workers– Well-being of all team members– Collaborative responsibility:

“our care”– Shared control– Team expertise

Physician vs. Team

Important Components

Align stakehold

ersWorkflows Team

based Patient

engagement

Technology

Physician engageme

nt Effectivenes

s

Risk Stratification Process

Clinical Risk Social Risk Behavioral Risk

Rising Risk

Moderate Risk

Low Risk

High Risk

Identification of Patients by Payor/

Program

Stratification of Patients by Risk

Allocation of Resources by Skill

Set/Type of Intervention

# C

hron

ic C

ondi

tions

Hea

lth C

are

Util

izat

ion

1 2 3

Source: Mount Sinai Health System , Managing High Risk Populations - Adding Value While Aligning Care Coordinators, Patients and Physicians , slide 14

Value Based Payment vs. FFS Volume

Emergency3.7%

Inpatient22.6%

Outpatient18.3%

Pharmacy17.5%

Primary Care4.6%

Specialists20.8%

Ancillary12.5%

Value Based Payment vs. FFS Volume

Emergency3.4%

Inpatient20.9%

Outpatien16.9%

Pharmacy18.4%

Behavioral0.5%

Primary Care9.1%

Specialists19.3%

Ancillary11.5%

Isn’t the second pie bigger? No.

Total Cost PMPM

Advanced Practices $479.30

Behavioral Health Payments $4.35

Total $482.85

Conventional Network Average $505.83

Risk Normalized Difference -4.54%

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• “The best way to predict the future is to invent it.”

• ~ Peter Drucker