Stuart J. Glassman, MD, FAAPMR - PowerPoint Presentation

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Stuart J. Glassman, MD, FAAPMRClinical Assistant Professor, Geisel School of Medicine at DartmouthClinical Instructor, Tufts University School of MedicinePresident, Granite Physiatry, PLLC, Concord, NH

The Transformers: ACO’s, Bundled Payments and Implications for Physician PracticeSlide2

Financial Disclosure SlideNothing to DiscloseSlide3

Concord Hospital/Capitol Region Health Care (Concord, NH)New CEO (Robert Steigmeyer) came from

Geisinger

Community Medical Center

Non-profit, Level 3 Trauma Center, 295 BedsSlide4

Dartmouth Hitchcock Medical Center/Geisel School of Medicine (Lebanon, NH)Level 1 Trauma Center, 396 bedsCEO/President—Dr. James Weinstein (Orthopedics/Spine Care)

Health System/Clinics serve 1.5 million population in NH and VermontSlide5

Accountable Care OrganizationsWhat's an ACO?--Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare

patients (

www.cms.gov

)

Incentive payments for cost-effective healthcare outcomesSlide6

ACO CategoriesMedicare Shared Savings Program—a program that helps a Medicare fee-for-service program providers become an ACO

Advance Payment ACO Model

—a supplementary incentive program for selected participants in the Shared Savings

Program

Pioneer ACO Model

—a program designed for early adopters of coordinated

careACO’s must manage 5,000 Medicare beneficiaries for at least 3 years (Obamacare) Slide7

ACO Data 2014Currently over 600 ACO’s in the United States (CMS/government contracts, private commercial ACO’s)Over 20 million lives covered--www.leavittpartners.comCMS indicates over $372 million in shared savings for ACO programs, with improvements in quality data reporting

ACO penetration map:Slide8

Business Issues in Health Care Delivery SystemsBundled Payments for Care Improvement Initiative (BPCI)Announced by CMS Jan. 31, 2013Organizations

will enter into payment arrangements that include financial and performance accountability for episodes of

careSlide9

BCPI (cont.)BCPI Locations:Slide10

4 Models of Bundled PaymentsModel 1: Retrospective Acute Care Hospital Stay OnlyUnder Model 1, the episode of care is defined as the inpatient stay in the acute care hospital. Medicare will pay the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare will continue to pay physicians separately for their services under the Medicare Physician Fee Schedule

..Slide11

Bundled Payment Model 2Model 2: Retrospective Acute Care Hospital Stay plus Post-Acute CareIn Model 2, the episode of care will include the inpatient stay in the acute care hospital and all related services during the episode. The episode will end either 30, 60, or 90 days after hospital discharge. Participants can select up to 48 different clinical condition episodes.Slide12

Bundled Payment Model 3Model 3: Retrospective Post-Acute Care OnlyFor Model 3, the episode of care will be triggered by an acute care hospital stay and will

BEGIN

at initiation of

post-acute care services with a participating skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency

. The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end either a minimum of 30, 60, or 90 days after the initiation of the episode. Participants can select up to 48 different clinical condition episodes.Slide13

Bundled Payment Model 4Model 4: Acute Care Hospital Stay OnlyUnder Model 4, CMS will make a single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. Participants can select up to 48 different clinical condition episodes.Slide14

Triple Aim (cont.)Has 3 simultaneous areas of focus:1. Improving the health of populations

2.

Improving the patient experience of care (including quality and satisfaction)

3. Reducing

the per capita cost of health

care

Emphasis on evidence-based medicine outcomes and comparative scientific research for healthcare decisionsSlide15

Triple Aim (cont.) Slide16

Patient Centered Medical HomePatient-Centered Medical Home Recognition  The patient-centered medical home—one of modern health care’s most important innovations—is a model of care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” NCQA Patient-Centered Medical Home (PCMH) Recognition is the most widely-adopted model for transforming primary care practices into medical homes.

Clinicians, insurers, purchasers, consumer groups and others know the patient-centered medical home is a proven alternative to the nation’s costly, fragmented delivery system. Research confirms that medical homes can lead to higher quality and lower costs, and can improve patient and provider experiences of careSlide17

PCMH (cont.)Safety Net PCMH ModelSlide18

Accountable Care Organizations in NH (2013)Pioneer ACO—Dartmouth Hitchcock ACO (NH/VT)Granite Healthcare Network/Cigna

North Country ACO (Littleton, NH)

New Hampshire Citizens Health Initiative Accountable Care Project

Concord Elliot ACO LLC (Medicare Shared Savings Program)

Northern New England Accountable Care Collaborative (Maine, NH, Vermont)

ElevateHealth

(Shared-Risk Arrangement between Harvard Pilgrim, DHMC and Elliot Hospital)Slide19

Accountable Care Organizations in NH (2014)Lahey Clinical Performance Accountable Care Organization, LLC

OneCare

Vermont Accountable Care Organizations,

LLC

The

Premier Health Care Network,

LLCWinchester Community COCircle Health Alliance, LLCNew Hampshire Accountable Care Partners ACODarmouth-Hitchcock ACONorth County ACOSlide20

NH Accountable Care Partners ACOMade up of 4 health systems—Concord Hospital, Elliot Health System, Southern NH Health System, Wentworth-Douglass Health SystemBased in Concord, NH965 Health Care providers

Cover 40,000 Medicare beneficiariesSlide21

A Cautionary Tale—Where Is Rehab?NO involvement of PM&R at any leadership level in the various ACO’sLack of involvement in Post Acute Care CommitteesMost physiatrists in NH are NOT employed by hospital systems—are we outside looking in?

NH has 2 IRF hospitals (Concord, Salem), 3 IRF units (Manchester, Nashua, Keene), 4

th

to open in March 2015;various SNF level facilities (Genesis), NO LTACH

No PM&R residencySlide22

PM&R in the Brave New Healthcare WorldPost Acute Care Issues and Outcomes within ‘shared care dollars’—Variable Care costs? (IOM variation was 73%)Based on patient needs, NOT patient location (2012 Medicare post acute care costs: $62B)

Functional Outcomes and Quality of Life Measures in ACO’s; 2 separate bundled payments (Acute/Post Acute Care)Slide23

Variation in Post Acute Services (IOM)Slide24

Physician Practice Concerns in ACO/Bundled Payment ModelsUpside only risk: Medicare Shared Savings, Medicare Advantage—no penalties if physician/hospital does not meet savings goal; can get bonuses if goals are met; up to 60% of savings goes to physician/hospital (one-sided risk)

Downside risk—hospitals/physicians lose money if savings goals are not met (two-sided risk)

Flat management fee—no bonus if savings goals are met (fee usually $3 to $5/month per patient)

Public versus private

payors

—much more downside risk with private

payor ACO; can’t tolerate losses in early years of the programContracts may switch from one-sided to two sided after a few yearsSlide25

Risk Versus RewardLoss of practice independence when joining an ACOSignificant financial up-front costsRisk of exclusivity (usually for PCP’s) in a single ACO

Balance of quality measure outcomes and cost savings generated (CMS Shared Savings program has 33 quality measures for reporting)

PCP’s will likely want to have routine follow up care stay within their offices and NOT refer to specialist physiciansSlide26

Global Risk ContractingBecoming popular in Minnesota and MassachusettsFixed-dollar payment amounts per patient for a specified time period (one month, one year)Large incentive on controlling costs

Bundled services at the patient level, not the episode of care level

May include supplemental payments based on quality measure outcomesSlide27

Avoiding Specialist Exclusivity ClausesACO exclusivity analysis focuses on whether ANY physician in a single-specialty or multispecialty group practice provides services under E&M codes for office, outpatient, home or nursing facility visits, and whether the Medicare patient sees a PCP during the applicable time period

Must be careful to avoid triggering the ACO exclusivity clause, which will limit the specialist to that ACO only

Specialists should encourage patients to see their PCP

Consider providing services under a separate entity that bills under a separate TIN (federal tax ID number)Slide28

Bundled PaymentsCovers payments to 2 or more providers during a single episode of care or over a specific period of timeAlready seen in ‘global surgery periods’‘Actual’ bundle—single payment to one entity (i.e. ACO) which then splits up the payment to multiple physicians

‘Virtual’ bundle—the payer makes payments to multiple providers, based on the negotiated pre-defined rules of the contract

It IS risk-contracting; physicians should know how payments and risk adjustment factors are calculatedSlide29

Commercial Bundled Payments MapSlide30

Bedford (NH) ASC/Harvard Pilgrim Healthcare Bundling Pilot ProgramApplies to routine colonoscopies—bundled payment for surgeon, anesthesiologist, facility and pathologist44 patients participated in the first quarter of 2014

Has a built in 5% price discount

Follows quality metrics from the

A

merican College of Gastroenterology (number of screening that identify polyps/cancer, type of anesthesia used)Slide31

Post-Acute Care Services and the Triple Aim$62 billion spent in 2012 by Medicare on post-acute care services (11% of Medicare outlays)IOM report shows that there is a 73% variation in total Medicare spending due to utilization of PACS

Hospital referral regions (HRRs) with high PACS also have the highest overall spending

Quality Outcome Measures for ACO’s in 2015 will likely add in a ‘SNF 30 day “all-cause” readmission’ quality metric

Improved patient outcomes do correlate with appropriate PAC utilization (SNF, IRF, Home Health, LTCH)Slide32

Engagement Spectrum of ACO’s and PAC Providers Minimal—no formal engagement. ACO informs physicians of their referral patterns

Conditional Collaboration—shared standards, protocols and data utilization; stay within preferred provider network

Partnership—shared quality metrics and discharge data; have ‘care transition coordinators’

Financial and Data Integration—PAC provider has access to EHR; shared financial risk; share technology

Full Integration—PAC providers are owned by ACOSlide33

Coordinated Model of Acute and Post-Acute CareIntegrated-Care markets—full array of PAC servicesTransitional hospital

care (LTACH),

short-term

rehabilitation (IRF), sub-acute, skilled

nursing, home health, palliative

care, hospice

Joint ventures for bundled payments initiative (i.e. Cleveland Clinic)Manage the transition of care for the patient, improve outcomes, decrease costs Attractive to payers, ACO’s and hospital systemsExample—Kindred Healthcare Inc. (Louisville, KY; KND; annual revenue $5B; Slide34

What Does the Physiatrist Bring to the ACO/Bundled Payment Table?Ability to work within a team formatFocus on functional, Triple-Aim outcomes

Understanding of care transitions in the post-acute world

Ability to treat multiple organ system issues (brain, spine, musculoskeletal, cardiac) and disease states (diabetes, CHF, cancer, pain, obesity, asthma)

Understanding of Durable Medical Equipment needs

YOU MAY HAVE TO CRASH THE PARTY—the ACO leaders may not

understand what we do!!