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Piecing Together Accountable Care
OrganizationsMGMA-MO Conference
May 7, 2018
Jill WatsonBackground
> Centrus Health of KC - 2017> KCMPA - 2013> Metro Med - 1997> Washington DC - 1991
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ACO Components
How ACOs Work
Pros and Cons of ACOs
Risks and rewards of being in an ACO
Best practices of ACOs
Success stories
Piecing Together ACOs
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Willingness to Transform
Providers
Payer
Population of Patients
Value Based Contract
Historical Claims
Quality Measures
Total Cost of Care Targets
Patient Centered Care
Robust Care Management
Mindful Referrals
Transparency
Pieces of an Accountable Care Organization
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*Not all full clinical FTEsSource: American Hospital Directory, 2015 Data.
370 staffed beds
22,002 discharges
105 employed providers
43 primary care providers
740 staffed beds
31,843 discharges
1,073 employed providers
144 primary care providers*
37 independent practices
301 independentphysicians
112 primary care providers
413 staffed beds
20,960 discharges
159 employed providers
85 primary care providers
Coalition of the Willing Centrus Health Kansas City Providers
& other independent practices
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Kansas City Market has been slow to transform
Medicare was firsto First Medicare ACO in KC – KCMPA-ACO in 2013
o Medicare Advantage in 2015
Commercial payers follow – 2017 & 2018
Self Funded Employers
Payers
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MSSPCPC+
Pursuing Value-Based Strategy Across Payers
Logical, principled and staged evolution from FFS contracts to “value-based” contracts across payer populations
TBDCentrus Health of
Kansas CityTraditional Medicare
Commercial Insurers
Self-Insured Employers
Self-Insured Employees
& Dependents
Medicare Advantage
Managed Medicaid
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Key to ACO
Without attribution (a population to be responsible for), an ACO is a provider network
Examples: o Traditional Medicare beneficiaries
o Blue KC Medical Home attributed patients
o Employees of a particular company
Population of Patients
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Start with attributed patientso Significant number to warrant the time and effort of a contract
Analyze claims and quality measures from last 2-3 yearso Negotiate realistic future targets
o Identify opportunities for improving quality and reducing expense
Fee for service billing and collecting continues as before
Operationalize tactics to improve quality and reduce expense
Reconcile at end of performance periodo Upside Risk
o Downside Risk
Value Based Care Contract
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Commonly understood evidence-based measures
Chronic disease, prevention, patient satisfaction, resource utilization
Culture of Quality Improvement (QI)o Internal Reporting
o Transparent Comparison
o Continuous Improvement
Focus on Quality
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Quality Measures - Medicare Shared Savings Program
Patient/Caregiver Experience
Care Coordination/ Patient Safety Preventive Health At Risk Populations
• Getting Timely Care, Appointments, and Information
• How Well Your MDs Communicate
• Patients’ Rating of MD
• Access to Specialists
• Health Promotion and Education
• Shared Decision Making
• Health Status/ Functional Status
• Stewardship of Patient Resources
• Fall Risk Screening
• Med. Rec. Post Discharge
• Use of CEHRT
• Use of Imaging for Low Back Pain
• All-Condition Readmission Rates
• SNF Readmit Rate
• DM Admit Rate
• Heart Failure Admits
• Multiple Chronic Diagnoses Admits
• Acute Admits Composite
• Influenza Vaccine
• Pneumococcal Vaccine
• Weight Screening
• Tobacco Cessation
• Colorectal Screen
• Breast Cancer Screening
• Depression Screen
• Statin Therapy for Cardiovascular Disease
Diabetes (Composite Score):
• Hgb A1c control ( >9%)
• Eye Exam
Hypertension
• Blood Pressure Control
Ischemic Vascular Disease
• Aspirin/Anti-Thrombic Use
Depression:
• Depression Remission at 12 Months
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Collaboration across community
Identify Champions
Share Best Practices
Right Care, Right Place, Right Time
Centrus KC Subcommitteeso ED Utilization
o Heart Failure Collaboration
Strive for Consistent Quality
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Think Medicare QRUR
All medical expenses o Regardless of which provider ordered them
o Even providers not in your practice or system or ACO
o Including pharmacy expenses
All attributed patientso Even the “non-compliant” ones
o Based on methodology
o Firing patients is not as effective as it may have been in FFS
Total Cost of Care
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Physician-Led
Patient Centered Care - Population Health Management
Supported By
Process
People
Technology
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Patient Centered Medical Home (or Specialty Practice)/CPC+
Team Based Careo Evidence Based Interventions
o Produce Consistent Performance
o Close Care Gaps
o Daily Huddles
Registries or other means to examine patients as groupso By disease
o By measure
o EHRs weren’t built to do this
Patient Centered Care
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New Members of the Care Team Care Manager
o Works across multiple providers
o Identify high risk and high utilizing patients
o Proactive contact with patients
Behavioral health
o Closer proximity to medical care
Social work
o Address social needs that impact achievement of health goals
Clinical pharmacist
o Assist with medication reconciliation and advise prescribers
Dietician/CDE
o Group visits
Robust Care Management
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Attribution is largely primary care based
Role for Specialistso Utilization
o Site of service
o Episodes of Care (Bundles)
Choosing Wiselyo Get familiar with specialty society lists
o Develop workflows to support
Mindful Referrals
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Quality Measure Dashboard
Utilization Measureso Claims data
o Referral patterns
Performance Feedback from Payers
High performers/low performers
Remediation and dismissal
Transparency
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1. ACO gets full claims data on all patients under contract
2. Coding for severity of illness is important for benchmarks
3. Establish cost and quality targets
4. Providers continue to receive FFS payment
5. ACO infrastructure• Analyze and stratify claims data
• Identify opportunities to improve quality and reduce cost
• Add care coordination, other patient centered interventions
• Patient Centered Medical Homes are foundational
6. Reconciliation after Performance Period
7. Distribution or repayment
How an ACO Works
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Independents are a Vanishing Breed – Physicians and Hospitals
Last Independent Standing
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Forces Pushing Physicians and Hospitals Together
Driving Factors for Alignment
Change Demands Collaboration
• Uncertainty around impact of new payment models, coverage expansion
• Change in incentives• Specialty demand destruction• Fear of being left out of accountable
care networks
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Economic Concerns
Health Reform
• Declining volumes• Ancillary reimbursement cuts• Professional fee cuts• Rise in practice costs
Physicians
• Continued cost pressures• Payer mix shift• Looming physician shortage
• Increased accountability for costs, outcomes
• Emphasis on care value• Inpatient demand destruction• Competition to lock in high-
value physicians
Hospitals
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Current Partnership Models Insufficient for Real ChangeIn Need of Partnership
Employed PhysiciansLimited Scale• Represent fraction of medical staff; restrained
by hospital resources, physician interest
• Often lack strategy-aligned incentive model and/or performance improvement infrastructure
Independent PhysiciansLimited Levers• Anti-trust and regulatory barriers restrict
financial incentives
• Limited data sharing, performance improvement infrastructure
• Collection of stakeholders too diffuse for organized performance achievements
Clinical Integration
Key Characteristics
• Selective, scalable membership
• Commitment to evidence-based, standardized care
• Care coordination infrastructure
• Performance management system
• Legal, meaningful performance-based incentives
• Capable of joint contracting with commercial payers
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Pros and ConsWhy Join an ACO?
Strength in numbers; alignment with other specialties
Maintain your autonomy
Large patient panel = influence in ACO
Access to best practices, population health expertise
MIPS reporting and performance
New revenue; understanding of value based contracts
Provider satisfaction
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Pros and ConsWhy an ACO might not work for you?
Anticipate unfavorable comparison to peers
Data sharing interest or capabilities
Specialty with minimal influence on measures
Downside risk potential
Not subject to MIPS
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Risks of ACOs
Data sharing – cost, time
Specialty may have minimal influence on measures
Comparison to peers if you don’t perform well
Exposure to financial penalties if benchmarks are missed
Legal concerns when poorly executed
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Rewards of ACOs
Alignment to larger network of providers
Thrive in new payment models
Provider autonomy
Potential new revenue
Optimized MIPS reporting
Provider satisfaction
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Best Practice: Clinical Integration
North Kansas City Hospital
Shawnee Mission Health
The University of Kansas Health System
Kansas City Metropolitan Physician Association
Community Physicians
Network Drives Unified Efforts Toward Care Transformation
IT & Population Health Solutions
Joint Contracting With Payers
Physician Leadership, Governance & Management
Quality Program & Care Management Infrastructure
Providers Partner Through Clinically Integrated Network
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Physician-Led Governance, Professionally ManagedBest Practice
Centrus Health Kansas City Board of Managers
Quality Performance Improvement Committee
Communications & Network
Development Workgroup
Payment Transformation &
Finance Committee
Practice Operations Workgroup
Care Delivery & Quality
Committee 12 Managers (67% Physicians):
• NKCH – 2 MDs, 1 Admin
• SMH – 2 MDs, 1 Admin
• UKHS – 2 MDs, 1 Admin
• Independent Physicians – 2 MDs
• Medicare Beneficiary
Physician Chair
Physician Chair 100% Physician Composition
Practice Manager involvement
Physician-oriented communication
Executive Director
Jill Watson
Centrus Health Population Health
Services Organization
People, Technology, and Process for Value-Based Care
Centrus Health Participating
Practices
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Centrus Health of KC Committees
Care Delivery & Quality Committee
• Establish target/benchmarks for quality initiatives
• Information technology strategy and coordination
• Initiate ongoing annual review/update of Clinical Quality Program
Payment Transformation & Finance Committee
• Oversee the Centrus Health value-based payer contracts
• Discuss payer strategy and prioritize additional payer/employer opportunities for pursuit
• Evaluate and draft physician incentive distribution model and policy
• Oversee incentive payouts
Communication & Network Development Committee• Oversee collection/filing of fully executed
Participation Agreements and practice surveys
• Evaluate/approve practice implementation and onboarding process
• Facilitate Centrus Health communications to participating practices
• Practice outreach and support
Quality Performance Improvement Committee
• Implement the Quality Performance Improvement policy and procedure
• Review physician and network performance data on at least quarterly basis
• Identify practices that may require workflow redesign
Physician-Led Governance
Practice Operations Workgroup
• Determine practice needs to succeed under payer contracts
• Determine practice funds flow
• Prioritize initiatives based on impact to practice workflows
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Understand Risk Adjustment
Risk score developed from past claims
Risk score impacts estimates of future medical expenses
Impact of coding on risk adjustment
Billing codes = language to communicate severity of illness
Getting it wrong = benchmark/budget too low to allow appropriate care in performance years
Savings goals will be unrealistic, unattainable
Start at least 1 year before first performance year
Best Practice
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ACO SuccessesKCMPA-ACO
2013 Start
$2.4m Advance Payment built ACO infrastructure
Increased Benchmark in 2nd contract – 2016
2016 performance Beat benchmark by $8.4m Repaid Advance Payment Funded KCMPA infrastructure Distributed to physicians
