Network Payment Innovation Overview Charge... · •Physician champions/leaders are important. Must...
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June 28, 2018 Taking Charge of Your Organization’s Alternative Payment Model / Value-based Contracting Strategy
Transcript of Network Payment Innovation Overview Charge... · •Physician champions/leaders are important. Must...
June 28, 2018
Taking Charge of Your Organization’s Alternative Payment Model / Value-based Contracting Strategy
Discussion Topics and Objectives
Alternative Payment Models: State of the Market
• Macro Trends
• Government Programs
• The Commercial Market
• Member-focused contracting promotes member-focused care
Assessing and Preparing for Value-based Contracting
• Success Requires Data-enabled Intervention
• The Primary Audience and Answering Key Questions
• Cultural Changes Are Necessary
Services and Solutions to Support Your APM Program
• People, processes, and technology solutions
Alternative Payment Models: State of the Market
Macro Trends in Value-Based Health Care
CMS Has Been Driving Innovation For Nearly 15 Years Setting the Foundation…
…Implementation Begins
Payment and Delivery Reforms
2003 2006 2009 2008 2010 2011 2012 2013 2014
Hospital Inpatient
Quality Reporting
Physician Quality Reporting
System
CMS Ceases Paying for
Hospital Acquired
Conditions
Health Information
Technology for Economic
and Clinical Health Act
Affordable Care Act
Meaningful use incentives
First generation of Medicare Shared
Savings Program
Hospital Value-Based
Purchasing and readmission
penalties
Physician value-based
modifier
Merit based incentive
payment system
and alternative payment
models
2015
Measurement Regimes Incentive for
Infrastructure
Development
2016 2017/18
BPCI Advanced
Commercial Payers Charge Forward
Source: Health Affairs, “Growth Of ACOs And Alternative Payment Models In 2017” June 28, 2017.
CMS has driven innovation for over a decade, but as employers demand containment of health care costs, plans are launching Commercial ACOs and other value based pilots
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New Provider Formations Emerge
Source: KLAS Emerging Payviders Report 10/2015
Provider Reimbursement Increasingly Rewards “Owning the Life”
Global payment/ capitation
Shared Risk
Shared Savings
De
gre
e o
f risk m
ana
ge
d b
y p
rovid
er
Level of provider sophistication and collaboration
Bundle payment (risk among providers)
Bundle payment (single bearer
of risk)
Pay for performance
Pay for activity/ coordination
Fee for service
Manage a population
Attain measure
targets
Payment for
service or activity Manage event/ condition
PAC Collaboration Essential
Value-based reimbursement
Managing Episodes Does Not Equate to Managing a Population
Examples:
• DRGs
• Bundled payment
Episodic Risk
Examples:
• ACOs
• Capitation (MA Capitation, Commercial
Capitation)
Population Health Risk
Emphasis on efficiency and best
practice
Emphasis on prevention, eliminating
episodes
Enabling Providers for Value-Based Care
High-performance network
management
Population health management &
quality
Data management Analytics & reporting
Enabling technology
Enterprise risk & financial
management
Org
aniz
atio
nal c
hange &
tale
nt a
ccele
ratio
n
Business operations excellence
Pro
duct
leaders
hip
Consumer engagement
Value-based care strategy Growth channels | Value-based entity | Strategic blueprint | Road map | Leadership & governance | Financial pro forma
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Provider Support and Enablement TRANSFORMATIONAL FEE-FOR-VALUE PROVIDER SERVICES
TRADITIONAL FEE-FOR-SERVICE PROVIDER SERVICES
BU
SIN
ES
S
OP
ER
AT
ION
S
NE
TW
OR
K
TE
CH
NO
LO
GY &
AN
ALY
TIC
S
CLIN
ICA
L
Assessing and Preparing for Value-based Contracting
VBC Performance Requires Data-Enabled Intervention
Hospital
Emergency Room
Primary Care Clinic
Specialty Care Clinic
Home
Post-acute
Analytics Technology
Intervention Outcomes
Strategy
Insight and
Expertise
Typical Analytics Audience
Chief Medical Officer
Chief Financial Officer
Chief Analytics Officer
Population health strategy • Are my population health management programs providing the value we expected?
– $admissions/readmits/ER visits/SNF LOS
– # risk scores
– # ER put through rates
• Which members need to be enrolled in a population health management program? Am I identifying the right patients for my programs?
– ID risk stratification
– Complex chronic condition members
– Disease registries
Participating provider strategy • Which physicians (in and out of my network) are performing well/poorly and why?
– Cost efficient providers (TCOC, Bundle, episodes, utilization, unit costs)
– High scoring quality providers
• Which post-acute care providers should I work with to create value?
– PAC strategy development
– Efficiency metrics (medical expenses, readmits, LOS, quality)
Key Questions Answered with Analytics Action:
• Optimize ID risk
stratification process and
align with population health
programs
• Modify programs to
improve outcomes
• Implement chronic care
management programs
Action: • Benchmark key metrics and
share with providers
• Implement value based
physician distribution
models
• Develop PAC strategy to
reduce PAC variation
Cultural change will be needed to succeed in a value-based environment
• Shift from FFS view to now focus on primary care and patient centered care across the continuum
• Must link opportunities found through analytics with budget objectives to the various medical management programs. Then, establish dashboard to monitor performance as close to real time as possible.
• Organizational change must happen to make an impact. Key components are:
– Leadership and Stakeholder Commitment
• Leaders and stakeholders understand their accountability for the project success.
• Physician champions/leaders are important. Must first identify, then provide training, mentoring and ongoing support.
– Organizational Design and Performance Management – The effect of the change will be assessed and aligned to the new work process, job descriptions, and performance measures to support the change.
– Culture – A clear articulation of the values, beliefs, and practices that define the desired culture
– Communication – A communication infrastructure with defined audiences and channels
– Individual and Group Capacity – Knowledge transfer and skill requirements will be clearly articulated
Facilitating Success Through Analytics
Services and Solutions to Support Your AMP Program
Services and Solutions for a Bundled Payment Program: Not a horse race…a continuous evolution
Analytics, Definition, and Modeling Analytics, bundle modeling, and finalizing go-to-market bundles
Bundled Payment Cycle of Administration
Finalize your go-to-market-bundles
Finalized bundles are published to your bundled payment management platform
Intelligent bundle reporting
Operationalize and administer the program
Enables bundle pricing via evaluation of claims data against bundle definitions and provider contract provisions
Payment distribution to participating providers
“Quarterbacking providers” Manage payment allocation and delivery, prospectively and retrospectively
Bundle financial analyses
Identify bundles that make financial sense for your organization
Contracting with payers
Develop contractual and payment provisions for all relationships
Network evaluation and potential bundle identification
• Are my providers
capable of managing to bundles?
• What bundles can be supported?
• How do I define a bundle or episode of care?
Strategy Creation Implementation and Operationalization
Governance, user provisioning, workflow and exception processing
Operational reporting
Analytic reporting
Back to Bundle Payment Spectrum
Contracting, operationalization, and payment
Analytics, provider measurement, and VBC finalization
Value-based Contracting Program Cycle
Finalize your go-to-market VBCs
• Finalized VBCs are
published into your VBC administration platform.
Intelligent provider performance reporting
Operationalize and administer your VBC program
• Contract monitoring via
evaluation of claims data against VBC definitions and contract provisions.
• Integrated with provider measurement technologies
• Payment calculations
Performance scorecards!!
• Ongoing scorecards
help identify corrective action within contractual period to facilitate provider success
Identify provider measures that are critical to success
• Identify key
measurements for behavior change
• Integrated with Impact Intelligence and can accept scores from other solutions as well (NCQA-certified HEDIS for example)
• Construct strong, reportable attribution rules
Contracting with payers
• Develop contractual
and payment provisions for all relationships
• Establish attribution rules and identify any exceptions / “tie-breakers”
Network evaluation and potential VBC identification
• What are the areas of
focus? Utilization, quality, patient satisfaction?
• What programs can be supported?
• What programs can be administered?
• What contract terms make sense for Horizon and providers?
Contracting, operationalizing, reporting, and payment
Strategy Creation Implementation and Operationalization
Governance, user provisioning, workflow and exception processing
Services and Solutions for a Value-based Contracting Program: Not a horse race…a continuous evolution
Why Optum?
100k+ providers
and payers • Physician Practices,
Hospitals, Post-acute,
Medical groups, FQHCs
• 4 out of 5 Hospitals
• Medicare, Medicaid,
Commercial, and
Employer Group Payers
19+ Clinicians
with APM/VBC experience
235 years Experience in APM/Value Based Care
management services.
205 years Managing APM/VBC
programs
200+ projects in value based care
management
The Team Combined Experience
Team’s Former Experience
1,000 Resources
2012 go-live • 500+ million claims processed
to-date
• 4.5+ million members / patients
• Managing over 100 APM types
and growing
• Prospective and retrospective
payment models
All lines of business • Medicare, Medicaid,
Commercial
• 24 markets and
expanding
The Technology
Kevin Dotson, FSA, MAAA Senior Director, Provider Actuarial Services 678-417-4929
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Ron Myers Vice President,
Network Innovation Payment Solutions 801-319-9082
Greg Shufelt Vice President, Value-based Care 763-732-8804
David Mauzey General Manager,
Network Innovation Payment Solutions 763-732-6549
Additional Information
Located on the HATA Web site on the General Resource web page: http://www.hata-assn.org/general-resource-page
HATA – Value Based Care Fact Sheet
Optum – CMS BPCI Advanced: Learn what has changed and why you should participate
Optum – Integrating bundle payments for long-term reimbursement strategy success Optum
Optum – Cleveland Clinic bundled payment program key learning
