Case Studies on Accountable Care
Organizations and Primary Care
Medical Homes
Monday, April 29, 2013
Presented by:
Richard Belko
Kara Clark, FSA
Society of Actuaries
Provider Payment Reform Seminar
Accountable Care Organizations
Accountable Care Organizations
Accountable Care Organizations & Triple Aim
Accountable Care Organizations (ACO)
• Physician-led team of health care providers
• Work together to provide fee-for-service Medicare patients with
• Work together to provide fee-for-service Medicare patients with enhanced care that is:
̶ High-quality
̶ Evidence-based
̶ Cost-effective
ACO Goal: THE TRIPLE AIM™
• Improve outcomesImprove outcomes
• Improve patient satisfaction and provide high touch experience
• Lower total medical cost and deliver appropriate care from lower cost providers, such as pharmacists and nurse practitioners
How is quality measured in an ACO?
Quality Metrics Reporting
ACO must meet the quality measures in each of the Quality
Domains and lower the cost of care delivery to obtain
financial rewards.
• Each Quality Domain accounts for 25% of the pay-for-performance calculation
Y 1 i ti l
• Year 1 is reporting only
Shared Savings Determination
To qualify for Shared Savings:
• The ACO’s actual PMPY is compared to an “expected” PMPY (known
• The ACO s actual PMPY is compared to an expected PMPY (known as the benchmark);
• If the actual PMPY is sufficiently less than the expected PMPY (by an t k th “h dl t ”) th ACO i li ibl t h i
amount known as the “hurdle rate”), the ACO is eligible to share in the difference between actual and expected PMPYs (50%/50% share with CMS).
Walgreens ACOs:
First pharmacy chain to be
approved by CMS to have an ACO
Dynamic and trusted community leaders positioned to
deliver best-in-class care:
Scott and White Healthcare – Temple, Texas
• A non-profit health system with 65 physicians’ offices
• Owns, partners or manages 12 current hospital sites over 29,000 square miles • ACO will manage 31,200 lives
Diagnostic Clinic – Largo, Florida
• A 100 provider multi-specialty practice located the Tampa Bay area • Main location in Largo contains a Walgreens Health System Pharmacy • ACO will manage 7,500 lives.
Advocare - Marlton, N.J.
• Over 350 multi-specialty physicians and 70 physician extenders
• Over 110 locations throughout New Jersey and Southeastern Pennsylvania • ACO will manage 11,500lives
How do the aims of the ACO drive strategy?
4x Aims of the ACO
↑
Patientexperience
ACO Strategies
↓
Cost↑
Health2 C G 1. Clinical
↓
Administrative burden2. Care Gaps
• Based on 33 quality measures • Others in support
f li i l
1. Clinical Programs
• End of Life • Readmissions • Etc.
of clinical programs
The Role of Analytics
Analytics supports the goals of the ACO through the
following processes:
1. Conducting opportunity analysis to identify (and then quantify) potential clinical programs;
2. Aggregating and warehousing data from multiple sources;
3. Predictive modeling/risk stratifying at the patient level for implementation of clinical programs;
4. Identifying gaps in care at the patient level;
5. Developing baseline quality measures for outcomes reporting (33
5. Developing baseline quality measures for outcomes reporting (33 quality measures);
6. Providing ongoing reporting for program management and outcomes.
Richard Belko
Actuarial & Analytics Blue Shield of California April 29 2013
Richard Belko
Actuarial & Analytics Blue Shield of California April 29 2013
April 29, 2013 April 29, 2013
d li b l k t t d deliver below-market trends
Achieve financial results in acceptable and sustainable returns for all parties
find cost and quality improvements
Increase market share Health
Increase market share Plan
Initial focus on HMO network
Goal in first year – hold Total Cost
Goal in first year – hold Total Cost of Care (TCC) flat, or to a minimal increase
Establishing up front savings goals and cost targets
Incentive model by establishing risk share arrangement with provider partners on all services provider partners on all services
Actionable ACO program initiatives to achieve targets
2010 outcome
2010-11 combined
• $15.5M in savings to CalPERS ($20.5M total savings)
• major reductions in:
• $37M in savings to CalPERS
• PMPM cost trend ~ 3% vs. ~7% for non-ACO
l ti • readmissions
• inpatient days
• inpatient stays of 20 or more days
population
• 2011 quality results:
• Increase in ACE/ARB use • Decrease in readmissions
• ALOS • Significantly higher patient
satisfaction
• Other measures comparable to non-ACO
CCSF:
Hill/UCSF /Dignity Health
CCSF: B&T /CPMC
(7/2011 6/2012)
St. Joseph Health
(1/2012-11/2012)
AllCare/ Doctors Medical
Center
(7/2011 – 6/2012) (7/2011 – 6/2012)
( ) Center
(1/2012-10/2012)
13%↓in
admits/1000 admits/100014%↓in admits/10009%↓in admits/100037%↓in
% reduction
9%↓in ALOS for
inpatient admits inpatient admits2% ↓in ALOS for inpatient admits4% ↓in ALOS for inpatient admits12% ↓in ALOS for
reduction vs. results in
baseline period
Emerging Financial Results
First Year ACO Prov ider Collaborations - 6 months experience
ACO1 ACO2 ACO3
ACO TCC Target 1: $368.14 $347.44 $523.84 ACO Experience 2: $340 90 $324 25 $500 52 ACO Experience : $340.90 $324.25 $500.52 Current indicativ e risk share totals: ($27.24) ($23.19) ($23.32) 1. Reflects flat TCC 12 month trend
2 Paid completed experience with two months run out 2. Paid completed experience with two months run-out Note: early PMPM experience is susceptible to volatility, and may be subject to significant fluctuation
Relationship building – Actuarial presence at the table
from start
Consultative role – responding to provider concerns to
establish comfort levels
establish comfort levels
Target setting (both financial and utilization) - great
motivator
Analytics and Reporting
Population analysis
Tools
•
Membership mix
•
Risk profile
•
Risk drivers
•
Case mix-adjusted ALOS
Inpatient tool - plug and play
•
OOA referrals
Case manager discharge follow-up
• Discharge instructions understood
F ll i it
• Follow-up visits
• Rx instructions
Specialty Clinics
Dedicated Hospitalists
• Leveraged senior program for ACO enrollees
ED out-reach
• Understanding date/time of use
• Proactive letters
Dedicated pharmacy resource
p
y
Service Category Target (pmpm) Hospital Physician Group Plan Hospital services (provider partner) $115 50% 25% 25%
Hospital services( id t ) $25 20% 30% 50%
Partner at Risk
Hospital services (non provider partner) $25 20% 30% 50%
Physician services $90 20% 50% 30%
Ancillary services $10 20% 30% 50%
Pharmacy card $50 10% 45% 45%
Total Cost $290