Agenda What is an Accountable Care Organization?

2October, 2010

Agenda

1. What is an Accountable Care Organization?

2. Industry Changes and Drivers

• Who can be an ACO? Reality testing…

• Role of Specialty Hospitals & NCI CCCs

• ACO Physician / Hospital Alignment Options

• ACO Development Challenges

3. ACO Pilots & US Oncology: What are they doing?

3October, 2010

What is an Accountable Care Organization (ACO)?

4October, 2010

ACOs can strengthen ongoing reform efforts

• Medical home,

• HIT

ACOs can operate in conjunction with current payment structures

FFS

Bundled payments

Partial/full capitation

ACOs

ACOs address fundamental health policy challengesConfusing aims

Absent or poor measurement

Fragmented care

Wrong financial incentives

ACO Reform consistent with Other Reforms

5October, 2010

Summary of current CMS ACO Criteria

CMS Requirements for an ACO:

1. Have a formal legal structure to receive and distribute shared savings

2. Have a sufficient number of primary care professionals for the number of assigned beneficiaries (to be 5,000 at a minimum)

3. Agree to participate in the program for not less than a 3-year period

4. Have sufficient information regarding participating ACO health care professionals as the Secretary determines necessary to support beneficiary assignment and the determination of payments for shared savings

5. Have a leadership and management structure that includes clinical and administrative systems

6. Have defined processes to (a) promote evidence-based medicine, (b) report the necessary data to evaluate quality and cost measures (this could incorporate requirements of other programs, such as the Physician Quality Reporting Initiative (PQRI), Electronic Prescribing (eRx), and Electronic Health Records (EHR), and (c) coordinate care

7. Demonstrate it meets patient-centeredness criteria, as determined by the Secretary.

8. Additional details regarding these requirements will be available in the proposed regulations expected by December 2010.

Source: Patient Protection and Affordable Care Act

6October, 2010

Establish robust HIT infrastructure

Implement cost-saving and quality-improving medical interventions

Evaluate performance at the system level

Restructure payment incentives to support accountability for overall quality and costs across care settings

Key Design Elements

Pay for better value – improved overall health while reducing costs for patients

Provide timely feedback to providers

Require providers to report on utilization and quality

New model: It’s the system - Establish organizations accountable for aims and capable of redesigning practice and managing capacity

Realign incentives – both financial and clinical – with aims

Core Principles

Clarify aims to emphasize better health, better quality care, lower costs – for patients and communities

Better information that engages physicians, supports improvement, and informs consumers

Accountability, “Systemness” & Incentives

7October, 2010

1 2 3

Important Caveats

• ACOs are not gatekeepers and don’t have closed networks (e.g., HMO networks)

• ACOs do not require changes to benefit structures

• ACOs do not require patient enrollment

ACOs differ but share a few, key Elements

8October, 2010

Payer / Provider Requirements

1. Sharing savings between payers and providers if performance exceeds both financial and quality targets

2. Set financial targets for assigned population based on historical spending and trend using a standardized actuarial methodology

3. Use standardized attribution methodology to assign patients to providers exclusively affiliated with that ACO

4. Ensure a minimum “risk pool” size to sustain meaningful measurement and acceptable statistical stability

• e.g., 15,000 commercial, 10,000 Medicaid, or 5,000 Medicare patients

5. Use a minimum common core set of quality measures (can add more)

6. Provide data feeds to ACOs in a timely manner

7. Work with providers on other steps to help the ACO in lowering costs and improving quality

9October, 2010

Providers sign agreement to participate with ACO

Patients are assigned to their PCP based on the majority of their outpatient E&M visits

• Defined by the ACO• PCPs must be exclusive to

one ACO Limits concerns about

selection and dumping• Specialists can be part of

multiple ACOs

• Uses data from insurer

How are patients assigned to the ACO?

10October, 2010

Community Providers

Accountable Care

Organizations

Bonus-Eligible

Providers (ACO

defined)

Community Providers are not part of the ACO, although they may provide care to ACO patient. Some community providers may have contractual relationships with the ACO or routinely receive referrals, while others may have no relationship with the ACO or be out of area, such as Oncology Centers. ACO Providers: These providers are members of the ACO and, for physicians exclusive to the ACO, can have patients assigned to them. Providers not used for patient assignment may participate in multiple ACOs. ACO members have governance rights. Bonus-Eligible Providers: Each ACO prospectively determines eligibility for and the allocation of shared savings to ACO members, which could range from a subset to all ACO members. The treatment of providers can vary (e.g., all PCPs could receive bonuses, while only some specialists might), and the amount of bonuses could also vary by provider.

Providers Used for Patient

Assignment(ACO Defined)

Understanding Provider Relationship

11October, 2010

Key considerations for ACO Providers

1. Patients can only be attributed to providers who are members of one ACO

Allowing patients to be assigned to providers participating in more than one ACO greatly complicates attribution and raises risk selection concerns

2. ACO Membership, Governance, and Referrals

ACO members have governance rights

• The ACO decides bonus allocation

Providers may direct referrals to ACO members and non-members

• The ACO monitors utilization and can establish referral policies

3. Shared Savings (or Losses)

Timely performance reporting essential for successful ACO

The ACO decides how to allocate shared savings bonus among its members

For ACOs selecting “symmetric risk” (level II), all ACO members would have fees cut if spending exceeds budget target

12October, 2010

ACO receives mix of FFS and prospective fixed payment

If successful at meeting budget and performance targets, greater financial benefits

If ACO exceeds budget, more risk means greater financial downside

Only appropriate for providers with robust infrastructure, demonstrated track record in finances and quality and providing relatively full range of services

Payments can still be tied to current payment system, although ACO could receive revenue from payers and distribute funds to members (depending on ACO contracts)

At risk for losses if spending exceeds targets

Increased incentive for providers to decrease costs due to risk of losses

Attractive to providers with some infrastructure or care coordination capability and demonstrated track record

Continue operating under current insurance contracts/coverage models (e.g., FFS)

No risk for losses if spending exceeds targets

Most incremental approach with least barriers for entry

Attractive to new entities, risk-adverse providers, or entities with limited organizational capacity, range of covered services, or experience working with other providers

Level 1 Asymmetric shared-savings

Level 2 Symmetric Model

Level 3 Partial Capitation Model

ACOs offer a wide range of approaches

Performance Payment Framework

13October, 2010

ACOs use more complete clinical data (e.g., electronic records, registries) and robust patient-generated data (e.g., Health Risk Appraisals, functional status)

Well-established and robust HIT infrastructure

Focus on full spectrum of care and health system priorities

ACOs use specific clinical data (e.g., electronic laboratory results) and limited survey data

More sophisticated HIT infrastructure in place

Greater focus on full spectrum of care

ACOs have access to medical, pharmacy, and laboratory claims from payers (claims-based measures)

Relatively limited health infrastructure

Limited to focusing on primary care services (starter set of measures)

Beginning Intermediate Advanced

Beginning, Intermediate, and Advanced Quality Measures

Over time, measures should address multiple priorities, be outcome-oriented, and span the continuum of care

14October, 2010

Starter set of measures

Domain Beginning Measures*

Overuse

Low back pain: use of imaging studies

Appropriate Testing for Children With Pharyngitis

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

Appropriate treatment for children with upper respiratory infection (URI)

Population Health

Breast Cancer Screening

Cervical Cancer Screening

Colorectal Cancer Screening

Diabetes: HbA1c Management (Testing)

Diabetes: Cholesterol Management (Testing)

Cholesterol Management for Patients with Cardiovascular Conditions (Testing)

Use of appropriate medications for people with asthma

Persistence of Beta-Blocker Treatment After a Heart Attack

Safety Annual monitoring for patients on persistent medications

Care Coordination** 30-day all cause (risk-adjusted) readmission rate

* Most are HEDIS measures

** Test measure

15October, 2010

ACOs and Oncology Clinics – A Need for Cooperation and “Systemness”Need

ACOs need to organize/coordinate services and be accountable for quality and a budget

• For Primary Care inside the ACO

• For some Specialty Care inside the ACO

• For many types of Specialty care outside the ACO

Role for Oncology Clinics

High value/efficiency

• Proof that patients are provided with cost-effective care

• A single oncology clinic/group will likely serve several ACOs

• Possibly use of episode bundles for payment

High quality, efficient care

• What are the right outcomes to measure?

• Are those metrics available today?

16October, 2010

ACOs and Oncology Clinics

Many Oncology Clinics will:

Not be a part of the ACO medical staff

• ACOs will have mainly Primary Care MDs using a primary care team approach (NPs, PAs, MAs)

• Some medical specialists (e.g., cardiologists, endocrinologists)

Serve multiple ACOs

• In a large metropolitan area, competing Oncology groups/clinics

• Most efficient/highest quality groups will get more ACO referrals

• As ACOs monitor their budgets and quality scores, they will need cooperative specialist partners

17October, 2010

Oncology Clinic Challenges

Measuring quality of processes and outcomes

Are there useful measures today?

Who does the measurement?

Measuring efficiency

Does CMS measure efficiency for Medicare beneficiaries?

Do private plans or ACOs do the measurement for <65 enrollees?

What is the role of ACOs with new cancer treatments?

At what site should most treatment take place?

Who makes choices about expensive new technology (e.g., proton therapy)?

What role does Comparative Effectiveness play?

What role with the new Patient Centered Outcomes Research Institute (PCORI) under ACA play?

Will the EMRs of ACOs collect data for evaluation of treatment efficacy?

18October, 2010

Key Challenges for ACOs and Specialist Groups

Will “critical mass” of providers and clinics join?

Enough assigned patients?

Will there be a Clinic assignment for MediCaid members?

Will payers agree to participate?

Will private insurers partner with ACOs? Is they willing to do gain-sharing?

Are there enough savings to be found through ACO changes?

Will specialists (e.g., oncology) show enough savings?

Adequate financing for ACO start-up costs?

Infrastructure, IT, analysis, limiting ER use, etc.?

Foundation or health plan grants?

Can ACOs change patient behavior & provider culture?

No enrollment, no “lock-in”, no change in benefits?

Roll of the ACO for overall community population health (e.g., for obesity, smoking cessation, vaccinations, etc.)

What’s the role in prevention for the ACOs and Oncology clinics? Early treatment?

19October, 2010

Why ACOs Might Succeed (Over Time)

Broad, flexible system built on essential core principles

Lots of local variation possible within ACO concept

3 ACO Levels permit tailoring to different circumstances

Broadly applicable throughout the country, with “Training Wheels” for newly formed Level I ACOs

Level II offers more reward/more risk (but still limited)

Partial Capitation for highly sophisticated Level III entities, extending their model to FFS Medicare and PPOs

Pathway to fundamentally shift incentives from FFS revenue centers to population health & accountable care

Opportunity to change clinical and business environment

Timely data and analysis

Working collaboratively as part of a system of care

Patient involvement and responsibility

20October, 2010

Health Reform, Oncology’s Role in ACOs and ACO Physician / Hospital Alignment Options

21October, 2010

Health Reform and emphasis on Quality

22October, 2010

What’s Driving the Development of ACOs?

1. Medicare eliminated payment for never events beginning September 1, 2008.

2. The National Quality Forum list of never events is currently at 28 and continues to grow.

3. Legislation has also proposed tighter restrictions on payment for readmissions.

4. In the IPPS FY 2009 Final Rule, CMS included 10 categories of conditions that were selected for the Hospital Acquired Conditions payment reduction provision.

5. Private payers are also no longer paying for never events and selectively paying for hospital acquired conditions. Additionally, there is mounting evidence that commercial payers are shifting risk to the providers due to healthcare reform.

6. Demonstrations are already in effect for providing care outside of traditional settings.

7. Sustainable growth rate reimbursement continues to decline. Congress is looking for a permanent fix to this increasingly burdensome problem.

8. Demonstrations are already in effect for physician and hospital partnerships.

23October, 2010

Quality is going to BE the bottom line

• Prevention of sickness, resource consumption, redundancy, wasteful inputs

• Right care, right place, right time, right provider (based on outcome evidence)

• Reduced lengths of stay and unnecessary services (admissions; re-admissions)

• Reduced direct cost of care delivery; greater efficiency

• Reduced double-whammy of incurring costs for non-reimbursable preventable events

• Potential to earn/keep gains (or avoid penalties) in payment arrangements providing quality incentives

• Reduced risk of malpractice losses

• Competitive advantage as a provider of choice, fueling consumer demand & revenue growth

• Community health improvement; mission fulfillment

Anticipated Outcomes

24October, 2010

Who can be an ACO? The role of Specialty Cancer Hospitals and NCI CCCs

25October, 2010

What Forms of Organizations May Become an ACO?

1. Physicians and other professionals in group practices

2. Physicians and other professionals in networks of practices

3. Partnerships or joint venture arrangements between hospitals and physicians / professionals

4. Hospitals employing physicians / professionals

5. Other forms that the Secretary of Health and Human Services may determine appropriate

Source: Patient Protection and Affordable Care Act

Physician / Hospital ACO Example

Primary Care Physicians have the ability to create an ACO without including Hospitals and/or Specialists but do they have the resources, leverage and infrastructure to manage the risk inherent in ACOs.

Key Takeaway

26October, 2010

Reality Testing - ACO Organizational Requirements

1. Have a formal legal structure to receive and distribute shared savings.

2. Have a sufficient number of primary care professionals for the number of assigned beneficiaries (to be 5,000 at minimum).

3. Agree to participate in the program for not less than a 3-year period.

4. Have sufficient information regarding participating ACO health care professionals as the Secretary determines necessary to support beneficiary assignment and for the determination of payments for shared savings.

5. Have a leadership and management structure that includes clinical and administrative systems.

6. Have defined processes to (a) promote evidence-based medicine, (b) report the necessary data to evaluate quality and cost measures, and (c) coordinate care.

7. Demonstrate it meets patient-centeredness criteria, as determined by the Secretary.

Requirements #2 and #4 prevent Specialty Cancer Hospitals and NCI CCCs as acting as their own ACOs but they have the expertise and knowledge to cost effectively produce predictable outcomes for very complex diseases. They will have to prove they can do it at a sustainable cost level to become the preferred solution to many ACOs in the market.

Key Takeaway

27October, 2010

ACO Levels & Clinical Integration

• Improved access to care• Reduction in preventable ER visits and admissions

• Appropriate use of testing / referral

• Prevention and early diagnosis

• Improved efficiency of patient care

• Reduction of adverse events• Reduction in preventable readmissions

• Use of lower-cost treatment options

• Improved management of complex cases

• Use of lower-cost, high quality providers

• Use of lower-cost, more accessible settings and methods for delivery of care

• Coordinated health and social services support

ALTERNATIVE METHODS OF PAYMENTCapitationFFS + Shared Savings Bundled Payments Global Payments

CLINICAL INTEGRATION(Additive Levels of Healthcare Providers)

CO

ST

RE

DU

CT

ION

OP

PO

RT

UN

ITIE

S Oncology’s Involvement in ACOs

28October, 2010

Cancer’s Role in ACOs

It is important to recognize that the goal of an ACO is to take responsibility for managing the costs and quality of care provided, not providing the care itself.

What does this mean for hospitals and specialists?

•Hospitals: It can be beneficial to have a hospital in an ACO if the hospital is committed to the goals of the ACO of reducing costs and improving quality.

•Specialists: Specialists will have an important role in patient care, but their services do not necessarily need to be part of the ACO itself.

What does this mean for Specialty Cancer Hospitals and NCI CCCs?

29October, 2010

Specialty Cancer Hospital ACO Role Option #1

DentonFrisco &

McKinney

Fort Worth Dallas

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Hospital

Internist

Oncologist

Cardiac SurgeonInternist

Family Practice

Hospital

Internist

Oncologist


Family Practice

Hospital

Internist

Oncologist


Family Practice

SCH

•ACOs are formed without including Specialty Cancer Hospitals (SCH). •ACOs contract with the SCH for specialty cancer cases.

Option Summary

Dallas / Fort Worth Metroplex

•The SCH will have to demonstrate high quality, cost-effective care to be attractive for ACOs to refer their patient population to the SCH.•To off-set lower patient admission rates, the SCH:

• Will have to establish arrangements such as gain-sharing with their hospitalists and specialists to find ways to cut costs; and / or

• Will have to specialize in treating more complex cancer patients to prevent outmigration of cases to NCI CCCs.

SCH Position

30October, 2010

Specialty Cancer Hospital ACO Role Option #2

Hospital

Internist

Oncologist


Family Practice

Hospital

Internist

Oncologist


Family Practice

Hospital

Internist

Oncologist


Family Practice

Fort Worth

DallasDenton

Frisco &McKinney

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Specialty Cancer

Hospital

•ACOs are formed including Specialty Cancer Hospitals (SCH). •The SCH assists in coordinating care for several ACO patient populations.

Option Summary

•With its extensive administrative resources and skills, ranging from information technology to finance to quality improvement tools, the SCH is in the position to facilitate the coordination of cancer care in ACOs, instead of participating in cancer delivery at the whim of other ACOs as in Option #1.

SCH Position

31October, 2010

NCI CCC Multiple ACO Referral Model

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

NCI CCC designation

•ACOs contract with NCI CCCs in the region (if not nationally) for highly-specialized cancer cases.•The NCI CCC will accept bundled / episode payments from the referring ACOs.

Summary

•Like the SCH, the NCI CCC will have to demonstrate high quality, cost-effective care.•The NCI CCC will have to develop “Delivery Care Teams” for specific types of cancer care to develop high quality, cost-effective care pathways.

NCI CCC Position

32October, 2010

NCI CCC Multiple ACO Referral Model

However, if a NCI CCC can provide cancer care for a specialty at the same or higher quality and lower costs than other NCI CCCs, ACOs will have the incentive to refer their patient population to that NCI CCC for that specialty because the ACO will be rewarded for reducing care delivery costs.

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

Hospital

Internist

Oncologist

Cardiac Surgeon

Internist

Family Practice

NCI CCC designation

33October, 2010

Why Hospitals and Physicians MUST align their collective goals and, thus, their incentive systems

Why Hospitals need Physicians

•Risk shift by payer to provider•Incentive model has changed-focus on quality and outcomes with physicians at the table•U.S. hospital market is under significant financial pressure•Accelerated and magnified due to health reform

Why Physicians Need Hospitals

• Lower reimbursement both for Part B & Technical/Facility •Ongoing significant Capital Needs (EMR/EHR) •Ability to drive quality out of a high cost environment•Need to integrate along the entire continuum of care•Need for Professional Management in Risk Environment

34October, 2010

ACO Physician/Hospital Organizational Designs

35October, 2010

Criteria for a Successful Model

1. Model facilitates alignment between physicians and hospitals;

2. Physician compensation structure will align the incentives of productivity, quality, cost and outcome;

3. Ensure physician engagement and leadership in the organization;

4. Develop data systems that support data exchange, co-management and measurement of longitudinal outcomes and costs; and,

5. Retain an element of flexibility that will allow the model to adapt as the rules of the game continue to change.

Most Common Alignment Models

36October, 2010

Primary Options for Physician/Hospital Alignment

1. Integrated Delivery Systems

• Provider Based Clinics

• Hospital Affiliated Group Practice

• Employing Physicians (Not Provider Based)

• Hospital Outpatient Department Contracting with Physician Group (Either Hospital Affiliated or Independent) (Provider Based)

• Medical Foundation (Not Provider Based)

• Group Practice Joint Venture

2. Physician-Hospital Organizations via Joint Ventures

• Group Practice

• Diagnostic Services

• PHO (Physician Hospital Organization)

3. Co-Management Company (w or w/o PHO)

Most Common Alignment Models

37October, 2010

Clinical/Service Line Co-Management Company

38October, 2010

What is the Co-Management Model?

1. The Hospital and Physicians would form a new entity in a joint venture (Management Company) that would contract with the Hospital to manage the a Service Line.

2. Ownership in Management Company would be scalable between the Hospital and the Physicians.

3. The compensation for services provided by Management Company would include both fixed and incentive components such as:

• Base Management Fee

• Incentive Compensation

4. Initial capital to form the entity would be limited.

5. Income from operations would be shared based on the investors’ proportional share.

39October, 2010

Co-Management Company Model Overview

Service Line

Hospital Physicians

Compensation

Co-Management Company LLC

• Base management fees• Director fees• Incentive compensation

Se

rvic

e C

on

tra

ct

to M

an

ag

e

X% X%

40October, 2010

Pros HOPD reimbursement rate maintained for OP services

delivered on campus

Quick to execute. No construction.

Potential to increase physician productivity, through improved operational and clinical outcomes.

Provides “Flexibility” to Hospital and Physicians for future collaborative initiatives

Strong model for initiating Hospital/Physician alignment and collaboration

Improved communication between Hospital and Physicians

Creates a mechanism for Physicians to play an active role in managing the service line

Financial returns from the management company could be realized shortly after launch

Limited capital investment requirements, limits physicians ‘at-risk’ investment.

No current issues of uncertainty because of regulatory issues (Medicare, IRS, etc…)

Provides access to capital for acquisition of technology, without duplicating resources.

Win/Win for Physicians and Hospital

Cons Not a passive investment, requires active participation

by the physicians.

Lack of familiarity with the management company concept.

Based upon the net revenues and physician interviews, there may not be enough of a monetary return to satisfy the physicians.

Co-Management Company

Co Management Company Model

41October, 2010

Co-Management Model Compensation Components

Base Management Fee

Medical Director

Fees

Day-to-Day Operations Oversight

Incentive Compensation

Budgetary(1) Objectives

Quality of Service Incentives

Operational(1) Efficiency Incentives

New Program

Development

Board Participation

Finance Committee

Participation

Operating Committee

Participation

(1) Subject to Legal and Regulatory limitations

Quality Thresholds

42October, 2010

Slide 42

Model options for hospital/physician alignment

PHOPhysiciansHospital

z

Service Contract

to Manage

X% X%


- Any profits of PHO are split 50/50 between Hospital and

Physician owners

Co Management Company Model with PHO

Payers

43October, 2010

Hospital-Physician Shared Service Joint Venture

Hospital Cardiology/Orthopedic/Oncology Group Practice

(must be located in same buildingas turn-key service)

Diagnostic/Other Services Supplier (MRI, 256 Slice CT,

PET/CT, Linear Accelerator, Gamma Knife)

Payors

Total services management including facility space,

personnel and equipment lease with group practice and hospital

Pass-through technical fees as

rental payment/ management fee

Pass-through technical fees as

rental payment/ management fee

Hospital bills as service provided “under arrangements”

Professional and technical services are billed under group practice’s provider number

•LLC would furnish service to hospital commercial patients under arrangements, serve as a turnkey supplier to physician group for Medicare patients.

•Supplier would bill hospital and physician group on a FMV, per click basis.

•Hospital will bill commercial payors as a service provided “under arrangements”; physician owners CANNOT refer hospital Medicare patients to receive hospital services “under arrangements”.

Model Summary

44October, 2010

Group Practice Joint Venture

Hospital Physicians / Physician Group

Medical Group Practice(MRI & CT)

Payors

Hospital and physicians share net income from technical services based on equity interests in the Group Practice

Professional and technical services are billed under group practice’s provider number

•Hospital buys into Physician Group Practice.

•Physician Group Practice acquires space, equipment and personnel necessary to provide MRI, 64 Slice CT services.

•Physician Group Practice employs physicians.

•Physicians are paid 100% of professional fees as base compensation.

•Technical service income is paid to Hospital and Physician owners based upon equity split.

Model Summary

45October, 2010

Integrated Delivery Systems

46October, 2010

Integrated Delivery Systems in Practice – Pros and Cons

Hospital / Health System

Physicians$

Practice Assets

•Provides greater control of physicians’ practice and referrals

•Reduces areas of hospital and physician conflict and competition

•Improve patient care and clinical outcomes

•Create operational efficiencies and drive high costs out of the health system

•Rapidly attract new services and technology to the market

•Possible conversion to provider based status

•Less fraud and abuse and anti-kickback risk

+ Pros

•Operational costs can be significant

•Difficult to include certain specialists in income opportunities from ancillary services

•Developing compliant productivity compensation models can be difficult

•Hospital is liable for physician malpractice

•Physicians may view employment as reducing their autonomy and control of their practice

•Possible disadvantages of provider based status (higher co-pays, patient confusion, etc)

- Cons

47October, 2010

Provider Based Clinics: Hospital Outpatient Department Contracting with Physician

Parent

Hospital

Hospital Division

Outpatient Dept. Group Practice

DivisionPhysician Group

Patients / Payors

Lease of Practice Assets

Professional Services Agreement

•“In house” medical foundation. Group Practice Program operated as outpatient department and division of Hospital.

•Hospital receives facility fee for outpatient department “clinic” services. Physician fees subject to site of service differential.

•Hospital buys or leases practice assets from the Physician Group for its outpatient department.

•Term of lease is coincident with term of Professional Services Agreement.

•Outpatient Group Practice Division obtains physician coverage through Professional Services Agreement with Physician Group. Hospital does not employ physicians.

•Subject to hospital licensing and JCAHO requirements.

•Subject to medical staff oversight.

Model Summary

48October, 2010

Hospital Affiliated Group Practice Employing Physicians (Not Provider Based)

Parent

Hospital Group Practice

Patients / Payors

Group Practice Program

Affiliate

Board of Directors

Chief Administrative OfficerMedical Director

Participating Physicians (Clinic Employees)

•Group Practice buys or leases practice assets and employs physicians, owns and operates Group Practice Program.

•Physicians are paid market (private practice competitive) compensation, usually net income/productivity-based.

•Most health systems have structured or restructured their affiliated group practices as tax exempt organizations so that the health systems can provide ongoing funding of the losses that these group practices usually generate

•Usually multiple practice sites.

Model Summary

49October, 2010

Medical Foundation: Hospital Affiliated Tax-Exempt Group Practice (Not Provider Based)

Parent

HospitalMedical

FoundationMD, Inc.

Patients / Payors

Managed Care Agreements

Professional Services Agreement

Group Practice Program

•Structure/Ownership• Affiliate of Hospital• Tax exempt – 501(c)(3)

•Function• Operates Group practice• Owns or leases practice sites/equipment• Employs all non-physician personnel• Bills in own name with its provider number

•Capital• Significant

Medical Foundation

•Structure/Ownership• Professional corporation• Wholly owned by physicians• Primary or multi-specialty

•Function• Provides physician services to medical foundation

pursuant to Professional Service Agreement• Employs individual physicians

•Capital• Relatively small

MD, Inc.

50October, 2010

Foundation Model – Key Tenets

The Medical Foundation model involves two entities – a medical foundation and one or more contracting medical groups.

The Medical Foundation itself would be established as a tax-exempt 501(c)(3) corporation.

The medical group (or groups) contracting with the medical foundation should either be a partnership or (preferably) a professional corporation.

The Medical Foundation and the medical group are tied together through a Professional Services Agreement (“PSA”) whereby the medical group provides professional services to the medical foundation’s patients.

In conjunction with the development of the Medical Foundation, the Foundation could purchase the assets of the medical groups. Fair market value compensation for the acquired assets would be paid to the medical groups.

51October, 2010

Strengths and Weaknesses of the Foundation Model

Strengths

• Reduced Success for a Legal Challenge Once Established

• Patients and Medical Records Owned by Foundation

• Access to Ancillary Income for Ambulatory Services

• Managed Care Contracting by Foundation

• Beneficial Tax Treatment

• Superior Physician Recruitment

• Possible practice Asset Acquisition provides Capital to Physicians

• Ease of Practice Management

Weaknesses

• Will take time to establish

• Physician Recruitment Success Crucial to Formation

• Possibility of Legal Challenge to Physician Recruitment

• Required by law to conduct research and education

• Other Filing, Legal and Accounting Costs

• Governance of Foundation is dictated by state law and, in certain states, the number of physicians directors may be limited.

52October, 2010

ACO Organizational Design Option Summary

53October, 2010

Clinical Co-Management Models PHO via Joint Ventures Integrated Delivery System (IDS)¹

1. Inclusive model for all physicians.2. Quick to execute; no construction.3. Strong model for initiating hospital

/ physician alignment and collaboration.

4. Improved communication between hospital and physicians.

5. Provides “flexibility” to hospital and physicians for future collaborative initiatives.

1. Physicians have improved operating efficiencies with potential increased productivity.

2. True medical management and aligned incentives.

3. Secure physician relationships.4. Improved capital deployment.5. Tracks and uses data to manage

the delivery system.6. Step to greater integration between

a hospital and its medical staff.

1. Aligns mission and strategic planning.

2. Best model to take full advantage of healthcare trends.

3. Ability to share risks and rewards.4. Shared enterprise and

transparency.5. Ease of practice management.6. Less fraud and abuse and anti-

kickback risk.7. More access to capital.

1. May not provide the strategic long term economic solution.

2. Management company has historically been focused at the service line, not towards a more comprehensive scope.

3. Lack of familiarity with the management company concept can create apprehension.

1. Different cultures and management styles result in poor integration and co-operation.

2. The ability to affect provider behavior is rather limited.

3. The partners may not provide enough leadership and support in the early stages.

1. Considerable amount of time and start-up capital.

2. Less physician “skin in the game”.3. Less physician control.

Str

en

gth

sW

ea

kn

es

se

s

Multi-Specialty

Possible Yes Yes

Level of Consolidation

Generally Fragmented Generally Fragmented Consolidated

Summary of ACO Organizational Design Options

¹ Includes Medical Foundations, Physician Employment and Academic Medical Centers

54October, 2010

Infrastructure necessary for ACO implementation

Co-Management

Models

PHO via Joint Ventures

Integrated Delivery

Systems¹

Joint governance Not likely Likely exists Likely exists

Aligned Incentives Likely exists Likely exists Likely exists

Shared Risk bonus settlement Possible Likely exists Develop process

Management Not Likely Not likely Likely exists

Pharmacy/device formal joint relationship Not likely Possible Optional

Physician-owned entities Possible Possible Optional

Primary Care Practitioner inclusion Possible Possible Likely exists

Management of patients out of network Not likely Not likely Likely exists

ACO provider contracting & co-ordination Not likely Not likely Develop process

Target negotiation and budget tracking Not likely Likely exists Likely exists

Strategic planning Not likely Not likely Likely exists

Payer contracting process Not likely Likely exists Likely exists

Strong care coordination and utilization management Possible Likely exists Likely exists

Quality and efficiency metrics analysis Likely Likely exists Likely exists

Access to analytical data & claims data Not likely Likely exists Develop process

Information Technology platform Not likely Likely exists Likely exists

ACO Design Options & Infrastructure Requirements

¹ Includes Medical Foundations, Physician Employment and Academic Medical Centers

55October, 2010

Challenges to ACO Implementation

56October, 2010

Critical Success Factors for Implementing an ACO

1. Strong, collaborative physician and management leadership across the organization.

2. A structure for joint decision-making that facilitates physician-hospital alignment.

3. Leadership demonstrating financial acuity to manage the reimbursement transitions towards an ACO.

4. Systems and efficient processes in place to support data exchange and measure quality and cost across the system / continuum.

5. Improved efficiency and efficacy through care management, use of clinical pathways, and dedicated hospital-based teams.

6. An ability for the organization to approach payors as an integrated (if not virtual) system.

7. An organizational culture focused on redesigning clinical care delivery across the system and improving efficiency and quality of care.

8. Compensation that aligns incentives and rewards desired outcomes in quality, costs and efficiency.

9. Large PCP integrated model and elimination of all points in Chronic Care Disease Management where the patient falls between the caregiver gaps and robust medical home model.

57October, 2010

Barriers for ACO Design & Implementation

1. Overcoming physician cultural barriers that reward a high degree of professional autonomy and individual responsibility;

2. Keep the patient population from obtaining care outside of the ACO (relationship) network;

3. Defining and measuring quality and resource costs for procedures;

4. Determining how quality scores and resource scores will interact to determine bonuses and penalties; and

5. Setting individual ACO’s resource use targets.

6. Integration of physician (non-lay) leadership into all levels of the IDN system and resources and systems to truly manage healthcare delivery risk.

58October, 2010

ACO Implications & Risks

Risks

1. Hospitals need to be part of the change or physicians will take the initiative and view hospitals as commodities.

2. The desire for hospitals to remain in control instead of truly partnering with physicians could limit the success of the ACO.

3.a. Excess capacity of hospitals will increase costs, causing poor performing hospitals to close.

3.b. Physicians that do not meet quality and resource targets could be excluded from the ACO.

4. Care models change before the payments are aligned, leading to negative financial results.

Implications

1. ACOs can be led by physicians or by a partnership between hospitals and physicians.

2. As an ACO, hospitals are part of a coordinated team that identifies the best, most appropriate care for the patient.

3. The ACO may not require all of the current hospital capacity or clinicians due to reduced utilization and increased coordination of patient care.

4. Fee-for-service reimbursement will be decreasing, so providers must change how they manage patient health to mitigate financial impacts.

59October, 2010

What should organizations do now to prepare?

1. Identify a champion in your organization who will take responsibility for leading the change

2. Assess your current situation and the gap to become an ACO. This includes understanding the current care paths patients take, the degree of variation, and key providers and care locations

3. Identify key stakeholders and build a shared need to work together to accomplish the vision.

4. Create or modify a structure that will allow for change.

5. Create or modify the infrastructure to support the new needs.

6. Start with specific patient populations to pilot within the organization. Build on employed / staff physician groups to pilot new care delivery processes.

7. Use Co-Management and a vehicle to align specialists and PCPs around disease specific quality improvement initiatives to align the financial incentives and build a platform for shared governance and management.

8. Use a PHO in combination with a Co-Management to test pilots or demonstrations with commercial, state and institutions to share the risk and benefits of care delivery around

populations or specific diseases.

60October, 2010

ACO Pilots and US Oncology: What are they doing?

61October, 2010

Questions?

© 2010 PricewaterhouseCoopers LLP. All rights reserved. “PricewaterhouseCoopers” refers to PricewaterhouseCoopers LLP, a Delaware limited liability partnership, or, as the context requires, the PricewaterhouseCoopers global network or other member firms of the network, each of which is a separate and independent legal entity. This document is for general informational purposes only and should not be used as a substitute for consultation with professional advisors.

www.pwc.com/healthreformwww.pwc.com/hriwww.pwc.com/healthcarewww.pwc.com/pharma

62October, 2010

Other Possible Slides

63October, 2010

Definition of an Accountable Care Organization

A combination of providers associated with a defined population of patients accountable for total spending and quality of care for that patient population.

Bonus for high quality and low cost growth• Bonus is a percentage of FFS payments• High quality is meeting benchmarks (e.g. mortality, readmissions)• Cost growth is the rate of increase in overall Medicare spending per

beneficiary assigned to the ACO

Possible penalty for low quality and high cost growth

64October, 2010

Key Elements of an ACO Model

Local Accountability• Foster provider accountability for quality and per capita cost for their patient population

Standardized Performance Measurement• Increased accountability on the part of providers should be accompanied

by improved incentives and information for consumers

Payment Reform• Transition payments from rewarding volume/intensity to increasing value• Payments should encourage collaboration and shared responsibility among providers and consistent incentives from payors

65October, 2010

Goals & Accountability

The goal and core of a successful ACO is effective primary care

Some of the most important mechanisms for reducing and slowing the growth in specialty and hospital expenditures are prevention, early diagnosis, chronic disease management, and other tools which are delivered through primary care practices in collaboration with specialists and institutions.

ACOs are accountable for managing performance, not insurance, risk

Although ACOs should accept responsibility for reducing costs, they should not be expected to take on insurance risk, that is, the risk associated with whether the patients who come to them are sick or well. ACOs should manage performance risk; the ability to successfully treat an illness in a cost-effective way.

66October, 2010

How do ACOs complement Medical Homes and Bundling?

Inpatient Care Efficiency

Use of Lower-Cost

TreatmentsAdverse Events

Preventable Admissions

Preventable ER Visits and AdmissionsUnnecessary

Testing and Referrals

Practice Efficiency

Prevention and Early

Diagnosis

Management of Complex

Cases

Use of Lower-Cost Settings & Providers

Lower Total

Healthcare Costs

All Providers

BUNDLING

MEDICAL HOME

ACCOUNTABLE CARE ORGANIZATION

Primary Care Specialists

Hospitals and Specialists

Source: Harold D. Miller, “How to Create Accountable Care Organizations.” Center for Health Care Quality and Payment Reform.

67October, 2010

Definition of a Medical Home

Medical Home is a clinical setting with the capability to improve care coordination and follow evidence-based guidelines; it services as the central resource for a patient’s ongoing care.

Medical Homes should have the following capabilities:• Furnish primary care;• Conduct care management;• Use health IT for active clinical decision support;

• Have a formal quality improvement program;• Maintain 24-hour patient communication and rapid access; and,• Keep up-to-date records of beneficiaries' advance directives.• Ability of the ACO to monitor patient adherence to chronic disease health status

indicators and wellness criteria on a “near real time basis.” Example: remote monitoring.

68October, 2010

Definition of Bundled Payments

Medicare would pay a single provider entity composed of a hospital and its affiliated physicians an amount intended to cover the costs of providing the full range of care needed over the episode.

Providers would not only be motivated to contain their own costs but also would have a financial incentive to collaborate with their partners to improve their collective performance.

Providers involved in the episode could develop a new ways to allocate this payment among themselves. This flexibility gives providers a greater incentive to work together and to be mindful of the impact their service use has on the overall quality of care, the volume of services provided, and the cost of providing each service.

69October, 2010

Integrating Care through ACOs

HospitalsPCP

Group

Specialty Group

Other Providers

Home Health

Services

Mental Health Facility

Other Providers

Community Services & Support (e.g.

transportation, translation services)

Wellness Initiatives (e.g. smoking cessation,

nutrition)

Health Plans

Implementation challenges:•Inability to effectively manage risk•Lack of infrastructure for providing and using reliable and timely cost and quality information to support care management •Lack of collegiality and collaboration among physicians

Illustrative ACOOther Providers Outside

the ACO

70October, 2010

Setting ACO Spending Targets

To allow providers in all regions to potentially benefit from the ACO model, the financial incentives would need to be based on changes in spending rather than on levels of spending.

However, in measuring changes in spending, low-resource-use ACOs could be at a disadvantage as they would have fewer opportunities for efficiency gains.

To address this, every ACO could have an allowance for spending growth per capita that is adjusted for area wage rates but not for regional differences in utilization.

71October, 2010

Setting ACO Spending Targets

Spending Targets for ACOs with Different Base Spending Levels

National Average

Low-use ACO

Average ACO

High-use ACO

Base spending per capita $10,000 $7,000 $10,000 $12,000

Dollar allowance for spending growth $500 $500 $500 $500

Target spending $10,500 $7,500 $10,500 $12,500

Percent increase 5.0% 7.1% 5.0% 4.2%

The purpose of the low-use ACO having a higher percentage increase than the national average is to reward the ACO for its historically low resource use

The fixed dollar allowance puts the high-use ACO under greater pressure to meet its target through efficiency gains. Reductions at the high-use ACO should be possible given the ACO’s high starting level of resource use.

72October, 2010

How does the ACO “Shared Savings” Model Work?

Initial shared savings derived from spending below benchmarks

ACO Launch

Projected Spending

Spending Benchmark

Actual Spending

Shared Savings

0

20

40

60

80

100

120

140

1994 1995 1996 1997 1998 1999 2000 2001

Sp

end

ing

Time

73October, 2010

Potential Bonus and Penalty Criteria for ACOs on a Multi-year Basis

Meets Target in All Three Years

Mixed Performance on Target

Fails Target in All Three Years

Meets Target in All Three Years

Return withhold and share of savings

(bonus)Return withhold

Withhold not returned (penalty)

Mixed Performance on Target

Return withhold Return withholdWithhold not returned

(penalty)

Fails Target in All Three Years

Return withhold Return withhold Withhold not returned (penalty)

Quality over Three Years

Res

ou

rce

Use

ove

r T

hre

e Y

ears

74October, 2010

ACO Organizational Designs

ACO configurations will vary reflecting the diversity of local markets. However, several characteristics are essential for all ACOs:

1. Can provide or manage the continuum of care for patients as a real or virtually integrated delivery system.

2. Are of sufficient size to support comprehensive performance measurement and expenditure projections.

3. Are capable of internally distributing shared savings and prospectively planning budgets and resource needs.

75October, 2010

Evolution of Payment Reform

Past and Emerging Models of Accountability in Provider Payments

Supporting Better Performance Paying For Better Performance Paying For Higher Value

Pay forreporting

Payment forreporting onspecificmeasures ofcare. Dataprimarilyclaims-based.

Payment for coordination Case management fee based on practice capabilities to support preventive and chronic disease care (e.g., medical home, interoperable HIT capacity).

Pay for performance

Provider fees tied to one or more objective measures of performance (e.g., guideline based payment, nonpayment for preventable complications).

Episode based payments

Case payment for a particular procedure or condition(s) based on quality and cost.

Shared savings with quality improvement

Providers share in savings due to better care coordination and disease management.

Partial or full capitation with quality incentives

Systems of care assume responsibility for patients across providers and settings over time.

Where are we now?

Pay for PerformanceValue-BasedPurchasing

Bundled/Global Reimbursement

Accountable Care Orgs.

76October, 2010

Quality of Care Drivers

The forces:

77October, 2010

Quality of Care

Readmissions: Beginning in FY 2013, the final bill imposes financial penalties on hospitals for so-called “excess” readmissions when compared to “expected” levels of readmissions based on the 30-day readmission measures for acute myocardial infarction (AMI), heart failure (HF) and pneumonia that are currently part of the Medicare pay-for-reporting program.

Value-Based Purchasing: The final bill establishes a VBP program for hospital payments beginning in FY 2013 based on hospitals’ performance in 2012 on measures that are part of the hospital quality reporting program. The value-based purchasing program (VBP) will begin to measure hospitals on efficiency, patient satisfaction and the quality of care around five conditions and procedures:

1. Acute myocardial infarction (AMI)2. Heart failure3. Pneumonia4. Surgery-associated infections (SCIP)5. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Hospital-Acquired Conditions (HACs): Beginning in FY 2015, the final bill adds a 1% penalty to hospitals in the top quartile of rates of HACs, resulting in nationwide reductions of $1.5 billion over 10 years.

78October, 2010

Quality of Care, Cont’d

Key concepts in VBP methodology:

• Replaces the current quality reporting program.

• Within the Inpatient Prospective Payment System (IPPS) there will be a “withhold” of 1-2% on DRG payments.

• Hospitals will “earn” that percentage back based on performance.

• Includes both public reporting and financial incentives for better performance as tools to drive improvements in:

• Clinical quality;

• Patient-centeredness; and,

• Efficiency.

79October, 2010

Map of National Cancer Institute Comprehensive Cancer Centers (NCI CCCs)

NCI CCC designation

80October, 2010


• HOPD reimbursement rate maintained for OP services delivered on campus.

• Quick to execute. No construction.

• Potential to increase physician productivity, through improved operational and clinical outcomes.

• Provides “Flexibility” to Hospital and Physicians for future collaborative initiatives.

• Strong model for initiating Hospital/Physician alignment and collaboration.

• Improved communication between Hospital and Physicians.

• Creates a mechanism for Physicians to play an active role in managing the service line.

• Financial returns from the management company could be realized shortly after launch.

• Limited capital investment requirements, limits physicians ‘at-risk’ investment.

• No current issues of uncertainty because of regulatory issues (Medicare, IRS, etc…).

• Provides access to capital for acquisition of technology, without duplicating resources.

• Win/Win for Physicians and Hospital.

• Not a passive investment, requires active participation by the physicians.

• Lack of familiarity with the management company concept.

• Based upon the net revenues and physician interviews, there may not be enough of a monetary return to satisfy the physicians.

Pro

s

Co

ns

The Medicare Shared Savings Program & Accountable Care

Organizations (ACOs)

Copyright © 2010 US Oncology, Inc. All rights reserved. 83

Accountable Care Organizations – Concept Concept to align provider incentives toward integration, quality

and efficiency – included in health reform legislation What is an ACO?

Physician groups Networks of physician groups JVs between hospitals/physicians Hospitals with employed physicians Integrated delivery systems

Voluntary participation ACO is to manage and coordinate care of a defined patient

population and will share in Medicare savings


ACOs – The Legislation

Medicare Shared Savings Program ACOs (physicians, physician network, hospital/physician JVs)

demonstrating quality share in Medicare cost savings Does NOT require hospital-physician integration Benchmarks set for expected spending across Parts A and B for ACO

patient population, adjusted for expected cost growth ACO-participating providers continue to be paid on FFS basis ACOs with per beneficiary spending less than 98% of benchmark

would be paid 50% of Medicare savings House version: option to choose capitation (not in final) House version: exemption from new SGR-like expenditure targets

(not in final)


There is no ACO Without Physicians Common thread

Physicians who manage the care of patients, at least 5,000 Medicare beneficiaries

Physicians

With or without other providers (ie, hospitals, other physicians)

Patient costs attributed to an ACO on the basis of the physician who provides the most primary care services to a patient

Not possible for an ACO to take credit for a patient managed by a non-participant


Why Form/Join an ACO?

Opportunity for margin creation in the Medicare book of business Reimbursement for things that don’t happen like ER visits,

hospitalizations, futile EOL interventions Reimbursement for using lower cost/equally effective regimens

Lessens importance of Medicare’s continued downward pressure on unit payments rates for oncology

Incentives to coordinate your patients’ care across settings Requires investments in staff and resources otherwise not reimbursed

Potential for referral development through partnerships with referring physicians

Potential future exemption from new SGR-like national expenditure targets, if SGR reform is ever passed


There Can Be Oncology-Specific ACOs

While the MSSP does contemplate the formation of ACOs that include hospitals, the Congress also expressly desires the creation of ACOs that are principally composed of physician groups, even specialty physician groups

Congress desires flexibility to test different models for the MSSP so as not to leave any potential efficiency on the table

The legislation offers a broad view of the MSSP and ACO concept in which oncologists could band together to form an oncology-specific ACO without the participation of a hospital or other providers


What Ways & Means Says About ACOs


ACOs – The Hospital Response

Some hospitals are saying:

Physicians must join a strong network to prepare themselves for the new environment

Physicians without strong capital, HIT, research, clinical partners will be lost in the new environment

Hospitals should serve as the core of a local ACO Physician should join their local hospital through employment

agreements or other arrangements to benefits from new funding sources where the hospital is the gatekeeper

Everyone should look like Geisinger, Billings Clinic, Intermountain Healthcare…or else


Hospital-Centric ACOs Hospital line can only be true if the physicians make it so

Physicians hold the card in the discussion if they choose

What to consider before joining a hospital-centric ACO:

Cancer care is very expensive per capita and there are numerous ways to impact those costs

Per capita value to an ACO of an oncologist is far greater than other physicians, even other specialists

Participation in a hospital-centric ACO may dilute value

Bottom line: Know and understand your value


ACO Frequently Asked Questions Do you have to have a hospital partner to provide the full episode of care through

an ACO? No. No version of the ACO policy requires hospital participation.

Are hospital systems that have acquired physicians more viable than physician groups for the development of ACOs? No but they are equally viable.

Can I participate in more than one ACO? No, but you may provide care to patients served by an ACO in which you are

not a participant. How is a beneficiary assigned to an ACO?

On the basis on the physician that provided the most primary care services (E&M as a proxy) to the beneficiary during the year.

What happens if I have an expensive outlier case? It would offset any gains from savings created. Mitigates toward joining a

larger ACO to spread outlier risk across a larger pool.


ACO Frequently Asked Questions (cont.) How can we form/participate in the ACO in our market or develop one specific to

our group? A physician group or network of physician groups may form an ACO if it

manages care for at least 5,000 Medicare beneficiaries and creates a structure that allows for distribution of performance payments.

Do we have to align with other physicians to develop an ACO? No but you may choose to do so for a variety of reasons, ACO-specific or not.

Will all of the funds for the care of patients affiliated with an ACO be managed by a hospital? No. Physicians and other providers participating in an ACO will continue to be

paid on a fee-for-service basis. Performance payments accruing to the ACO pursuant to Medicare savings will be distributed through the structure agreed to between the ACO and the participant.

Is ACO participation mandatory? No. Participation is voluntary.

Questions/Discussion

Agenda What is an Accountable Care Organization?

Documents

Transcript of Agenda What is an Accountable Care Organization?