ACCOUNTABLE CARE ORGANIZATIONS: MOVING FROM VOLUME TO VALUE

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ACCOUNTABLE CARE

ORGANIZATIONS: MOVING FROM

VOLUME TO VALUE

Brent Priday, MBA/MHSA

Senior Director of Managed Care

Banner Health

DISCLOSURE OF COMMERCIAL SUPPORT

Brent Priday, MBA/MHSA does not have a significant financial interest or other Learning

Objectives

:

 Review new developments in Accountable Care Organizations.

 Describe healthcare reform and its impact on Arizona.

 Explain what local healthcare providers are doing to respond to today's

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Banner Health

Network

AZ Geriatrics Society Fall Symposium

Accountable Care Organizations:

Moving from Volume to Value

11 11--88--1313 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Current Healthcare Environment ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Our fiscal health is top priority

• 7.9% unemployment; 160,000 new jobs in January • 2% GDP growth in 2012; ‐.1 decline in January • Federal spending 23% of GDP; Tax revenues @16% of GDP • 2001 Debt = 33% of GDP; 2013 projected debt = 75% of GDP 70 years of Federal Debt Held by the Public ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

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HEALTHCARE SPENDING PER CAPITA & LIFE EXPECTANCY ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Drivers of Change: Changing Health Care Landscape • Health Care Reform Evolution – CMS estimates of 10,000 new beneficiaries daily – ACO regulations – Expanded bundled payment pilots • Arizona State Budget – AHCCCS Impact • Commercial Payer Changes – Affordability concerns (less than 50% of employers offer health insurance) – Increased levels of value transparency to inform consumers ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

• 23 Acute Care Hospitals • Banner Health Network • Banner Medical Group with

more than 1,000 doctors • Banner Health Centers and

Clinics • Behavioral Hospital • Outpatient Surgery • Medical Education • $4.9 billion in revenue • 36,700 employees • AA- bond rating

Banner Health Snapshot

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Banner Health Network (the ACO) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Banner Health Recognitions • Truven Top 5 Health System in U.S. (3 of past 4 years) • Top Leadership Team in Healthcare (HealthLeaders Media) • Top 10 Integrated Health Network in U.S. (SDI) • 21 Banner facilities achieved Stage 7 EMR (of 92 hospitals in U.S. (by HIMSS Analytics) • Most Wired Award (Hospitals & Health Networks) • Best Places to Work (Az. Business Magazine) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 252 Medicare ACOs in 43 states Over 430 Medicare and Commercial ACOs 500 providers in CMS Bundled Payment initiative Growing number of ACOs nationwide ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

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ACO Shared Savings Model -3 -2 -1 0 1 2 3 E xpe ndi ng Year Projected Spending Actual Spending SharedSavings Confidence interval ACO Launched

Source: Lewis, Julie. “What Could be Next for Health Reform? The Debate In Washington” Presentation. The Dartmouth Institute for Health Policy & Clinical Practice. 2009-07-02.

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Value Proposition in an ACO Type Model …while increasing quality and member experience ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Patient Centric Care……. Health Management Solutions Consumer •Employers •Payers •Individuals Banner Brand Awareness Provider Network Health Centers Wellness & Health Coaches Tele‐health Disease Management Onsite Services Applications Ac ce ss & Va lu e ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

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Health Home – Team Based Care Types of interactions PCP 1:1 clinic visits Reactive Phone Follow‐Up eMail Follow‐Up Types of interactions PCP 1:1 clinic visits Reactive Phone Follow‐Up eMail Follow‐Up CURRENT MODEL Physician Centric Sickness Model Reach ~ 35 patients/day FUTURE MODEL Member Centric Wellness model Reach ~ 100 members/day PCP group visits Clinic team member 1:1 visits Clinic team member group visits Proactive Chart Reviews Proactive outreach  Snail Mail  eMail  Phone  Text  Other P o pula tio n He al th Ma n ageme n t ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

BHN at a Glance

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Clinical Consensus Groups (CCG)

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Evidence‐Based Practices • Medical Imaging for Dx Community Acquired Pneumonia • Chlorhexidine Alcohol for Surgical Skin Preparation • Seprafilm Use in Cesarean Sections • Knee High SCDs and TEDs • Early Sepsis Identification • Acute Respiratory Distress Syndrome (ARDS) • Delirium • Newborn Hypoglycemia Screening & Mgmt • Medical Imaging for Peds Appendicitis • Large/Small Bowel Surgical Care • Diagnosis of Diarrheal Disease • Pooling of Bronchoscopy respiratory specimens • Diagnosis of Coccidioidomycosis by Seriological Means • Diagnosis of Clostridium difficile Associated Diarrhea • Elective Deliveries Prior to 39 Weeks • Behavioral Health Medical Clearance • Ventilated Patient Management (oral care, sedation) • CT Scan in ED for Atraumatic Headache • Dysphagia Management for peds patients • Subcutaneous Insulin • Syncope • ED Ischemic Stroke tPA • Scorpion Envenomations • ED to Critical Care Admissions • Intra Op Goal Directed Therapy • PET Scan • Admin Intravenous Contrast Media • Vertebroplasty • Pre‐Term Labor • Ambulatory Lower Back Pain • Insulin Drip Transition Post Cardiac Surgery • Palliative Sedation • Readmission Risk Assessment and Management • Pediatric Sepsis • Enhancing Progression of Labor • Indwelling Catheters in Laboring patients • Pharmacy Drug Level/Lab Monitoring Service • Appropriate Use of PPI’s (Proton Pump Inhibitors) • DKA Hyperglycemic Crisis • Moderate‐Severe EtOH‐Substance Withdrawal • Pediatric Bronchiolitis • Pediatric Fevers • Adult Implantable Automatic Cardio‐Defibrillators (ICD’s) • Epoetin‐Adult • Orthopedic Care for Total Knees, CPMs, Cold Therapy • Anesthesia Administration • Post Partum Hemorrhage • Early Warning System for Adult Patients • ED Pulmonary Embolism Rule‐Out Criteria (PERC) • ED Discharge Transition • ED Acute paint management • Midline Sternotomy – Post Operative Management‐Adult • Point of Care Chest Ultrasonography • Chorioaminonitis Management • Developmental Screening for Peds • Acute Blood Loss • ED Chronic Pain • T Dap Vaccine • Use of BMP • Nitrous Oxide • Reducing Postoperative Pulmonary Complications • Ambulatory Diabetes Care • Hepatic Encephalopathy Patient Management ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

ED CT Scans ‐ Atraumatic Headache

Initiative Started July 2011 target ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Mortality Observed/Expected Acute Care Patients Mortality outcomes are >50% better than

predicted Clinical Practice: _{Severe Sepsis}

Delirium 1.2 1.0 0.8 0.6 0.4 0.2 0.0 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

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Case Management Model Patient Acuity Resource Demand ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Case Management Practice Settings

There is a single, standardized model for Case Management; the setting varies. A standardized process requires standardized assessment tools, action plans, and workflows. Supporting programs are developed that support and mimic the standardized approach to case management (IAC and Bundled Payment). ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Patient Registry ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

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Case Management Programs Program Description Complex Case management Case manager, RN, and/or MSW monitor and manage medically complex members, assist with care coordination, disease education, and community services. Embedded Case Management ECM is practice focused to collaborate with Providers at High Volume Primary Care offices Readmission Reduction Program 65+ CHF, AMI, Pneumonia and 18+ all cause Management Clinic Without Walls Internists working in tandem with nurse case managers provide medical, preventative, educational, and supportive services to stabilize symptoms and slow disease progression. Infertility Case Management Case Managers help members initiate infertility benefit, guide to designated providers, and provide counsel through diagnostics and the treatment Maternal Child case Management Moms with high risk pregnancies and sick neonates are offered access to specialized care networks and benefits customized to facilitate optimal outcomes. Pediatric Case Management Case Managers help manage high rsik pediatric patients, guide to designated providers, and provide counsel through diagnostics and the treatment End Stage Renal Disease (ESRD) Case Management Members with declining or failed kidney functioning are assigned a renal case manager who helps the individual make informed decisions regarding method of dialysis, access selection, and transplant timing. The case manager monitors efficacy of dialysis, and educates members Transplant Case Management Co‐management with Optum case manager helps with selection of transplant facility. Medication Management Clinical pharmacists evaluate and advise regarding medication regimens, members are taught to understand their medications and take appropriately. Information also available on potential resources to preserve benefit or help offset cost ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ 0 100 200 300 400 500 600 700 800 900 2012Q1 2012Q2 2012Q3 2012Q4 2013Q1 Declined/UTR In CM Impact on Inpatient Admissions/K Case Management Results 0 10 20 30 40 50 60 70 80 2012Q1 2012Q2 2012Q3 2012Q4 2013Q1 Declined/UTR In CM Impact on ER Visits/K R² = 0.0414 0 1000 2000 3000 4000 5000 6000 2012Q1 2012Q2 2012Q3 2012Q4 2013Q1 Declined/UTR In CM Linear (Declined/UTR) Linear (In CM) Impact on Physician E&M Visits/K ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Impact on Allowed PMPM Estimated Savings per Engaged Case •Initial views show reductions in Allowed PMPM of the CM Managed Population •Initial estimates for savings per engaged case (from a comparative health plan’s programs) –$555 Advance Illness Planning –$103 for CM •CM Managed Population Average PMPM $1855 (1Q12‐ 4Q12) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

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Pioneer ACO First‐Year Results 8.9% reduction in overall hospital admissions 14.4% reduction in average length of stay 6.0% reduction in avoidable hospital readmissions 6.7% reduction high‐tech imaging services 2.53% reduction in CMS paid amount per beneficiary ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Pioneer ACO Financial Performance _{- 10%} - 5% 0% 5% 10% 8 29 5 7 11 19 14 13 4 10 21 27 31 17 6 20 2 9 26 22 28 18 30 3 32 24 12 23 1 15 25 16 1 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Health Care Exchange Update

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Winning under reform – Critical success factors • High quality; reduce costs • Ability to aggregate clinical capabilities and deliver evidence‐ based care • Brand • Access to capital • Ability/partner to aggregate lives • Physician / Hospital alignment • Ability to aggregate and analyze data • Ability to engage consumers • Manage transition with one foot in FFS and stepping into risk‐ based contracting • Ability to manage performance risk • Understand/partner on benefit design ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________