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?