tim mccoy d.o. mercy des moines aco cin medical director [email protected] mercy aco...

Tim McCoy D.O.

Mercy Des Moines ACOCIN Medical Director

[email protected]

Mercy ACO DiscussionIowa HIMSS Training

May 2015

Mercy ACO

• LLC organized in Feb. 2012 to meet CMS ACO rules for the purpose of:– Forming a network of providers to work collaboratively to

achieve the triple aim goals of Better Health, better care, lower cost

– Creating an environment to optimize the opportunity for providers to achieve the goals

• Data Systems, Care Management, Quality Improvement, and a Clinically Integrated Network

– Assuming of risk for a defined population• Contract to reward the value produced

2

Mercy ACO: A Look Back…• Wholly owned subsidiary of CHI-Iowa• Mercy ACO, LLC Formed Feb. 1st 2012

– Nationally recognized Health Coach/Care Management Program (MCI)

– Pay-4-Performance Program Success– Hold Value Based Product contracts

for CHI-Iowa and ACO Participants

02/2012Mercy ACO LLC was

founded with 5 Participant Members and ~400 Providers

07/2012Mercy ACO

Accepted into Medicare Shared Savings Program

12/2012Mercy ACO Expands in Central Iowa to 35 Participant Members and 700+ Providers

01/2013Mercy - Coventry MA product launches in

Central Iowa

10/2013Mercy ACO

Participants Join UIHA Medicaid

IHWP ACO Model

04/2012Mercy ACO Signs Wellmark Shared Savings Contract

09/2012Mercy ACO has 50,000 Attributed

Lives

01/2013Mercy ACO partners with CHI to offer a

Tier 1 Panel for Mercy employees

06/2013Mercy ACO/MHN Awarded HRSA

Rural Grant $450,000

10/2013Mercy ACO Expands

to 58 Participant Members and

1,000+ Providers

10/2013Mercy ACO - North

Iowa Chapter is Developed

Growth: Mercy ACO Today

01/2014Mercy ACO expands

to 99,740 Attributed Lives



1,100+ Providers

07/2014Mercy ACO Earns Medicare Shared Savings Payment

$4.4 million

09/2014Mercy ACO/MHN

Awarded CMS Innovation Grant

$10.1 million

05/2014Mercy ACO expands

to 117,145 Attributed Lives

06/2014Mercy ACO Earns Wellmark Shared Savings Payment

$3.7 million



1,300+ Providers

11/2014Mercy ACO Expands to 100+ Participant

Members and 1,800+ Providers

10/2014Siouxland, Dubuque and Clinton Chapters

are Developed

05/2014Mercy ACO/MHN

CoOportunity attribution received

13,323 Lives

03/2014Mercy ACO/MHN-

UIHA Medicaid ACObegins 5,879

Attributed Lives

• Government & Commercial Value Based Products– 6 active Value Based Contracts – 117,000+ Attributed Lives

• 105+ Participant Organizations– 1,800+ Providers

• Participant sites in 54 of Iowa’s 99 counties– 2 counties in Nebraska

Mercy ACO Mission / Vision

To provide the infrastructure for providers to thrive in a value based reimbursement

system which will:– Reward keeping people healthy– Deliver better care at lower cost– Require taking financial risk for

populations of patients

ACO - Clinical Strategy

• Advanced Primary Care Medical Home– Access, Health Coaches, coordination of care, Self-management support– Preventive care – CMS Annual Wellness visit

• IT systems – AEHR, Data Warehouse, TAV• Population based care (versus individual episodic care)

– Diabetes population, HTN population, Multiple chronic Disease population

• Focus on High risk patients – Hospital discharge, ED visits, 2 or more chronic diseases

• Top 1% of patients account for 30% of healthcare cost• Top 5% of patients account for 50% of healthcare cost

• Systems and Standardization– Reduction in Variation

• Clinical Integration across the continuum– Ambulatory care, Acute Care, Home health, SNF

Mercy ACO CI Tactics for 2015• Disease Registry – McKesson Population Manager

– Claims data from the practice management system– Clinical data starting with HgA1c and BP.

• TAV Health– Standardize and document care management interventions

• BP and HgA1c improvement projects for MSSP patients– Review & adopt the care models. – Use registries to identify patients not meeting goals and call in for

intervention with provider and/or coach.• High risk Patient intervention for MSSP patients

– Start with patients at hospital discharge – Add other high risk patients later

• Multiple Chronic diseases, multiple ED visits, high risk scores• Annual Medicare Wellness Visits

Local CIN is responsible for local CI work:• Quality across the continuum of the local market• Care Management in the local market• Local Network development and maintenance• PI to help providers meet goals

MHN CIN is responsible for:• Statewide guidelines and care models• Coach Training and standards• Data management • Performance monitoring• Setting metrics and goals• Contracting

Local vs. Statewide CIN Responsibilities

9

CIN Chapters as Sub-Committees of Mercy ACO

Mercy ACO

NI ChapterDQ

ChapterCL

ChapterSC

Chapter

Delegation of Authority to CIN Chapters thru Mercy ACO Operating Agreement

• NI Hospital • Employed

Doctors• Independent

Groups• CAH

• DQ Hospital• Independent

Groups• CAH

• CL Hospital• Independent

Groups• CAH

• SC Hospital• Employed

Doctors• Independent

Groups• CAH

Participation Agreements with Chapter Entities

DSM Chapter

• DSM Hospital • Employed

Doctors • Independent

Group• CAH• Rural Hosp

Participation Agreements with Chapter Entities

MHN Payer Contract

Strategies Group

Mercy ACO Governance and CommitteesMercy ACO

BOD

Central IA Chapter CIN Governance

North IA Chapter CINGovernance

Dubuque Chapter CIN Governance

Clinton Chapter CIN Governance

Sioux City Chapter CIN Governance

Quality / PI Committee

Mercy ACO CI Workgroup

Mercy ACO Data Commitee

Mercy ACO Contracting &

Finance committee



Mercy ACO Care Mgmt Committee



Clinical Integration Workgroup• Includes of Chairs of the local chapter Gov. Committee• Standardize clinical care & care management across Mercy ACO

Data Warehouse / Disease Registry

• McKesson Population Manager and Risk Manager• Aggregates clinical and claims data• Used to:

• Create provider performance reports• Identify Gaps in Care• Identify high risk patients• Create analytic reports at system, chapter, and practice

levels• Clinical, utilization, and cost reports

Visit Manager

ACO CHAPTER HYT Total Eligible PatientHYT Outcome Compliant

CountHYT Outcome Compliant

Score

Mercy ACO 56433 41131 72.9%Central Iowa 40440 29858 73.8%North Iowa 15317 10827 70.7%Siouxland 601 392 65.2%Clinton - NO DATADubuque - NO DATA

Mercy ACOChapter Compliance Report

Data Source: MedVentive Population ManagerReport Run Date: 04/01/15 (Rolling 12 months*)

Controlling High Blood Pressure ComplianceDef; Pts. 18-85 with diagnosis of hypertension and result of <140/90 (NQF#0018)

Time Period: Numerator (rolling 12 months) Denominator (rolling 12 months)

Chapter Organization HYT Total Eligible PatientHYT Outcome Compliant

CountHYT Outcome Compliant

Score

Central Iowa 40440 29858 73.8%Central Iowa CHI - Iowa Corp 2911 2254 77.4%Central Iowa Grinnell Regional Medical Center 10 7 70.0%Central Iowa Knoxville Community Hospital, Inc. 107 77 72.0%Central Iowa Madison County Health Care System 67 53 79.1%Central Iowa Mercy Clinics, Inc. 30360 22293 73.4%Central Iowa Monroe County Hospital & Clinics 15 9 60.0%Central Iowa Primary Health Care, Inc. 301 194 64.5%Central Iowa Wayne County Hospital 77 57 74.0%

Mercy ACOOrganization Compliance Report


Controlling High Blood Pressure ComplianceDef; Pts. 18-85 with diagnosis of hypertension and result of <140/90 (NQF#0018)


16

ACO CHAPTER DIAB Total EligibleDIAB Outcome Compliant

CountDIAB Outcome Compliant

Score

Mercy ACO 23913 12198 51.0%Central Iowa 16606 7293 43.9%North Iowa 7051 4732 67.1%Siouxland 223 164 73.5%Clinton - NO DATADubuque - NO DATA

Mercy ACOChapter Compliance Report


Comprehensive Diabetes Care: HbA1c control (<8.0%) Def; Percent of pts. 18-75 with diabetes and most recent HbA1c < 8 (NQF#0575)


17

Chapter Organization DIAB Total EligibleDIAB Outcome Compliant

CountDIAB Outcome Compliant

Score

Central Iowa 16606 7293 43.9%Central Iowa CHI - Iowa Corp 1165 371 31.8%Central Iowa Grinnell Regional Medical Center 36 0 0.0%Central Iowa Knoxville Community Hospital, Inc. 77 5 6.5%Central Iowa Madison County Health Care System 146 2 1.4%Central Iowa Mercy Clinics, Inc. 12275 5456 44.4%Central Iowa Monroe County Hospital & Clinics 20 0 0.0%Central Iowa Primary Health Care, Inc. 112 33 29.5%Central Iowa Wayne County Hospital 224 4 1.8%

Mercy ACOOrganization Compliance Report


Comprehensive Diabetes Care: HbA1c control (<8.0%) Def; Percent of pts. 18-75 with diabetes and most recent HbA1c < 8 (NQF#0575)


Health CoachesCurrently staffed at 1 per 3000 ACO patients

• Self-Management Support – Health Behavior change and Motivational interviewing– Connection to community resources

• Coordination of care– Closing the loop on referrals and transitions

• Review population data for opportunities – Gaps in Care

• Shared decision making– Distribution and decision aids and f/U

• Quality Improvement– Point person for introduction of new care processes

• High Risk Patient case manager– Proactive follow up– Care access point – direct phone & e-mail

TAV Care Management Software

• Created in partnership with TAV Health• TAV is built on a CRM platform allowing us to track

patient preferences and resources used• Coach interventions are standardized and

documented in TAV templates• Community resources are cataloged and rated• TAV tracks coaching interventions so Mercy ACO can

report on the number and types of interventions provided to patients

Mercy ACO Disease Management• Care models are developed collaboratively across Mercy

ACO• Set standards for care• Guide programs for interventions• Determine metrics• Set patient and system goals• Care models exist for:

• Diabetes, Heart Failure, Hypertension, Coronary Artery Disease, Asthma, and COPD

Transition & High Risk Coaching

• ACO patients identified while in the hospital – Risk Assessed by LACE scores

• LOS, Admit through ED, Co-Morbidities, ED visits in last 6 months– Transition back to the medical home is facilitated

• Appointment for joint F/U with doctor and health coach• Patient is encouraged to bring all meds to the office visit • Discharge info Communicated to the medical home Health Coach

• Patient is tracked by the Coach until seen back in the medical home

• High Risk Coaching initiated with the office visit– Teach warning symptoms and what to do if they occur– Assesses medication issues– Goal setting and motivational interviewing– Office coach makes weekly calls for 4 - 6 weeks

Mercy ACO and PCMH integration

• 31 clinics from 6 MBOs in first wave of PCMH transformation pilot started in 2013. Includes 5 Mercy Clinics

Mercy Johnston Mercy South Mercy Indianola Prairie Trail – Ankeny Pediatrics Central

• TransforMED – a division of American Academy of Family Physicians – consulting with pilot clinics and Quality Improvement Practice Coaches through first wave (January 2014)

• To accomplish the Triple Aim

– To improve the health of the population – To improve the experience of health care– To decrease the cost of health care

• PCMH is an initial tactic toward a larger transformation of care


• Team based care• Enhanced access• Population based care• Planned/evidenced based care• Care Coordination• Patient centered care• Continuous quality improvement

TRANSFORMATIONAL HIGH LEVERAGE CHANGES

Huddles

Regular staff meetings

Satisfaction surveys

Pre-visit planning

Patient & family

engagement

Continuous improvement

Effective Team Communication

Team-Based Care – Daily Huddles

• Increased respect among team members• Deal with unanticipated issues smoothly• Improved conflict resolution• Greater responsiveness to patient needs• Sense of collective accountability• Increases productivity and quality, reduces

adverse events

• Identify specific patient population– Age, gender, chronic disease

• Criteria for quality care (EBG)

• Define how those criteria will be met (pre-visit planning/outreach)

• Tool to identify gaps (Medventive Registry)

• Process to address gaps

• Reporting – Accountability – Performance Improvement

Proactive Population Health Management


• Integrate our PCMH processes with ACO– Increase preventative screening outcomes with team based care

– Continue data management/scorecards to track metrics and monitor population health and cost of care

– Hold providers/system accountable for achieving goals

– Mercy ACO app pending May 2015 for instant access to metrics

– Financial changes to reward Quality internally and externally


• Results from this collaboration

• 25 Primary care sites submitted simultaneously March 2015

• 5 Pediatrics, 3 Internal Medicine, 17 FP’s• Level II certification 22 sites• Level III certification 1 site• 2 more pending at this time• Lack of Patient Portal very limiting-likely 6 or 7 more

Level III certifications if was present

Mercy ACO CMS Readmit Rate

BY 09

BY 10

BY 11

CY12 Q3CY12 Q4CY13 Q1CY13 Q2CY13 Q3CY13 Q4CY14 Q1CY14 Q2CY14 Q3CY14 Q4

120

125

130

135

140

145

150

155

160

151.64

140.78

150.21

143.98

138.69

134.20

141.01139.19

137.00

134.00132.59

130.16129.02

154.02154.90

157.84

145.61147.44

146.36145.52

143.48142.00

147.00 147.29 147.38 146.55

30 Day All Cause Readmission Per 1k Discharges

Performance

CY13 Q1 claims data miss-ing 2 weeks of run-out

Mercy ACO Contribution (June ‘12 – Aug. ‘14)

Total Contribution: $21.71 million

$11.06 millionOperating Revenue

$9.83m

Value Based Contracts

$4.95m Commercial $4.88m Government

$1.02m

Care Management Agreements

$212k

Health Coach Training

$10.65 million Grant Awards

$100k

Shared Decision

Making Grant

$450k

H.R.S.A Grant

$10.1m

CMS Innovation

Grant

Compared to $7.2 million in expense and a initial projection of a $2m/year loss for the first 3 years.

PY1 Q1 PY1 Q2 PY1 Q3 PY1 Q4 PY1 Q5 PY1 Q6 PY2 Q1 PY2 Q2 PY2 Q3 PY2 Q4$7,600

$7,800

$8,000

$8,200

$8,400

$8,600

$8,800

Benchmark Performance

PY1 Q3 claims data missing 2 weeks of run-out

Mercy ACO - Total Expenditures Per Medicare Beneficiary Performance Year One – final CMS results showed savings of 3.2% Performance Year Two – calculation based on prospective attribution

Mercy ACO 2013 Results

Contract Year: PY2 (2013)

Quality

• 0.08 Overall VIS• 0.04 Share Savings VIS

Cost / Savings

• ($7.99) PMPM – 2.35%• $1.86M VIS quality incentive• $1.84M Savings (at 70%)• Total $3.7M incentive

Contract Year: PY1 (2012-2013)

• 12.5% ↓ hosp. re-admits

• 16.8% ↓ hospitalizations

• 3.2% Cost Savings • $9.0M total CMS savings• $4.4M incentive payment (Only 24% received $)

Contract Year: PY1 (2013)• 4.5 Star Plan

• 4.8% MLR (85% Target)

• $320K incentive

Contract Year: PY1 (2013)

• 5.9% ↓ Admissions

• 10.8% ↓ hosp. re-admits

• 8.7% ↓ ED Visits

• 3.1% ↑ PMPY (5% ↑Target)• $533K incentive• $225K Mgmt. fee

Of the 220 ACO’s in 2013…

35TH LARGESTACO

with 27,662 Beneficiaries1

By 2015 Mercy ACO is projected to be one of the Top 5 LARGEST MSSP ACOs in the NATION

27TH

in Overall

$AVINGSWith

$9.03 millionreported.

Medicare Shared Savings PY1

to receive Shared $avings

The ONLY

IOWAACO

Top 34%

in OVERALL

QUALITYScores2

• Purpose is to implement population health infrastructure in rural Iowa sites

• Health Coaches• Physician Champions• IT – McKesson disease registry and TAV care management• Performance improvement - PCMH• Inclusion in a Clinically Integrated Network (CIN)

• 25 Rural Hospitals 73 Clinic sites 165 physicians, 58 ARNPs, 35 PAs 164,199 patients impacted

• $10,171,000 over three years• Goal is to make this financially self-sufficient through Value Based

contracts• Shared savings and others

CMMI Rural ACO Development GrantCenter for Medicare & Medicaid innovation

2015• Additional 29 Participant Organization for MSSP 01.01.15

• Total of 67 MSSP Participants• Estimated Lives 100,000+

• Mercy ACO & CHE-Trinity Employee Plan Agreement (Tier 1)• Additional Medicare Advantage Products 01.01.15

2016• Intend to remain active in the Medicare Shared Savings Program• Increased number Medicare Advantage Products / Covered Lives• Increased Efforts / Contracts for Direct to Employer

Looking ahead… 2015/2016

Mercy ACO Vision

• Shared savings is not the end game– Stepping stone to assuming risk

• Covered lives will be the measure of growth not hospital admissions

• The only way to reduce cost is to have healthier patients– Volume based system penalizes you for healthy patients

• Health Coaches are a key to success in value based payment systems

• ACOs align the reimbursement system with our mission and values– Better Health instead of more services

tim mccoy d.o. mercy des moines aco cin medical director [email protected] mercy aco...

Documents

mercy aco llc

million052014mercy aco

million082014mercy aco

iowamercy aco

providers072012mercy

cms aco rules

mercy acollc

participant members