Population Health in 2016: Know How to Move Forward
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Accountable care organizations (ACOs) present a significant opportunity to reduce health care expenditures and ensure quality care. Successfully managing the transition to an ACO is one of the most difficult challenges facing health organizations today. The key is to focus on the risk contract and approach population health management in a staged, incremental way.
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Population Health in 2016: Know How to Move Forward
- 1. Population Health in 2016: Know How to Move Forward Mike Maus VP Enterprise Strategy This event is live as of
- 2. We spend more on health care than Canada does… on everything.
- 3. 0 2 4 6 8 10 12 14 16 18 Health expenditure as a share of GDP, public and private Source: OECD Health Statistics 2014 3 Public Government Spend Private Spend
- 4. And we compete on quality of care with… Costa Rica.
- 5. Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf; Projected Medicare Fee-for- service Payment Cuts per the ACA 2014 2015 2016 2017 2018 2019 2020 Projected number of Medicare beneficiaries 54M 56M 57M 59M 61M 63M 64M -14B -21B -25B -32B -42B -53B -64B Source: CMS, “2013 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds,” May 31, 2013, available at: http://downloads.cms.gov/files/TR2013.pdf
- 6. 2018: 90% of Medicare payments tied to quality. 2020: 75% of commercial plans will be value-based. Jan 2015. http://www.hhs.gov/news/press/2015pres/01/20150126a.html
- 7. Three types of bundled payment programs 7 Penalty-based MU Meaningful Use PQRS Physician Quality Reporting System VBM Value-Based payment Modifier program Incentive-based CCM Chronic Care Management TCM Transitional Care Management PCMH Patient Centered Medical Home Risk-based ACO, MSSP Capitation Bundles
- 8. Three types of bundled payment programs 8 Penalty-based MU Meaningful Use PQRS Physician Quality Reporting System VBM Value-Based payment Modifier program Incentive-based CCM Chronic Care Management TCM Transitional Care Management PCMH Patient Centered Medical Home Risk-based ACO, MSSP Capitation Bundles MIPS (2018) APMs (2018)
- 9. Three types of bundled payment programs 9 Penalty-based MU Meaningful Use PQRS Physician Quality Reporting System VBM Value-Based payment Modifier program Incentive-based CCM Chronic Care Management TCM Transitional Care Management PCMH Patient Centered Medical Home Risk-based ACO, MSSP Capitation Bundles MIPS (2018) APMs (2018)
- 10. 10 Pioneer ACO 2012 MSSP 2013 MSSP 2014 MSSP Private ACO 23 114 106 123 240 742 ACOs Total 52% of US population lives near an ACO 14% of US population treated by an ACO
- 11. $342M shared savings payments ✔ $4M average shared savings payment ✔
- 12. Only 26% of ACOs earned shared savings payments ✗ 11 ACOs failed to report✗ 94 ACOs hit the benchmark but received no savings ✗
- 13. Medicare Shared Savings Program (MSSP) Quick View
- 14. • No Downside Risk • Retrospective Attribution 50 % • Upside and Downside Risk • Retrospective Attribution • Upside and Downside Risk • Prospective Attribution 14 MSSP Shared Savings Bonus Payments 60 % 75 % Track 1 Track 2 Track 3
- 15. Low Risk Patients Rising Risk Patients High Risk Patients Near term high cost Highly- automated, virtualized engagement
- 16. 16 Focus on data management solutions….
- 17. 17 …with little ability to realize value and extract results
- 20. Network services Population health management Patient access and care coordination Inpatient services Electronic health records Revenue cycle management Ambulatory services Revenue cycle management Electronic health records
- 22. 22 Data Sources CLINICAL SYSTEMS Allscripts Meditech EPIC eClinicalWorks GE Centricity Cerner NextGen PAYERS CIGNA AETNA Anthem United CMS BCBSMA Harvard Pilgrim AGGREGATED PATIENT DATA PHARMACY BENEFIT MANAGEMENT Caremark Envision ESI REGIONAL LABS Quest Diagnostics LabCorp Converge Diagnostics We aggregate data across multiple sources in the cloud
- 23. v Network Data Our population health services approach:
- 24. Over the past five years, athenahealth clients achieved strong results 24 45%Improvement in 1st year ACO33 quality scores 16%Increase in network utilization retention 63%of our MSSP clients earned shared savings payment 55%Bend in medical cost trend (lower spending growth)
- 25. Our clients include some of the most forward-thinking provider organizations 25
- 26. Our MSSP ACO Guarantees You’ll receive ACO Shared Savings. Pay us only if you do. Pay us nothing if you don’t We will go at risk for our fee
- 27. Questions 27
- 28. Thank You
Editor's Notes
- title
- We spend more on healthcare than Canada does on everything… It’s not even close, we spend nearly twice as much actually. The US spends $3.8 trillion annually on healthcare alone. Canada’s GDP is only $1.8 trillion.
- Here are a list of the developed nations that spend a lot less per capita, yet still have better outcomes. From a system standpoint, the US HC system compete on quality of care with Costa Rica… Life expectancy in United States: 76 for males, 81 for females Life expectancy in Costa Rica: 76 for males, 80 for females Public gov spend Private spend
- From a system standpoint, the US HC system compete on quality of care with Costa Rica… Life expectancy in United States: 76 for males, 81 for females Life expectancy in Costa Rica: 76 for males, 80 for females
- The whole healthcare industry is moving toward value. Because the number of Medicare beneficiaries continues to grow, payer reimbursements are a huge target for Medicare cuts to try and offer a solution to a cumulating financial problem. Rather than cutting public payer programs altogether, the government has decided to tie payments to the demonstration of quality rather than just cut public payer programs altogether. It is by the Affordable Care Act, the government continues to move toward a consistent delivery of quality care. Hospital payment cuts will represent : 260B ----- Meeting Notes (11/23/15 13:23) ----- quality national US issue - spend verus other countries
- The Department of Health and Human Services supports this trend, stating that half of all Medicare payment will be tied to value through alternative payment models by 2018. CMS stands behind this transition by fundamentally changing how health care is paid for. Emerging payment mechanisms such as Accountable Care Organizations and bundled payment arrangements are increasing at a very fast clip in order to further support all these changes.
- What kind of programs are there? Those coming from the government are some penalty-based and some are incentive-based, and then some that are risk-based. Risk-based models are all about managing the budget of a population of patients, engaging them, and bringing them into the health system to deliver better care. Within the risk-based models, Today we’re going to focus on these risk-based models, particularly on ACOs. ----- Meeting Notes (12/2/15 15:01) ----- ACO/CIN Bundled Payments
- What kind of programs are there? Those coming from the government are some penalty-based and some are incentive-based, and then some that are risk-based. Risk-based models are all about managing the budget of a population of patients, engaging them, and bringing them into the health system to deliver better care. Within the risk-based models, Today we’re going to focus on these risk-based models, particularly on ACOs. ----- Meeting Notes (12/2/15 15:01) ----- ACO/CIN Bundled Payments
- What kind of programs are there? Those coming from the government are some penalty-based and some are incentive-based, and then some that are risk-based. Risk-based models are all about managing the budget of a population of patients, engaging them, and bringing them into the health system to deliver better care. Within the risk-based models, Today we’re going to focus on these risk-based models, particularly on ACOs. ----- Meeting Notes (12/2/15 15:01) ----- ACO/CIN Bundled Payments
- The traditional fee-for-service model so more providers are gravitating toward the ACO model, now showing a huge trend with the ACO model being adopted across the country. According to KLAS, accountable care is moving faster than many thought it might be two years ago. The most popular ACO contract today is the Medicare Shared Savings Program (MSSP)
- 2014 MSSP Program data - $4m is the average shared savings payment for MSSPs that earned a total of $342m (86 total/26%participants) ACOs can apply to be in the Medicare Shared Savings Program and have the opportunity to achieve a lot of monetary benefits. So how have these MSSP programs performed so far? 64 of 260+ reporting to date ACO with adequate experience created savings With a total of $800 of total savings below budget target $372M to CMS directly The wording around payments is a bit different and refers to them as “shared savings payments” now as they’re a bonus on top of baseline capabilities.
- However, many ACOs have not seen shared savings Shared savings don’t come easy Several 1st year ACO had trouble reporting quality measures. 11 ACO failed to report quality scores all together Leavitt Partners, a health care accountable care company says, “if you’re good at this, there is some really good potential” Driving quality and closing care gaps require aligned goals, process, knowledge, and enabling technology
- Medicare adjusts bonus payments (and in some case the loss-sharing rate) based on quality performance. For Example: In Track 1 and Track 2 providers with quality scores below the 30th percentile cannot retain savings; those at the 50th percentile receive 35% of savings, and those above the 90th percentile retain the full 60% of savings. Retrospective = Assigns patients to an ACO only at the end of the year based on where patients received their care during a performance year. Ensures that ACOs are only responsible for the cost of care for patients they actually see, but it makes it difficult to target interventions to patients for whom ACOs are accountable Prospective - assigns patients at the beginning of each year based on where they sought care over the previous three years. Prospective attribution allows ACOs to better track spending and project financial performance during the course of a given year, but means that ACOs may be financially responsible for patients they do not actually treat.
- You need the data to figure out your patients with chronic care Near term high cost – 5% of patients that drive over 50% of your spend
- unlike others, swivel chair method, have to have it on two screens you need team of nurses well our approach to everything we do we ----- Meeting Notes (11/23/15 13:23) ----- technology partners data managment
- ----- Meeting Notes (11/23/15 13:23) ----- stratify and run analitcs data aggregation
- So I’m going to talk to you a little about how we work with those companies here at athena, much different than others ----- Meeting Notes (11/23/15 13:23) ----- okay to be on swivel chair
- We drive results through software, knowledge, and work.
- one of the network services is population health management Cerner epic mkesson bubbles other vendor logos
- one of the network services is population health management
- Our approach is three pronged We believed it requires a three-pronged approach with our data based on 70 million providers at the center of everything in order to be powerful KLAS highlights 4 necessary capabilities to perform POP Health Mgmt: Data aggregation Risk stratification Patient outreach Care coordination. At athenahealth we extend KLASs model one stage to drive performance and results through continuous tracking and optimization. Combine the green and the pink – “Stratefy and manage risk utilization” stratify and track care management patient engagement optimization
- Link to slide with $4m average payments. The 63% of our MSSP clients who earned shared savings earned on average $1m more than the national average of $4m