State of the Union: The New Era of Health Care Reform · Expansion of Existing System • Insurance...

Health Care Advisory Board

State of the Union:The New Era of Health Care Reform Health System Strategy Amid Empowered Consumers, Activated Employers, and Reactive Insurers

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State of the Union:The New Era of Health Care Reform Health System Strategy Amid Empowered Consumers, Activated Employers, and Reactive Insurers

Health Care Advisory Board


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Road Map

Healthcare State of the Union

Enhancing CV Specialist Partnerships with Primary Care

Proving Our Value


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The 42nd and 45 th Presidents of the United States

Source: Health Care Advisory Board interviews and analysis.


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Evaluating the ACA Against its Intentions


Chosen Method:Medicare-led Payment Reform

• FFS cuts

• New payment models

• Intent to catalyze broader commercial market change

1 2 3

Chosen Method:Incentives + Transparency

• IT mandates

• Pay-for-Performance programs

• Market-facing transparency

Chosen Method:Expansion of Existing System

• Insurance market regulation

• Expanded public coverage

• Market-based exchanges

Replace Costly Fee-for-Service Incentive Structures

Improve Health Care Quality

Achieve Universal, Affordable Coverage

Obama-era Enabling Legislation

February 17, 2009:Health Information Technology for Economic and Clinical Health (HITECH) Act

March 23, 2010:Patient Protection and Affordable Care Act

April 16, 2015:Medicare Access and CHIP Reauthorization Act (MACRA)

Major Reform Goals


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Kicking the Legs Out From Under Fee-For-Service

Policymakers’ Intention to Migrate Payment Perfectly Clear

Objective #1: Replace Costly Fee-for-Service Incentives

Source: CBO, “Letter to the Honorable John Boehner Providing an Estimate for H.R. 6079, The Repeal of Obamacare Act,” July 24, 2012; CBO, “Cost Estimate and Supplemental Analyses for H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015; The Daily Briefing, “How to Understand Last Week’s Big Budget Deal,” November 2, 2015; Budget of the United States Government (Proposed) FY 2016; Pham H, et al., “Medicare’s Vision for Delivery-System Reform – The Role of ACOs,” New England Journal of Medicine, September 10, 2015; Health Care Advisory Board interviews and analysis.

1) Inpatient Prospective Payment System2) Disproportionate Share Hospital3) Medicare Access and CHIP Reauthorization Act

“Productivity” Adjustments and Other Cuts2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

($4B)

($14B)

($24B)($29B)

($38B)

($54B)

($67B)

($76B)

($86B)($94B)

ACA IPPS1 Update Adjustments

ACA DSH2 Payment Cuts

MACRA3 IPPS Update Adjustments

Providers should compare ACO earnings not with what they could earn in today’s fee-for-service payment environment but with what they could expect to earn in the future if they didn’t participate in such alternative payment models.”

No Subtlety Here

CMS Officials


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0%

1%

2%

3%

4%

5%

6%

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029

MACRA Providing an Accelerant for Risk

Greater Payment Updates, Bonuses Depend on Payment Migration

Source: The Medicare Access and CHIP Reauthorization Act of 2015; : CMS, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, April 25, 2016; Health Care Advisory Board interviews and analysis.

1) Relative to 2015 payment.

2015 – 2019: 0.5% annual update(both tracks)

2020 – 2025:Payment rates frozen(both tracks)

Annual Provider Payment Adjustments

2026 onward:0.25% annual update (MIPS track)0.75% annual update (Advanced APM track)

Advanced APM Track

MIPS Track

Baseline payment updates1:

APM Bonuses/PenaltiesMIPS Bonuses/Penalties

5%Annual lump-sum bonus from 2019-2024

+/-4% Annual adjustment, 2019; scales up to

+/-9% Annual adjustment, 2022

$500M Additional bonus pool for high performers

(plus any bonuses/penalties from Advanced Payment Models themselves)


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Unavoidable Episodic Price Cuts Coming in 2017

1) Bundled Payments for Care Improvement Initiative. 2) Lower extremity joint replacements.

No Dodging Downside in 98 Markets

Program Features

Mandatory in at least 98 markets

Excludes hospitals participating in BPCI¹ Model 1 or Phase 2 of BPCI Models 2 or 4 for LEJR²

Retrospective bundle

CMS makes FFS payment to each provider separately, conducts annual reconciliation process

Comprehensive episode

Includes all related Part A and Part B services for 90 days post-discharge for select orthopedic and cardiac services

CMS Rapidly Scaling Mandatory Bundled Payment Effor ts to New Conditions, Markets

Program Timeline

November 2015

Final details for CJR program announced, including hospital participant list and revised quality methodology

April 1, 2016

Joint replacement (CJR) first performance year begins; no episode discount for first year

2017-2021

Downside risk incorporated; up to 3% episode discount, depending on hospitals’ quality performance scores

$478MESTIMATED SAVINGS TO MEDICARE OVER THE 5 YEARS OF THE MODEL

Source: Centers for Medicare and Medicaid Services; Health Care Advisory Board interviews and analysis.

Allows Fulfilment of Advanced APM requirements

Inclusion of HIT requirements allow bundles to count toward advanced APM track in MACRA

July 1, 2017

Cardiac conditions first performance year begins; no episode discount for first year


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Echo2 Volume Change by Setting,2010-2014

Source: MedPAC, www.MedPAC.gov; CY 2015 Hospital Outpatient Prospective Payment System Final Rule, CMS; H.R.1314 - Bipartisan Budget Act of 2015; Cardiovascular Roundtable research and analysis.

1) Hospital outpatient department.2) CPT 93306.3) Place of service.

Site-Neutral Payments Becoming the Reality

Disproportionate HOPD Volume Growth

Unbalanced Volume and Payment Growth by Setting Captures Attention

Historic Support for Site-Neutral Payments

CMS Begins Collecting Site-of-Service Data

• Finalized in CY 2015 HOPPS rule

• Hospitals billing under HOPPS will report modifier, providers will use new POS3 codes on claims

• Reporting voluntary in 2015, mandatory 2016

• First recommended in March 2012

• Reiterated earlier recommendations in March 2014 and August 2014

MedPAC Urges Site-Neutral Payments

Higher Reimbursement at HOPD 1

Versus Freestanding Physician Office

Medicare payment differential for a level II echo performed in HOPD vs. physician office setting

140%

(20%)

69%

HOPD

Physician Office

• Signed by President Obama on Nov. 3

• Prohibits newly opened or acquired off-campus HOPDs from billing on HOPPS beginning January 1, 2017

Included in Bipartisan Budget Act of 2015


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Budget Deal to Reduce 2017 Payments for Newly Acquired Practices

Source: H.R.1314 - Bipartisan Budget Act of 2015,; “Estimate of the Budgetary Effect of H.R. 1314,” CBO, 28 Oct. 2015; Cardiovascular Roundtable research and analysis.

Site Neutral Payments Now a Reality (For Some)

Bipartisan Budget Act of 2015

November 2, 2015

Budget Deal Modifies Payment for Hospital-Owned Physician Practices

Payment Changes for Physician Practices Meeting Three Criteria

Hospital-owned practices designated as “off-campus, provider-based sites”

Acquired or opened after November 1, 2015

Located farther than 250 yards from a hospital’s main campus

• Limits the ability of billing on the higher HOPPS fee schedule for certain physician practices

• All services provided at applicable practices will be billed on lower fee schedules beginning January 1, 2017

• Practices opened or acquired before November 2, 2015 may maintain current fee schedule

Significant Projected Savings

Estimated Medicare savings from 2016-2025 from payment changes

$9.5B


14

Similar Story for Medicare Shared Savings

Overwhelming Majority of ACO Participants Still in Shallow Water

Source: CMS, “New Hospitals and Health Care Providers Join Successful, Cutting-Edge Federal Initiative that Cuts Costs and Puts Patients at the Center of Their Care,” January 11, 2016, available at: www.cms.gov; Becker’s Hospital Review, “River Health ACO drops out of Next Generation program,” February 12, 2016, available at: www.beckershospitalreview.com; Source: CMS, “Next Generation Accountable Care Organization Model (NGACO Model),” January 11, 2016, available at: www.cms.gov; CMS, “Open Door Forum: Next Generation ACO Model”, March 17, 2015, available at: www.innovation.cms.gov; Becker’s Hospital Review, “River Health ACO drops out of Next Generation program,” February 12, 2016, available at: www.beckershospitalreview.com; Health Care Advisory Board interviews and analysis.

• Option to renew for second three-year term

• Savings rate kept at 50% for second term

• Shared savings, loss rate remains at 60% based on quality performance

• Revises savings, loss thresholds from fixed 2% to variable2%-3.9% based on number of beneficiaries

Continuum of Medicare Risk Models

MSSP Track 2 MSSP Track 3 Next Gen ACOMSSP Track 1

Upside Risk Only Downside Risk

412 Participants 18 Participants 6 Participants

• Shared savings up to 75%, shared losses from 40%-75% based on quality performance

• Fixed 2% savings, loss thresholds

• Prospective assignment

• Risk arrangements include 80%-85% sharing rate or full performance risk

• Option for capitation

16 Participants


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Metrics and Transparency Drive Quality Approach

Emphasis on Collection, Reporting of Performance Data

Objective #2: Improve Health Care Quality


IT-Powered Delivery System

(Meaningful Use Mandates)

Rigorous Scorekeeping

(P4P Programs)

Public Transparency

(Hospital Compare, Physician Compare)

1

2 3

Information-Focused Approach to Quality Improvement


16

Multiple Initiatives to Measure and Incent Quality

Rapid Proliferation of Metrics

Source: CMS, “National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures Reports,” February 14, 2016, available at: www.cms.gov; Health Care Advisory Board interviews and analysis.

Value Based Purchasing

• Pay-for-performance based on success against variety of value measures

• Only 792 hospitals out of 3,087 received bonuses

Hospital-Acquired Condition Penalty

• Reimbursement penalty targeted hospitals with higher rates of HACs

• 25% of hospitals mandated to face penalty

Hospital Admissions Reduction Program

• Reimbursement penalty based on excessive 30-day readmission rates

• 1%-3% hospital inpatient Medicare payment at risk

700+Quality metrics providers must report to CMS

Other CMS Programs


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Source: Commins J, “HACs Plummet 17%, Save $20B Under Obamacare,” HealthLeaders Media, December 2, 2015; Health Care Advisory Board interviews and analysis.

Having a Measurable Impact on Quality

Patrick Conway, MDChief Medical Officer, CMS

These results represent real people who did not die or suffer infections or harm in the hospital."

Health care cost reductions$20B

Fewer hospital-acquired conditions2.1M

CMS Estimates of ACA’s Impact on Quality2010-2014

Hospital ReadmissionsHRRP1 and all-causes, 2010-2014

1) Hospital Readmissions Reduction Program.

87K Patient lives saved

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23

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Rea

dmis

sion

Rat

e

HHRP ConditionsOther Admissions

ACA Passed

Readmission Penalties Begin

2


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MIPS Rewriting Rules for Physician Quality, Payment

1) Physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians.

Weights of MIPS Score Components

Source: CMS, “Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models,” May 9, 2016, available at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-10032.pdf; Advisory Board Company interviews and analysis.

25% 25% 25%

15% 15% 15%10% 15%

30%

50% 45%30%

2019 2020 2021+

Quality

Cost

Clinical Practice Improvement Activities

Advancing Care Information

MIPS Score Components

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Quality (Replaces PQRS, VBPM):• Over 200 measures to choose from, 80% of which

are tailored to specialists• Providers only required to report 6 measures

Cost:• Continuation of two measures from VBPM: Total per

capita costs for all attributed beneficiaries and MSPB

• Adds episode-based measures for specialists

• Seeks to include Part D costs

• No reporting requirement

Clinical Practice Improvement Activities:• Over 90 activities to choose from;

some activities weighted higher than others

• Clinicians in non-eligible APMs and NCQA Patient-Centered Medical Homes receive favorable scoring

Advancing Care Information (replaces Meaningful Use for physicians)• Applies to all clinicians1

• Clinicians given opportunity to report as group or individual• No longer requires all-or-nothing EHR measurement• Only requires reporting of 11 measures


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Difficult to Use…

Historically, the Compare websites have conveyed few conceptual clues to help orient lay users to the sites’ overall purpose and content.”

L&M Policy Research and Mathematica Policy Research

Scant Efforts Toward Meaningful Transparency

Compare Websites Not Hitting the Mark

Source: Findlay SD “Consumers’ Interest in Provider Ratings Grows, and Improved Report Cards and Other Steps Could Accelerate their Use,” Health Affairs 35 no. 4 (2016): 688-696; L&M Policy Research and Mathematica Policy Research, Quality Reporting on Medicare’s Compare Websites: Lessons Learned from Consumer Research, 2001-2014. December 2015: Health Care Advisory Board interviews and analysis.

1998:Nursing Home

Compare

…And Little Used

AnnuallyHealthgrades users

10M

8.9M Monthly

2005:Home HealthCompare

2005: Hospital Compare

2010:Physician Compare

Hospital, Physician Compare users

Establishment of Compare Websites


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Attempting to Create an Orderly Marketplace

Enrollment Not Hitting Original Estimates, but Not Dropping Either

Source: HHS, “Health Insurance Marketplace Open Enrollment Snapshot – Week 13,” February 4, 2016; HHS, “Health Insurance Marketplace Open Enrollment Snapshot – Week 7,” December 22, 2015; HHS, “Health Insurance Marketplace 2015 Open Enrollment Period: December Enrollment Report,” Dec. 30, 2014; HHS, “Health Insurance Marketplace 2015 Open Enrollment Period: March Enrollment Report,” March 10, 2015; HHS, “Open Enrollment Week 13: February 7, 2015 – February 15, 2015, available at: http://www.hhs.gov/healthcare/facts/blog; HHS, “Open Enrollment Week 14: February 16, 2015 – February 22, 2015, available at: www.hhs.gov/healthcare/facts/blog; CBO, January 2015 Baseline: Insurance Coverage Provisions for the Affordable Care Act, available at: www.cbo.gov; Washington Times, “Obamacare Official: 7.3 Million Americans Are Still Enrolled and Paid Up,” Sept. 18, 2014; available at: http://www.washingtontimes.com; Kaiser Family Foundation, “Total Marketplace Enrollment and Financial Assistance,” June 30, 2015; Pradhan R, “White House Lowballs Obamacare Target in an Election Year,” Politico, October 15, 2015; Health Care Advisory Board interviews and analysis.

1) Open Enrollment Period. 2) Drop-off due to individuals not paying premiums or

voluntarily dropping coverage.

Exchange Enrollment

2016 federal exchange enrollees aged 18-34 (compared to 2.5M in 2015)

2.7M

“Young Invincibles” Still Scarce

State-run vs. Federally-facilitated Exchanges

2014-2016

8M

11.7M

8.2M

12.7M

10M

End of 2014 OEP1

End of 2015 OEP

December 20152

End of 2016 OEP

Final 2016 Enrollment (including projected drop-off)

December 20142

6.3M 75.6%

24.4%

Enrollment on federally facilitated exchanges

Enrollment on state run exchanges

Objective #3: Achieve Universal, Affordable Coverage


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Competitive Marketplace Driving Premium Changes

Premium Adjustments Abound

38.4%34.7%

33.6%32.2%31.4%31.0%30.0% 28.4%

25.5%22.5%20.2% 18.6% 18.3%18.0%16.9%15.4% 13.8% 13.8%13.5%12.2%11.8%10.1%10.1% 9.1% 7.3% 7.1%

7.0% 6.2% 6.0% 5.7% 4.7% 4.4% 4.0% 3.7% 3.0% 2.4% 1.2% 1.1% 0.4%

-0.4% -0.8%-1.2% -1.7% -2.1%-4.4% -5.0% -5.3%

-7.9% -9.2% -9.4%-10.6%

Percentage Changes in Benchmark Silver Plan Premium s

2015 – 20161

1) Data based on premium changes from major cities within each state where complete rates were available for all insurers; no data were available for Massachusetts. Source: Kaiser Family Foundation, “Analysis of 2016 Premium Changes in

the Affordable Care Act’s Health Insurance Marketplaces,” October 27, 2015; Health Care Advisory Board interviews and analysis.


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Medicaid Expansion Unexpectedly Fragmented

Benefit Clear for Hospitals, But Opposition Remains

Source: Kaiser Family Foundation, “Current Status of State Medicaid Expansion Decisions,” January 27, 2015, available at: www.kff.org; Fausset R and Goodnough A, “Louisiana’s New Governor Signs an Order to Expand Medicaid,” New York Times, January 12, 2016; HHS, “Insurance Expansion, Hospital Uncompensated Care, and the Affordable Care Act”, March 23, 2015, available at: www.aspe.hhs.gov; PwC Health Research Institute, “The Health System Haves and Have Nots of ACA Expansion”, 2014, available at: www.pwc.com; CMS, “Medicaid & CHIP: February 2015 Monthly Applications, Eligibility Determinations and Enrollment Report”, May 1, 2015, available at: www.medicaid.gov; Health Care Advisory Board interviews and analysis.

1) Montana’s expansion requires federal waiver approval. 2) Children’s Health Insurance Program.3) Excludes CT and ME.

Medicaid Expansion Positively Impacting Hospital Finances

31 States and DC Have Approved Expansion 1

As of May 2016

Medicaid Admissions increased 21% for investor-owned hospitals in expansion states

Self-Pay Admissions decreased by 47% for investor-owned hospitals in expansion states

Uncompensated Care costsreduced by $5 billion in expansion states in 2014

Growth in Medicaid, CHIP enrollment in expansion vs. non-expansion states, July-Sept. 2013 to Feb. 2015

27% vs. 8%11.7MNet increase in Medicaid, CHIP2

enrollment, July-Sept. 2013 to Feb. 20153

Not Currently Participating

Participating Expansion by Waiver


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Coverage Expansion Impact Unmistakable

“Universal Coverage” Still a Distant Goal, but Millions More Now Covered

Source: Gallup, “U.S. Uninsured Rate at 11.0%, Lowest in Eight-Year Trend,” April 7, 2016, http://www.gallup.com/poll/190484/uninsured-rate-lowest-eight-year-trend.aspx; Gallup, “U.S. Uninsured Rate 11.9% in Fourth Quarter of 2015,” January 7, 2016, available at http://www.gallup.com/poll/188045/uninsured-rate-fourth-quarter-2015.aspx; Health Care Advisory Board interviews and analysis.

US Adult Uninsurance Rate

Q4 2008 Q4 2010 Q4 2011 Q4 2012 Q4 2013 Q4 2014 Q4 2015

Major ACA coverage expansion provisions took effect January 1, 2014

20MHHS estimate of adults gaining health insurance coverage as a result of ACA

Q3 2013:18.0%

Q1 2016:11.0%


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Final Grade: Incomplete

Progress Towards Administration’s Own Goals Only Part of the Picture


1 2 3

Replace Costly Fee-for-Service Incentive Structures

Improve HealthCare Quality

Achieve Universal, Affordable Coverage

A-BC-Unfinished Business:

Reengineer health care delivery system, not just payment system, to generate greater value

Catalyze private market reform, not just entitlement program reform


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Serving Two Masters

PublicSector

• Medicare, Medicaid

Private Sector

• High cost per capita

• Chronic illness, comorbidities

• Rising share of population

• Insurers, employers, individual consumers

• Generally healthy with episodic care needs

• Access, experience, convenience paramount

• Large share-of-wallet opportunity

Purchaser Approach to Value:

“Public Utility”

• Rate setting

• Regulation

• Accountability controls

“Market Commodity”

• Market dynamics

• Consumer preference

Provider Approach to Value:

Population-level Focus

• Total cost control

• Care management

End-user Focus

• Unit cost control

• Consumer-oriented innovation

Public, Private Markets Demanding Different Value in Different Ways



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Sentinel Efforts to Circumvent Traditional Approach

Boeing Signs Value-Based Direct Contracts in Two New Markets


2015: Direct Contract with Major Systems Near Seattle Headquarters

78KTotal employees

2016: Expansion to Other Major Boeing Locations

Free primary care

Enhanced Benefits Attract Employees

St. Louis

Provider partners:

Charleston

Case in Brief: The Boeing Company

• Over 148,750 US employees

• Issued highly-prescriptive RFP for risk-bearing health system partners in Seattle region

• Early success prompts expansion to other markets

Free generic drugs

Reduced premiums


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Some Employers Steering for Specific Procedures

United Airlines Expands Bundle Offerings to Orthopedics

Source: Sachdev A., “United Offers Employees Cheaper Hip, Knee Replacements if They Travel to Chicago’s Rush,” Chicago Tribune, May 6, 2016, http://www.chicagotribune.com/business/ct-rush-united-cheaper-surgery-0508-biz-20160506-story.html; Health Care Advisory Board interviews and analysis.

Financial incentive for participating employees (waiving of copays and coinsurance)

Comprehensive travel planning for patient and caregiver

Physicians review medical record, determine eligibility

Flat bundle price paid to Rush

Key Program Features

Rush at financial risk for complications, such as infections or implant failures

Case in Brief: United Airlines

• 82,000 employees; headquarters in Chicago, Illinois

• Recently launched bundled payment contract with Rush University Medical Center for hip and knee replacements, and spinal fusion surgeries

• Bundled payment contract also in place with Cleveland Clinic for cardiac surgery

Quality Is Top Concern

The entire motivation for us is the quality of the care…. We don’t want cost to be a barrier for our employees.”

Anthony Scattone, VP of BenefitsUnited Airlines


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Onboarding Risk, then Offloading to Employees

Employers Increasingly Turning to High-Deductible Plans

Source: Kaiser Family Foundation and Health Research & Educational Trust, “Employer Health Benefits 2015 Annual Survey; Health Care Advisory Board interviews and analysis.

1) Among covered workers with a general annual health plan deductible.

2) Includes HDHP/SO.3) For single coverage.

$1,025

$958

$1,318

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

HMO PPO All Plans

ESI Average Deductible for Single Coverage 1

By Plan Type, 2006-2015

36%

19%

12%

0%

5%

10%

15%

20%

25%

30%

35%

40%

3-199 WorkersAll Firms200 or more workers

Percentage of Covered Workers with Annual Deductible of $2,000 or More 3

By Firm Size, 2006-2015

2


29

3M

6M

8M

2014 2015 2016

12M

19M

9M

9M

2013 projections

Private Exchange Enrollment Continues to Grow

Source: Accenture, “Eight Million U.S. Employees Enrolled in Private Health Insurance Exchanges for 2016 Benefits, According to Accenture” January 20, 2016;Accenture, “Private Health Insurance Exchange Enrollment Doubled from 2014 to 2015,” April 7, 2015, available at: www.accenture.com; Towers Watson, “Enrollment in Health Benefits Through Towers Watson’s Exchange Solutions Expected to Reach About 1.2 Million in 2015,” March 19, 2015, available at: www.towerswatson.com; Mercer, “Mercer Marketplace-the flexible private exchange-posts individual participant and client gains,” October 13, 2014, available at: www.mercer.com; “Private Insurance Exchanges: What You Need to Know” Health Care Advisory Board 2015; Health Care Advisory Board interviews and analysis.

Defined Contribution the Next Major Shift?

Private Exchange Enrollment Still Grows in 2016, But Lags Behind Initial Projections Projected Private Exchange Enrollment Among Pre-65 Employees and Dependents

Enrollment growth for Towers Watson’s exchange solutions, 2014-2015

50%Enrollment growth for Mercer’s exchange solutions, 2014-2015500%

(800k�1.2M)

(220k�1M)

Newer Market Entrants Hitting Their Stride

40-60% Employees on private exchanges who select a high-deductible health plan option

2015 projection


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Expressing a Preference for Low-Cost Coverage

Consumers Electing to Bear Very High Cost Exposure

Source: HealthPocket.com, “2015 Obamacare Deductibles Remain High but Don’t Grow Beyond 2014 Levels,” November 20, 2014, available at: www.healthpocket.com; Health Care Advisory Board interviews and analysis.

1) Federal Employee Health Benefits Plan.

$233

$1,165

$3,117

$5,731

$243

$1,198

$2,927

$5,181

$347

$1,277

$2,907

$5,081

Platinum

Gold

Silver

Bronze

2014 2015 2016

Average Deductible for Exchange-Sold Health Plans2014-2016

Exchange Enrollment, by Metal Tier2015

20%

69%

7%4%

Bronze

Silver

GoldPlatinum

Nearly 90% of exchange enrollees are in bronze or silver plans


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Consumer Responses Generally Dangerous for Provider Economics

1) $1,200 Single; $2,400 Family.2) $2,500 Single; $5,000 Family.

Higher Deductibles Driving Increased Price Sensitiv ity

Source: Brot-Goldberg Z et al., “What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics,” The National Bureau of Economic Research, October 2015, available at: http://www.nber.org; Altman D, “Health-Care Deductibles Climbing Out of Reach,” Wall Street Journal, March 11, 2015, available at: www.blogs.wsj.com; Health Care Advisory Board interviews and analysis.

Fail to Pay?

Households Without Enough Liquid Assets to Pay Deductibles

24%

35%

Mid-rangedeductible

Higher-rangedeductible

1 2

2Shop Carefully?

56%

74%

Consumers with deductibles higher than $3,000 who have solicited pricing information

Consumers searching for price information before getting care

3Forgo Care?

Spending Reductions Following Implementation of High-Deductible Health Plans

1

25%Reduction in physician office spending

18%Reduction in ED spending


32

Turning to Unlikely (and Uncomfortable) Sources

Crowdsourced Reviews Getting More Reliable

“Yelp’s Consumer Protection Initiative: ProPublica Partnership Brings Medical Info to Yelp” Yelp, Official Blog, August 5, 2015; https://www.yelpblog.com/2015/08/yelps-consumer-protection-initiative-propublica-partnership-brings-medical-info-to-yelp; Health Care Advisory Board interviews and analysis.

ProPublica compiles and provides Yelp with Hospital Compare metrics on ER wait time, doctor communication and room noise levels

“Now the millions of consumers who use Yelp… will have even more information at their fingertips when they are in the midst of the most critical life decisions, like which hospital to choose for a sick child or which nursing home will provide the best care for aging parents.”

Jeremy Stoppelman, CEOYelp

Acclaimed news source partners with review website with more than 85 million monthly users Incorporates Medicare data on more than 25 thousand facilities, including 4,600 hospitals


33

Just What Consumers Are Looking For

Yelp Reviews Capture Surprisingly Detailed Picture of Consumer Experience

Source: Ranard B et al.; “Yelp Reviews Of Hospital Care Can Supplement And Inform Traditional Surveys Of The Patient Experience Of Care,” Health Affairs, April 2016; Health Care Advisory Board interviews and analysis.

Topics Covered in Yelp Reviews Without Clear HCAHPS Analogue

• Cost of hospital visit

• Insurance and billing

• Ancillary testing

• Facilities

• Amenities

• Scheduling

• Compassion of staff

• Family member care

• Quality of nursing

• Quality of staff

• Quality of technical aspects of care

• Specific type of medical care

12 7 4

Study in Brief: Yelp Reviews Of Hospital Care Can Supplement And Inform Traditional Surveys Of The Patient Experience Of Care

• Published in Health Affairs, April 2016

• Analysis of 16,862 hospital Yelp reviews, HCAHPS scores for 1,352 hospitals

• Moderate correlation found between Yelp, HCAHPS scores

Domains covered in Yelp reviews, but not HCAHPS

Covered in both Yelp and HCAHPS

Covered by HCAHPS only

Topic Domains Addressed by Yelp, HCAHPS


34

Online Dating Comes to Health Care

Finding Your Match

Case in Brief: Pardee Hospital

• 222-bed community hospital in North Carolina managed by UNC Health

• Patients can select a doctor by selecting up to 14 personality characteristics

• Algorithm also lists doctors based on compatibility, distance, and location

Source: Pardee Select, available at :www.pardeeselect.org; Health Care Advisory Board interviews and analysis.

12%Volume growth at hospital’s physician practice network


35

Ever More Services Poised to Leave Provider Settings

Sources: PwC, “Healthcare’s new entrants: Who will be the industry’s Amazon.com?” Health Research Institute, April 2014, https://www.pwc.com/us/en/health-industries/healthcare-new-entrants/assets/pwc-hri-new-entrants.pdf; AmericanWell, “Telehealth Index: 2015 Consumer Survey,” AmericanWell.com, January 2015; http://cdn2.hubspot.net/hubfs/214366/TelehealthConsumerSurvey_eBook_NDF.pdf?submissionGuid=484469d1-8864-4efa-93c7-07e5c43fe4a5; Health Care Advisory Board interviews and analysis.

1) “Are you open to trying new, non-traditional ways of seeking medical attention or treatment?”2) “How likely would you be to choose these options, if they cost less than the traditional choice?”

Percent of respondents answering “Very likely” and “Somewhat likely.”

Consumer Preferences Re-Drawing the Landscape

Consumers with access to telemedicine have used it55%

82%

37% 42% 43%55% 59%

Have chemotherapyat home

Do urinalysis test athome with deviceattached to phone

Remote pacemakeror defibrillator check

by physician

Send a digital photoof rash for

dermatologist consult

Use an at-homestrep test purchased

at a store

Of people 18-34 would switch to a physician who offered telemedicine11%

Consumers Willing to Try New Ways of Seeking Medical Attention or Treatment 1

Percentage of consumers willing to choose more conv enient options 2


36

To Disrupt or to Sustain?

Market Evolution Will Force Incumbents to Innovate

Source: Christensen C, Raynor M and McDonald R, “What is Disruptive Innovation?,” Harvard Business Review, December 2015, available at: https://hbr.org/2015/12/what-is-disruptive-innovation; Health Care Advisory Board interviews and analysis.

by dismantling a still-profitable business. Instead, they should continue to strengthen relationships with core customers by investing in sustaining innovations.

Clay ChristensenHarvard Business Review, December 2015

Incumbent companies do need to respond to disruption if it's occurring, but they should not overreact

Can We Undermine Our Legacy Business?

“Sustaining” Innovations

“Disruptive” Innovations

Physician practice acquisition

Telemedicine, remote diagnosis and treatment

Freestanding emergency departments

Retail, urgent care footprint

Partnerships for pricing leverage

Provider-sponsored health plan


37

Confronting a False Choice


PublicSector

• Medicare, Medicaid

Private Sector

• High cost per capita

• Chronic illness, comorbidities

• Rising share of population

• Insurers, employers, individual consumers

• Generally healthy with episodic care needs

• Access, experience, convenience paramount

• Large share-of-wallet opportunity

Population Health Imperatives

• High-value network assembly

• Scalable care management

• Low total costNo-Regrets Priorities

• Superior access

• Reliable care delivery

• Leaner fixed cost structures

• Platforms forongoing loyalty

Population Health, Consumerism Equally Urgent

Consumer Imperatives

• Improved experience

• Customization

• Low unit cost


38

2

3

1

Road Map



Proving Our Value


39

As Value Proposition of CV Services Evolves, So Must the Specialist Role

Source: Cardiovascular Roundtable interviews and analysis.

Physicians at the Center of CV Transformation

Ensure multidisciplinary care delivery

Enhance thepatient experience

Coordinatecare acrossthe continuum

Controltotal costs

Increase access,market capture

CV PhysiciansIntegral to Achieving

New Service Line Aims


40

A Steady Trend of CV Physician-Hospital Alignment

Source: 2012 American College of Cardiology Physician Practice Census, www.cardiosource.org; 2014 Cardiovascular Roundtable CV Physician Alignment Strategy Survey; Cardiovascular Roundtable research and analysis.

1) American College of Cardiology.2) Hospitals instructed to select “yes” response if any CV

specialist is employed or under co-management.

CV No Stranger to Physician Integration

63% 61%49% 54%

38%41% 38% 34%25% 19%

MedicalCardiology

InterventionalCardiology

EP CardiacSurgery

VascularSurgery

Employment Co-management

Continuing to Engage in Formal AffiliationRoundtable Members Using Each Alignment Strategy, by CV Specialty, 20142

ACC1 Outlines Recent Trends in Employment

11% 35%

Percentage of Cardiologists Employed by Hospitals, 2007 vs. 2012

2007 2012


41

Bundled Payment Initiatives• Number of BPCI candidates tripled

in July 2014

• 77% of original BPCI1 participantsbundled at least one CV condition

• Both CMS, commercial bundlingrequire hospitals, physicians partner to reduce episodic costs

Partnership Essential to Meeting Emerging CV Cost, Quality Mandates

Source: FY2015 Inpatient Prospective Payment System Final Ruling, CMS; Evans M, “Interest Surges in Medicare Bundled-Payment Initiative,” Modern Healthcare, July 31, 2014; 2012- and 2013 Medscape Physician Compensation Reports; Cardiovascular Roundtable research and analysis.

1) Bundled Payment for Care Improvement.2) Inpatient Quality Reporting program.3) Accountable Care Organization.

Payment Innovations Increase the Urgency to Align

Select Initiatives Incentivizing Hospital-Specialist Alignment

Readmission Reduction Program• Maximum penalty increased

to 3% for FY 2015

• CABG added for FY 2017

• Increases hospital accountabilityfor post-discharge care, largely managed by physician practices

Shared Savings Programs, ACOs• Estimated 542 ACOs3 as of

January 2014

• Cardiologist participation in ACOsgrew from 2% in 2012 to 28% in 2014;14% plan to participate within next year

• Participating programs must increase market capture, patient base, through strong affiliations with physicians

CV Cost Efficiency Metrics• IQR2 adding Medicare Spending per

Beneficiary metrics: AMI spendingper 30-day episode in FY 2016, similar HF metric in FY 2017

• Requires reporting on longitudinal cost for expanding CV diagnoses, mandating coordination across hospital, physician sites


42

Primary Care Redesign Transforming the Specialist-PCP Relationship

Source: Colla CH, et al., “First National Survey of ACOs Finds that Physicians are Playing Strong Leadership and Ownership Roles,” Health Affairs, 2014, 33: 964-971, Cardiovascular Roundtable research and analysis.

1) Patient-centered medical home.2) National Committee for Quality Assurance.

Hospital Partnerships Not the Only Ones Changing

Key Forces Elevating the Role of PCPs in CV Care

• 51% of ACOsphysician-led in 2014

• Largely focus on PCPs; specialist role in ACOs often undefined

• Participating providers incentivized to keep patients healthy, reduce specialty utilization

• 8,000th PCMH1

recognized by NCQA2

in August 2014

• Model places PCPs at the center of care decisions, holds accountable for cost, outcomes

• Reform prioritizes managing patients in lowest-cost setting, deemphasizes acute care

• New CMS chronic care management codes in 2015, PCPs most likely to utilize

Emphasis on Prevention, Disease

Management

Proliferationof Patient-Centered

Medical Homes

ACOs Forming Around PCPs


43

Key Implications of New Market Forces on Specialist-PCP Dynamics

Source: Cardiovascular Roundtable research and analysis.

Disrupting the Traditional Referral Relationship

Deferred Specialist Referrals

PCPs more likely to retain patients longer before referring to maintain greater control over care decisions, reduce potentially unnecessary specialty utilization

Narrowing Referral Networks

Emerging primary-care based entities (e.g., ACOs, PCMHs)shift the direction of specialist referrals for broad group of primary care providers

Increased Selectivity of Specialists

Referring physicians more selective in partnering with high-quality, low-cost specialist, given greater accountability for total value of care

Greater PCP Managementof Long-Term CV Care

PCPs more comfortable with managing chronic CV patients across the continuum, providing care traditionally managed by specialists


44

Transforming Demands in Collaborating with Hospitals, PCPs


Resulting in a Paradigm Shift for CV Specialists

The New Dynamics of CV Specialist Partnerships

Former Goals of Affiliation:

• Expand referral network

• Maximize procedure volume

New Expectations of Physician Partners:

• Help guide strategic vision for the CV enterprise

• Support value-based care goals

CV Specialist Primary CareCV Service Line

Changing Expectationsof Physician Alignment

Shifting Roles inCV Care Management

Traditional Specialist Role:

• Specialist provides majorityof CV care

• Focuses on acute care

Evolving Roles:

• PCPs managing morelong-term care

• Specialists must ensure coordination, define place in the referral stream


45

Chronic, Comorbid Nature of CV Has Often Blurred Specialist-PCP Roles

Source: 2009 Medicare Physician Claims; Cardiovascular Roundtable research and analysis.

1) Percentages do not add to 100 due to removal of other specialties.

Sharing Patients Not a New Trend

Cardiology Internal Medicine General Practice

AMI 57% 19% 4%

Arrhythmia 46% 20% 9%

Chest Pain 37% 15% 7%

HF 31% 26% 10%

Hypertension 8% 35% 22%

Valve Disease 70% 13% 3%

CV Conditions and Treating Physician Specialty

Percentage of 2009 Medicare Claims1

Cardiology Primary Care


46

Care Transformation Further Altering the Roles of PCPs, Specialists


Payment Innovation Shifting Strategic Importance

Volume Maximization Population Cost, Quality ManagementShifting Strategic Imperatives

FFS Transition Risk-Based Payment

Role of PCPs

• Serve as source of referrals for specialists, hospital

• Provide coordinated, comprehensive care

• Ensure chronic care population well-managed

• Population health management

• Emphasis on total patient wellness

Centrality to Care Delivery

Role of CVSpecialists

• Generate revenue through procedures

• Serve as source of referrals for hospital

• Take on larger role as care managers

• Continue performing procedures when appropriate, with focus on outcomes, cost

• Work collaboratively with PCPs to manage care

• Perform appropriate procedures only when necessary, possible volume reduction due to upstream prevention and alternative care options

Centrality to Care Delivery

Role of Physicians in Health System Transformation


47

Lack of Relationships Could Leave Specialists Locked Out of Network

Source: Cardiovascular Roundtable interviews and analysis.

1) Pseudonym.Note: Medical neighbor scorecard available in the online Appendix.

Important to Lay the Foundation Now

Westminster PCMH Selecting One Preferred CV “Neighbor”

CV Services at Smith 1

Locked Out of New ACO

• Level III NCQA-certified medical home

• To build medical neighborhood, selectively deployed coordination agreements with 20 different specialty practice “neighbors”

• Grade each neighbor quarterly on adherence to care coordination agreement

• Distribute patient guides that indicate selected neighbors, only one CV specialist group

• New ACO entered Smith’s market

• ACO has 15 PCP groups, 10 of which were familiar working with a competitor, Carter CV group

• ACO now bringing that Carter into network

• Smith no longer receiving referrals from 5 other PCP groups

Our Medical Neighborhood

Your Medical Neighborhood Specialists are physicians who are pioneering a program here in CO to improve your patient experience in the healthcare system. They work closely with us to provide you the safest, highest quality care possible.

Group Physician Office

Cardiology CV Group A

Carter1 Smith


48

Specialists Must Become the Best Partners to Secure Referrals


Getting Inside the Mind of the PCP

Characteristics a PCP Looks for in a Specialist

Can assure quality, patient-centered care

Gives timely feedback on consults, referral requests

Provides easy-to-use guidelines on when and how to refer

Guarantees to return patient once appropriate

Communicates and keeps referrer in loop throughout patient care

Returns patient with all necessary information and data

Provides support for ongoing care


49

Lessons for Collaborating with Hospitals and Primary Care


CV Specialist Partnerships

1. Unify Leadership and Governance Structures

2. Align Strategic Aims

3. Support Operational Integration Across Practices

4. Facilitate Practice Performance Transparency

IIntegrating the Service Line and Affiliated Groups

• Benchmarking Current Compensation Models

• Adjusting Productivity Measures

• Structuring Incentives

• Selecting Appropriate Performance Metrics

5. Build an Infrastructurefor CV-PCP Collaboration

6. Establish Service Agreements

IIFostering Collaborationwith Primary Care

10. Create Guidelines to Delineate CV Care Management

11. Support PCPsin Longitudinal CV Care Delivery

IVClarifyingRoles in Patient Management

7. Develop Communication Pathways for Referring Physicians

8. Streamline Specialist Consults

9. Guide Identification of Appropriate CV Referrals

IIIHardwiring Referral Streams from PCPs

Advancing Hospital-Specialist Alignment Enhancing CV Specialist Partnerships with Primary Care

DesigningEffective Physician Compensation Models

Special Report:


50

Case 2: Kaiser’s Multidisciplinary Complex CV Case Conference

1) End stage renal disease.

Bringing PCPs to the Table for Care Decisions

Full conference charter available through advisory.com

Conference Attendees• Relevant

specialists (e.g., cardiologists, nephrologists)

• Referring PCP• Care managers

(HF, ESRD1)

• Social services • Hospitalist• Pharmacist• Continuing care• ED/urgent care • Quality team lead

• One-hour meeting held monthly

• Review two complex CV patientsper meeting

• Care manager and utilization management physician lead facilitate discussion

CV Case Conference Assembles Full Spectrum of Caregivers

Source: Kaiser Permanente Southern California Region, Pasadena, CA; Tuso P, et al., The Permanente Journal, 2013, 17: 58-63; Cardiovascular Roundtable interviews and analysis.

Create a multidisciplinary care plan for complex CV cases

Goals of Conference

Delineate responsibilities for ongoing patient management

Engage and support PCP in implementing care plan

Identify opportunities for improvement in CV care coordination

Lesson 5: Build an Infrastructure for CV-PCP Collaboration


51

Advanced Planning Ensures Productive Meetings

1) Readmission risk score based on length of stay, acuity of admission, comorbidities, and ED visits in past six months.

Including PCPs in All Stages of CV Care Planning

• Physicians or care managers refer complex cases requiring multidisciplinary insight; physician champion selects two

• Informal criteria may include multiple comorbidities, multiple readmissions, LACE1

score ≥ 11

• Submit patient ID to care manager

Overview of Case Conference Process

Complex Patients Identified

PCP Engaged by Care Manager

Multidisciplinary Case Conference

Care Plan Implemented


• Identifies referring PCP for each patient

• Schedules PCP’s time in advance to join conference

• Sends case summary to PCP to review before meeting

• Framed as a chance for multidisciplinary collaboration, clarifying not peer review

• Each PCP dials into conference for 20 minutes to discuss their patient

• Team develops cohesive long-term plan

• If PCP can’t attend, care manager sends care plan after conference to get feedback

• PCP aims to schedule 20 minutes following conference to meet with patient and discuss the care plan

• Care plan documented in EMR

• Open line of communication to complex CV care team for future guidance


52

Improving Coordination and Building Ongoing Communication

1) n of 81 cases discussed across three pilot sites.

Broad Impact of Case Conferences

Tangible Results of Conference

68%


Additional Information Tracked

• Principal comorbidities of cases

• Pre-, post-conference utilization

• Conference attendance

• Success of case conference approaches at each site in system

Benefits of Including Primary Care in the Discussion

PCPs provide insight on patient’s history, psycho-social factors, home support

Enfranchises PCP to manage long-term CV care

Strengthens collaboration, lines of communication between PCPs and specialists

Reduction in hospitalizations between six months prior to case conferences, six months after conferences implemented1


53

Service Agreements at CHS1 Set Patient Management Expectations

Lesson 6: Establish Service Agreements

1) Catholic Health System.

Codifying Standards Through Shared Agreements

Areas for improvement include:

• Timeliness of referral, consult request

• Appropriateness of referral to specialist

• Bi-directional flow of patient information pre-, and post-referral

System Identifies Opportunity to Improve Relationships Between Referring PCP, Specialist

• System requires formal agreements between PCPs and specialists for high-priority specialties (e.g., cardiology, vascular)

• CV leader encourages CV specialists to proactively form relationships with PCPs

Requires PCPs to Develop Service Agreements with Specialists

• Agreements can be physician-physician or group-group, must be signed by both parties

• PCPs and partnering specialists determine individualized standards based on comfort with managing certain conditions

PCPs and Specialists Collaborate to Create Mutually Agreeable Standards

Source: Catholic Health System, Buffalo, NY; Cardiovascular Roundtable interviews and analysis.


54

Agreements Address Key Components of PCP-Specialist Interactions

Note: Referral agreement available in the online Appendix.

Strengthening Physician Referral Relationship

Indicates timeliness of feedback for requests

Specifies information PCP needs to send with referral patient

Designates role delineation in management of patient

Specialist agrees to send new clinical information, care recommendations to PCP

Signed by both PCP and specialist

Source: Catholic Health System, Buffalo, NY; Cardiovascular Roundtable interviews and analysis.


55

Roundtable’s Online Library of Sample Standards


Providing Service Agreements to Get You Started

Ideal Components of Agreements

Defines responsibilities between specialist and PCP

Physician feedback, annual re-assessment of components

Mutually developed and agreed upon by PCP and specialist

Indicates timelines of bi-directional information flow (e.g., test results, clinical data, education, protocols)

Designates preferred method of communication

Note: Service agreement compendium available in the online Appendix.


56

























Special Report:


57

Many Factors Prevent PCPs from Referring CV Patients at Right Time

Source: Mehrotra A et al., “Dropping the Baton: Specialty Referrals in the United States,” Milbank Q, 89, no. 1, (2011): 39-68; Kyruus ,“Physician Referral Survey,” 2014; Cardiovascular Roundtable research and analysis.

PCPs Face a Number of Hurdles When Referring

PCPs unaware of how, and to whom to refer a potential CV patient

Unclear on what information they need to send, tests to order ahead of time

Lack of specialty background needed to identify CV patients

PCPs fear losing patients if refer to a specialist

Potential Drivers ofReferral Inconsistencies

Variation in specialist referral rates between most frequently

and infrequently referring PCPs

5-fold

75%

25%

At Least One Clinically Inappropriate Referral

No Clinically Inappropriate Referrals

Often Leading to Inappropriate Referrals

Percentage of Specialists Receiving “Clinically Inappropriate” Referrals in the Past Year


58

Case 1: FHO1 Engaging Medical Home in CV Discussion

Lesson 7: Develop Communication Pathways for Referring Physicians

1) Florida Hospital Orlando. .

Going to the Source to Improve Referrals

PCMH Representative Provides Primary Care Perspective

Key Challenges Identified Through Discussion

!

• Identified opportunity to improve relationship with PCMH

• Invited internal FHO PCP medical home expert to attend one session

• Shared perspective on needs of PCP, PCMH in specialist interaction

• Encouraged both sides to identify challenges in PCP-specialist referrals, collaboration

• Hospital service line, CV physician leaders, and facilitators participated in institution’s Innovation Lab to identify opportunities to improve alignment

• Five sessions total across three months

• Variety of ad hoc stakeholders invited to attend dependent on session topic

CV Innovation Lab Aiming to Enhance Physician Collaboration

PCPs and specialists primarily interacting through paper, EMR

PCPs do not know who to consult due to rotating cardiologists and frequent new hires

CV specialists unaware who to include in care team (e.g., care coordinators, pharmacists)

Source: Florida Hospital, Orlando, FL; Cardiovascular Roundtable interviews and analysis.


59

Proposing Three Strategies to Streamline Referrals for PCPs

Improving Visibility for Referring Physicians

Medical Group “Facebook”

• Create a “facebook” directory to improve visibility of medical group physicians in the “neighborhood”

• Includes contact information, how to refer

Cardiologist of the Day

• One designated cardiologist at each hospital per day

• Information would publicly available so PCPs know how and who to contact for CV referrals

Group Block Parties

• Hold gatherings for all physicians in the medical home and specialty services

• Opportunity to get toknow everyone in their “neighborhood”

1 2 3

Source: Florida Hospital, Orlando, FL; Cardiovascular Roundtable interviews and analysis.


60

“Curbside Consults” at Lancaster Ensure Appropriate CV Referral

Lesson 8: Streamline Specialist Consults

Delivering Instant CV Care Recommendations

PCP-Patient Visit

PCP has CV question during patient visit

Curbside Consult

PCP emails question through EMR system

• Do I need to give this patient a test?

• Do I need to refer to a CV sub-specialist?

Overview of Curbside Consult Process

Patient Referred to Cardiologist

Patient Managed by PCP

CV Response

Assigned cardiologist on duty responds to PCP question via online messaging system

Source: Lancaster General Health, Lancaster, PA; Cardiovascular Roundtable interviews and analysis.


61

Optimizing Impact of Consult Program

Strategic Implementation Critical to Success

Key Implementation Guidance

1 Assign Designated Role

Rotate cardiologist who staffs consult; take consults during assigned urgent care and image reading session

3 Create Service Standards

Hold CV specialist accountable to turnaround time of four hours or less

4 Educate PCPs

Target directors of PCP groups, information spread through word of mouth

2 Align Incentives

Deemphasize productivity in compensation model to enable cardiologist’s time for consults, mitigate impact of reduced unnecessary referrals



62

Streamlining Appropriate Referrals, Redirecting Unnecessary Care

Far Ranging Benefits of Immediate Consult Support

Strengthen relationship, collaboration between PCP and CV specialist

Reduce Avoidable Services

PCPs and CV specialists able to communicate faster, minimize hassle

Streamline Communication

Decrease in unnecessary CV office visits, tests

Build Relationships

Expected Impact of Curbside Consults

Additional Metrics Tracked

� Number of curbside consults

� Number of messages answered

� Outcomes of answered questions

� Informal feedback from PCPs

� Indirect impact on number of consults, office visits



63

Roundtable’s Online Compendium Offers Sample CV Referral Guidelines

Lesson 9: Guide Identification of Appropriate CV Referrals

Guidelines Aid Timely Transitions to CV Care


Note: Referral guideline compendium available in the online Appendix.

Condition-Specific Guidelines

� Heart failure

� Peripheral arterial disease

� Atrial fibrillation

� Hypertension

� Atherosclerosis

� Chest pain

� Palpitations

� Lipid management

� Syncope


64

Case 1: AtlantiCare’s Echo Alert Identifies At-Risk Patients for Referral

1) Picture archiving and communication system.3) Aortic valve area.

Providing Greater Support in Patient Identification

z

Patient gets echo at any site in network

1

Echo tech collects reports through interconnected PACS1

2

Echo tech runs report to identify patients with AVA3<1.0cm2

3

Sends “echo alert” list of at-risk patients to valve coordinator on weekly basis

4

z

Patient gets echo in hospital

1

If patient has measurement of AVA3<1.0cm2, echo tech makes note

2

Patient’s name and medical record number immediately emailed to valve clinic

3

Valve coordinator contacts PCP, offers appointment for patient evaluation in valve clinic

Outpatient Flow

Inpatient Flow

Source: AtlantiCare, Egg Harbor, NJ; Cardiovascular Roundtable interviews and analysis.


65

























Special Report:


66

Unclear Lines of Responsibility Lead to Breakdowns Across Continuum

Confusion Over Patient Management

Source: Mehrotra A et al., “Dropping the Baton: Specialty Referrals in the United States,” Milbank Q, 89, no. 1, (2011): 39-68; “Chronic Illness and Caregiving,” Harris Interactive, 2000; Cardiovascular Roundtable research and analysis.

Inefficiencies result when patients receive conflicting care plan information, which can include duplication of services or patients not seeing the most appropriate provider

Failure to delineate patient care management can result in reduced continuity of care, delayed diagnosis, delayed treatment, or hospitalization

If PCPs do not feel specialists return patients at an appropriate time, their dissatisfaction leads to fewer future referrals to that specialist

Duplication of Services or Conflicting Plans

Patient Falls Through Cracks

PCPs Less Likely to Refer in Future

14%17% 18%

DifferentDiagnoses

ConflictingInformation

DuplicateProcedures

Percentage of Patients with Chronic Disease Experiencing Breakdown

Complications with Multiple Providers


67

Case 1: Intermountain Engaging PCPs in Developing, Piloting Guidelines

Lesson 10: Create Guidelines to Delineate CV Patient Care Management

Delineating Management of Low-Risk CV Patients

• Multidisciplinary development team includes both CV specialists and PCPs

• Collectively developed best-practice guidelines, sequence of treatment for various conditions (e.g., hypertension, atrial fibrillation, lipid management, CHF)

Multidisciplinary Team

• Guidelines converted into paper, electronic two-page flashcard

• Sent to 15 PCPs to pilot guidelines, report on feedback

• CV administrator and physician lead present guidelines to all 22 hospitals in system

• Revisit institutions once a year to update guidelines

Pilot with Feedback Educate PCPs

Source: Intermountain Healthcare, Salt Lake City, UT; Cardiovascular Roundtable interviews and analysis.

Key Components of Guideline Development and Impleme ntation

1 2 3


68

Best Practice Guidelines Advise PCPs on Hypertension Management

1) Blood pressure.Note: Full high blood pressure guideline manual and two-page flashcard available in the online Appendix.

Consolidating Information Into Useful Tool for PCPs

High BP Readings in a Specialty Care Office

For undiagnosed high BP identified by a specialist:

• Refer to PCP

• Code as “suspected High BP” in the EMR

• Make sure correct PCP is listed in EMR

• Emphasizes aim to transition low-end CV services to PCPs

• Helps specialists identifywhich patients should be returned to primary care


Components of Guidelines

Algorithm for BP1 screening, diagnosis, and treatment

Condensed advice in two-page flashcard for quick guidance

Recommended strategies and tools for patient education

Special considerations for certain patient populations (e.g., coronary artery disease, heart failure, pregnant women)

Medications to control high BP with detailed notes on brands, dosage, and side effects

Additional resources on high BP for patients and providers


69

Significant Reduction in Uncontrolled Hypertension

Guidelines Enabling PCPs to Manage Hypertension

Guideline Distribution

Clear Advice for PCPs

• Dispersed guidelines to PCPs; advised to use for all patients with hypertension, uncontrolled blood pressure

• Guidelines include strategies for medical assistants to contact patients bi-weekly to fine-tune treatment

• Added reminder that if patient with hypertension has not been seen in three weeks, should call in for check-up

25% National Average

65% Intermountain

Percentage of Diagnosed Hypertension Patients with Controlled Blood Pressure

Given success, Intermountain has created additional guidelines (e.g., lipid management) through a similar process



70

Case 2: AtlantiCare’s Care Model Delineates HF Care Across Continuum

1) Centers for Medicare & Medicaid Services‘ Medicare Shared Savings Program.

Hardwiring Bi-Directional Flow of Patients

HF Care Model

Development

• Care models (e.g., HF, diabetes) developed to hardwire when appropriate to refer to specialists, return back to PCP

• Effort to enhance collaborative relationship between PCP and specialists

• HF, PCP medical directors collaboratively develop evidence-based guidelines

Implementation

• Medical director of clinical integration (cardiologist) reviewed model with PCP leadership group, PCPs across network

• Ensures consistent care model delivered in inpatient setting, HF clinic, PCP offices

Metrics

• Tracking HF readmission rates, drill down to PCP and ACO populations; benchmarking with CMS MSSP1 report



71

HF Care Model Describes Appropriate Steps for Different Risk Levels

Note: HF care model available in the online Appendix.

Clearly Indicating Which Provider Should Offer Care


Care model adapted from ACC/AHA 2013 guidelines

Regular PCP visits for lower risk patients

Suggests collaborative care between PCP and cardiologist for higher risk patients

Comprehensive care coordination requiring both PCP and cardiology necessary for highest risk patients

Advises potential referral to other specialists


72

Case 1: Bon Secours Supporting CV Patient Transition to PCMH

Note: Nurse navigator job description available in the online Appendix.

Enabling PCPs to Manage Long-Term Care

Source: Bon Secours Health System, Richmond, VA; Cardiovascular Roundtable interviews and analysis.

Nurse Navigator in Hospital

Role of Nurse Navigator

Navigate both the primary care and CV side of the equation

Initiate and track patient referrals

Act as central line of communication between patients and caregivers

Ensure patients are following medical interventions as directed by cardiologist

Facilitate patient transfer back to PCP following referral visit

• Coordinates transition to primary care

• Available for CV consults as needed

• Manages long-term CV care

• Refer back to CV specialist as necessary

CV Nurse Navigator in PCMH

Lesson 11: Support PCPs in Longitudinal CV Care Delivery


73

Nurse Navigators Use HF Workflow to Optimize Ongoing CV Care

Providing CV Care Pathways in the Medical Home


1

Development of HF Workflow

HF flowchart authored by CV physician champion based on literature and own expertise, education

2

3

4

Guidelines help PCP navigator recognize HF abnormalities for referral to cardiologist

Multidisciplinary physician engagement in approval process critical for PCP acceptance

Algorithm entered into EMR to simplify usage

Enabling Navigators to Utilize Workflow

Navigators participate in continuing education program bi-weekly, with multiple sessions on HF algorithm

Skillset necessary to care for HF patients repeatedly updated, re-taught to navigators

Annual competency assessment built into individual performance evaluation, tied to compensation


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HF Guidelines Detail Protocols and Indicate CV Referral Trigger Points

Note: HF workflow available in the online Appendix.

Guiding Appropriate Care to Appropriate Provider

Bon Secours HF Workflow Guidelines


Explicitly states what nurse navigator will do in clinical care, assessment of each patient

Designates who within the medical home or CV practice is responsible for care of each patient based on symptoms

Emphasizes goal of managing patient in primary care


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CV Leaders Able to Justify the Investment

Successes Prove Value of PCMH Nurse Navigators

30-day all-cause readmission rate for HF and MI4%

Additional Information Tracked

• No-show percentages

• Physician productivity

• Patient cycle time in office

• Patient and physician satisfaction

• Reduced 30-day readmission rates

• Increased compliance with treatment regimens (e.g., testing, labs, follow-up)

• Critical for physician buy-in

• Decreased no-show percentages

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• Increased visit volumes in specialty programs

• Appropriate referrals for procedures

• Additional non-physician services (e.g., compliance in primary care wellness visits, transition of care codes)

• Increase in top-of-license care


Increase in Appropriate Volumes for System

Positive Clinical Impact

Post-discharge cardiology visit rate within 7-14 days80%


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Road Map



Proving Our Value


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Viewing Our Strategy Through a New Lens

Source: Kirby J and Stewart TA “The Institutional Yes,” Harvard Business Review, October 2007; Health Care Advisory Board interviews and analysis.

Jeff Bezos

[I have a] passion to figure out customer-focused strategies as opposed to, say, competitor-focused strategies. If you’re competitor-focused, you tend to slack off when your benchmarks say that you’re the best. But if your focus is on customers, you keep improving.

Competitor-centric Strategy Consumer-centric Strateg y

Strategic Benchmark: Closest competitor’s performance Financial Metric: Share of existing marketExecutive Focus: Stewardship of community asset

Strategic Benchmark: Maximum consumer value Financial Metric: Share of wallet, lifetime loyaltyExecutive Focus: Ongoing drive for improvement

2445 M Street NW I Washington DC 20037P 202.266.5600 I F 202.266.5700 advisory.com

State of the Union: The New Era of Health Care Reform · Expansion of Existing System • Insurance...

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