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ADVANCED CARE MODEL,
CARE DELIVERY
& ADVANCED APM
Khue Nguyen, Chief Operating Officer
2
Guiding Principles
Support timely, nimble, and flexible implementation of the Advanced
Care Model
Integrate and strength...
3
Context for Demonstration Project
Advanced illness
population
Advanced Care
Model services &
payment
Better care,
health...
4
Improving Care for Advanced Illness
Improved Quality
Greater Access
Increased Physician Support
Reduced Cost
Value-based...
5
Advanced Illness Population
One or more chronic
conditions
Recurrent or
extensive disease:
acute care
utilization, funct...
7
Identifying Target Population
1. Prospective selection
– Chronic conditions associated with early mortality
2. Eligibili...
8
Model Services
Comprehensive,
person-centered care
management
Interdisciplinary team
approach
Customized mix of
curative...
9
Metrics Tied to Payment
Domain Metric Data
Source
Quality
1. Level of symptom control Survey
2. Level of decision suppor...
10
Metrics Tied to Payment cont.
Domain Metric Data Source
Access
1. Visit within 48 hours of hospital discharge EHR/Claim...
11
Metrics Tied to Payment cont.
Domain Metric Data Source
Person-
centeredness
1. Person-centered goals documented in
rou...
12
Payment Model Structure
• Overall goals:
– Support provider investment in infrastructure
– Create ROI opportunity for p...
13
ACM Payment Components
PMPM* $400
Wage-adjusted
*Per enrolled member per month
Phase 1:
• Shared Savings
Phase 2:
• 2-s...
14
Shared Risk Model
Model ACO Tracks 2-3 Next Gen ACO ACM
Shared Savings Rate 60-75% 80-85% or 100% 75-85%
Total Saving L...
15
Program Level Patient & Spending Target
Attribution
Options:
– By Defined PCPs
– By Defined Specialists
– By Defined PC...
16
Integration Across Multiple APMs/PFPMs
Integration
Options
Applicable APMs/PFPMs Impact
Migrate Over to
ACM
• Models wi...
17
Advanced APM Eligible
Advanced APM Requirements Advanced Care Model Fit
Certified EHR Technology*:
• 50% use by eligibl...
18
KHUEN@THECTAC.ORG
Contact Information
17
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CTAC Innovations ACO Summit

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Our advanced care model fills current gaps between intensive medical management of complex chronic illness, palliative care and hospice, and promotes appropriate use of these services.

Its features include:
- Accurately identifying and segmenting the high-risk, high-need advanced illness population (3-4% of Medicare beneficiaries; 6% duals),
- Engaging the personal physician (primary care and/or specialist) as a core member of the interdisciplinary team,
- Re-tooling existing clinicians’ roles and workflows in order to maximize skill-sets through team-based care management,
- Delivering advance care planning at the person’s own pace and in the preferred setting, and
- Extending the reach of palliative care into the community and across post- acute settings.

Learn more in this presentation!

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CTAC Innovations ACO Summit

  1. 1. ADVANCED CARE MODEL, CARE DELIVERY & ADVANCED APM Khue Nguyen, Chief Operating Officer
  2. 2. 2 Guiding Principles Support timely, nimble, and flexible implementation of the Advanced Care Model Integrate and strengthen other value-based CMS models Align with MACRA Physician Quality Payment Program Coordinate existing provider capabilities or promote investment in new capacity Create a path to scale advanced illness care nationally
  3. 3. 3 Context for Demonstration Project Advanced illness population Advanced Care Model services & payment Better care, healthier population, smarter spending Chronic Disease Mngmt. Complex Care Models Advanced Care Model Hospice Better care of advanced illness in the last year of life
  4. 4. 4 Improving Care for Advanced Illness Improved Quality Greater Access Increased Physician Support Reduced Cost Value-based Payment Person-centered Care Delivery Capability Advanced Care Model
  5. 5. 5 Advanced Illness Population One or more chronic conditions Recurrent or extensive disease: acute care utilization, functional decline and/or nutritional decline High 1-year mortality risk
  6. 6. 7 Identifying Target Population 1. Prospective selection – Chronic conditions associated with early mortality 2. Eligibility screen: program level – Active decline: clinical & utilization data 3. Retrospective evaluation – 1-year mortality 80+5% 6
  7. 7. 8 Model Services Comprehensive, person-centered care management Interdisciplinary team approach Customized mix of curative & palliative care, coordinated among inpatient, ambulatory & home settings Systematic advance care planning Patient/family engagement 24/7 availability of contact with clinician 7
  8. 8. 9 Metrics Tied to Payment Domain Metric Data Source Quality 1. Level of symptom control Survey 2. Level of decision support Survey 3. Hospital admissions, last 12 months of life Claims 4. ED visits, last 12 months of life Claims 5. ICU days, last 12 months of life Claims 6. Hospice LOS (average & median) Claims 8
  9. 9. 10 Metrics Tied to Payment cont. Domain Metric Data Source Access 1. Visit within 48 hours of hospital discharge EHR/Claims 2. Responsiveness to emergent medical issues Survey 3. Evidence of advanced care planning within 14 days of enrollment EHR/Claims 4. Advanced Directive completion rate EHR/Claims 5. POLST completion rate (or equivalent, e.g. Code Status) EHR/Claims 9
  10. 10. 11 Metrics Tied to Payment cont. Domain Metric Data Source Person- centeredness 1. Person-centered goals documented in routine care notes EHR/Claims 2. Care/treatment consistent with preferences EHR/Claims 3. Level of confidence in managing illness Survey 4. Composite patient satisfaction score Survey 10
  11. 11. 12 Payment Model Structure • Overall goals: – Support provider investment in infrastructure – Create ROI opportunity for providers, especially integrated systems – Help providers migrate from FFS to risk, population health • New alternative payment model (APM), eligible for advanced APM • Payment model components: – Care management fee: PMPM – Population-based payment: shared savings & shared risk – Integration with existing value-based payments – Support specialists and primary care provider participation for physician-focused payment 11
  12. 12. 13 ACM Payment Components PMPM* $400 Wage-adjusted *Per enrolled member per month Phase 1: • Shared Savings Phase 2: • 2-sided Shared Risk • Cover care management and ambulatory palliative care provider E&M visits • Up to 12 months per enrollee • Ends at death, hospice enrollment, healthy discharge, or disenrollment • Included in the total cost of care calculations • Metric: Total cost of care in last 12 months of life • Impact size must be statistically significant • Compared to a matched cohort of patients in the region • Minimum quality threshold requirement • Underperforming programs will be required to drop out • Small proportion of healthy discharges will not be counted in the shared risk payment, evaluation of this cohort to be conducted at the end of pilot 12
  13. 13. 14 Shared Risk Model Model ACO Tracks 2-3 Next Gen ACO ACM Shared Savings Rate 60-75% 80-85% or 100% 75-85% Total Saving Limit 15-20% 15% 30% Shared Losses Rate 60-75% 80-85% or 100% 75-85% Total Loss Limit 5-10% 15% 10% Other ACM ACP Components: • $400 PMPM up to 12 months • Bear nominal total risk of 4% • Phased-in timeline over 1 year 13
  14. 14. 15 Program Level Patient & Spending Target Attribution Options: – By Defined PCPs – By Defined Specialists – By Defined PCPs & Specialists 14
  15. 15. 16 Integration Across Multiple APMs/PFPMs Integration Options Applicable APMs/PFPMs Impact Migrate Over to ACM • Models with shorter duration: OCM, Bundles, • Migrate over at the end of episode • Patients and shared savings attributed to ACM • Models with lower payment or shared risk potential: IAH, future PFPMs, CPC+ • Migrate at identification Subset/Layered Payment within Other Models • Shared savings program • Two-sided risks determined at ACO level • ACM maintain down-sided risk for Track 1 • Patients & shared savings attributed to MSSP 15
  16. 16. 17 Advanced APM Eligible Advanced APM Requirements Advanced Care Model Fit Certified EHR Technology*: • 50% use by eligible clinicians PY1 • 75% use by eligible clinicians PY2  Payment-based quality measures comparable to MIPS Quality Performance Measures • At least 1 outcome measure  Bear more than nominal risk • Total risk of at least 4% • Marginal risk of at least 30% • Minimum loss ratio of no more than 4%  *ACM programs may operate in a non-certified EHR, but electronically interact with providers’ certified EHR 16
  17. 17. 18 KHUEN@THECTAC.ORG Contact Information 17

Our advanced care model fills current gaps between intensive medical management of complex chronic illness, palliative care and hospice, and promotes appropriate use of these services. Its features include: - Accurately identifying and segmenting the high-risk, high-need advanced illness population (3-4% of Medicare beneficiaries; 6% duals), - Engaging the personal physician (primary care and/or specialist) as a core member of the interdisciplinary team, - Re-tooling existing clinicians’ roles and workflows in order to maximize skill-sets through team-based care management, - Delivering advance care planning at the person’s own pace and in the preferred setting, and - Extending the reach of palliative care into the community and across post- acute settings. Learn more in this presentation!

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