Douglas Pogue, MD… · Capitated Care Baseline 2008 Reinvestment/Recovery Act of 2009 –The...
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1 Accountable Care Update HFMA Spring Conference 2015 Douglas Pogue, MD Medical Director BJC Accountable Care St. Louis, MO
Transcript of Douglas Pogue, MD… · Capitated Care Baseline 2008 Reinvestment/Recovery Act of 2009 –The...
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Accountable Care Update
HFMA Spring Conference 2015
Douglas Pogue, MDMedical Director
BJC Accountable Care
St. Louis, MO
From FFS to MSSP to RiskACO Now and Going Forward
• Who we are
• How we got here
• Unpacking Accountable Care
• Understanding Current Experience
• What you need to get started
• Keys to success/Pitfalls to avoid
• Where will CMS take this program going forward
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About BJC HealthCare
BJC Hospitals:
• Alton Memorial Hospital
• Barnes-Jewish Hospital
• Barnes-Jewish St. Peters Hospital
• Barnes-Jewish West County Hospital
• Boone Hospital Center
• Christian Hospital
• Missouri Baptist Medical Center
• Missouri Baptist Sullivan Hospital
• Parkland Health Center/Mineral Area
• Progress West HealthCare Center
• St. Louis Children’s Hospital
• The Rehabilitation Institute of St. Louis
BJC Health Services:
• BJC Medical Group
• BJC Behavioral Health
• BJC Corporate Health Services
• BJC Home Care Services
• BJC Long Term Care Services
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About BJC Collaborative
Adams
Mclean
Peoria Woodford
Tazewell
Christian
Macon
Sangamon
Logan
Ford
Champaign
Franklin
Saline
Hamilton
Gallatin
Jackson
Wayne
Marion
Jefferson
Macoupin
Greene
Fayette
Bond
PerryWashington
KnoxHenderson
Putnam
Monroe
Shelby
Livingston
Mcdonough
Schuyler De Witt
Morgan
Hancock
Piatt
Clay
Richland
Lawrence
Wabash
Pemiscot
DunklinButler
Ripley
Putnam
AdairSullivan
ScotlandClark
Newton
Barry
Cape
Girardeau
Greene Webster Wright
Christian
Jackson
Pulaski
Osage
Callaway
Stoddard
Vernon St. Clair
Polk
Barton
Atchison
GentryHolt
Ste.
Genevieve
HenryBates
Laclede
Grundy
Johnson
Cass
Dent
Texas
Platte
Clay
Buchanan
Carroll
Livingston
St. Charles
Boone
Moniteau
Perry
Montgomery
Bollinger
Pike
Reynolds
Randolph
Audrain
Pettis
Taney
Howell
Ozark
Douglas
Shawnee
JeffersonLeavenworth
Johnson
Wyandotte
Jackson
Osage
Cherokee
Wabaunsee
Crawford
Bourbon
Pottawatomie
Atchison
Brown DoniphanNemahaMarshall
Riley
Geary
Miami
Franklin
Montgomery
Labette
Allen
Neosho
Coffey
LinnAnderson
Woodson
Wilson
Washington
Clay
Dickinson
Morris
Sedgwick
Cowley
Elk
Butler
Marion LyonChase
Greenwood
Chautauqua
Mississippi
Clay
Greene
Benton
Washington
Carroll
MarionSharp
Fulton
Baxter
Madison
Newton
CrawfordJohnson
Izard
Stone
Boone
Pope
Lawrence
Craighead
PoinsettVan Buren
Randolph
Jackson
Independence
Cleburne
Franklin
Searcy
Ottawa
Delaware
Mayes
Adair
CraigNowata
Noble
Payne
Lincoln
Creek
OkfuskeeMcIntosh
Okmulgee
Tulsa
Pawnee
Kay
Osage
Wagoner
Muskogee
Sequoyah
Cherokee
Washington
Rogers
AppanooseWayneTaylor
Page
AdamsMontgomery
Ringgold
Fremont
Van Buren
Davis Lee
JeffersonWapelloMonroeUnionMills
Des MoinesHenryLucasClarke
Muscatine
Washington KeokukMahaska
MarionWarren
MadisonAdairCassPottawattamie
Louisa
Decatur
Richardson
Cass
Otoe
Pawnee
NemahaJohnson
Douglas
Sarpy
Dodge
Saunders
Colfax
Butler
Jefferson
Saline
Lancaster
Gage
Alexander
Brown
Bureau
Calhoun
Cass
Clark
Clinton
Coles
Cook
Crawford
Cumberland
De Kalb
Douglas
Edgar
Edwards
Effingham
Fulton
Grundy
Hardin
Henry
Iroquois
Jasper
Jersey
Johnson
Kankakee
Kendall
La Salle
Lee
Madison
Marshall
Mason
Massac
Menard
Mercer
Montgomery
MoultriePike
Pope
Pulaski
Randolph
Rock Island
Scott
St. Clair
Stark
Union
Vermilion
Warren
White
Whiteside
Will
Andrew
Benton
Caldwell
Camden
Carter
Cedar
Chariton
Clinton
Cole
Cooper
Crawford
Dade
Dallas
DaviessDe Kalb
Douglas
FranklinGasconade
Harrison
Hickory
Howard
Iron
Jasper
Knox
Lafayette
Lawrence
Lewis
Lincoln
LinnMacon
Madison
Maries
Marion
Mcdonald
Mercer
Miller
Mississippi
Monroe
Morgan
New Madrid
Nodaway
Oregon
Phelps
Ralls
Ray
Saline
Schuyler
Scott
Shannon
Shelby
St. Francois
St. Louis
Stone
Warren
Washington
Wayne
Worth
Harvey County
Sumner County
Conway CountyCrittenden County
Cross County
Faulkner County
Logan County
Sebastian CountyWhite CountyWoodruff County
Yell County
Cleveland CountyHaskell County
Hughes County Le Flore County
Logan County
McClain County
Oklahoma County
Pittsburg County
Pottawatomie County
Seminole County
Audubon County
Cedar County
Dallas CountyGuthrie CountyHarrison CountyIowa CountyJasper County Johnson County
Polk County
Poweshiek County
Scott County
Shelby County
Washington County
100-miles
60-miles
Jefferson
BJC Collaborative Members
KANSAS
IOWA
NEBRASKA
OKLAHOMA
ARKANSAS
MISSOURI
ILLINOIS
The BJC Collaborative covers Southern Illinois, Missouri and Eastern Kansas, a population of 11 million.
Williamson
Saint Luke’s
MemorialBlessing
Southern Illinois
HealthCare
BJC HealthCare
CoxHealth
Boone Hospital Center
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About BJC HealthCare
BJC HealthCare % Net Revenue
Medicare Traditional
29%
Medicare Risk 4%
Medicaid 9%
Medicaid Risk 5%
Commercial 49%
Other 4%
ACO/PCMH/P4P Lives
CMS Shared Savings Plan 40,300
CMS “Bundles” 1,000+
Med Advantage and Commercial (5 Payers)
30,500
BJC “Total Rewards” Plan 42,000
Employer TBD
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About BJC Accountable Care Organization
BJC ACO Composition
339 BJC Employed Providers
207 Independent Community Providers
546 BJC ACO Providers
BJC ACO Specialties (500+ Physicians)• Primary Care
• Allergy and Immunology
• Cardiology
• Endocrinology
• ENT/Otolaryngology
• Gastroenerology
• General Surgery
• Geriatrics
• Germatology
• Gynecology, OB/GYN
• Hematology
• Infectious Diseases
• Nephrology
• Neurology
• Oncology
• Ophthalmology
• Orthopedic Surgery
• Physiatry, Rehabilitative Medicine
• Podiatry
• Pulmonology
• Rheumatology
• Urology
• Vascular Surgery
BJC Healthcare ACO
• July 2012 Start under MSSP
• 41,000 Medicare Beneficiaries (60,000)
• 508 Providers (50% BJC, 50% private)
• 13 Hospitals
• Roughly $300M book of business (A,B)
• Added 18,000 lives in Medicare Advantage in 2014. Risk in 2015
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BJC ACO Current Offerings
Transitions of Care
ED Frequent Flyer Program
Complex Care Management
Polypharmacy Support
ED/Admission Alerts
Remote Monitoring
About BJC Accountable Care Organization
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Data Analytics & Reporting
Medication Management &
Adherence
ESRD Patient Care
Telehealth
In-Home Patient Visits: Home
Care & Advanced
Paramedics
Behavioral Health
BJC ACO 2015 Areas of Focus
About BJC Accountable Care Organization
Total Federal Budget Debt as % of Gross Domestic Product (GDP)
Source: Federal Government Office of Management and Budget
82.4
91.5
96.0
99.7
100.6
103.2
80
85
90
95
100
105
2009 2010 2011 2012 2103 2014 Est.
Note: In 2000, total Federal Debt was 55.4% of GDP
Ascending to the “Triple Aim” Summit
Capitated Care
Baseline 2008
Reinvestment/Recovery Act of 2009 – The “Stimulus”
Affordable Care Act of 2010 – “ObamaCare”
Budget Control Act of 2011 – “The Sequester”
Taxpayer Relief Act of 2013 – “The Fiscal Cliff”
Fee-For-Service Pay for Performance
P4P Shared Savings Programs
MSSP Full Risk Medicare Advantage
Accountable Care Organizations
• Value-Based Purchasing• Hospital Readmission Reduction• Hospital-Acquired Conditions
ImprovingHealth
Improving Qualityof Care/Service
Reducing Per Capita Cost
U.S. Spending on Electronic Medical Record Solutions
$1
$2
$3
$4
$5
$6
2009 2010 2011 2012 2013 2014 2015
$ in
bill
ion
s
Source: MarketandMarkets, U.S. Electronic Medical Records Market, 2010 - 2015
$6 billion
Population without Health Insurance Coverage
Percent of Population without Health Insurance Coverage (under age 65)
Source: US Department of Health and Human Services
20.0%20.3%
19.6%19.2%
18.4%
17.7%
15.4%
16.4%
15.3%15.0% 14.9%
13.0%
2009 2010 2011 2012 2013 2014 (Jan-Mar)
States Not Expanding States Expanding
Population without Health Insurance Coverage
Percent of Population without Health Insurance Coverage (under age 65)
Source: Gallup-Healthways Well-Being Index
14.6%
15.0%
14.4%
15.4%
16.1%
16.3%
16.1%
16.4%
16.3%
16.4%
16.3%
16.6%
16.1%
17.4%
17.3%
17.5%
17.3%
17.2%
16.9%
16.3%
16.8%
17.1%
18.0%
17.1%
15.6%
13.4%
% Uninsured
Q1
2009
Q1
2011
Q1
2012
Q1
2013
Q1
2014
Q1
2008
Q1
2010
Medicaid Enrollment
Medicaid Enrollment as a Percent of Total Population
12%
14%
16%
18%
20%
22%
2009 2010 2011 2012 2013 2014 (June)
Missouri Illinois US Expansion States States Not Expanding
Source: Centers for Medicare & Medicaid Services (CMS) and US Census Bureau
Note: 2014 data is based on CMS Medicaid and CHIP enrollment as of June 2014. Total population data is based on Census Bureau estimates.
Annual Federal Budget Deficit as % of Gross Domestic Product (GDP)
Source: Federal Government Office of Management and Budget
-10.8
-9.3-8.9
-7.1
-4.3-3.9
-11
-9
-7
-5
-3
-1
2009 2010 2011 2012 2103 2014 Est.
Ascending to the “Triple Aim” Summit
Capitated Care
Baseline 2008
Reinvestment/Recovery Act of 2009 – The “Stimulus”
Affordable Care Act of 2010 – “ObamaCare”
Budget Control Act of 2011 – “The Sequester”
Taxpayer Relief Act of 2013 – “The Fiscal Cliff”
Fee-For-Service Pay for Performance
P4P Shared Savings Programs
MSSP Full Risk Medicare Advantage
Accountable Care Organizations
• Value-Based Purchasing• Hospital Readmission Reduction• Hospital-Acquired Conditions
ImprovingHealth
Improving Qualityof Care/Service
Reducing Per Capita Cost
Understanding Current Experience
• For 2012 and 2013, 53 of 243 ACOs generated some savings. 4 generated most of the savings. 372 M saved, 445 M paid out
• A handful of Pioneer ACOs have lost money
• 13 Pioneers have dropped the program and gone to MSSP. 19 remain in the program
• Currently 424 ACOs
• Quality is Better: 50,000 fewer deaths, 1.3 Million fewer patient harms.
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1.30%
1.74%1.56%
1.34%
0.97%1.21%
-0.30%-0.01%
-1.00%
-2.50%
-2.00%
-1.50%
-1.00%
-0.50%
0.00%
0.50%
1.00%
1.50%
2.00%
12Q3 12Q4 13Q1 13Q2 13Q3 13Q4 14Q1 14Q2 14Q3 14Q4
Beneficiary Spend as a % of Benchmark
Benchmark
Shared Savings Target (-2.3%)
2013 (Pay-for-Reporting) 2014 (Potential)
Domain Result:
Pts Achieved
Pts Possible
Score Pts Achieved
Pts Possible
Score
Patient/Caregiver Experience 14.00 14 25.0% 12.80 14 22.9%
Care Coordination/Patient Safety 14.00 14 25.0% 7.60 14 13.6%
Preventive Health 16.00 16 25.0% 13.75 16 21.5%
At-Risk Population 14.00 14 25.0% 12.80 14 22.9%
Final Score: 100.0% 80.8%
2.5% reduction in Medicare beneficiary spend since 2nd quarter 2013.
ACO Quality Results
Continued focus on quality and patient outcomes.
About BJC Accountable Care Organization
Accountable Care Organizations by Sponsoring Entity
Source: Leavitt Partners Center for Accountable Care Intelligence
73
145 150
197 201203
260
109
147159 186
197203
238
20
31 35
46 49 5055
611 12
29 32
33
53
0
50
100
150
200
250
300
Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013
Physician Groups Hospital Systems Insurer Other
# o
f A
CO
s
Estimated “Lives” Attributed to ACOs (both Medicare and Commercial)
Source: Leavitt Partners Center for Accountable Care Intelligence
0
2
4
6
8
10
12
14
16
18
20
Jan
- 1
0
Ap
r -
10
Jul -
10
Oct
- 1
0
Jan
- 1
1
Ap
r -
11
Jul -
11
Oct
- 1
1
Jan
- 1
2
Ap
r -
12
Jul -
12
Oct
- 1
2
Jan
- 1
3
Ap
r -
13
Jul -
13
Oct
- 1
3
Jan
- 1
4
Live
s (M
illio
ns)
18 million
Understanding Current Experience
• The average investment to become an ACO is about 1.5 M for Physician groups and 3 M for health systems.
• CMS investment: 10 Billion
• A recent poll of major ACOs asked the question if they would re-enroll at the end of 3 years if the rules/policies did not change. 70% said either “somewhat unlikely” or “very unlikely.”
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Medicare (Advantage) Private Health Plan Enrollment, 1999-2013
6.9 6.86.2
5.6 5.3 5.3 5.6
6.8
8.4
9.710.5
11.111.9
13.1
14.4
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
In millions:
18%% of Medicare Beneficiaries 17% 15% 14% 13% 13% 13% 16% 19% 22% 23% 24% 25% 27% 28%
Note: Includes MSAs, cost plans, demonstration plans and Special Needs Plans as well as other Medicare Advantage plans.Source: MPR/Kaiser Family Foundation analysis of CMS Medicare Advantage enrollment files, 2008 – 2013, and MPR, “Tracking Medicare Health and Prescription Drug Plans Monthly Report,” 2001-2007; enrollment numbers from March of the respective year, with the exception of 2006, which is from April.
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Should We Make the Jump to ACO?
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What You Need to Get Started
• Minimum 5,000 Medicare Beneficiaries as determined by Medicare. (at least 8,000)
• A primary care base that is motivated to do this.
• Data analytics engine to process claims data and turn it into useful information.
• Care management function to work with complex and high utilizing patients
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Keys to Success
• Create an alignment of pay incentives for your providers to the ACO success
• Risk stratify your patients to know who is the sickest/most expensive and who is rising to become the next “most expensive patient”
• Expand access in your primary care base
• Train your PCPs to handle more issues in office
• Robust medicine reconciliation
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0%
1%
2%
3%
4%
5%
6%
7%
8%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
ACO ED Visits by Time of Day (0-24)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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Pitfalls to Avoid
• Work hard on being able to measure, record, and report your quality metrics through GPRO
• Don’t choose Track 2 (downside risk) unless you are VERY experienced at risk contracting.
• The attribution methodology is retroactive, so you must treat ALL Medicare patients as if they are in the ACO, and will only find out later which ones actually will be counted by Medicare. Plan accordingly.
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Pitfalls to Avoid
• If your providers are still paid on a FFS/RVU type system, change will come slow.
• If you are hospital owned, be careful about destroying demand for hospital services that never makes up for ACO profits.
• Remember SNFs are incentivized to keep Medicare patients the maximum allowed days
• If you let too many specialists in the ACO, then membership will become meaningless.
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Where is CMS Taking the Program
• CMS wants to give providers the risk
• The quality metrics are expanding and changing.
• The amount you need to save to get paid will increase.
• CMS is eager to move health systems towards a Kaiser and Mayo like format.
• MSSP now has some extended life.
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Where is CMS Taking the Program
• Pay attention to CMS dropping the FFS Physician Fee Schedule and creating a differential schedule
• When that happens, look for physicians to jump to ACOs or go concierge
• Look for major changes after the 2016 election – status quo, defined benefits or acceleration.
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Questions
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