applying aco principles to a pediatric population. applying aco principles to . a pediatric...

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Applying ACO Principles to a Pediatric Population

UH Rainbow Care Connection: Transforming Pediatric Ambulatory Care

with a Physician Extension Team

Ethan Chernin, MBADirector

Objectives

•

Understand the underlying principles of accountable care organizations and value-based payment

•

Understand the development of the Physician Extension Team model

•

Likely evolution

University Hospitals Rainbow Care

Connection

University Hospitals Accountable Care

Organization

University Hospitals Coordinated Care

OrganizationACO Type:

Pediatric ACO Employee/Commercial ACO

Medicare ACO

Attributed Membership:

78,000 53,000 42,000

Payer: Ohio Medicaid Apex / Cigna / United Traditional Medicare

Term: July 1, 2012 –June 30, 2015

September 2010 /October 1, 2013 / February 1, 2014

July 1, 2012-December 31, 2015

Sponsor: Center For Medicare & Medicaid

Innovation (CMMI)

University HospitalsExecutive Leadership/

UHACO

Centers For Medicare & Medicaid Services

(CMS)

UH ACO Models

Pediatric Accountable Care Organization (ACO)

•

Providers who work together, alongside families, to provide and coordinate services for individuals…

and collectively

take accountability for improving the lives of these children

- Ohio Department of Jobs and Family Services (ODJFS)

ACO Key Components•

Accountability

•

Triple Aim–

Better Health

–

Better Care –

Lower Cost

•

Risk–

Upside

–

Downside

Rainbow Care Connection 5

Value-based Payment Terminology

•

Total cost of care•

Per member per month (PMPM)

•

Member months -

months per year on Medicaid•

Utilization = visit rate per 1,000 member months

•

Capitation –

lump sum payment for all costs•

Bundled Payment –

lump sum payment for all

costs around a defined episode•

Shared savings -

Risk Models

Bridging the Transition Transforming Pediatric Care

Adult vs. Pediatric ACOAdult (Medicare) ACO Pediatric ACO

PPAC A Defined PPACA not defined, delegated to State

Based on PCMH Based on PCMHDemonstration models No demonstration modelsMinimum 5,000 patients Many needed to evaluate savingsWaiver for MSSP for fraud and abuse laws

No waiver for fraud and abuse laws

Major component disease management / coordination

Only one component disease management / coordination

Focus on preventing readmissions Readmissions less prevalent

Population Management - Medicaid

Only 2% of Medicaid recipients account for 25%

of program’s spending

Identifying the Targets

•

Children do not get recommended preventive care•

Cost of care for children rapidly rising

•

5% of Medicaid enrollees account for 50% of cost •

70% ED visits by children on Medicaid are avoidable

•

Poor access for behavioral health services, rising admissions

•

Rising prescription costs •

80% of pediatric expense is ambulatory

Better Care, Better Health, Lower Cost for Children

Where to look? -

ED visits

-

Behavioral health services-

Children with complex chronic conditions

-

Drug expenditure-

Quality primary care

•

Want to make changes•

But they don’t have –

Infrastructure

–

Money–

Time

–

Knowledge•

No two pediatric practices are alike–

Change implementation must be flexible

–

Often more than one method is needed–

Local academic children’s hospitals are trusted

Community Practices

Providers – How likely are you to utilize the following to help guide you through

healthcare transformation?

Current State of Care

Patients ProvidersMeaningful Care

Future State of Care

Patients Providers

Physician Extension Team

Care Provided

Current Model1 Type of Care Interaction

Physician Extension Team Model4 Types of Care Interaction

More opportunities to create change

Hospital

Physicians

Patients

Behavioral Health Agencies

Community Agencies

Medicaid Plans

Government

Physician Extension Team–Better Health–Better Care–Lower Cost

Creating the Physician Incentive Plan

•

Align incentive targets with ACO goals•

Identify and define variables associated with targets (types of patients, type of provider)

•

Determine rationale behind incentive dollar amounts (cost to provider to implement change)

•

Discuss with PCP focus group•

Finalize definitions and requirements

•

Ensure compliance with laws and regulations–

No waivers for non-MSSP ACOs from fraud & abuse

Physician Incentives

1.

National quality recommendations2.

Access

3.

Care coordination

*Made 2 incentive payments to date

Health Care Innovation Award •

University Hospitals was one of 107 recipients from an applicant pool of approximately 3,000 for a Health Care Innovation Award*–

$12.7 million over 3 years

–

Funding began July 1, 2012

–

Service delivery began January 1, 2013

•

The project described is supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

•

The data presented has not been audited or verified by CMMI.

Program Goals1.

Improve quality of care delivered in primary care practices

2.

Improve health and quality of care delivered to children with complex chronic conditions

3.

Improve access and functionality of children with behavioral health problems

4.

Decrease avoidable ED visits 5.

Create a sustainable model

Pediatric ACO Programs

ACO Structural Programs


Provider Network Geographic strategy

‐ Broad patient access‐ 8 counties in NE Ohio‐ Urban, suburban, rural‐ FQHC‐ Solo and group

Incentive payments

Shared Savings Contract with Payers Coordination of opportunities‐ Physicians‐ Patients‐ Quality

Shared savings program

Population Health & Care Gap Analysis

Cost of care Utilization patterns Quality gap targets

Provider Network


•

154 Pediatric Providers•

60% UH, 40% Independent•

29 Practices•

47 Sites•

~ 78,000 Medicaid members,

130,000 non‐Medicaid patients





Incentive payments





Shared Savings

•

5 Medicaid managed care plans•

2 commercial plans (with adult ACO)

•

Arrangements include dollars earned for:–

reduced cost (ED and Pharmacy)

–

improved quality





Incentive payments





Population Health

•

Ohio Medicaid claims data monthly feed–

Medical

–

Pharmacy–

Behavioral health costs

•

All claims for the network panel

Population Health

Clinical Operational Programs


Check-up for QualityMetric

Attainment (to date)

Year 1Obesity 96%Lead 100%Fluoride Varnish 96%

Year 2

URI 100%Asthma 93%Well Visits 3‐6 yrs 93%Preferred Drug List 100%

Year 3

(proposed)

ADHDPharyngitisAdolescent VaccinesAdolescent Visits 13‐18 yrsBest Value Rx

79% of practices

meeting all 7 metric targets

Practice-Tailored Facilitation

2,550 Face-to-face contacts•

83 Assessment & Observation Visits

•

188 Education and Feedback Meetings•

417 Major chart reviews

•

1,821 Facilitation visits•

41 Training sessions for fluoride varnish

1,146 Email/phone communications

Example - Asthma

Children with Complex Conditions

•

110 patients enrolled•

Innovative electronic assessment documentation

•

Telemedicine program connects patient to care team•

52% of patients have fewer admissions than compared to baseline*

•

54% of families reflect increased functionality scores**•

Over 4,500 “touch points”

with patients and families and

6,900 PCP communications

* Patients enrolled > 6 months** Family Impact Score

Behavioral Health Patients

Service Pts. To Date

Office-based Assessment 555

Telephone Consultation 32

Resource and Referral Service 1,356

ED SW Crises Intervention 183

Patient Functionality*

47%

7%

37%

5%5%

0%

20%

40%

60%

80%

100%

Clinically Significant Deterioration

Partial Deterioration

No Change

Partial Improvement

Clinically Significant Improvement

54% with improved functionality scores

ED SW Crisis Intervention


Cum

ulat

ive

% A

dmitt

ed

∆-25%

24/7 Three-tiered Medical Team Access


The Clear Need

UH Rainbow Babies &

Children’s Hospital

HealthSpot™

Station

45

HealthSpot Outcomes

•

61 patients seen at Friendly Inn•

98% patient satisfaction

•

96% -

would return if needed•

76% -

would have gone to ED/UC if not

available

Outreach Example•

Pediatric Community Health Workers–

Central Promise Neighborhood (pilot location)

–

Partnership with Sisters of Charity Foundation–

Developed customized training curriculum

–

Initiated door-to-door outreach campaign

Care Connection Program

•

Intervention:–

4 or more ED visits/year

–

Real time ED enrollment, education–

Phone follow-up 1 day, 2, 6, 12 weeks

•

Outcomes:–

240 patients enrolled

–

58% “graduation rate”

ED Recidivism Rate

70%

55%

47%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Within 0‐3Months

Within 0‐6Months

Within 0‐9Months

% Decrease ED Medicaid Visits from Prior Year*

‐5.9%

‐4.2%

‐8.4%

‐11.9%

‐14.0%

‐12.0%

‐10.0%

‐8.0%

‐6.0%

‐4.0%

‐2.0%

0.0%Q1 Q2 Q3 Q4

CareSource 2013 ED PMPM

PMPM = per member per month

CareSource 2013 ED Utilization

Utilization = visits per 1,000 member months

‐4.5%

1.2%

‐3.6%

‐8.5%‐10.0%

‐8.0%

‐6.0%

‐4.0%

‐2.0%

0.0%

2.0%

Q1 Q2 Q3 Q4

ER Visits per 1000 Comparison


Likely Evolution

•

Commercial ACO involvement•

Payment for specific RCC/PET services

•

Obtain PMPM administration fee•

Receive greater % of shared savings

•

Move down the risk continuum -

capitation

Sustainability Timeline

Sustainability Funding‐

No Cost Extension‐

Current Shared Savings‐

Additional Innovative Payment Models

University HospitalsRainbow Care Connection

Transforming Pediatric Ambulatory Care with a Physician Extension Team

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