Accountable Care Organizations:
Perspectives from the Billings
Clinic Experience
Montana HealthCare Forum
November 28, 2012
Helena
F. Douglas Carr, MD, MMM
Medical Director, Education & System Initiatives
Health Care, Education and Research
www.billingsclinic.com
Physician Group Practice Demonstration
2005-2010
The Alpha Medicare ACO
Testing the concept that
physician group practices can
better coordinate care (Part
A&B) than other delivery models
to reduce rate of growth in percapita expenditures while
improving quality
Shared Savings
Model:
FFS continues
CMS shares % of
calculated savings
•
•
•
•
•
Types of organizations:
2 MSGP
2 AMC
5 IDS
1 PHO
• Rate of growth of PGP compared to same county
comparison
• Individually risk adjusted (HCC)
• Attribution by plurality of office visits, All-Specialty
• Retrospective, blinded to both organization and
beneficiary, changes yearly
• Minimum Savings Threshold: 2%, Cap: 5%
• Sharing is 80% only on savings >threshold but < cap
• Data feedback intended on quarterly basis
• 32 Quality measures (outpatient only, process +
outcomes) create a gate for 50% of shared savings
payment
10 Organizations
Physician Group Practices
Everett, WA – Everett Clinic
Integrated Delivery Systems
Marshfield, WI – Marshfield
Clinic
Springfield, MO – St Johns
Danville, PA-Geisinger
Billings, MT-Billings Clinic
St. Louis Park, MN – Park
Nicollet
Winston-Salem, NC-NovantForsyth
Academic Medical Center
Ann Arbor, MI - University of
Michigan
Bedford, NH-Dartmouth
Hitchcock
Physician-Hospital Organization
Middletown, CT – Integrated Resources
for Middlesex Area (IRMA)
Common Basis for Strategies among the
PGP Groups
1. Focus: High Cost Areas
Components of Medicare
Expenditures
For Billings Clinic (base year
2004)
•
•
•
•
•
•
Inpatient
Hospital OP
Part B
SNF
Home Health
DME
40%
24%
22%
7%
3%
4%
Reduce avoidable admissions,
ER visits, etc.
2. Focus: Chronic Care & Prevention
•
•
•
•
High prevalence and high cost conditions
Provider based chronic care management
Care transitions
Palliative care
Financial Savings are
INPATIENT driven.
Quality Measures are
OUTPATIENT driven.
Heart Failure
Diabetes
Coronary Artery Disease
Billings Clinic
PGP Year 5
HTN, Screening, Prevention
5
“A detailed analysis of the demonstration is
currently available only for the first two years.
That analysis showed that, for patients in the
10 group practices during the 2nd year,
average Medicare spending excluding the
bonuses paid to physician groups was about 1
percent below projections…similar estimates
are not yet available for other years…”
PY1
PY2
PY3
PY4
PY5
Average Annual
5 year Expenditures
Summary Results
1.21%
2.00%
2.56%
5 Year
3.63%
Savings
2.37%
2.39%
$218,573,184
$9,161,179,345
How The PGP (2005-2010)
Influenced the Development of ACOs
Transition
Demo (2011-12)
Accountable Care
Act-2010: ACO
provisions include
• Primary Care Attribution
• National comparison
targets
• Target is absolute
spending increase over
base
• Retains risk adjustment
• Incorporated
changes in ACA
provisions
• Improved data
reporting from CMS
• Quality Measures
3245
• Discussions/develop
ment led to first ACO
proposals that
ignored some PGP
recs
• The national
consensus
supported the PGP
groups
recommendations
Final ACO Regs
• Quality Measures
6533
• Eliminate 25%
withhold
• First Dollar sharing
after minimum
savings threshold
• Allows for 1 or 2sided risk
• Preliminary
prospective
assignment
10
Comparison of Shared Savings Models
Attribution
Base
Term
(before rebasing)
Comparison
Threshold
(MSR)
Savings
Quality Gate
Quality
Measures
Loss Risk
Risk
Adjustment
PGP
TD
ACO
Pioneer
retrospective
All Specialty
retrospective
Primary Care
retrospective
Primary Care
retrospective
Primary Care
Prior Year (2004)
3 -year wt.
Averaging
3-year wt.
Averaging
3-year wt.
Averaging
3-->5 years
2
3
3
National
Absolute amount
National
Absolute amount
National
50% amount +
50% rate growth
2%
1.47%-4.65%
2-3.9% or
2%
1%
80%
above MSR
50%
first dollar
50% above MSR or
60% first dollar
50%
first dollar
50%
80%, 90%
100%
100%
32
45
33
33
No
No
No (1 sided)
Yes (2 sided)
Yes
retrospective
updated yearly
prospective
adjusted yearly
prospective
fixed for term
prospective
fixed for term
Local
Rate of growth
Growth and Dispersion of Accountable
Care Organizations November 2011
ACOs BY SPONSORING ENTITY
“The range of entities that have sponsored ACOs,
from small IPAs to national insurance companies indicates
the wide range of business models that will ultimately
provide accountable care.”
•
•
•
Medicare SSP has lead to
commercial adoption of ACOs
Market specific clustering of activity
Basic tenets of accountable care
previously existed; title is new
“It appears, for now, that defining oneself as an
ACO represents an acceptance of the direction the
industry has been headed rather than an adoption
of a truly new form of care delivery.”
Growth and Dispersion of ACOs November 2012
Sponsorship Type
Payment
Shared
Savings, 1
sided
IDS
27
30
151
Muliple
Providers
Health Plan
133
36%
30%
Other
SS-2 sided
FFS
Capitation
Episode/DRG
Single
Provider
34%
53%
Many ACOs are reimbursed on a Shared Savings model based on Spending Targets
ACO Launched
Projected Spending
Target Spending
Shared Savings
Actual Spending
14
15
Movement Towards ACO Raises Key
Questions
• What is the COST impact of
delivering accountable care?
• What is the REVENUE impact
of delivering accountable care? 100%
90%
• What is the COST impact of
80%
building an ACO?
70%
60%
• How do you manage the
50%
hospital and physician
relationship through transition to 40%
30%
an ACO?
20%
• How do you manage two
10%
parallel entities through the
0%
0
transition?
• How do you manage the pace
of that transition?
16
Transition
Current FFS
System
Accountable
Care Organization
n
Time
16
16
The Bridge from FFS to
Accountable Care
Current
FFS
System
What are the
underpinning
building blocks?
Accountable
Care
ACO Core Components
People
Centered
Foundation
Health Home
High Value
Network
Population
Health Data
Management
ACO
Leadership
Payer
Partnerships
Foundational Philosophy: Triple Aim™
Measurement
17
17
The ACO Model
A group of providers willing and capable of accepting accountability for the total
cost and quality of care for a defined population.
Payer
Partners
 Insurers
 Employers
Core Components:
• People Centered
Foundation
• Health Home
• High-Value Network
• Population Health Data
Mgmt
• ACO Leadership
• Payor Partnerships
 States
 CMS
18
Why PCMH within ACO?
• Emphasizes prevention
• Encourages cognition/relationship over
technology
• Less variation in utilization
• Allows for most efficient delivery methods: allied
professionals, phone, e-mail, web-enabled
• Proven concept in other modern nations, staffmodel HMOs
• Access closest to patients
• Promotes shared decision making
• Leverage point for post-hospital care
Montana Patient Centered Medical Home
Initiative
10-2009
• MT Medicaid received planning grant from NASHP to develop PCMH model;
stakeholder discussion developed into planning for a multi-payer model
• Commissioner of Securities and Insurance assumed role of facilitating discussions
among MT payers and providers
10-2010
• Working group adopts NCQA Recognition as a definition standard of PCMH for
Montana
5-2011
9-2011
2012
• Creation of PCMH Advisory Council sponsored by office of Insurance Commisioner
• Adopted Framework for Payment as guideline for contract development
• Created Uniform Quality Measure Set
• Recommended the attributes of a state technology reporting platform;
verified that designated HIE (Health Share Montana) meets them
• Developed proposed legislation to create commission with statutory
authority to develop the market rules that encourages multi-payer PCMH
www.csi.mt.gov/medicalhomes
BCBSMT PCMH Program
• Begun in 2009 with Western Montana Clinic (St.
Patrick Hospital) and Billings Clinic.
• Added St. Patrick’s, CMC, Kalispell, Bozeman, and St.
Vincent’s 2010-2011. Added Northern Montana
Hospital and South Hills Medical Group in 2012.
• Planning to add St. Peters, Benefis, Holy Rosary.
• Limited to PCP providers with access to EMR.
• 2009/2010: Chronic disease only.
• 2011 and beyond: Chronic disease and preventative
care.
21
PCMH-Physician Groups (*=active)
Physician Group
Number of Physicians
Billings Clinic*
77 MD (16 IM, 25 FP, 18 Peds, 18 OB), 23 Midlevel
Western Montana Clinic*
31 MD (8 IM, 14 FP, 5 Peds, 4 OB), 7 Midlevel
St. Patrick’s Hospital*
15 MD (6 IM, 9 FP), 5 Midlevel
Benefis
14 MD (7 IM, 3 FP, 4 OB), 5 Midlevel
St. Peters Hospital
14 MD (2 IM, 12 FP)
Kalispell Regional MC*
20 MD (3 IM, 6 IM-Peds, 11 FP), 11 Midlevel
Comm. Medical Center*
20 MD (5 IM, 11 FP, 4 Peds), 7 Midlevel
Bozeman Deaconess*
26 MD (9 IM, 6 FP, 6 Peds, 5 OB), 7 Midlevel
Northern Montana Hosp* 10 MD (3 IM, 5 FP, 2 OB)
St. Vincents*
9 MD (7 IM, 2 FP)
Holy Rosary Healthcare
4 MD (1 IM, 1 FP, 2 OB)
South Hills Med. Group*
2 MD (1 NP)
Total Phys./Midlevels
242 MD (67 IM, 99 FP, 6 IM-Peds, 33 Peds, 35 OB), 66 Midlevel.
22
2012 BCBSMT PCMH Program
Chronic Diseases
Preventative Care
Preventative exam
Asthma
Ischemic
Vascular
Disease
Smoking status
BMI
BP
Breast cancer
screening
Depression
Diabetes
Cervical cancer
screening
Colon cancer
screening
Immunizations
23
BCBSMT-PCMH Early Trends
PCMH
All other PCPs
~ 16,000 Lives
~36,000 lives
Total Trend: 3.1%
Total Trend
7.1%
Stop-loss, excess
risk adjusted Trend:
2.6%
Stop-loss,
excess risk
adjusted
Trend: 7.2%
Improved
documentation
and reporting on
quality measures
• Evidence-Based Care
• Prevention
Status quo
Blues CMO says there's 'no question' medical-home
model works
11:30 am, Oct. 23
Tags: Coordinated CareMedical HomesInformation TechnologyPatient Care
Without hesitation, Dr. Allan Korn, the Blue Cross and Blue Shield Association's chief
medical officer and senior vice president for clinical affairs, declared that the patient centered medical home has the potential to transform the U.S. healthcare system.
"The things you want going up are going up, and the things you want going down are
going down," said Korn in an interview following his appearance Monday on a panel
assessing the state of the healthcare industry presented in San Antonio at the MGMAACMPE's annual. "There's no question that the medical home is working, and that's
what's gratifying to me."
While speaking on the panel, Korn said he thinks steps could be taken to improve the
patient-centeredness of the medical-home practice model. Still, he said later, medical
homes—which use information technology to coordinate care and track the treatment of
patients who have chronic diseases—have led to double-digit declines in patients'
exposure to radiation from diagnostic tests, in "ambulatory-sensitive" hospital
admissions, and in unnecessary and costly healthcare episodes.
They have also boosted physician satisfaction.
"When you permit a physician to perform at his or her highest level, to do what they
want to do, these are things that happen," Korn said, adding that one important thing the
Blues' medica- home programs have done is remove the "mother may I’s” from the
practice of medicine. "We're having doctors tell us 'I'm looking forward to going to the
office again.' "
He added that, with some 5.3 million members covered by Blues medical homes, "we're
not piloting anymore."
25
PCMH Perspectives
Payer
Provider
Team Model best able to
•Improve access
•Ensure EBM care
•Re-energize profession
Financial
risk/commitment
with need for
eventual ROI
Assurances that a
practice is
transforming
•Standards
•Quality reporting
Patients
“Rules of the Road”
will help
•PCMH standards
•Framework for payment
•Quality metrics/reporting
Requires Investment
& Change
Improved
Access
•IT
•FTEs
•Financial risk
(reimbursement for nonRVU work, critical mass of
pts.)
Better
outcomes
• Prevention
• EB Care
Increased
satisfaction
Questions?
28