the long and winding road to accountable care · pgp demo. all systems 1% 5%. marshfield 9% 11%....
TRANSCRIPT
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Elliott Fisher, MD, MPHDirector, The Dartmouth Institute
John E. Wennberg Distinguished ProfessorGeisel School of Medicine
The long and winding road to Accountable Care
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Past
How did we get here?
Present
Where are we now?
Future
What will we do?
The long and winding road
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Per-Capita 2009 Medicare Spending by HRR (Age, Sex, Race Adjusted)
Miami, FL
$16,639McAllen, TX
$14,576Manhattan, NY
$13,453Los Angeles, CA
$12,711Detroit, MI
$11,647Chicago, IL
$11,646Philadelphia, PA
$10,640San Francisco,
$9,913Cincinnati, OH
$9,388Lebanon, NH
$8,124La Crosse, WI
$6,532
% 10 + MDs
59.459.0
26.922.7
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An
additional
1 in 5
patients
survive
Delivering safe
reliable, and
effective care
Cost decreases by $20,000 per patient
Avoiding unnecessary care
(hospital stays, ER visits, duplicate tests)
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Flawed conceptual model New model: organized
systems of care focused on
population health
Wrong incentives Shift to value‐based
payment
Confusion about aims Clarify aims: better health
better care, lower costs.
Absent or poor data Provide high‐integrity
information to patients
and clinicians
Problem Solution
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Affordable Care ActInvestments in public healthHealth information technologyExpanded coverageNew payment models
“No Outcome, No Income”
David NashDean, Jefferson School of Population Health
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Volume Value
Individual patientSpecific encounter
Patient and PopulationContinuum of Care
Individual provider
Single site of care
OrganizationAll sites of care
Incentives
Focus of
responsibility
Locus of
accountability
Pay for
performance
Episode‐based
payment
Global
payment(no risk)
Global
payment(with risk)
Community‐
based
payment
Accountable Care Organizations
The Transition to New Delivery Models Is Underway
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The Randolph Project
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Core IdeasPopulation‐based virtual budgetsReal or virtual organizationsPerformance measurementPatient choiceAccommodate diversity
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2009: 21 ACOs
in the US.
Physician Group Practice Demonstration (10)Alternative Quality Contract (8)Brookings‐Dartmouth Pilots (3)
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2014: 600+ ACOs
in the U.S
ACOs
cover an estimated 20.5 million lives
Pioneer
669,000
3.3%MSSP
5.3 million
25.8%Commercial
12.4 million
60.5%
Leavitt Partners, 2014
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WHAT DO THEY LOOK LIKE?
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WHAT DO THEY LOOK LIKE?
Optimus Healthcare Partners, Summit NJOrganizational Structure Partnership between two IPAs: Vista Health Systems IPA and
Central Jersey Physician Network
Physicians 550 physicians; mostly solo / small office practices; 60+
specialists
Payer‐Partners Private: Horizon Blue Cross Blue Shield; others pendingPublic: MSSP
ACO Governance Four physician‐driven committees: (1) quality, (2) finance,
(3) medical/management/utilization, (4) credentialing
Payment Model Private: PCP care management fees, netted against shared
savings Public: Upside only Shared Savings,
Attributed Patients Private: 40,000 patients under BCBS contractPublic: 27,000 Medicare beneficiaries under MSSP
Anticipated Distribution
of Shared Savings
30% to Optimus operations; 70% to providers (mostly
physicians); distribution determined by finance committee
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WHAT DO THEY LOOK LIKE?
FQHC Urban Health NetworkCoalition of 10 independent federally
qualified health centers; 40 service
sites extending through seven
Minnesota counties
Three MSSP ACOs in partnership with health
systems and physician organizations in FL,
NJ, and TX
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Physicians RepresentMajority on
Governing Board
94%
65%
20%
80%
50%
0%
60%
National Survey of Accountable Care Organizations: Colla et al.
Health Affairs 2014
WHAT DO THEY LOOK LIKE?
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WHAT DO THEY LOOK LIKE?
Fully developed readmissions program
Inappropriate ED use program
All PCPs attested to meaningful use
Comprehensive care management
Advanced HIT capabilities
Comprehensive previsit planning
10% 20% 30% 40% 50%
Transitions program across settings
National Survey of Accountable Care Organizations: Colla et al.
Health Affairs 2014
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HOW ARE THEY DOING? FINANCIAL PERFORMANCE
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HOW ARE THEY DOING? QUALITY
MSSP Release of final year one results in Sept
220 ACOs launched in 2012 and 2013
Nine failed to report (4 would have received savings)
ACOs better than FFS providers on 17 of 22 comparable measures
Improvement reported on 30 of 33 measures
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HOW ARE THEY DOING? PIONEER 2012‐2013Patient caregiver experienceACO‐1
Getting timely careACO‐2 How well providers communicateACO‐3
Patients overall rating of providerACO‐4
Access to specialist ACO‐5 Health promotion and educationACO‐6
Shared decision‐makingACO‐7 Self‐rated health and functionCare coordination‐safetyACO‐8
Readmission rate (risk adjusted)ACO‐9 COPD/Asthma admission rateACO‐10
Heart Failure admission rateACO‐11
PCP ‐
EHR qualification rateACO‐12
Medication reconciliationACO‐13
Screening for fall riskPreventive HealthACO‐14
Influenza vaccination statusACO‐15
Pneumonia vaccination status ACO‐16
BMI index screeningACO‐17
Tobacco use screening and adviceACO‐18
Depression screening and follow‐up planACO‐19
Colorectal cancer screeningACO‐20
Breast cancer screeningACO‐21
Blood pressure screening and follow‐upAt‐risk populationACO‐22
BP control in diabeticsACO‐23
LDL control in diabeticsACO‐24
HgB A1c control in diabetics <8%ACO‐25
Daily aspirin with DM and CVDACO‐26
Tobacco non‐useACO‐27
HgB A1c in poor controlACO‐28
BP controlACO‐29
CVD – LDL controlACO‐30
CVD –
Aspirin or other antithromboticACO‐31
Beta blocker for CHFACO‐32
CVD compositeACO‐33
ACE/ARB for CHF or DM
Improved on 28 measuresMean percentile score 71.8 to 85.2
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HOW ARE THEY DOING?
ALTERNATIVE QUALITY CONTRACT
Song et al. NEJM, Oct 30, 2014
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OTHER FINDINGS FROM ONGOING RESEARCH
Easier to succeed in high cost regions
Physician‐led ACOs may have edgeHalf of those getting savings were MD ledBut: hospital as part of ACO unrelated to performance
Strategies:Focus on high cost patients; Behavioral health integration a target; but limited success
yetHIT use important Physician engagement a high priority
Challenges: Only 1 of 59 patients in focus groups aware of ACOStart up costs
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THE CURRENT MOMENT
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Republican control of Congress: impact on ACA Wholesale repeal unlikely; Vulnerable:
employer mandate; medical device tax
Uncertain:
CMMI; IPAB
ACOs likely safe – for now Generally non‐controversial and supported by conservatives
Welch‐Black ACO BillSeen as possible contributor to slower spending growth
Per‐bene spending growth averaged 0.8% past two years
THE CURRENT MOMENT
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Challenges – Technical / Legal
Notice of proposed rule expected “soon”Feb 2014 RFI elicited range of ideasBroad authority to restructure program
Revisions in play: Prospective benchmarks and attribution (many)Include NP’s and PA’s in attribution (MedPAC)Synchronize ACO and MA benchmarking (MedPAC)Attestation and
attribution (Premier; Welch‐Black)
Financial incentives for patients to align w/ ACO (Welch‐Black)Regulatory relief if bearing 2‐sided risk (MedPAC; Welch‐Black)Encourage 2‐sided risk, but support continued “on‐ramp”
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Challenges – to our professions
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Phil Bretthauer
Lincoln Wallace
Tammy Bennett
NPR Nov 21, 2013
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Savings Achieved
PGP Demo
All Systems
1%
5%
Marshfield
9%
11%
Overall Duals
Kori Krueger, MDMarshfield Clinic
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1.
The health care system is failing us
2.
This need not be so
3.
New payment and delivery models offer promise.
4.
It won’t be easy
5.
But it might be fun
The argument in brief
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Please helpWe are in the field with Round 3
National Survey of Accountable Care OrganizationsThanks!