accountable care organizations: health care delivery redesign thomas j. biuso md, mba...
TRANSCRIPT
Accountable Care Organizations: Health Care
Delivery RedesignThomas J. Biuso MD, MBA
UnitedHealthcare Medical Director
Clinical Assistant Professor of Medicine, University of Arizona
Presentation Goals
Understand the reasons why we need new models of care and the implications of the ACA
Answer the question: what is population health and what drives its costs?
Define accountable care organization and its primary role
Appreciate the difficulties for a network to integrate and coordinate care
Understand the importance of community involvement
Why We Do What We Do –
Achieving the “The Triple Aim”!
Improve population
health
Improve individual experience
Control inflation of per capita costs
Triple Aim
The Triple Aim: Care, Health, And Cost. Health Affairs, 27, no.3 (2008): 759-769. Donald M. Berwick, Thomas W. Nolan and John Whittington
Population Health
Figure 1 Relationship between chronic disease complexity (number of comorbid diagnoses) and health care spending in Medicare recipients. Population health 2010 data from the Mayo Clinic Health Services Evaluation Research (HSER) program. Fifty pe...
Amy W. Williams , Robert E. Nesse , Douglas L. Wood
Delivering Accountable Care to Patients With Complicated Chronic Illness: How Does It Fit Into Care Models and Do Nephrologists Have a Role?
American Journal of Kidney Diseases Volume 59, Issue 5 2012 601 - 603
http://dx.doi.org/10.1053/j.ajkd.2012.02.318
Williams Amy et al. Delivering accountable care to patients with complicated chornic illness. Am J Kidney Dis 2012;59(5):601-603
Map or revascularization rates, by hospital referral region, from 2003 to 2006.
Goodney P et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes 2012;5:94-102
What Accounts for Variation
Patient-level differences Physician-level differences (volume,
specialty, and use of endovascular procedures)
Hospital-level differences (size, teaching status, financial status)
Supply sensitive vs preference sensitive (shared decision making)
Alignment Drives Value
High Quality
Low Cost
VV
AA
LL
UU
EE
Care Management Programs
Transparency and Premium Designation Program
High Performing Preferred Networks
Value-based Benefits
Value-based Contracting
Delivery System Transformation
Value-based Continuum
Lev
el o
f F
inan
cial
Ris
k
Degree of Provider Integration
Fee-for-service
Performance-based Contracts (PBC)
Bundled/Episode Payments
Shared Savings
Shared Risk
Capitation
Capitation + PBC.
Performance-based Programs
Performance-based Programs
Centers of ExcellenceCenters of Excellence
Accountable Care
Programs
Accountable Care
Programs
What is an ACO?
Primary care led, coordinated care organization that accepts a global budget for managing a defined population
Facilitate the transformation of the current fee-for-service payment system into one that rewards greater quality and efficiency in care delivery and improved outcomes
Types
Large primary care clinic Multispecialty group Integrated delivery system Physician Hospital Organization Independent Physician Association
Facts 114 provider groups in Medicare Shared
Savings Program Shared Savings ACOs include 2 dozen
smaller groups in CMS Advance Payment ACO Model
Almost all Shared Savings ACOs chose the 3 year contract model with only 7 that opted for two-sided risk model
32 large provider groups launched Medicare Pioneer ACO
6 large integrated delivery systems in Physician Group Practice Transition Demonstration
Transformation
Health information technology Care management Performance measurement Physician engagement Patient engagement Community involvement
Prioritizing Care Plan Management & Care
Coordination
14
Multiple Chronic
Conditions &
Complex Patients
Rules for the Shared Savings Program
Performance measures specified by CMS fall into four domains:
- patient caregiver experience - care coordination and patient
safety - preventive health - at risk population
Quality
33 quality measures in 4 domains that include patient experience, care coordination/patient safety, preventive care, and at-risk population
first 18 months is for reporting must exceed 30th percentile in 70% of the
measures in all domains
Strategy
Consider financial opportunity vs. strategic move
Strategy means 3 year commitment with several questions that need to be answered:
Will an ACO harm financial performance? Can ACO increase market share? Will an ACO allow better competition for
commerical payer book of business?
Costs
Network development and management Care coordination, quality improvement,
and utilization management Clinical information systems Data analytics