From a Position of Strength Objectives Define Accountable Care Organizations ACO Define Pioneer ACO Define Transitions of Care Determine the Opportunities for implementation of the Pharmacy Practice Model Initiative in an ACO setting ID: 553546
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Slide1
Negotiating Pharmacy's Role
From a Position of StrengthSlide2
Objectives
Define Accountable Care Organizations (ACO)
Define Pioneer ACO
Define Transitions of Care
Determine the Opportunities for implementation of the Pharmacy Practice Model Initiative in an ACO settingSlide3
What are the core elements of ACO’s?
Accountable for health, quality, and costs of care over the full continuum of their patients’ care
Collaborate, share information and manage patient health for a population of patients (physicians, acute care hospitals, wellness, home care, long term care, pharmacies, et al)
Focus on improving health and reducing overall costs for a population of patients
Able to measure and report improvements in patient health and overall costs
Integrate financially to accept and distribute bundled payments and incentive payments or penalty retractionsSlide4
Health Care Reform formalizes the Accountable Care Organization (ACO) model
Beginning 1/1/2012, hospitals-physician entities may provide ACO services
Beginning in 2013, Voluntary bundled payment pilot programs
FTC expected to waive restrictions that prohibit effective formation of ACOs.
5 guiding principles:
ACOs have a strong foundation of primary care
ACOs report reliable measures to support quality improvement and eliminate waste and inefficiencies to reduce costACOs are committed to improving quality, improving patient experience and reducing per capita costsACOs work cooperatively towards these goals with stakeholders in a communityACOs create and support a sustainable workforceSlide5
Accountable Care Objectives
Create efficient teams of hospitals, primary care physicians and specialists
Reduce or eliminate duplication of services and fragmented care
Reduce costs – Shared savings
Improve quality
Bundle paymentsSlide6
P
U
B
L
I
C
HEA
L
T
H
Care Transitions InfrastructureSlide7
Accountable Payment at Risk
Care Transformation
Lower unnecessary utilization for
the ACO population.
Have sufficient
ACO population.
Careful not to undermine non-
ACO revenues.
Efficient Delivery System Transformation
Inadequate physician alignment.
High cost pathways.
Poor analytics for measurement
Financial
Care Delivery
Synchronizing change
Are you on the Road to Accountable Care ?
a. ACO Pioneer b. Commercial ACO c. Don’t knowSlide8
Some Elements of Care Common to Most of the Transitions Models
Medication Management
Assessing Patient's Understanding/Ability to Follow Care Plan
Discharge Support
Coaching for Primary Care Physician Visit
Use of Home Visits Screening for cognitive ability
Use of Centralized Health RecordInvolving Family and other CaregiversArranging Community-Based Support ServicesFrom: The Lewin Group, December 16, 2009 Care Transitions Workgroup and ASHP Ambulatory Practice GroupSlide9
What is the Pioneer Program?
Patient Protection and Affordable Care Act (2010)
Center for Medicare and Medicaid Innovation (CMMI)
Separate from Medicare Shared Savings Program
Accountable Care Organizations (ACO)
Triple Aim
Quality and cost efficiency = valueSteward’s community care model is considered an ACOSlide10
What is the Pioneer
Program? (cont’d.)
Pioneer ACOs will be held financially accountable for the care provided to their aligned beneficiaries
The Pioneer program begins on January 1, 2012 and continues for three, one-year performance years. There is an option to extend for two additional years.
60-day termination provision and no settlement if effective within first 6 months of performance yearSlide11Slide12Slide13Slide14
ACO Pioneer Project
Demonstration project for certain entities to start Pioneer ACO in 2012
More flexibility than traditional ACO program
Assignment of patients, for example
Quality reporting measures similar to ACO
CMS named 30 Pioneers – 5 in MassachusettsSlide15
Institution A as a Pioneer
Accountable Care Organization
Health Care Reform (Insurance Reform)
Treat patients in best location
Avoid unnecessary admissions
Requires physician groups and hospitals to collaborate
Focus on chronic careFocus on preventative careRefer internallyExperience with transitions of care modelReduces cost and adds valueSlide16
Institution A as a
Pioneer ACO - Infrastructure
Physician groups and hospital are in the same pool together for all risk contracts
Institution A - 10 hospitals (1,980 beds)
Institution A - 149 physician sites (2,200 physicians)
Institution A
Owned physiciansInstitution ANon – owned, affiliated physiciansTreat 1.2 million Patients AnnuallySlide17
Commercial ACO Model Contracts
Blue Cross Blue Shield (BCBS) 66,000 members choosing Steward - BCBS AQC – Since 2009
5 year AQC design based on total costs
Member opt in
Quality Measures
X Health Plan 30,000 members that choose a PCP – Since 2012
Based on PMPM Quality MeasuresXX Health Care 38,000 members that choose a PCP – Since 2012Based on PMPM Quality MeasuresSlide18
Institution A’s Business Strategy
4th year
5 - 6
7 - 10
Per Unit Cost
Utilization
Where We
Are Today
Infrastructure
Redefine “Health Care”
&
shift the focus to
VALUE
V
alue
: Quality, Access and Costs (TME –Time & Materials Estimate)
Lower
annual rate of TME (unit price
and
utilization
)
Drive
provider efficiency
Coordinate
care and keep it “in the community”
Improve quality, enhance patient experience
Keep cost trend low, affordable
Build
scale: enhance services, apply efficiencies across entire delivery
system
Create
better value for patients and
employers
Creative
disruptions in the market, where needed
Budget as Medical Loss Ratio
Slide19
19
Value: keep care in right place, at right time, at right cost
Academic / Tertiary / Quaternary
Community Hospital
Physician office / Clinic
Home
There is a 20% --
25% drop in cost as you move care from high cost, to low cost settingsSlide20
Community Care Model:
The Role of Payment Reform
Value is the new paradigm
Keep appropriate care local
Payment Reform is a tool not the goal
Move away from FFS (volume)
Alignment of Key Stakeholders: CI and FIHospitals, LTAC*s, Rehab, FQCHCProvidersPayersEmployersConsumers / PatientsThe role of risk contracts
Commercial: BCBS, THP, HPHC all risk contracts
Pioneer
Avoids mixed mode and aligns key stakeholders
*LTAC
Long Term Acute Care
Affordability
Access
Quality
ValueSlide21
Key Strategies for Success: Population Health Management
Analyze population to identify patients health status and drive the most appropriate and effective care interventions
Population Identification and Stratification
Evidence based clinical pathways and protocols to define and deliver the most appropriate intervention for all patients based on their identified health status
Deliver Care Interventions
Improve ability to measure population health to the patient level, disease/condition level and physician level
Measure & Track Performance
IT and communication infrastructure to enable improved care delivery
Optimize Care & Physician Communication
Primary prevention initiatives including cultural compatibility and community education outreach
Community & Patient EngagementSlide22
Distribution of Complexity and Costs
Biggest opportunity is managing medical costs for complex and complex prevention categoriesSlide23
Focus Area: Patients with Heart Failure And Its
Co-morbidities
TOP 10% Most Costly Members
HF
COPD
CAD
Diabetes
Asthma
Members with HF and at least the Condition
6,357
2,873
4,559
4,008
924
Avg. Cost PMPM
$16,252
$15,546
$16,120
$17,622
$15,791
Avg. Acute IP Admits
4.1
4.6
4.2
4.2
4.8
Avg. All IP Admissions
5.2
6.0
5.3
5.4
6.0
Avg. ER Visits
1.6
1.9
1.7
1.7
2.3
* CAD is the most prevalent Disease Management co-morbid condition
* Diabetes is the most expensiveSlide24
Initial Analysis and Identification
Population Identification and Stratification
Population is analyzed to identify patients and group by health status:
High Risk($)
Impactable
Facility based care, re-admissions, etc
Active, high current claims
At Risk Patients
Diabetes, CHF, CAD, COPD, IVD, HBP etc.
All Beneficiaries
Quality, wellness, prevention
Palliative Care and/or End of Life Care Slide25
Key Strategies for Success
Quality
Pioneer ACOs who fail to achieve certain minimal quality standards may be terminated from the program
High quality scores can mitigate potential losses and maximize sharing in successful performance years.
The Quality Score is based on 33 measures comprising four domains, weighted equally at 25% each
ACOs must meet minimum attainment level of the 30th percentile or 30 percent to earn points on given quality measure
ACOs not eligible for savings unless achieve the quality performance standard on at least 70% of measures within each domainException: Meeting the EHR measure is required in order to be eligibleSlide26
Pioneer Quality Measures (N=33): Four Domains
Patient/Caregiver Experience
(
N=7)
Care Coordination/Patient Safety (N=6)
Includes meaningful use of Electronic Health Record
Preventive Health (N=8)At-Risk Populations (N=12, 5 are “all-or-nothing”)DiabetesHypertensionIschemic Vascular diseaseHeart FailureCoronary Artery disease
Year
Pay-for-Performance
Pay-for-Reporting
PY1 (2012)
0
33
PY2 (2013)
25
8
PY3 (2014)
32
1Slide27
Top Down and
Bottom Up Approach to Readmission PreventionSlide28Slide29
CHF Care mapSlide30Slide31
Percentage Re-admission Rates - MedicareSlide32
Percentage Re-admission Rates –All PayersSlide33
Percentage Re-admission Rates -AMISlide34
Re-admits by MSDRGSlide35
Pay For PerformanceSlide36
Pay For PerformanceSlide37
HCAHP’s Inpatient HospitalSlide38
HCAHP’s Inpatient Hospital
Pharmacist
RoleSlide39Slide40
STAAR Initiative
Effective Interventions to Prevent Readmissions
RED – Re-Engineered Discharge
Education, Discharge Follow-up, Med plan
Transitional Care Model
Pre, post discharge coordinated care for high risk – Steward Healthy Transitions
Care Transitions ProgramSelf management skills training – “Red Zones”Evercare™ - Care ModelAimed at LTC, Chronic conditions, hospice, palliative careCare in home settingPhone follow-upSlide41
Patient Discharge Information
in Nine LanguagesSlide42
Conclusions
Evaluation of ACO readiness is critical
ACO organizations must have sufficient numbers of risk patients
Value proposition of ACO differs from FFS
Pharmacists are part of the care team
Pharmacist reimbursement for services is part of the bundle not FFS
Pharmacists have a role in the success of the ACO in both inpatient and outpatient settingsSlide43
Appendix
Readiness as an ACO
Strategies for Success
Re-Admission Prevention
Care Maps
Data collectionSlide44
Barriers to Effective Care Transitions
Structural
Lack of integrated care systems
Lack of longitudinal responsibility
Lack of standardized forms and processes
Incompatible information systems
Lack of care coordination and team-based trainingLack of established community linksProceduralIneffective communicationFailure to recognize cultural, educational or language differences
Processes are not patient-centered nor longitudinal
Performance Measurement and Alignment
Underuse of measures to indicate optimal transitions
Compensation and performance incentives not aligned with care coordination and transitions
Payment is for volume of services rather than outcomesSlide45
Initial Analysis and Identification
Population Identification and Stratification
Population is analyzed to identify patients and group by health status:
High Risk($)
Impactable
Facility based care, re-admissions,
etc.
Active, high current claims
At Risk Patients
Diabetes, CHF, CAD, COPD, IVD,
HBP,
etc.
All Beneficiaries
Quality, wellness, prevention
Palliative Care and/or End of Life Care Slide46
Key Strategies for Success
Population Health Management (cont’d.)
Develop a real-time understanding of physicians who are managing the populations effectively in terms of quality and cost efficiency
Cluster patients with chronic disease and co-morbidities with physicians and care teams who demonstrate expertise in management
Team based care and practice redesign
Care management tool enables the development and delivery of evidence based clinical pathways and protocols based on the health status of all patientsSlide47
Key Strategies for Success
Ambulatory-driven care management program
Improve care coordination and care management through disease management for complex and chronic conditions, ER readmissions, homecare VNAs, SNFs, hospice and palliative care programs
Since the ACO is responsible for the total cost of care of aligned beneficiaries, it is essential that Steward look to improve coordination along the entire continuum of care
One of the largest opportunities for achieving shared savings arises from enhanced post-acute care that reduces readmissions
Medically complex beneficiaries also offer significant opportunities to improve care coordination and realize immediate savings
Telephonic and embedded case management Slide48
ReadmissionsSlide49Slide50
Pneumonia Care MapSlide51
Pneumonia Care MapSlide52
Institution A
Readmissions Summary
October 2009 – December 2011Slide53
Percentage Re-admission Rates – All CauseSlide54
Percentage Re-admission Rates - PneumoniaSlide55
Percentage Re-admission Rates – HF – All Cause