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Explaining Accountable Care Organizations (ACOs): Key Strategies for Educating Constituents


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We at Boehringer Ingelheim know that there are many issues affecting health care in the United States. In this presentation Dr. Lee Sacks of Advocate Health takes a look at accountable care organizations (ACOs) and their role in health care reform. Understanding the Implications of Accountable Care Organizations for Patients and Providers, was a web conference given on July 31, 2012 and which we hope will provide offer an understanding of best practices among ACOs and tips for helping constituents adopt and participate in ACOs.

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Explaining Accountable Care Organizations (ACOs): Key Strategies for Educating Constituents

  1. 1. Explaining Accountable CareOrganizations (ACOs): Key Strategies for Educating Constituents Boehringer Ingelheim Patient Advocacy Relations Web Conference Agenda July 31, 2012 Lee B. Sacks, MD
  2. 2. AGENDA• Introductions and Goals• Introduction to ACOs• Communicating with Health Care Providers Lessons Learned Challenges• Communicating with Patients• Questions and Answers2
  3. 3. New Payment Models Incentivize Value and Accountability High Insurance product Prepaid/capitation Degree of Complexity Shared savings/global budgets Condition-specific budget/medical home Bundled payment for episodes of care Bundled payment for acute care (inpatient only) P4P/value-based purchasing Inpatient case rates (eg, DRGs) Fee for service Low Scope of Risk HighP4P = pay for performance; DRG = diagnosis-related group. 3
  4. 4. Accountable Care Organizations* • Strategy to “Bend the Cost Curve” and Improve Coordination and Quality of Care • Implementing a Learning System – Strategic Focused Goals and Objectives – Skills and Tools – Measurement and Accountability – Leadership *Shortell, Stephen M., Lawrence P. Casalino, Elliott S. Fisher How the Center for Medicare Innovation Should Test Accountable Care Organizations Health Affairs 29. No 7 pp. 1293 - 129844
  5. 5. Accountable Care Organization • Affordable Care Act required HHS to create ACOs by January 2012 • Provider Groups accept responsibility for cost and outcomes for a specific population • Must provide data to be used to assess performance • Attribution / Alignment 55
  6. 6. Federal ACO Requirements • “Become Accountable for • Report Key Data to HHS: Quality, Cost, Overall Care” of Assignment, Quality, Etc FFS Beneficiaries • Leadership and • At Least 3 Yr Contract Management Structure • Formal Legal Structure to • Processes to Promote EBM, Receive/Distribute Shared Patient Engagement, Quality, Savings Cost, Care Coordination • Enough Primary Care for • Meet Patient-Centered Assigned Beneficiaries (At Criteria Least 5000)6 6
  7. 7. CMS Description of MSSP• New approach to health care delivery• Provider organizations become accountable for quality, cost and service to defined group of Medicare beneficiaries (Medicare Parts A and B services)• Encourages investment in infrastructure & redesigned care processes• Providers with attributed patients may only participate in one ACO• Medicare shares savings with ACO• Patients continue Medicare FFS benefit and retain their ability to choose any provider7
  8. 8. What MSSP Isn’t . . .• MSSP is not a bundled payment program• MSSP is not a capitated payment program• Physicians and hospitals continue to submit fee- for-service bills to Medicare• Physicians and hospitals continue to be paid by Medicare using the Medicare fee schedule – No FFS payments are sent to ACO• No assignment of Medicare patients to PCPs – CMS attributed patients retrospectively based on physician services provided during the year8
  9. 9. MSSP Contract Structure• 3½ year contract starting July 1, 2012• Retrospectively attributed beneficiaries with prospective data sharing• Shared savings with no downside (repayment) risk• Up to 50% share of savings based on quality score9
  10. 10. Status Through July 2012• 154 Organizations Participating in Shared Savings Programs (2.4 M beneficiaries) – 32 Pioneer – 6 Physician Group Practice Transition Demonstration – 27 April 1 Medicare Shared Savings Program (MSSP) – 89 July 1 MSSP (1.2 M beneficiaries)10
  11. 11. Challenges for ACOs • Large Multi-specialty Groups are the Exception • 9 of 10 Americans Get Their Medical Care in a Solo or Small Practice* • Infrastructure is Required to Drive Quality Outcomes Demonstrated by Multi-specialty Groups • Culture is not Created Over Night • Patient Mistrust or Misunderstanding *NEJM 360;7 Feb. 12, 2009 1111
  12. 12. MSSP Is Good for Patients &Physicians• Infrastructure to support coordinated care management across the continuum – Outpatient care managers follow complex patients to support access to appropriate care – Inpatient care managers coordinate care and provide communication to the patient’s family – Transition coaches assist patients in follow-up with their physician following discharge• Patients retain full FFS Medicare benefit12
  13. 13. Changing Paradigms From TOSilo Care Management Enterprise Care ManagementEpisodes of Care Coordination of CareDischarges TransitionsUtilization Management Right care, at the right place, at the right timeCaring for the sick Keeping people wellProduction (volume) Performance (value)13 13
  14. 14. Clinical Integration is the Foundation of an ACO• Provides Infrastructure for Integration of Small Practices• Overcomes Problems Seen Within the Fee- for-Service Model – Incentives to Providers Drive Improvement• Creates Business Case for Hospital and Doctors to Work for Common Goals• Allows One Approach for Commercial and Governmental Payers14
  15. 15. What Clinical Integration Looks Like Jane Smith, OB-GYN Patient with Diabetes Mammography Endocrinologist Lab Test Results Primary Pharmacy Care Physician APP Data Warehouse and Disease Registries Primary Care Physician • OB-GYN • Endocrinologist15
  16. 16. Clinical Integration 4.0:Increasing Physician/System Integration Clinical Integration to Increasing Accountable Primary Physician/ Care Care/ System Ambulatory Increasing Integration Measures Specialist Measures Maturing Years: Health Reform: Early Years: Middle Years: 2010 - 2011 2012 - ongoing 2004 - 2006 2007 - 2009 16
  17. 17. Creating a Culture of EngagedPhysicians• Physician Engagement in Governance• Physician Leadership Development• Shared Identity and Values → “Membership”• Infrastructure Investment to Enable Success• Appeals to Pride and Sense of Excellence – Recognition for Quality and Efficiency – Consistent Use of Evidence-based Medicine – Power of the Outcomes of the Group17
  18. 18. ECM Infrastructure & Support Physician Office Communication Performance Strategies Coaches Outpatient Care Management • Dedicated Outpatient PCP CMs for High-RiskAccess/Virtual patients Market Share Visits Growth/Backfill Emergency/Acute Post Acute Care Management • SNF CM Model • Inpatient CMs • SNF, LTACH, • ED CMs Inpatient Rehab • Hospitalists Network • Physician-Partnered • Transition Coaches CM Model CM Data & Analytics Risk/Reporting System 18
  19. 19. Achieving Savings• Inpatient Hospital Utilization Potentially Avoidable Admissions Readmissions• Imaging – MRI, CT, PET, Nuclear Medicine• Post Acute – Skilled Nursing Home Length of Stay – Home Care Services19
  20. 20. Sharing Savings Issues• Pay for Performance is the catalyst for clinical integration• Physicians versus Hospitals• Primary care versus Subspecialists• Replace lost revenue vs incentive for work20
  21. 21. In Network Care Coordination• Electronic Medical Record Available• Avoids Duplication• Better Communication and Handoffs• Access to Care Managers• Variety of Access Points• Cost Effective for Patient21
  22. 22. Challenges of PatientCommunication• Medicare Rules• Physician Office is key resource• Customize for condition, cultural issues, etc.• Keep in mind – “What’s In It For Me”22
  23. 23. Challenges of PatientCommunication• Resources – Outbound Call Center – Targeted Mailings – Web Site – Coaches – Care Managers – Asynchronous / Virtual Visit- E Mail – Group Visits23
  24. 24. Questions?