Better Care Outcomes: Financial Performance in Clinically ... · Value-Based Contracts Reward...

Better Care Outcomes: Financial Performance in Clinically Integrated Networks

Tim Gronniger, MPP, MHA

Sr VP Strategy and Development

Caravan Health

Kansas City, MO

Anna Loengard, MD

Chief Medial Officer

Caravan Health

Berkeley, CA

Tim Gronniger and Anna Loengard, MD do not have any financial conflicts to report at this time.

©2018 MGMA. All rights reserved.

Learning Objectives

• Review the strengths, weaknesses, opportunities and threats related to developing a CIN

• Identify the basic components and structure of a CIN

• Describe a process with steps needed to establish an effective CIN

3

Background

©2018 MGMA. All rights reserved. 4

5

Everyone Needs to Join a Team

Value-Based Contracts Reward Clinical Integration• PCPs are the heart of the network• Hospitals are the soul (and usually the sole source of

funds)• Specialists are the frosting on the cake

Your Network May Already Be Under Attack

If You Lose Your Network, You Lose…• Communication across providers• Referrals• Reputation• Contracting opportunities


Medicare Changes Help Physicians and Beneficiaries

• The Medicare population has changed since 1965 when the program began:

• People are living on average 10 years longer, with 65% having 2+ chronic conditions - which accounts for 93% of Medicare costs

• Medicare, designed as a safety net for acute medical problems, needs to evolve for our aging population

• Value-based care is part of this movement to make Medicare financially sustainable

• Payment models will require physicians to be accountable for cost and quality

Life expectancy in 1965

Life Expectancy in 2017

70 80


CIN SWOTStrengths, Weaknesses, Opportunities and Threats


Exercise- CIN SWOT AnalysisINTERNAL FACTORS

STRENGTHS (+) WEAKNESSES (-)

What you're good at, assets and resources, and how these positive attributes are perceived by others.

Talk about improvements that are needed, any resources that are lacking you lack, and how these negative attributes might be perceived by others.

EXTERNAL FACTORSOPPORTUNITIES (+) THREATS (-)

Doors that are currently open to you, opportunities you can capitalize on, and how your strengths can create new connections.

List any harmful hazards, competitors, and how known weaknesses can open the door to threats.


ExerciseCIN SWOT Analysis - Strengths

Physicians can partner with hospitals and other partners who have capital to fund

infrastructure where clinicians do not

Partner IT support is criticalto population health success

Program drives positive impact on community health and aligns with mission and organizational goals

Integration with case management and post-acute care is critical

Culture of quality reportingand improvement

Hospitals have employed physicians


ExerciseCIN SWOT Analysis: Weaknesses

Many Physicians unaware of MACRA/MIPS impact

Independent physicians must align for success in MACRA

Some difficult relationshipsand mistrust between hospitals and clinicians

Costs may notbe repaid from shared savings


ExerciseCIN Analysis: Threats

PCPs can only chooseone Medicare ACO

Competition from ACOs who want to organize PCPs without hospital (Aledade, Privia, etc.)

Poor physician compareresults will affect elective procedure revenue

Part B fee schedulefrozen at 2015 rates

Declining inpatient revenues worsened by managing care

Value-basedpurchasing penalties


ExerciseCIN SWOT Analysis: Opportunities

1

2

3

4

56

7

8

9

10 Adoption of Stark and Anti-Kickbackwaivers through ACO

Capture PCP/populationaligned referral base

Improve outcomes for community

Receive data from Medicare for FFS lives

Build confidence in population health/CIN strategy

Population Health improves in-network utilization

New population health revenue

Improved results under value-based purchasing – lower

penaltiesCreate more open beds formore profitable admissions

New value-based revenuein ACO or bundles


CINComponents and Structure


14

What Does a CIN Do for You?• Establishes a network of providers that enables enhanced

coordination of care.• Creates a new partnership model with employed and

independent physicians that includes defined roles for physician leadership.

• Defines performance improvement initiatives to provide demonstrated value to the market.

• Provides a platform for joint contracting to support care redesign and performance improvement initiatives.

• Negotiates with potential partners for risk-based contracts.


Organizational Structure

• Limited Liability Company (“LLC”)• LLC Operating Agreement

Ownership InterestsBoard Composition and Management

• LLC Tax Treatment• Ownership: Hospitals, Rural Health Clinics, Physician Group

Practices, Federally Qualified Health Centers• Tax Identification Number (“TIN”) that bills Medicare,

Commercial Third Party Payor or Medicaid for health care services


16

CIN Participation Agreement

• The Participation Agreement• Largely Driven by the requirements of the third

party payor• Establishes the Participants’ rights and

obligations as a participant in the CIN• Participation Criteria

• The CIN’s representation of the Participant• Exclusivity from the third party payor and

participant perspective• Exclusivity from the anti-trust perspective


Establishing a CIN


CIN Components

CIN

PhysicianLeadership

ParticipationCriteria

PerformanceImprovement

InformationTechnology

PayorContracting

Legal Entityand Waivers

Flow ofFunds


CIN Formation, Application and Licensing

• Physician Identification and Enrollment

• Post Acute Care• Tertiary and Quaternary Care• Participation Agreements• Physician Engagement

Network Development

• Operating Agreements• Bank Accounts• State Licenses• Employer Identification Numbers• Tax Reporting and Filing• Application Template• ACO Participation Agreements• Physician Engagement and

Enrollment Support

CIN Formation and Licensure

• Directors and Officers insurance• Cybersecurity insurance

Insurance


Governance and Administration

The Steering Committee meets quarterly to review data, improve processes and help overcome implementation barriers. This committee oversees execution of all programs and ensures goals are met.

Steering Committee Meetings

Quarterly board meetings are required for compliance and provide the forum for management to learn about progress, discuss important CIN developments and set strategic objectives. In these meetings, board members also approve waivers, approve payer contracts, admit new members, and place members in remediation.

Board Meetings

• Finance• Information Technology• Evidence-Based Medicine• Quality• Patient Engagement

Other Committees


CIN Staff Support

The Executive Director serves under the direction of the Board and manages the day to day operations of the CIN.

Executive Director

The Compliance Officer helps your organization maintain an effective and comprehensive compliance program and provides ongoing education and training to ensure your CIN adheres to legal requirements.

Compliance Officer

Project management is key to keep multiple complex tasks on track and to maintain proactive communication with the members of the CIN.

Project Manager


CINSuccess Strategies


23

•

12 12 11 11 1216

9 8 9 10 9

21 21 20 18 15 916 15 11 10 11

0

10

20

30

40

FR SWE SWIZ GER NETH US NOR UK NZ CAN AUS

Health care Social care

Combined Clinical and Social Service SpendingPERCENT

GDP

Source: E. H. Bradley and L. A. Taylor, The American Health Care Paradox: Why Spending More Is Getting Us Less, Public Affairs, 2013.

$ The U.S. Spends on Health Care


24

How Can Clinical Integration Efforts Help?

• Build Robust Primary Care• Align Physicians• Increase Revenue through population health• Improve quality of care for the community• Leverage data to identify opportunities• Improve Post-acute strategic alignment


25

Develop Sustainable Team-Based Care

• Have additional staff to support primary care providers• Working at “top of license”

• This does not mean giving all the “easy” patients to someone of lower licensure

• Does mean having a nurse to support you for those patients whose needs can not be met in 10-15 minutes

• All Medicare patients would have up to an hour with a nurse before seeing their provider

• Would be assessed and triaged to highlight the most urgent problems• Could be identified for chronic care management for support in between

provider visits• Have one process to meet quality measures


26

Population Health Nurses Generate Income

Chronic Care Management

$45-$90/month

Cognitive Assessment & Planning

$238/year

Behavioral Health

Integration

$126/month

Wellness Visits

$118/year

Advance Care

Planning

$86/year


27

Billing “Incident to” Providers Generates RVU’s

Service Billing Code Average National Medicare Payment

IPPE G0402 $168.68- RVU’s 2.43

Initial AWV G0438 $173.70- RVU’s-2.43

Subsequent AWV G0439 $117.71-RVU’s-1.5

Advance Care Planning 99497 $82.90-RVU’s-1.5

Depression Screening G0444 $18.30-RVU’s-0.18

Smoking Cessation 3-10 min 99406 $14.71-RVU’s-0.24

Smoking Cessation >10 min 99407 $28.35-RVU’s-0.5

Chronic Care Management (CCM) 99490 $42.71/Month-RVU’s-0.61

Complex CCM 99487 $93.67/Month-RVU’s-1.0


28

2017 Quality Measures Year to Year Comparison: Caravan HealthBenchmarks Measure Rates

Measure 2016 2017 2017 Caravan Health ACOs 2016 2017 2016 to 2017 %

Change

PREV-12 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan 30th 50th 50th 31.65 57.25 80.89%

MH-1 Depression Remission at Twelve Months * * * 3.4 6.06 78.34%

CARE-2 Falls: Screening for Future Fall Risk 60th 80th 80th 53.7 75.69 40.95%

DM-7 Diabetes: Eye Exam * * * 39.61 45.71 15.40%

PREV-8 Pneumonia Vaccination Status for Older Adults 60th 70th 70th 66.57 73.36 10.21%

PREV-6 Colorectal Cancer Screening 50th 60th 60th 59.85 64.98 8.56%

PREV-5 Breast Cancer Screening 60th 60th 60th 62.69 67.81 8.17%

PREV-9 Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 60th 60th 60th 64.84 68.76 6.04%

DM-2 Diabetes: Hemoglobin A1c Poor Control * * * 16.78 15.84 5.60%

PREV-13 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease * * * 77.78 80.34 3.29%

PREV-7 Preventive Care and Screening: Influenza Immunization 70th 70th 70th 71.6 73.27 2.33%

PREV-10 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 90th 90th 90th 92.97 94.57 1.72%

IVD-2 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet 90th 90th 90th 90.85 92.15 1.43%

HTN-2 Controlling High Blood Pressure 60th 60th 60th 69.47 67.82 -2.37%

CARE-1 Medication Reconciliation Post-Discharge * * * * 75.87 *

Increased Pneumonia Vaccines: Reduced Hospital Admission Rates

Cha

nges

in a

dmis

sion

rate

s


30

Maximize Power of Claims and EHR Data

Analyze your population to understand prevalence of chronic illness, hospitalizations and related costs.

Prioritize areas for improvement and identify where you need additional resources based on which population has the most clinical and financial risk.

Plan early for in-house and outsourced expertise.Ingesting claims data and drawing meaningful reports takes time.


Clinical Episode Comparison$2

8,58

4

$26,

708

$25,

791

$25,

690

$24,

500

$23,

633

$23,

250

$22,

987

$22,

313

$22,

252

$21,

955

$21,

923

$21,

879

$21,

746

$21,

580

$21,

372

$20,

692

$20,

572

$20,

455

$20,

452

$20,

417

$20,

010

$19,

956

$19,

923

$19,

849

$19,

844

$19,

765

$19,

653

$19,

407

$19,

365

$19,

097

$19,

023

$18,

942

$18,

940

$18,

868

$18,

332

$18,

155

$20,

761

AVERAGE TOTAL COST OF MAJOR JOINT REPLACEMENT OF THE LOWER EXTREMITY BUNDLE


ACO Level: Clinical Episode Cost BreakdownACO ID Clinical Episode

CountEpisodes per 1000 Patients RAF Median Total

CostAverage Total

Cost

Cost % Difference vs Caravan 75th

Average SNF Cost

Average Home Health

Cost

Average Part A

Office Visit Cost

Average Part B Office Visit

Cost

CH00 5860 9.20 0.785 $17,016 $20,761 0% $1,816 $1,575 $155 $129

ACO 1 360 13.03 0.758 $16,132 $20,010 -9% $1,495 $572 $506 $102

ACO 2 339 9.40 0.850 $16,240 $18,942 -14% $1,007 $1,912 $80 $170

ACO 3 302 7.81 0.824 $15,701 $18,332 -17% $1,197 $1,543 $18 $207

ACO 4 269 8.24 0.680 $15,575 $19,365 -12% $1,973 $1,799 $38 $152

ACO 5 217 7.71 0.847 $17,674 $20,572 -6% $1,537 $2,022 $44 $152

ACO 6 142 8.02 0.800 $17,535 $19,407 -12% $1,493 $1,755 $73 $205

ACO 7 95 5.27 0.874 $22,515 $28,584 30% $4,191 $2,645 $112 $167

ACO 8 93 11.20 0.771 $14,874 $18,155 -17% $429 $1,238 $98 $152

ACO 9 90 7.11 0.676 $21,532 $25,690 17% $2,264 $1,990 $219 $112

ACO 10 74 5.26 0.873 $16,810 $19,956 -9% $1,899 $1,055 $129 $99

ACO 11 50 4.78 0.842 $18,465 $21,580 -2% $1,521 $1,911 $105 $134

ACO 12 46 6.26 0.769 $16,796 $21,746 -1% $3,009 $1,275 $182 $94


33

Analytics Provide New Insight into Old Problems

Rehab /Care Center #1



AverageCost per Day

$399.94 $468.80 $329.35

Risk Adjusted AverageCost per Day

$189.18 $219.41 $66.53

Admissions 52 20 4

Nursing Home Compare Score

5 out of 5 stars 4 out of 5 stars 3 out of 5 stars

Source: Tri-state Memorial Hospital


34

Get Your Coding in Order

• Ensure you receive credit for the sicker patients you treat

• Your benchmark cannot go up from better identification of sick patients, but it can go down.

• Numerous ACOs have found that inattention to HCC-coding workflows has been the difference between collecting shared savings and falling below the minimum savings rate.

• Integrating coding best practices into your workflow can help you get credit for caring for sicker patients without driving your clinicians crazy.


35

Build on PerformanceTeach

Expertise & Compliance

Practice Transformation

Clinical Excellence

Intelligence & Analytics

Guidance through the complex regulatory environment and governance procedures

Drive clinical and non-clinical transformation initiatives

Lead the physician engagement aspects of value-based care

Healthcare data experts delivering mission-critical insights

Improve

Implement1

4

2

Report 3


36

ACO Score Card: The Key to SuccessPractice ABC

Category Metric PointsPoints

PossibleRN Care Coordinator in place ✓ 6 6Physician Leader in place ✓ 6 6Lightbeam Interface Status as of X/X/XXXX date In Dev. 4 6# Active Medicare AWV Cases - Claims + EHR Interface Data Q1 2017 300 0% of patients with AWV - full credit for over 50% 41.0% 4 6# Active Medicare CCM Cases - Self Reported Q1 2017 140 0% of patients in CCM - full credit for over 10% 17.0% 6 6# Active Medicare TCM Cases - Self Reported Q1 2017 170 0% of patients in TCM - full credit for over 10% 8.0% 4 6Billing AWV ✓ 4 4Billing CCM ✓ 4 4Billing TCM ✓ 4 4Billing Advance Care Planning (ACP) X 0 4Patient Satisfaction Tablet Utilization Rate 27.0% 6 6Quality score 100.0% 6 6Total Cost - full credit for reduction beyond statistical threshold -3.2% 6 6ED utilization - full credit for reduction beyond statistical threshold -2.5% 2 2SNF utilization - full credit for reduction beyond statistical threshold 3.0% 0 2IP utilization - full credit for reduction beyond statistical threshold -1.0% 2 2Representative at Board Meeting ✓ 4 4ACO Champion at Road Map Call ✓ 2 2Practice Manager at Road Map Call ✓ 2 2Care Coordinator at Road Map Call ✓ 2 2Attend QIW ✓ 4 4Attend Care Coordinator Cohort Calls ✓ 4 4Attend Quarterly Steering Committee Meeting ✓ 3 3Attend Cohort Calls ✓ 3 3

TOTAL SCORE 88 100

ACO BOARD SCORECARD ADDITIONS/ADJUSTMENTSAttend EBM Webinars X 0 2Attend Cohort Calls ✓ 2 2Attend Physician Leader Cohort Calls ✓ 2 2

Status

Physician Lead

ACO Medical Director

Key Billing Indicators

Care Coordination

Outcomes

Leading Indicators

Staff Engagement


Risk-Sharing Models for ACOs & Where the ACO Program Stands Today

• New MSSP proposed rule is an affirmation of support for value-based payment models

• Tracks 1, 1+, 2, and 3 replaced with Basic and Enhanced ACO tracks with five year agreement periods

BASIC: Five year glidepath – replaces current Tracks 1, 1+, and 2• Up to 2 ½ years of no downside risk• No risk period followed by limited downside risk • Max risk increases from 1 percent → 2 percent → 4 percentENHANCED:• Replaces current Track 3• Downside risk up to 15 percent, same as Track 3

• No Jan 1, 2019 new ACO starts• July 1, 2019 ACO starts or Jan 1, 2020 starts


38©2018 MGMA. All rights reserved.

The Future of Population Health Depends on Scale

Participants need to form collaborative ACOs with more than 100,000 lives to minimize impact of statistical variance and administrative burden

Greater likelihood of predictable shared savings through:• Lower minimum

savings rates • Better link between

effort and outcome

Be fully prepared for future risk models, payer and employer contracting and provider based health plans, which also need scale

39

Wild Swings in Performance are Common

Year over Year Changes in ACO Savings and Losses by ACO Size


40

Maintain Independence and Control

Every community of providers operate independently and are paid on their own performance.

Independent providers can fully participate in value-based payments while retaining their autonomy.

All health care decisions are kept local.

Significant changes to participation agreements (if any) will be made by July 1 of each year so participants can elect to leave the ACO and form their own in the unlikely event they don’t agree.


Tim Gronniger(916) 542-4728

[email protected]

Anna Loengard(808) 253-8772

[email protected]

mailto:[email protected]

mailto:[email protected]

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