future of acos payment innovations · future of acos & payment innovations ernie schwefler...
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Future of ACOs &
Payment Innovations
Ernie SchweflerRegional Vice President Network Management & HMO Strategy
November 2, 2011
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Topics for Today
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Increasing Premiums
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California Premiums vs. Inflation
Cumulative Premium Increases Compared to Inflation, California, 2002 - 2010
Sources: California Health Care Foundation; California Employer Health Benefits Summary Survey 2007-2010; California Division of Labor Statistics
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Since 2002, health insurance premiums in
California have increased by 134.4%, more than five times the 25.4% increase in California’s overall inflation rate.
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The marketplace can not sustain this trend. Traditional methods to keeping costs down have not been successful enough.
5x increase
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Improving Value and AffordabilityNew Model:
Rate increases tied to quality, safety, and value
Old Model: Rate increases not tied
to value
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Reforming the Delivery System: Changing the way members access and receive health care
The delivery system is constantly improving -
continuous innovation leads to higher quality and lower costs
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A Balanced Approach: A Menu of Solutions
Accountable Care Organizations
Bundled PaymentsSurgical Services
Patient Centered Medical Home
Payment for Quality Enhanced reimbursement for value-based quality behavioral changes
Enhanced Fee For Service
PCMH
Population Based
Payments
Episode Based
Payments
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Anthem ACO
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ACO Work Groups
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Linking Patients to Providers (attribution)Linking Patients to Providers (attribution)
HMO PPO
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Both plans and ACOs recognize limits of attribution logic in current PPOs
Solutions for AttributionSolutions for Attribution
Working together on new PPO product designs that would favor use of ACO providers with three tiers of benefits in 2012
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Payment Methods: StructurePayment Methods: Structure
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ACO Model 2011: Shared Savings –
Quality Gate
Quality Gate
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Physician Quality Metrics
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Hospital Quality Metrics
Can participate in Shared Saving if passed Quality
Gate
Note: Points are scored based on both improvement and an attainment threshold
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Payment Method: Calculating SavingsPayment Method: Calculating Savings
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Hard for the PPO to delegate CM for enrollees who are affiliated with ACO but not for other enrollees in PPO (who are not in an ACO)
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Variation in breadth of CM programs operated by the PPO for different employers
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Variation in breadth of CM programs across ACOs•
Large employers often carve DM/CM out to specialty companies
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Some PPO customers dislike care management; that’s why they are in the PPO
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Data exchange between PPO and ACO is imperative but difficult
Delegation of CM is difficult in PPODelegation of CM is difficult in PPO
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ACO Critical Pathways
•Align incentives:
quality improvement and cost reduction require careful
discussions.
•IT Development:
must involve the IT department early in the process to
assure that it has the data and infrastructure needed to support
integration.
•Transparency:
participants
commit
to
the open
sharing of performance data across the organizations.
•Dialogue:
initial step is beginning a dialogue with community
physicians/ACO partners.
•Flexibility:
process of refining and improving ACO performance is ongoing.
The ACO is a dynamic organization; Stakeholders must be equipped
to
adapt and execute.
•Resources:
carefully assessing the current environment and taking
inventory of available resources and identify additional needs.
•Time:
requires substantial time and ongoing internal and external
support.
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Questions