practice transformation: using technology to improve models of care and transitions in care mat...
TRANSCRIPT
Practice Transformation: Using Technology to Improve Models of Care and Transitions in Care
Mat Kendall, EVP Aledade
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Learning Objectives
Define Accountable Care Organization
Describe Medicare Shared Savings Programs
Factors of successful ACO
Identify criteria for selecting an ACO
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Fee for Service Health Care: The Wrong Incentives
The result...
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Fee for Service Health Care has created a system where doctors are rewarded for ordering more test, referrals, and procedures – health care volume.But the system does not reward providers for keeping patients healthy and creating value.
Accountable Care: Lasting Health Care Reform
Accountable Care Organizations (ACOs) are groups of providers
who assume responsibility for the
quality and cost efficiency of the health care for a designated
patient population
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ACOs Are Growing Rapidly
As of 2015, 420+ ACOs have been established across the country, representing 7.8 million Medicare beneficiaries
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In 2014, Medicare distributed over $300 million to 53 ACOs
Types of Accountable Care Organizations
All cost reductions go to payers; no financial incentive for providers to deliver high-quality care at lower cost
Fee for Service
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ACO: Shared Savings
Payers set quality targets and
baseline costs per patient; ACO
receives reimbursement if quality targets are
met and costs come below
baseline
ACO: Two-Sided Risk
Payers set quality targets and baseline
costs per patient; ACO shares in higher
percentage of savings, but can see losses if costs come in above
baselines
ACO: Capitation
(Full or Partial)
CO receives a per patient payment;
providers responsible for
delivering care at or below that level
Avoiding Hospital Admission: Current FFS System
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Primary Care Provider Implements a Flu
Shot Drive Increasing Adherence by 300
Patients
3 Patients Avoid Hospital
Admission Due to PneumoniaTotal Savings
for Medicare: $27,144
Avoiding Hospital Admission: Current FFS System
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Drive Cost:
$1,500Flu Shot Profit:
$567
Total Savings
for Medicare:
$27,144
$933 Net Loss for Provider ($567 -
$1,500)
Provider Financial Results from Flu Shot Drive
Avoiding Hospital Admission: MSSP ACO
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3 Patients Avoid Hospital Admission Due to PneumoniaTotal Savings for Medicare:
$27,144
ACO Successfully Participates in
Medicare Shared Savings Program
Medicare Savings:$13,572
ACO Shared Savings$13,572
Physician-Led ACOs: Early Results
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72%
28%
In 2013, 24% (53/220) of qualifying ACOs earned shared savings – and those ACOs
generated savings of $652 million, taking home >$300 million in bonuses
72% of the ACOs that earned
savings were physician-led.
%
ACOs: The Role of Primary Care Physicians
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Patients and
primary care
doctors are the players
who win when
money is saved
We waste about $1T per year in US healthcare
80% of providers are digitized, so we have the data we need to identify waste and capture savings
We have new payment models that reward providers for saving money
Most of the savings come from avoiding hospital visits and specialists
A Network of Primary Care Providers
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These doctors influence 85% of downstream cost and only account for 5% of costs. They dictate:
• What treatments• Which hospitals• Which specialists• Which tests and
drugs
Primary Care Doctors Own the patient
relationships and trust
Primary care providers are
the “quarterbac
ks” of the system – it’s
time they were paid and treated like it
Primary Care Physicians are Best Positioned to Coordinate Care and Drive Savings
Case Study: Rio Grande Valley ACO Health Providers
• Rio Grande Valley ACO
• 18 primary care docs and 20 mid level practitioners in 13 practices
• Focus on practice changes
• Central role for Information Technology
• Year 1 results:
$20 million in total savings
$11 million return to ACO
Per Patient Costs went from $14,100 to $12,000
Top 5% in the nation for diabetes control
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Case Study: Palm Beach ACO
• Palm Beach ACO case study
• 130 primary care docs in 83 independent practices
• Central ACO staff of 13
• Focus on practice changes
• Year 1 results:
$22 million in total savings
$11 million return to ACO
Hospitalizations per thousand fell by 5.8% ($6.5 million)
SNF costs reduced by 16.6% ($6.7 million)
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Key Factors: ACO Selection
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When choosing an ACO, consider four key factors:
Characteristics and
Composition
Does the ACO include specialists, or just primary care
providers?
Cost and Reimbursem
ent
Are there upfront costs? How are shared savings dispensed
among ACO participants?
Provider and Partner
Engagement
Will ACO management provide in-office guidance and
expertise?
Data and Technology
Who owns patient data? Does ACO management provide
analytical capabilities and EHR optimization?
How Different ACO Types Compare
Hospital-organized
Insurer-organized
Primary Care-organized
Characteristics and Composition
Grow hospital network; shared savings competes with bottom line
Improve data collection for provider tiering; centralize care management
Maintain independence; focus on unnecessary costs (ED visits, hospitalizations) to achieve savings
Costs and Reimbursements
Use hospital infrastructure; apply savings after expenses
Use insurer infrastructure, apply savings after expenses
Optimize provider’s existing infrastructure, no ACO costs, savings distributed before expenses
Physician / Practice Engagement
Minimal; hospital-ledModerate; leverage central administrative support
Moderate; providers comprise ACO leadership
In-Practice Support
Minimal; practice remotely reports metrics
Minimal; practice submits reports like P4P programs
Consistent; trusted, capable on-the-ground staff partners with practice
Patient Expectations
Maximize hospital capacity/technology use
Use centralized tools/resources
Better care; stronger physician/patient relationship
Patient FocusIn hospital network; hospital holds patient data
In insurance plan; insurer holds patient data
All; provider holds patient data
Data / technology Approach
Use hospital information exchange, analytic tools
Use insurer claims-based analytic tools
Comprehensive – support community information exchange, EHR optimization
Examples of Different ACO Models
