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Delivering Value Based Care:
Strategies for Success
Presenters
Tammie Galindez, MHA,
CHFP
AVP, Value Based Care
Conifer Health Solutions
Stephanie Mills, MD, MHCM
President
inHealth Strategies
2 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Objectives
At the end of this course, you will be able to:
▪ Discuss what is driving the shift from volume to value
▪ Describe foundational elements of a value cased care
strategy
▪ Describe how technology and data can be leveraged to
decrease cost while informing a broader clinical strategy
▪ Describe strategies to engage a broad coalition of
stakeholders across the care continuum
▪ Describe the impact of an effective wellness and care
management plan on population health management and
reimbursement
3 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Introduction to Fee-For-Value Payment ModelsDefinition Value to provider
P4P & Medical Home
Bundled Payments
Shared Savings (upside only)
Shared Risk (upside/downside)
Full Risk/Capitation
Medical Home and Pay-for-Performance models provide
financial rewards to providers for a narrow list of quality
and cost metrics.
The episode payment for a specific DRG, inclusive of most
costs and typically inclusive of the hospital stay and costs
incurred 30 to 90 days post hospital discharge.
• Aligns providers around quality goals
• Allows for collection of data to show quality
improvement
• Experiment with value-based arrangement on a
limited basis
• Moves service line to integrated delivery model
• Analyze and drive up/down stream care to
preferred network
With both Shared Savings and Shared Risk, the integrated
network is held accountable for the total cost performance for
a defined population. With Shared Savings the network is
rewarded for reducing the cost for the defined population
below a set cost target with a percentage of the total savings.
The integrated network receives a set premium amount
per aligned member, from which claims are paid for a
defined scope of services.
• Movement to domestic utilization to drive
savings and quality goals
• Optimize cost of network to drive savings
• Larger sharing of savings
• More aggressive actions to utilize network
providers and evaluate who is in network
• Manage utilization and network usage to ensure
network optimization
• Limit network to provide providers
Under Shared Risk the network has the potential for
greater reward opportunity of the total cost savings, and
also assumes a percentage of the cost increases above a
negotiated target.
Form Clinically Integrated Networks Manage the Population Advise on Financial Risk
Capabilities needed
4 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Factors fueling the shift to value-based payments
CMS - MedicareMedicare has 80 alternative payment
models which are being applied to non-
Medicare Advantage lives:
• 20% (8 Million) of Medicare FFS lives
are in Medicare ACOs1
• At least 3.6 Million additional lives
are tied to other alternative payment models
(i.e. CJR, Comprehensive ESRD,
Oncology Care Model)
• 30% of Medicare payments tied to quality
through APM’s as of 3/3/2016
Consolidation of models is expected specifically
around:
• Service line / condition specific bundles
(e.g. CJR, Cardiac Bundle)
• Pushing more risk to providers
(e.g. NextGen ACO)
1 MSSP (7.2M), Pioneer (0.6M), NextGen (est. 0.2M)
“Our target is to have 30% of Medicare payments tied
to quality or value through alternative payment
models by the end of 2016, and 50% of payments by
the end of 2018.”
Sylvia Burwell, Secretary HHS, Jan. 2015
85% 90%
50%
2016 2018
All Medicare FFS
Medicare FFS linked to quality
Alternative payment models
30%
Target percentage of Medicare FFS linked to quality and alternative
payment models in 2016 and 2018
Source: CMS.gov
5 © 2017 Conifer Health Solutions, LLC. All rights reserved.
MACRA is a federal program that will be a catalyst
for further transformation
In 2015, “The Medicare Access and CHIP Reauthorization Act of 2015” is passed, creating the framework to
redesign how CMS pays physicians.
In April 2016, CMS released the MACRA Proposed Rule outlining a Part-B physician payment methodology
update that would replace existing PQRS and Meaningful Use initiatives with a more robust and streamlined
program.
Under the new program, physicians will fall under one of three reporting and payment “Tracks”
MIPS (Merit-Based Incentive Payment System)
• Traditional track for providers not in a value-based program
MIPS – APM (Alternative Payment Model)
• Track for providers that participate in a CMS value-based initiative
Advanced APM
• Requires significant share of revenue in contract with two-sided risk and EHR requirements
Today, the most widespread Alternative Payment Models are the CMS ACO programs.
Physicians that participate in Alternative Payment Models, such as ACOs, benefit from less burdensome quality
reporting to CMS and are positioned for favorable Part-B payments.
6 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Other factors fueling the shift to value-based
payments
7 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Commercial and Medicare are driving alternative
payment models with ACOs
1199
505
617
77
0
200
400
600
800
1000
1200
1400
Q22011
Q32011
Q42011
Q12012
Q22012
Q32012
Q42012
Q12013
Q22013
Q32013
Q42013
Q12014
Q22014
Q32014
Q42014
Q12015
Q22015
Q32015
Q42015
Q12016
Total Medicare Commercial Medicaid
Source: Leavitt Partners ACO Landscape Presentation; April 8, 2015
ACO contracted payment arrangements by payer type
Number of arrangements
8 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Growth in ACOs and value-based arrangements is
projected to be regionalized based on 4 characteristics
Urban Environment Disease Burden
Payer Fragmentation Large Employer Concentration
Rising population in
urban areas increase
the regional market
opportunity as well as
Payer and Provider
competition
As the Payer
market
continues to
grow, there will
be more
innovative and
attractive
payment models Leavitt Partners Center for Accountable Care
Intelligence
Census.gov
Fortune 1000
companies tend
to cluster in urban
areas – attracting
more population
and service
providersBased on Aug. 2014, Geolounge.com
Individuals with
chronic diseases
benefit most from
care coordination;
moreover, they have
a higher rate of
utilization
9 © 2017 Conifer Health Solutions, LLC. All rights reserved.
0
200
400
600
800
1000
1200
ACOs
ACOs have had strong growth in past 5 years
-
5
10
15
20
25
30
Q42011
Q42012
Q42013
Q42014
Q42015
Q12016
Lives…
Growth in ACOs
Lives (left), Number of ACOs (right), number of payment
arrangements (right)
• ACOs have been
expanding covering
more lives and
signing more
payment
arrangements
• 9% (28M) of U.S.
population is under
the care of an ACO
• Estimates vary from
41-177M lives
contracted for by
ACOs in 2020
Lives (M)
ACOs
Payment Arrangements
Source: Leavitt Partners ACO Projections White Paper;
December 22, 2015
10 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Shared savings are the most common risk arrangements with
shared risk having the most lives per contract
Reported non-Medicare reimbursement models for ACOs
Percent (4.1M lives reported)
1 Leavitt ACO Database. Only Non-Medicare ACOs reporting payment arrangements; 16% of ACOs covering greater than 12M lives did not report payment model
• Majority of non-
Medicare payment
arrangements are for
shared savings
• Average lives per
arrangement are:
• 24K for shared
savings
• 48K for shared risk
• 28K for capitation
• Even the low growth
scenario of ACOs would
create a 46% growth in
the market
69% 63%
7%13%
23% 24%
ACOs Lives
Shared Savings Shared Savings and Shared Risk Capitation
11 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Characteristics in-play confirm regionalized
concentration that supports VBC’s market-based
growth strategies
Source: Leavitt Partners Value-Based Payments Market Analysis
1 Quantitative indicators in appendix
The Northeast,
Michigan-
Chicago corridor,
and Pacific
Northwest will
quickly be
seeking to
transition to
Value-Based
Payments.
Darker shades indicate
geographies with higher
probability of moving towards
Value-Based Payments
12 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Driving factors of activity for Value-Based Payments
Source: Leavitt Partners Value-Based Payments Market Analysis
13 © 2017 Conifer Health Solutions, LLC. All rights reserved.
There is upside in revenue and market share as rate of
risk-adoption by providers increases through 2020
0
20
40
60
80
100
120
2016 2017 2018 2019 2020
Scenario A Scenario B Scenario C
Source: Leavitt Partners Projected Growth of ACOs: December 2015
Scenario A: baseline scenario – most likely to happen
Scenario B: baseline scenario with impact of MACRA removed
Scenario C: Market B scenario with ACO financial outcomes becoming
increasingly negative
ACO Covered Lives Projections
Millions CAGR
39%
25%
10%
14 © 2017 Conifer Health Solutions, LLC. All rights reserved.
FOUNDATIONAL
ELEMENTS TO
EFFECTUATE A VALUE
BASED CARE STRATEGY
15 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Value based care strategy foundation
16 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Actionable Data is Key to Achieving CIN Success
17 © 2017 Conifer Health Solutions, LLC. All rights reserved.
Strategies to succeed in value-based models
Form clinically
integrated
networks
• Form provider partnership with aligned incentives
• Articulate causes of low cost and quality (including those
providers)
• Provide transparency into cost and quality results
• Enable virtual integration a lower cost alternative to
employment
Manage the
population
• Identify the high risk individuals who would benefit from
care management
• Coordinate care for individuals, diving individuals to the
preferred providers, when appropriate
• Educate to move individuals to self-management
Manage
financial risk
• Negotiate risk-based contracts
• Report and manage financials of risk-based contracts,
providing advice on how to improve
• Perform transactions for delegated risk (e.g. claims,
customer service)
18 © 2017 Conifer Health Solutions, LLC. All rights reserved.
OPTIMIZING RESULTS
Strategic touch points | Focus on “health”
• Focusing on “health” and not “hospital” care
• Driving value-based care: cost and quality
• Redesigning care: connecting silos across environments
• Fostering relationships with providers in care delivery
• Developing practical solutions in the face of competing priorities
• Linking to innovative payment models
© 2017 inHealth Strategies, LLC
Health care expense trends | Making the case
• Employer expense growth rates have slowed since 2010: 4-5%
• Premium increases outpace incomes in all states
• Average annual premiums = 20-25% of median income
• Increased out-of-pocket expenses for workers
• Employee premium contribution nearly doubled in the past decade,
increasing 93 %
• Deductible expense doubled from 2003-2013
• High deductibles are becoming the norm
The Commonwealth Fund, Issue Brief, January 2015
© 2017 inHealth Strategies, LLC
Caring for populations
© 2017 inHealth Strategies, LLC
Achieving outcomes
© 2017 inHealth Strategies, LLC
FMOL Health System | A case study
© 2017 inHealth Strategies, LLC
Healthy Lives | Population health in action• >13,000 employees and >17,000 insured members
• 75% participation rate
• >$20 million in savings over 5 years
• Quality measures exceed national benchmarks
• Five years in a row with no premium increase for members
• Recognized by the National Business Group on Health:
Best Employers for Healthy Lifestyles in 2012-2016
© 2017 inHealth Strategies, LLC
Analytics
• Integrate
Claims, clinical, well-being & care management data warehousing
• Analyze
Relational database tools
Financial, utilization, quality, risk stratification, predictive modeling & engagement
• Manage
Integrated care management platform, protocols & documentation
• Share
Dashboards, executive summaries & ad hoc reports
Connect with clinicians via portal & EHR options
© 2017 inHealth Strategies, LLC
Health risk assessments
• Assess emerging risk
• Enhance claims data
• Engage individuals
• Track progress
© 2017 inHealth Strategies, LLC
Well-being for your populations
© 2017 inHealth Strategies, LLC
Engaging individuals
• Tailored incentive programs
• Participation & outcomes-based
• Link to employer & community activities
• Automated web management
© 2017 inHealth Strategies, LLC
Care management & coaching
© 2017 inHealth Strategies, LLC
Connecting with providers
• Patient-centered approach
• Care management workflow integration
• Data integration: linking claims and clinical data
• Strong governance processes to drive best practice
• Transparency
© 2017 inHealth Strategies, LLC
Imperatives for providers | How do we get there?
• Leverage your strengths
• Build relationships
• Invest in analytics
• Optimize your care
management resources
• Be creative
© 2017 inHealth Strategies, LLC
32 © 2017 Conifer Health Solutions, LLC. All rights reserved.
APPENDIX
33 © 2017 Conifer Health Solutions, LLC. All rights reserved.
DefinitionAccountable Care Organizations (ACO): A network of hospitals, employed and affiliated physicians collaborating through a
robust care coordination program designed to improve the quality and efficiency of care delivered to is aligned patients.
Commercial ACOs engage in the full range of value based payments with private payers. Medicare ACOs are contracted with
CMS.
Bundled Payment: Bundled payments are fixed amounts of reimbursements for a predefined set of services. There are two
specific programs CMS have in place to move the initiative forward: Comprehensive Care for Joint Replacement Model (CCJR)
and Bundled Payment for Care Improvement (BPCI).
Clinically Integrated Network (CIN): Partnering between employed and affiliated providers in an attempt to better negotiate
collectively with payers on reimbursement arrangements.
Medicare Shared Savings Plan (MSSP): A broad CMS ACO program with varied bonus models that establishes quality and cost
targets for providers who are early adopters of value based payment arrangements. The program has been widely adopted under
its current design. There are three main Tracks within the MSSP program with increasing risk/reward. There are 433 Medicare
ACOs today; 411 are in Track 1 with no downside risk.
Next Generation ACO: TA new Medicare ACO model introduced by CMS in 2016 that offers providers the maximum opportunity
for upside bonus rewards of any Medicare ACO program. This model also includes downside risk and has many of the same
attributes of Medicare Advantage plans.
Pay for Performance (P4P): Financial incentives give to providers for meeting certain criteria such as achieving optimal
outcomes for patients
Pioneer ACO: The Medicare ACO program was introduced in 2012 for provider networks that had experience with value based
models and wanted greater risk/reward opportunities. The program will sunset at the end of 2016 and has been replaced with the
Next Generation ACO program.
Glossary of terms