Toward Accountable Care
• Where Policy Meets
Practice: Lessons from
the CMS Physician
Group Practice Demo
• Nicholas Wolter, M.D.
• Alliance for Health
Reform Hill Briefing
• Washington, D.C
• May 10, 2010
ACO: Accountable Care Organization
•
Current use evolved from discussion between MedPAC Commissioners &
Elliott Fisher on November 9, 2006 in effort to define ways to control
healthcare costs in an environment of regional variation in utilization and a
largely unorganized & fragmented delivery system
•
Further defined the following month in an article in Health Affairs
[Health
Affairs 26, no. 1 (2007): w44–w57 (published online 5 December 2006;
10.1377/hlthaff.26.1.w44)]
•
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Onslaught of ACO conferences, white papers, consultant Power Points,
RWJF Pilot in New Jersey, etc.
Effect of Physician Group Practice demonstration on discussions with
CMS, MedPAC, Congress
Culmination in Health Reform bill (both HR and Senate versions)
Program Environment:
Billings Clinic
•
Group Practice
• 240 Physicians, 65 midlevels, all employed
• 29 (~50 sub-) specialties (Allergy to Vascular Surgery)
• 8 clinic locations
• 272 (220) bed tertiary hospital
• Manage/support 6 CAHs
• ~3500 Committed Employees
• 3rd largest employer in Montana
•
Integrated Delivery System/ Medical Foundation
• Board of Directors: community-based
• Leadership Council (Internal Board): physician majority + senior
administrators
10 Organizations
Physician Group
Practices
Everett, WA – Everett Clinic
Integrated Delivery Systems
Marshfield, WI – Marshfield
Clinic
Springfield, MO – St Johns
Danville, PA-Geisinger
Academic & Network
Middletown, CT – Integrated
Org.
Billings, MT-Billings Clinic
Resources for Middlesex Area
(IRMA)
St. Louis Park, MN – Park
Nicollet
Ann Arbor, MI - University of
Michigan
Winston-Salem, NC-NovantForsyth
Bedford, NH-Dartmouth
Hitchcock
Service Region Locations
Lincoln
Flathead
Glacier
Hill
Toole
Blaine
Havre
Kalispell
Pondera
Clinic Locations &
Number of Providers
Chouteau
Cascade
Billings Clinic - Columbus (2 MDs, 1 NP)
Lewis &
Clark
Judith
Basin
Billings Clinic - Heights (4 MDs, 1 PA)
Missoula
Billings Clinic - Miles City (10 MDs, 3 PAs)
Billings Clinic - West (8 MDs, 1 PA)
Bow
Bozeman OB/Gyn (6 MDs, 2 NPs, 1 PA)
Affiliate Management
Services
Big Timber - Pioneer Medical Center
Madison
Garfield
Petroleum
Lewistown
Roundup
Forsyth
Valley
Gallatin
Bozeman
Livingston
Park
Billings
Cody
Colstrip - Colstrip Clinic
Hardin
Carbon
Red Lodge
Powell
I-15
I-94
Custer
Miles City
Wibaux
Fallon
Colstrip
Powder
River
Sheridan
Bighorn
Buffalo
Hot
Washakie Johnson
Spring
s Thermopolis
Fremont
Counties with Affiliate or Branch
Clinic
Scobey - Daniels Memorial Hospital
Other Service Area Counties
Adams
Carter
Sheridan
Lovell
Crook
Gillette
Worland
Red Lodge - Beartooth Hospital
Slope
Baker Bowman
Columbus - Stillwater Hospital
Lovell - North Big Horn Hospital
Dickinson
Big Horn
Greybull
Park
Livingston - Livingston Healthcare
Stark
Yellowstone
Big
TimberColumbu
s
Dillon
Glendive
Rosebud
Musselshell
Sweet
Grass
Dunn
Prairie
WheatlandGolden
Jefferson
Billings Clinic- Main (200 MD, 47 PA) Deer
Lodge SilverButte
Ravalli
McCone
McKenzie
Dawson
Meagher
Billings Clinic - Red Lodge (4 MDs)
Granite
Williston
Richland
Sidney
Fergus
Great Falls
Missoula
Williams
Wolf Point
Glasgow
Phillips
Sheridan
Roosevelt
Valley
HWY 2
Teton
Lake1 PA)
Billings Clinic - Cody (7 MDs,
Sanders
Divide
Daniels
Scobey
Weston
Campbell
Natrona
Riverton
Casper
I-25
I-90
Montana: 147,138 square miles and 922,002 people
PGP Demo Concepts
• Medicare Fee For Service continues as before
– Business risk for the PGP
• If PGP is able to reduce the rate of growth of Medicare
spending for the cohort under its care compared to a
local comparison, CMS will share part of its savings
with PGP
– Savings is a function of expenditure control and health status changes
• Budget neutral project for CMS
• Meeting Financial Target= “Gate”
• Once “Open”, PGP’s portion dependent on meeting
Quality Measures
PGP Project Financial Model
SAVINGS >2%
20%  CMS
80%
Performance Pay
Q: Quality
E: Efficiency
Y1
Y2
Y3-5
0.3 Q
0.4 Q
0.5 Q
0.7 E
0.6 E
0.5E
CMS PGP Quality Measures
Outpatient
Total 32
• Year 1: Diabetes
• Year 2: Year 1 plus HF and CAD
+ flu and
pneumonia • Year 3: Year 2 plus Hypertension and
colorectal and breast cancer screenings
vaccines
PGP Quality Thresholds:
Absolute or Relative Targets benchmarks or
>10% improvement in gap (100%- baseline)
Taken from the Doctor’s Office Quality measurement set in 1992.
Thus some of the target measurements are not the current quantitative benchmark.
The demonstration uses a total of 32 measures that focus
on common chronic illnesses and preventive services
Diabetes
CHF
CAD
Preventive Care
HbA1c Management
Left Ventricular Function
Assessment
Antiplatelet Therapy
Blood Pressure
Screening
HbA1c Control
LV Ejection Fraction
Testing
Drug Therapy for
Lowering LCL-C
Blood Pressure Control
BP Management
Weight Management
Beta-Blocker Therapy
Prior MI
Blood Pressure Control
Plan of Care
Lipid Measurement
BP Screening
Blood Pressure
Breast Cancer Screen
LDL Cholesterol Level
Patient Education
Lipid Profile
Colorectal Cancer
Screen
Urine Protein Testing
Beta-Blocker Therapy
LDL Cholesterol Level
Eye Exam
Ace Inhibitor Therapy
Ace Inhibitor Therapy
Foot Exam
Warfarin Therapy
Influenza Vaccination
Influenza Vaccination
Pneumonia Vaccination
Pneumonia Vaccination
10
Common Basis for Strategies among
the PGP Groups
1. Focus: High Cost Areas
Components of Medicare
Expenditures
For Billings Clinic (base year)
2. Focus: Chronic Care & Prevention
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Inpatient
Hospital OP
Part B
SNF
Home Health
DME
40%
24%
22%
7%
3%
4%
Reduce avoidable admissions, ER visits,
etc
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•
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.
Interactive Telephone System with
Web-enabled Data Tracking
•
Utilizes daily monitoring system for patients via Interactive Voice data
collection
Patients call daily between 4 AM and Noon
•
Data appears immediately on a web server
•
HF “Care Coaches” (RNs) call outliers
•
– Manage per HF protocols (diuretic ∆)
– Refer to HF Clinic MD/NPP or PCP
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Goal: coordinate care w/“Tx Physician”
Validated, proven system that manages by exception
Allows for 1 RN to follow 2-300 patients
12
35-43% reduction in hospitalizations
~80%
Averted Admissions - All Payers
Quarters
Se
pt
08
08
Ju
ly-
M
ar
ch
Ja
n-
Se
pt
07
07
Ju
ly-
M
ar
ch
06
pt
Ja
n-
Se
Ju
ly-
M
ar
ch
06
120.00
100.00
80.00
60.00
40.00
20.00
0.00
Ja
n-
Averted Admissions
or ~ 5/100/month enrolled in TA
Total: # 780
Medicare:
Averted Admissions
vs RTI Rate^^
Averted Admissions
vs NonIntervention
Group^^
13
Advisory Board
CMS-PGP Demonstration
CMS PGP Objectives
• Encourage coordination of
Part A & Part B
• Coordinate care for
chronically ill and high cost
beneficiaries in an efficient
manner
• Decrease the growth in
Medicare spending over the
next 3 years
Timeline
•
Base Year: Calendar year 2004
•
Performance Year 1:
April 1, 2005 March 31, 2006
•
Performance Year 2:
April 1, 2006 March 31, 2007
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Performance Year 3:
April 1, 2007 March 31, 2008
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Performance Year 4:
April 1, 2008 –
March 31, 2009
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Performance Year 5:
April 1, 2009March 31, 2010
Accountable Care Organizations
Key Features
Key Design Components
• Local Accountability
• Organization well defined
• Shared Savings
• Scope of providers
• Performance Measurement
– PCP essential
– Continuum of care
• Spending and quality
thresholds to ensure success
• Distribution methodology for
shared savings
Brookings-Dartmouth ACO Learning Network
https://xteam.brookings.edu/bdacoln/Pages/BackgroundInformationonACOs.aspx
Advisory Board
Accountable Care Organizations:
A group of providers willing and capable of accepting accountability for the
total cost and quality of care for a defined population.
7 Core Components
1. Providers
2. Payers
3. Management
4. Alignment Structure
5. Population IT/Data
6. Medical Home (PCMH)
7. Patients
Providers
• PCPs
• Specialists
• Hospital
• LTC
• Home Care
• Pharmacy
• Ancillary/DME
• Alternative/Integrative
• Hospice
Scope of Accountability
• Single Service/Episode
• Bundled Payment/ETG
• Disease Specific
• P4P for outcome measures
diabetes, etc.
• Service Oriented
• Medical Home payments
• Segment by Illness
• CMS Chronic Care demo
• Total Population Care
• Accountable Care Org
(HF,
Stuart Guterman, Karen Davis, Stephen Schoenbaum, and Anthony Shih,
Using Medicare Payment Policy To Transform The Health System: A Framework For Improving Performance,
Health Affairs, Vol 28, Issue 2, w238-250w
Copyright ©2009 by Project HOPE, all rights reserved.
Patient Protection and Affordable Care Act
ACO Definitions
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“Secretary (of HHS) shall establish”
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significant degree of discretion in rule making
Starts “not later than” January 2012
Shared Savings Program
Accountable for a population (>5,000 beneficiaries)
Coordination of Medicare A&B
Investment in infrastructure
High quality and efficient delivery
“groups of providers of services and suppliers meeting criteria” = ACO
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Group practice arrangements
Networks of practices
JV between hospitals/providers
Hospitals w/ employed providers
Others?
Patient Protection and Affordable Care Act
ACO Requirements
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Accountable for quality cost and overall care for assigned beneficiaries
Agree to ≥ 3 year period
Form legal structure to receive and disperse payments
PCP enough for population (≥ 5K)
Specify the providers in ACO
Leadership for clinical and administration services
Processes to ensure it
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promotes EBM
reports quality, cost, & utilization measures
coordinates care (emphasizes technologies, care transitions)
assesses patient and provider experience
Engagement in PQRI, e-Rx, EHR (?meaningful use), possibly higher standards than
general Medicare providers
Patient Protection and Affordable Care Act
ACO Methodologies
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Assignment of FFS beneficiaries based on use of PC services
– “appropriate method”; prospective vs. retrospective
– Beneficiaries enrolled in A+ B, excludes Part C (Medicare Advantage)
FFS payments continue + potential for shared savings payments
Benchmark to determine shared savings
– prior 3 year average per capita expenditure for assigned ACO population
– updated by national growth trend (absolute amount, not rate)
– risk adjustment methodology required but not defined by statute
– updated each performance period
Savings occurs if the average per capita expenditure is below a percentage of the
benchmark that assures performance is not due to normal variation
– ? 95% confidence interval, thus population dependent
– Quality requirements must be met
– Secretary to determine percentage & maximum amount of net savings shared
Other features
– Monitoring of risk avoidance by ACO
– Termination possible if ACO not meeting quality standards
DESIGN ISSUES
• Attribution
• Beneficiary Participation
• Comparator Group
• Rapid Performance Feedback
• Risk Adjustment
• Infrastructure Investment Requirements
• Financial Design- 2% Threshold
• Shared Savings as a Longterm Design Feature
Other Thoughts
• Focus on high volume/high cost
• Continued need to refine FFS payment
• Eliminate incentives driving fragmented behavior
• Importance of some stick with the carrot
• Relationship between delivery system organization
and payment policy can be nonlinear
• Importance of leadership/culture
• Importance of collaborative learning
• Rural healthcare providers can be players
Collegiality is the Key
“The key feature of the new integrated health care
enterprise is not a balance of power, however, but the
emergence of collegiality as the fundamental organizing
principle. The essence of collegiality is tolerance and a
sharing of common professional values. This trust and
sharing of values is, in turn, the central precondition of
the ability to share and successfully manage the
economic risk of health costs.”
Jeff Goldsmith
Driving the Nitroglycerin Truck
Healthcare Forum Journal
March/April 1993
Culture of Quality and Safety:
Billings Clinic
• CMS PGP Demo
• Early adopter CMS Core Measures
• ICU Bundles(Pronovost)
• MRSA reduction using positive deviance technique
• Specialty Society Quality Data: STS, ACC, NSQP
• Chronic Disease Registeries
• PACE
• Magnet/Beacon
• Center Translational Research
• Quest/Premier ACO Demo
The past 50 years have been marked
by advances in the science of medicine.
The next 50 will be marked by
improvements in the organization and
teamwork of how healthcare is
delivered.
Charles Mayo, M.D.
January, 1913
Thank You