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NH Citizens Health Initiative
Accountable Care Project
Learning Webinar
March 18, 2013
NH Citizens Health Initiative
Welcome and logistics
Overview of the Pioneer
ACO Model
Site Sharing
• Cheshire Medical
Center/Dartmouth-Hitchcock
Keene
• North Country ACO/Mid-
State Health Center
Agenda
The NH Citizens Health Initiative
•Leading New Hampshire to a better health future
• Better health
• Better care
• Lower costs for everyone…
OVERVIEW OF THE PIONEER
ACO MODEL
Kevin Stone, MBA
5
DARTMOUTH-HITCHCOCK HEALTH
PIONEER ACO
Presentation for Accountable Care Project
Systems Transformation Learning Webinar
May 8, 2013
DARTMOUTH-HITCHCOCK HEALTH-PIONEER
Organizations Involved: -DHC; MHMH
-New London Hospital (1/13)
Focus Population -Medicare
Start date January 2012 –DHC; MHMH
January 2013- New London
Note- D-H has ACO arrangements w/:
-Anthem
-Cigna
-HPHC
Care Model Highlights -Medical Home Model
-Embedded Care Management
-”Gold Star” High Risk Patient
Identification
-Patient Centered ‘Super Registry’ Prevention “Gaps in Care”
Chronic Disease
High Risk
-Care Pathways
-Performance Reporting via: • Intranet
• Hard Copy Reports
• Monthly Leadership Meetings
Gold Star HIGH RISK : Population: Adult only (age
18 and older) Automatic High Risk: • Under 65 and covered by
Medicaid and Medicare disability (dual eligible)
A single asterisk (“*”) will appear in the “FYI” section of eD-H, as well as in the Chronic Disease Registries ]\ Flag is present in Centricity IDX (DH1 and DH4) Flag is not available in Centricity or AllScripts EHR
Two or more (out of 3) of the following during past 12 months: 1) 7 or more E&M - codes: New and Est office visits; New and Est Preventive care; including outpatient consults --or--- 2 ) 3 or more co-morbidities [CAD, COPD, DIABETES, CHF, HYPERTENSION, PSYCH AFFECTIVE DISORDER, RENAL DISEASE, VASCULAR DISEASE, CANCER; 8/15 added Liver, Chronic Peptic Ulcer, Cirrhosis, Crohn’s Disease, Ulcerative Colitis and Valve surgery (ICD 35.1x, 35.2x) or History (V42.2 History of Valve] --or--- 3) Medication classes - 3 or more classes on current med list
2013 D-HH Pioneer ACO Configuration
8
D-HH Pioneer ACO
~26K lives
D-H
~23K lives
DHC
MHMH
New London Hospital Association
~3K lives
New London Hospital
New London Physician Practices
Newport Health Center
Medicare Shared Savings Program (SSP)
5,000 minimum attributed Medicare
beneficiaries
Attribution refreshed every quarter
Two-stage attribution algorithm based on plurality
of qualifying E & M codes provide by primary care or
any other specialty type
Primary care defined as: MDs and DOs practicing in
General Practice, Family Practice, Internal Medicine,
Geriatric Medicine
Pioneer ACO
15,000 minimum attributed Medicare
beneficiaries
Attribution refreshed annually
Two-stage attribution algorithm based on
preponderance of qualifying E & M codes provided by primary care and 8 other
specialty types
Primary Care defined as: MDs, DOs, NPs, and PAs
practicing in General Practice, Family Practice, Internal
Medicine, Geriatric Medicine
Medicare ACO Model Considerations- Attribution Method
9
Algorithm: While both models use a two-stage algorithm for attribution, these algorithms are not the same
Nurse Practitioners & Physician Assistants: Under the SSP model, E & M codes billed under the name of a Nurse Practitioner and Physician Assistant do not “count” for attribution purposes
Medicare Shared Savings Program (SSP)
One-Way Risk (Upside Bonus
Potential)
2.0-3.9% Minimum Savings Threshold
Rate(“MSR hurdle”)
Share in 50% of cost savings in Year 1 if
MSR hurdle and quality gate passed
Pioneer ACO
Two-Way Risk (Upside Bonus Potential AND
Downside liability exposure)
1.0% Minimum Savings Threshold
Rate
Share in 60% of cost savings in Year 1 if
MSR hurdle and quality gate passed
Medicare ACO Model Considerations- Risk Sharing
10
Under the SSP model, the trade-off is no downside risk but a much larger MSR hurdle and lower risk share percentage
Under the Pioneer model, the trade-off is downside risk but a lower MSR hurdle and higher risk share percentage
Number of Beneficiaries MSR (low end of assigned beneficiaries)
MSR (high end of assigned beneficiaries)
5,000-5,999 3.9% 3.6%
6,000-6,999 3.6% 3.4%
7,000-7,999 3.4% 3.2%
8,000-8,999 3.2% 3.1%
9,000-9,999 3.1% 3.0%
10,000-14,999 3.0% 2.7%
15,000-19,999 2.7% 2.5%
20,000-49,999 2.5% 2.2%
50,000-59,999 2.2% 2.0%
60,000+ 2.0% 2.0%
SSP MSR Hurdle Rates
Medicare Shared Savings Program (SSP)
2.0-3.9% Minimum Savings Threshold Rate(“MSR
hurdle”)
MSR hurdle varies by the overall attributed
beneficiaries aligned with the ACO
Illustrative Example:
20,000 beneficiaries
Cost Target =$200,000,000
MSR hurdle = Cost Target * 2.5% = $5,000,000
Pioneer ACO
1.0% Minimum Savings Threshold Rate (“MSR
Hurdle”)
MSR hurdle remains fixed at 1%
Illustrative Example:
20,000 beneficiaries
Cost Target =$200,000,000
MSR hurdle = Cost Target * 1% = $2,000,000
Medicare ACO Model Considerations- ‘Hurdle Rate’
12
Under Pioneer: Actual expenses would have to be below the cost target by at least $2 million to be eligible to share 60% of savings back to dollar one
Under SSP: Actual expenses would have to be below the cost target by at least $5 million to be eligible to share 50% of savings back to dollar one
• More applicable attribution model for DH
• Ability to retain a higher percentage of savings
-But more downside exposure as well
• ***Lower hurdle rate to earn upside bonus
• Cost trend methodology may be better for D-H
-Treatment of IME and DSH payments
• Opt out provision (90 days)
-Helps Tolerate 2 way risk
• ***More select group of participants
-Greater CMS attention and Responsiveness
-Potential for greater influence on future design revisions
BIGGEST CONSIDERATION-2 WAY RISK MAKES THIS
SERIOUS
13
Why D-H Chose Pioneer Over SSP
• Analysis of select clinical conditions:
• CHF : 13%, CAD : 10%, Diabetes: 24%, COPD : 14% ,
-HBP Co-Morbidity- 62%,
Led to…development and rollout of targeted clinical pathways
• Analysis of health expenditure locations :
• I/P : 41%, Hospital O/P : 27%, MD : 17%
Led to … targeted care process interventions-Transitions
• Targeted Patients- High Risk (top 10%)
Led to… Gold Star Identification; Dedicated Care Manager
• Quality Measure Diagnosis; Gaps in Care
Assessment
Led to…….registry development
What Has DHH Focused On?
Primary Drivers
Secondary Drivers
Provide Right Care at Right Place and Right Time
Effective Primary Care Engagement
Effective Care Coordination Assess Patient Risk/Health Needs Manage Transitions in Care Focus on high risk patients
Effect Specialist-Primary Care clinician relationships
Effective Distribution of Care Pathways throughout System
Achieve Healthiest Population Possible
Aim and
Outcome
Secondary Drivers
Drivers to Accomplish D-HH Pioneer ACO Aim
Use Technology and Data to its Maximal Functionality for Patients and Providers
Patient Engagement with Primary Care Provide Performance data to clinicians Incorporate Behavioral Health Fully Deploy Shared Decision Making
• DH migrating internal Data Warehouse to new
Data Trust- NNEACC
• Joint Ownership-DH; DC; Maine Health; EMHS
• Common Needs- Spread Cost
• Improve Benchmarking
• Spread “good ideas”
• Transition during CY 2013
16
Data & Analytic Infrastructure
• Integrates clinical information (EHR, laboratory, ADT, etc.) claims data, public health
and patient reported data
• Allowing for:
► Population health analytics
► Predictive modeling
► Quality performance
► Benchmarking
support
• Enhancing current EHR
► Creates patient-centric data model
► Provides a “single source of truth”
across all applications for all users
► Transforms integrated data into
actionable information
Information Suite
Combination of existing foundational
technology and innovative analytic &
reporting solutions
17
Questions??
USING DATA TO INITIATE
PERFORMANCE IMPROVEMENT
Don Caruso, MD, MPH
Using Data to Initiate Performance Improvement in an
ACO
Don Caruso, MD, MPH
Medical Director Dartmouth Hitchcock Keene
March 8, 2013.
Dartmouth Hitchcock Health Accountable Care Organization
• Organizations involved – Dartmouth Hitchcock – Mary Hitchcock Medical Center – Cheshire Medical Center – New London Hospital
• ACO Program – Pioneer – Commercial
• Focus Population(s) – Medicare, Anthem, Cigna, Harvard Pilgrim, DH
employees
• Population size – Medicare: 18,000 – DH employees 16000 – Anthem 17000 – Cigna: 16,000 – HPHC 7000
• Start date(s) by focus pop – Oct 2011 Hospital employees – Jan 2012 Medicare and commercial patients
• Care Model Highlights – Medical Home – Integration with Behavioral Health – Integration with public health – Case Management/Coordination – Patient engagement – Provider engagement – Population Health Management -
registries, HRAs, Chronic Disease mgt.)
– Analytics & reporting
Performance Improvement
• “The Racers Edge”
– STP
• ACO’s Edge
– Utilization Data
– Clinical Quality Data
Data Dashboards
• Data at different levels
– Strategic
– Operational
– Physician
Strategic Imperatives Cheshire Medical Center/Dartmouth-Hitchcock Keene
Strategic Imperatives
Don Caruso, MD, MPH – Medical Director
Art Nichols, Pres/CEO
IMPROVE POPULATION HEALTH INTEGRATED HEALTH SYSTEM LEADERS IN VALUE INNOVATION DISTINCTIVE EDUCATION
AND RESEARCH
PEOPLE FINANCE
Goal: Define specific populations
and achieve measured
advancement in their health
status while providing high-value
care.
Goal: Achieve seamless
coordination within D-H, making
us the high-value health system
of choice for our region based on
a Culture of Caring; regionalize
clinical and administrative
services with neighboring
hospitals as opportunities unfold
Goal: We will set the
standard for Value in the
DH system: (appropriate,
safe & effective patient
care, positive patient
experience, work systems
optimized to be easy and
efficient
Goal: CMC/DHK will be
recognized as a national
leader in the effective use
of technology and
innovative clinical practice
that measurably improves
health.
Goal: Create a
Sustainable Health
System that integrates
clinical service,
teaching, and
research to inform the
delivery of exceptional
care.
Goal: D-H will be the
employer of choice
for the best and
brightest talent, and
our workforce will
be fully aligned to
achieve our strategic
goals.
Goal: KHA will
meet budget this
year
STRATEGIES STRATEGIES STRATEGIES STRATEGIES STRATEGIES STRATEGIES STRATEGIES
Manage populations with Medical Home/ACO and Community Integration interventions to improve outcome
Strongly support Vision 2020 initiative as the community interface for population health
Fully integrate CMC/DH-Keene into the DH Health System
Expand clinical integration with BMH, MCH, possibly Springfield
Review opportunities for administrative service consolidation with other hospitals
Foster a culture of Quality and Safety -patient centered focus
Insure that management models support individual accountability
Drive Vision 2020 by having a sustainable Health System
Pursue grant-funding opportunities to support innovation
Increase philanthropic support for innovative strategies
Create a centralized process to enhance Geisel medical student experience at DHK:
Focus on improving employee engagement
Become financially stable to allow competitive wages, benefits
Fiscally responsible redesign of staffing
Match required staff complement to volume trends
TACTICS TACTICS TACTICS TACTICS TACTICS TACTICS TACTICS
Focus on Cardiovascular Care, Oncologic care and
Work with the DH integration team and Cheshire board to
Improve ACO quality metrics by utilizing
Through the RWJ Exemplar Medical Home
Work with Geisel curriculum
Increase staff participation in
Begin Flex staffing
Strategic Imperatives Drive:
• A cascading metric approach
– Strategic
• Organizational dashboard
– Operational
• Departmental scorecards
– Team/Section
• Team specific based on unique process’s
– Physician
• Matrix report
Data is a Powerful Tool
• Historic physician non interest
– “I provide great care”
• Show them the data
– “My patients are sicker”
– “The data is wrong”
Data is a Powerful Tool
• Chronic Disease Management
– Hypertension
– 32 other Pioneer Metrics
• Process mapping
• Improvement Interventions
Data Doesn’t Lie????
Does it tell the Truth?
Questions?
ENHANCING CLINICIAN/STAFF
ENGAGEMENT IN ACO WORK
Fred Kelsey, MD
Current Participants Ammonoosuc Community Health Services (FQHC)
Coos County Family Health Services (FQHC)
Indian Stream Health Center (FQHC)
Mid-State Health Center (FQHC Look-ALike)
Type of ACO Shared Savings
Advance Payment Model
Focus Population(s) Medicare currently – system wide implementation of improvements
Medicare: 5,678
Start date(s) April 2012 Medicare Patients
27 month, one-sided risk model
North Country ACO
CMS Attributed Patients
Benchmark Cost
Actual Cost of Care
Savings or Loss
Quality Gateway
Payment to Group
The Guiding Principle
Patient-Centered at Mid-State
means passing the “Grandmother
Test” …
“If this were your Grandmother,
what would you want the answer to
be or the plan to look like?”
Patient-Centered
Clinician Focused
How did we get here?
Patient-Centered & Clinician Focused
Engaging Clinicians requires organizations to become
patient-centered at every level
Support for “patient-centeredness” is guided by being
clinician focused – recognizing that most care at some
point must pass through a clinician
Supporting the clinician in every
possible way to facilitate their
function
Here is what we have done so far…
Embraced and repeatedly re enforced “patient centeredness”. This is
the essential first step to engage clinicians.
Validate that this change is not easy
Educate how the ACO/shared savings models work with particular
attention to the function of the quality gate.
Be sensitive to the accuracy of the data and how it is presented.
Work with clinicians in the art of “letting go”
Re-direct clinician satisfaction to include improved data results not
only for patients individually, but also for patient populations
Teaching how to gain professional satisfaction from the success of
others on the team
Pointing out that the PCMH/ACO/Shared savings Programs are the
best models that hold promise to be beneficial to all
CMS Attributed Patients
Benchmark Cost
Actual Cost of Care
Savings or Loss
Quality Gateway
Payment to Group
Frederick Kelsey, MD FACP
Medical Director
Mid-State Health Center
101 Boulder Point Drive
Plymouth, NH 03264
fkelsey@midstatehealth.org
603-536-4000
Contact Information:
Questions for
Don or Fred?
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