Accountable Care An Update on Providers Managing Risk

November 17, 2016

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Agenda

Future of Value Based Contracts and ACOs

ACO Performance

Emergence of Accountable Care Around the World

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Agenda

Future of Value Based Contracts and ACOs

ACO Performance

Emergence of Accountable Care Around the World

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Smarter

Spending Improve

Population Health Patient Care Experience

Triple Aim

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The U.S. health care market is in the process of a transition from fee-for-service (FFS) reimbursement to value-based care, is your plan ready?

Market Momentum Toward Value-Based Care

Keeping up with competition1

• UHC has $43 billion in value-based contracts representing 13 million lives and expected to reach $65 billion by 2018

• Anthem has $38 billion invested in value-based contracts, representing 30% of its commercial claims for 40,000 providers

• Health Care Transformation Task Force — 20 major health systems, payers pledge to convert 75% of business to value-based arrangements by 2020

Sources: 1. Forbes–Aetna press release, UHC press release; 2. Leavitt Partners; 3. Centers for Medicare and Medicaid Services

Value-based payment modifier3

• HHS has set goal of tying 50% of Medicare payments to quality or value through alternative payment models (e.g., ACOs or bundled payments) by the end of 2018

• A number of states are pursuing value-based care payment models for Managed Medicaid as well

Addressing provider ACO needs2

• 750 ACOs created to date, representing >23 million covered lives as of Q1−15

• 132 Payers (Medicare, Medicaid, commercial, regional) are participating in ACOs

• Estimated future growth of lives covered by ACOs in 2020 more than 70 million Regulatory

Provider

Payer

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Current ACO Prevalence and Geographic Distribution

782 Total ACOs

464 Medicare ACOs

23 million covered lives 50 million patients

served by ACO providers

8 million covered lives

Source: Number of ACOs by Hospital Referral Region, December 2015 Source: Leavitt Partners Center for Accountable Care Intelligence

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State-based Medicaid Accountable Care Organizations

WA

OR

AZ NM

TX

OK

KS CO

UT NV

CA

ID

MT ND

SD

NE

MN

IA

MO

AR

MS AL LA

FL

GA

TN

WI

IL IN OH

MI

KY

NJ

NY

CT RI MA

NH ME

WY PA

VA WV

DE MD

VT

NC

SC

AK

HI

Source: Center for Health Care Strategies, Inc.; Effective September 2016

States with active ACO programs

States pursuing ACO programs

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Medicaid Patient Centered Medical Homes

WA

OR

AZ NM

TX

OK

KS CO

UT NV

CA

ID

MT ND

SD

NE

MN

IA

MO

AR

MS AL LA

FL

GA

TN

WI

IL IN OH

MI

KY

NJ

NY

CT RI MA

NH ME

WY PA

VA WV

DE MD

VT

NC

SC

AK

HI

Source: kff.org

States with PCMHs

States pursuing PCMHs

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Medicare Episode-Based Payment Initiatives

• Aligned incentives for providers

• Four models focused on acute and/or post-acute care

• Model outcomes: – Higher quality

– More coordinated care

– Lower cost to Medicare

Bundled Payment for Care Improvement

(BPCI) Oncology Care Model

Specialty Practitioner

Payment Models

• Compulsory

• Better and more efficient care for most common inpatient surgeries (hip and knee replacements)

• Hospitals financially accountable for admission and 90 days post-acute

• 67 geographic areas (MSAs)

• Chemotherapy episodes

• Aimed at physician practices administering Chemotherapy

• Goals include: – Improve care

coordination

– Appropriateness of care

– Access to care

– Lower costs

• Outpatient setting

• Models of care focused on: – Specific diseases

– Patient populations

– Specialty Practitioners

• Incentivize: – Improved care

– Better health

– Lower costs

Comprehensive for Care Joint

Replacement (CCJR)

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Commercial Bundled Payment Programs

• Predominately focused on the following service lines: – Cardiovascular

– Orthopedic

– Spine

– Oncology

• BCBS most active in commercial bundled payments

• Leader in employer-based bundled payments is Walmart. Lowe’s, PepsiCo, Boeing and Kroger also have bundle payment programs.

• Considerations for commercial bundle payment programs include:

Source: https://www.advisory.com/research/health-care-advisory-board/resources/2013/commercial-bundled-payment-tracker

- Price - Availability of Data - Service Line Selection - Financial Incentive - Payment Methodology - Practice Pattern Variation - Flexibility - Episode Definition - Quantify Financial - Opportunity/Risk - Outlier Terms - Number of Participants - Operational, Financial, Clinical Efficiency

Orange dots represent Commercial Insurers. Green dots represent Employers.

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Medicare ACO Success?

Source: Leavitt Partners

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Pioneer ACO Performance

18 ACOs with total savings of $140 million/ $77 million revenues

1 generated loss, owed CMS $2.5 million

9 exited the Pioneer program, 7 moved to MSSP

50% First Year Results (2012) – 32 ACOs as of 1/1/12

14 ACOs with total savings of $130 million/ $66 million revenues

6 generated losses, owed CMS

3 exited the Pioneer program

Second Year Results (2013) – 23 ACOs as of 1/1/13 60% Third Year Results (2014) – 20 ACOs as of 1/1/14

15 ACOs with total savings of $142 million/ $82 million revenues

3 generated losses, owed CMS

1 exited the Pioneer program

75%

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First Year

220 ACOs with reported results

53 ACOs generated total savings of $695

million

53 ACOs received $315 million

6 ACOs missed out on receiving $33 million

1 ACO had losses of almost $10 million,

owes CMS almost $4 million

Second Year

333 ACOs with reported results

92 ACOs generated total savings of $800

million and received $340 million

95 ACOs missed receiving shared savings

0 ACOs had losses

in two sided risk

MSSP ACO Performance

25%

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Has the ACO Experiment Been Successful?

MSSP ACO •Adjusted differential change in mean total Medicare spending: -$144 (1.4%, 2012 starters); -$3 (2013)

•The 1.4% savings in 2012 represents approximately $2.6M for the average size ACO (18,000 beneficiaries)

•Savings of 1.4%: Inpatient (1.4%), shift from outpatient hospital to outpatient office (0%, offset), SNF (6.1%), home health (2.7%)

•Independent primary care groups consistently had more savings than vertically integrated organizations

Pioneer ACO • Mean total per-beneficiary spending in the ACO group differentially changed

as compared with the control group (-$29.2 per quarter (1.2%), p=0.007) • Spending reductions in acute inpatient care, hospital outpatient care, and

post-acute care (SNF); increase in outpatient office mostly offset reductions in hospital outpatient

Source: McWilliams JM. Michael, Hatfield LA, Chernew ME, Landon BE, Schwartz AL. Performance Differences in Year 1 of Pioneer Accountable Care Organizations. N Engl J Med 2015 372;20:1927-36 Source: McWilliams JM. Michael, Chernew ME, Landon BE, Schwartz AL. Early Performance of Accountable Care Organizations in Medicare . N Engl J Med 2016; 374;24:2357-66

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Has the ACO Experiment Been Successful?

“The ACO contracts motivate participants to eliminate unnecessary care, reduce hospital and nursing home capacity, improve safety and quality, and promote

effective coordination…… of care.” The ACO Experiment in Infancy – Looking Back and Looking Forward, Song and Fisher, 08/16/16

“Why then would the nation give the keys to reform to hospital-led delivery systems, the organizations with the most capital intensive and costly

infrastructure?” Reassessing ACOs and Health Care Reform: Schulman and Richman, 08/16/16

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Agenda

Future of Value Based Contracts and ACOs

ACO Performance

Emergence of Accountable Care Around the World

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Type of value-based payment

Value-based payments tied to quality and risk

53% 47%

Value-based payments by provider type 38%

24% 10%

Source: Catalyst for Payment Reform

Value-based payments 2015 National scorecard for commercial market

Value-based payments

40% Tied to quality

Not tied to quality

Hospital Outpatient PCP Outpatient specialist

At risk Not at risk

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Future of Value Based Care Programs

• The Innovation Center (CMMI) • Accountable Care Organizations • Bundled Payments for Care Improvement (BPCI) • Mandatory Bundles (CJR, Cardiac) • MACRA • Specialty programs (ESRD (CEC), Oncology (OCM), etc.)

• Medicaid • Accountable Care Organizations • Bundled Payment Programs • DSRIP

• Commercial

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Willingness to accept performance-based risk

Base: All qualified respondents: (Physicians n = 1,602; Hospital n = 400). Respondents: reflect those that responded “well prepared” and “adequately prepared.”

Reflects the percentage of providers who expect performance-based risk will make up more than 10% of their reimbursements.

Are Providers Ready?

Source: Multi-stakeholder Study, October 2013* more recent study needs to be in here conducted for The Optum Institute by Harris Interactive.

Adequately prepared to take: Greater responsibility for managing patient care

Greater financial risk for managing patient care

Physicians Hospitals

Physicians Hospitals

34% 43%

16% 30% Today 5 years from now

21%

42% 44%

79% Physicians Hospitals

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Acceleration of Value Based Care Programs

“…this proposed rule raises serious concerns about the agency’s pace of change, as well as its ability to accurately track and process the outcomes of its myriad increasingly complex alternative payment models. As such, we urge CMS, in the strongest possible terms, to refrain from expanding mandatory bundled payment models to other geographic areas or conditions before there has been enough time to assess the lessons learned under the existing models.”

“We urge the agency to proceed at a more deliberate pace and simplify the rule”

“Hospitals strongly support CMS’s push for adoption of alternative payment models and are working to help ensure these complex models work for patients. However, if the agency does not, in turn, support hospitals by recognizing the significant investments of time, effort and finances that these models require, neither we nor the agency will find success.”

-Letter from the American Hospital Association to Centers for Medicare & Medicaid Services

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Agenda

Future of Value Based Contracts and ACOs

ACO Performance

Emergence of Accountable Care Around the World

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Accountable Care Around the World

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“We need clinical commissioning groups to become accountable care organisations”

-Jeremy Hunt, Secretary of State for Health (UK)

The Future

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NHS England Future of Value Based Care

• Accountable Care • New Care Models

• Multispecialty Community Provider (MCP) • Primary and Acute Care Systems (PACS)

• Sustainability and Transformation Plans (STPs) • Acute Care Collaboration (ACC)

• Ultimate goal is Population Health Systems

• Coordination between health and social care systems and public health • Macro, Meso, Micro

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NHS England

Source: England Department of Health

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NHS England Case Study: New Models of Care: South Somerset’s Symphony Project

PROBLEM RESULT APPROACH

Yeovil District Hospital NHS Foundation Trust, primary care in South Somerset and other organisations aim to work in partnership to oversee a single budget for the population. Goals are to shift resourcing and services into the community by developing enhanced primary care services and establishing integrated care hubs for people with long-term conditions.

Single Budget for the population to deliver a range of primary care, community health, mental health, and hospital services, with the intention to move over time to cover almost the entire health and care budget.

Goal to establish a county-wide Accountable Care Organization by 2019.

1) Yeovil NHS Foundation Trust created Symphony Healthcare Services to deliver core and additional primary care services.

2) Creation of Symphony Care Hub with care coordinators and multidisciplinary teams for people with three or more chronic conditions.

3) Established an enhanced primary care model that sees additional roles, particularly health coaches, introduced into practice teams.

Collins, Ben (October 2014). New Care Models: Emerging innovations in governance and organisational form. London: The Kings Fund. Available at: http://www.kingsfund.org.uk/sites/files/kf/media/the-kings-fund-house-style-references_0.pdf (accessed on October 18, 2016).

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What can we learn? Transformation to Accountable Care

Need to focus on small population of people who account for high proportion of use and cost through risk stratification.

Case management and care coordination

Support development of integrated care through information sharing and investment in information technology

Need to engage patients

Payment systems and incentives that are aligned

Networks and provider partnerships

Contact information

Jeremiah Reuter, ASA, MAAA Director, Provider Risk Advisory 303-714-3873 Jeremiah.Reuter@Optum.com

Thank you

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