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Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

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Berner T Health Economics Research Collaborating with ACOs to Improve Patient Data EXL 3rd Partnering with ACOs Summit 3.18.2014

  1. 1. Health Economics Research: Collaborating with ACOs to Improve Patient Data Todd Berner MD Director, Health Economics & Clinical Outcomes Research Astellas Scientific and Medical Affairs 3rd Partnering with ACOs Summit March 18, 2014
  2. 2. “Todd Berner is a paid employee of Astellas. The opinions stated in this presentation do not necessarily reflect those of Astellas.”
  3. 3. Muller RW, ECRI Institute Conference 11.28.2012
  4. 4. NAACOS Survey of 35 ACOs First year start-up experience: “What were your most vexing problems?” • Meeting implementation schedules • Finding suitable software • Delays in getting claims data • Developing new skill sets to analyze data • Obtaining addresses of assignees • Slow stand-up of IT systems • Data inconsistency from CMS • Translating data into actionable information for care managers and providers NATIONAL ACO SURVEY CONDUCTED NOVEMBER 2013 www.naacos.com accessed 3.12.2014 The typical ACO is risking $3.5 million, plus feasibility and pre-application costs, until it can get “cash flow relief” from possible savings At least one-third of the ACOs took out legal debt to finance their venture  So many are certainly banking on recouping investment costs
  5. 5. Estimated Number of Lives Covered by ACO Contracts Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013
  6. 6. Total ACOs Over Time Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013
  7. 7. Physician Led ACOs: Physician practices have the potential to encourage hospitals to compete on price and quality for the allegiance of physician sponsored ACOs
  8. 8. Reasons for Slowing in Growth of ACOs • Reason 1: Tapped Out Market for Trailblazers • Reason 2: No Proven Model to Follow • Reason 3: Payer Delays Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013
  9. 9. Providers Assuming Risk: • Nationwide, about 120 provider- sponsored health plans are owned by hospitals or health systems or are in the process of applying for license to own health plans • Few provider-owned health plans will participate in exchanges • About 15% of hospitals had PPOs, 13% HMOs and 5% fee-for-service products in 2011, with percentages relatively flat over a decade, according to AHA’s latest data Health Plan Week August 19, 2013 Volume 23 Issue 28 There are limitations for smaller provider organizations in taking full risk and becoming an insurance plan, “because you need large numbers in terms of how capitated rates are set.”
  10. 10. • North Shore-LIJ began a health plan for its 50,000-some employees and their families about four years ago • North Shore is the primary network and UnitedHealthcare the plan’s administrator, provides the “wrap” network • More than 85% of inpatient services occur at North Shore- LIJ facilities • Benefit design encourages employee base to use their health system and lowers costs • The Plan’s experience, coupled with market changes under the reform law and interest from employers and unions, allowed the move into fully insured products and to become an insurance company Health Plan Week August 19, 2013 Volume 23 Issue 28 North Shore-LIJ: Started With Own Workforce North Shore-Long Island Jewish (LIJ) Health System is marketing an array of commercial products under North Shore-LIJ CareConnect It will sell individual and small-group options on the exchange and individual and group products off the exchange The delivery vehicle is an exclusive provider organization (EPO) offering only in-network benefits falling on the low end of 2014 pricing ranges for various metal levels
  11. 11. Catholic Health Initiatives (CHI) • Colorado-based CHI, a nonprofit system, operates in 18 states and includes 86 hospitals; 40 long-term care, assisted- and residential-living facilities; two academic medical centers; and home health agencies • CHI has been developing its strategic plan for how it should participate in risk-based relationships with the payer community • CHI sponsors health benefits for as many as 70,000 workers, so they are at risk for their own employees • CHI purchased Soundpath Health, Inc., a Medicare Advantage (MA) plan in Washington state, for $24 million in 2012 • CHI also is involved in bundled pricing, the Medicare Shared Savings Program, a couple of ACOs, and a managed Medicaid globally capitated program in Nebraska • The health system is involved in a growing number of “value-based relationships” with insurers —offering financial underwriting gains if CHI demonstrates that it meets certain quality, cost and service measures • In 2014 and 2015, CHI will make a significant investment in electronic health records and informatics for better evaluation of patient data and claims, taking active opportunities to learn about the populations they’re serving, and how to better manage their care and costs at the same time Health Plan Week August 19, 2013 Volume 23 Issue 28
  12. 12. • Anchored by the system's two flagship academic medical centers, with referral volume generated by a large group of employed and aligned physicians and by multiple community hospitals within the Partners system. • Largest non-university based research enterprise in the United States with over $1.6 billion in research revenue • Research revenue provides a meaningful source of revenue diversification and contributes to Partners' ability to recruit physicians • The system is affiliated with Harvard University for medical training. • There is significant consolidation and merger and acquisition activity among Boston area hospitals resulting in the emergence of networks of physicians and hospitals with overlapping geographies that are competing for similar patient populations • Multiple academic medical centers in Boston are pursuing similar strategies. • Partners acquired a moderately sized healthcare insurance company (Neighborhood Health Plan) in 2013  NHP generated a 1.0% margin in FY13  Two thirds of NHP's business is Medicaid managed care, exposing the system to rates dictated by the state  Focus on cost control has lead to increased government regulation in Massachusetts  Growth of health insurance products that provide financial incentives for cost control could limit patient care revenue growth in future years Moody’s Investors Service Jan 27,2014
  13. 13. Innovation Health Plans: Inova Health System + Aetna “Streamlining the process” • Jointly owned health plan serving Northern Virginia  Inova provides care to more than 1.1 million Northern Virginia residents annually  Aetna provides health care benefits to approximately 570,000 members in Virginia • Aetna  Health benefits administration and care management capabilities  Inova  Health care delivery • The partnership will promote clinical integration of the health care community  Health system will engage community physicians to focus on promoting wellness  Improve patient outcomes through better care coordination  Streamline access to patient information  Aetna will support Inova with technology that makes it easier for physicians to exchange information and track their patients’ care across all settings. • Commercial and Medicare Advantage HMO and PPO products will be offered in Northern Virginia as part of the joint venture  The new products will give employers and consumers access to less expensive, more coordinated and integrated health care fostered by the partnership and engagement with community physicians. “Both Inova and Aetna believe that shared accountability translates into a powerful new value proposition for consumers,” Mark T. Bertolini, Aetna chairman, CEO and president
  14. 14. Listening to the Patient Voice in Research
  15. 15. “When you come to a wall that is too high to climb, throw your hat over the wall, and then go get your hat.” -Old Irish Adage
  16. 16. HECOR Value Evidence Generation Access
  17. 17. Real World Evidence: Efficacy vs. Effectiveness Example- • RCT data • Extremely high placebo response rates • Difficult to show efficacy for drug compared to placebo • It is essentially all non-pharmacologic therapy compared to non-pharmacologic therapy + drug • Real World data • All of the behavioral, non-pharmacologic intervention associated with the RCT moves over to the drug side of the ledger • This becomes a comparison of activated, engaged Rx recipients vs. those with just an Rx
  18. 18. Winning under reform: Critical success factors  High quality; reduce costs  Ability to aggregate clinical capabilities and deliver evidence-based care  Access to capital  Ability to aggregate lives  Physician / Hospital alignment  Ability to aggregate and analyze data  Ability to engage consumers  Manage transition with one foot in FFS and stepping into risk-based contracting  Ability to manage risk  Understand benefit design
  19. 19. Opportunities for ACOs to Better Manage Costs • Consider distinctions among medications • Acquisition costs • Utilization • Overall medical costs • Identify interventions • Utilization management strategies • Drug formulations • Best practices for risk management • Care coordination
  20. 20. Identifying the various Stakeholders
  21. 21. The Imperative to Remain Relevant • Forging new types of relationships to answer questions of relevance to ACOs • Developing a “Change Package”
  22. 22. Sample Research Project #1: Primary Nonadherence to Medication within a Health System • Phase 1  Retrospective database analysis that will help evaluate the treatment patterns and health care resource utilization amongst our population of interest. This will build the foundation to understanding the adherence rates, discontinuation rates and switching rates within this population. This will quantify the burden of both primary and secondary nonadherence. We will also identify patient and prescriber characteristics for this population, and evaluate the factors associated with patients being non adherent or discontinuing. Stratification between age will be conducted to evaluate the Medicare population versus non-Medicare (>=65 y/o versus <65 y/o). We will assess factors associated with the nonadherence or discontinuation of the various therapies. It would be ideal to evaluate patients newly initiated on therapy and possibly prevalent users. Both primary and secondary nonadherence will be evaluated. Newly initiating therapy patients will be defined as no prior history of therapy in the prior 12 months. • Phase 2  Study focusing patients newly initiated on therapy. Once we define discontinuation, primary non adherence, secondary non adherence, we will send them a survey to ask the reasons. This will help examine the real world reasons for why patients are non adherent or discontinuing. Survey will be designed or a prior validated survey could be used. We may use an existing instrument since this may be easy for operational purposes. • Phase 3  Intervention built from the findings from Phase 1 and Phase 2. Explore which types of interventions would be needed to help improve care and overall adherence in this population. Phase 1 and Phase 2 findings will be evaluated with Clinical Leadership to figure out ways to intervene and what the Health System can do as next steps.
  23. 23. Sample Research Project #2: Performance Improvement within a Health System with Significant ‘leakage’ of patient care outside the system • In order to assess treatment approaches, project will explore a number of measures:  Compare the number of visits during which condition was:  was in the problem list  listed as a diagnosis  drug was prescribed for the condition  Examine appropriateness of referral patterns:  For purposes of this project, a primary care provider should try at least one drug for this condition– but only one – before referring to a specialist  Referrals made without trying any drug or after prescribing more than one will be classified as potentially inappropriate or suboptimal  We will also distinguish between referrals from the Health System’s primary care clinic system vs others  Examine the use of diagnostic testing and imaging  Examine the use and documentation of validated symptom assessment tools.  Compare the use of different treatment options among those that we can identify via the EHR
  24. 24. Sample Research Project #2: Performance Improvement within a Health System with Significant ‘leakage’ of patient care # Condition specific Rx’s # Condition specific medication classes Referrals Use of diagnostic tools Treatment Options Patient Characteristics Age <65 65+ Race Wh Other Sex M F Insurance Status Medicare Medicaid Commercial Provider Characteristics Primary care physician Other primary care provider Specialist Hospital #1 Hospital #2
  25. 25. Sample Research Project #3: EHR Based Condition Specific Prompts and HCP Decision Support National Quality Strategy--The Future of Quality Measurement ONC, AHRQ, CMS Presentation. September 14, 2012
  26. 26. Sample Research Project #3: EHR Based Condition Specific Prompts and HCP Decision Support • Clinical Decision Support (CDS) − Detect potential safety and quality problems and help prevent them − Detect inappropriate utilization of services, medications, and supplies − Foster the greater use of evidence-based medicine principles and guidelines − Organize, optimize and help operationalize the details of a plan of care − Help gather and present data needed to execute this plan − Ensure that the best clinical knowledge and recommendations are utilized to improve health management decisions by clinicians and patients Osheroff JA, Pifer EA, Teich JM, et al. Improving Outcomes with Clinical Decision Support: An Implementers' Guide Chicago: HIMSS; 2005.
  27. 27. “Knowing is not enough; we must apply. Willing is not enough; we must do.” -Johann Wolfgang von Goethe

Editor's Notes

  • Hill Physicians, based out of California, reported $11.8 million in net income on $491 million in revenue this past year, up from $11.6 million in net income and $480 million in revenue the year before. CEO Darryl Cardoza stated: “We kept pace with a rapidly changing healthcare environment. Our three, commercial ACO arrangements have led to improvements in overall performance, while also reducing the cost of care for the population as a whole, saving money for employers and consumers. It’s clear that alignment works.” While still achieving cost savings, Hill Physicians also paid over $44 million in bonuses to physicians for improving quality and efficiency metrics. - See more at: http://leavittpartners.com/2013/12/case-physician-led-acos/#sthash.vFFmB4RY.dpuf

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