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Health Plan-Provider Collaboration Strategies
Jim Hammond Publisher/CEO The Hertel Report Managing Consultant, Professional Healthcare Solutions
David Hanekom, MD CEO and CMO Arizona Care Network
September 27, 2018
• Jim Hammond
– Publisher & CEO of The Hertel Report
– Managing Consultant, Professional Healthcare Solutions
– State-wide Healthplan & Provider Relations Expert
– Conference Speaker & Resource to:
AzHHA, AHE, MCMS, HFMA - AZ, CBIZ, ASPA, AMN, HCAA,
CMSA, Sonora Quest, Humana, Dignity Health, U of A,
CNBC, Money Radio, Wall Street Journal, NPR, Modern
Healthcare, Phoenix Business Journal, Arizona Daily Star,
Vitalyst Health Foundation, Web AZ, and more
– Former AZ HFMA President
Introduction
The Hertel Report
• Trusted & Respected
• Impartial & Timely
• Solutions Focused
• Locally Owned
• Weekly News
• Monthly Newsletter
• Quarterly Data
• Networking & Conferences
• Value = Quality/Price • Quality requires definition
• Evidence critical – IT and UM/QA
• Meeting critical measures
• Prove to yourself, then the market
• Bundled payments
• Pay for performance, earn shared savings
• Moving to Risk
Word of the Day
Value A. Increase Quality, Costs same B. Decrease Costs, Quality same C. Increase Quality, Decrease Costs
V Cost/Quality Time
So in order to reduce cost….
A. Decrease in # units B. Decrease in $/unit C. BOTH!!
Costs Rate ($/Unit) x Utilization (#Units)
• Healthplan Cost = Provider Revenue
• Healthplan reduces price
• Providers incentivized to
Cost = Rate x Utilization
Increase Utilization
wait for it……..
Fee-For-Service
LEVELS OF FINANCIAL RISK
Incentives
Provider Incentives:
High
Degree
of
Risk
Low
Fee-for-
Service
(FFS)
Discounted
Fee-for-
Service
(DFFS)
Per
Diems
Per
Case
(DRG)
Capitation
& Percent
of Premium
•
•
•
• More ancillaries
• More days
• More cases
•
•
•
• More ancillaries
• More days
• More cases
•
•
•
• Less ancillaries
• More days
• More cases
•
•
•
• Less ancillaries
• Less days
• More cases
•
•
•
• Less ancillaries
• Less days
• Less cases
• • •
•
•
•
• •
•
Fee-for-service (FFS)
Per Diem Per Case (DRG) Percent of Premium
More Ancillaries Less Ancillaries Less Ancillaries Less Ancillaries
More Days More Days Less Days Less Days
More Cases More Cases More Cases Less Cases
RISK TO PROVIDER
Degree o
f Risk
Fee-for-service (FFS)
P4P VBM
Transactional Services
Per Diem Per Case
DRG Payment
Shared Risk Upside only Gainsharing
MSSP Track 1 Pioneer (APM)
Shared Risk upside and downside
ACO Tracks 1+, 2, 3 Next Gen
Bundled Payments
Percent of Premium Capitation
Medicare Advantage
More $ Prove quality Identify high
cost efficiency
Upfront costs, reward
Provider is decision-maker Financial Risk
Full-Risk Incidence and prevalence
More Cases More Cases More Cases Avoid waste prevention
Quality Measures
Reserves Partnerships
Risk tolerance Reduce utilization
True Pop Health
Pro
vide
r A
ccou
ntab
ility R
isk/reward
Value=Quality/Cost Time
Indicators of Value-Based Networks
• Aggregate Providers into Integrated networks • Contract with health plans with rewards tied to triple aim • Connect electronically • Track and report quality data • Track and report utilization data • Upside risk only agreements (MSSP Track 1, Commercial ACO deals) • Upside and downside risk (MSSP Track 1+, 2-3, Next Gen) • PMPM Targets • Percent of Premium
ACO Value Based
Network
Healthplan Network
OON/OOA OON/OOA No Benefits
Healthplan Network Reduced Benefits
ACO ”Value Network” Best Benefits
Can be System Independent Owned Affiliated Networked Share • Values • Information • Measurement • Risk
New Clinical Models
Innovation
Collaboration
Efficient predictable
safe
Patient Centered Wellness
Prevention
New Funding Models
Risk to Provider
Reward Quality
Embrace Technology
Process improvement
Shared Information
Safety
Decrease Duplication
“Value Based Networks”
Aggregated Providers
Affiliation
Evidence of Quality,
Efficiency
Willing to Take Risk
Let’s talk about Nomenclature
• Accountable Care Organizations – ACO’s are funded by the ACA and specifically address traditional Medicare
• Clinically Integrated Networks
• Physician Hospital Organizations
• Independent Physicians Associations – Primary Care
– Multispecialty
• Single TIN Groups
All can be Value-Based Networks
VBN’s *All of the attributed lives in the
Medicare column are through the MSSP or Next Generation
programs. **PCPs is total MD/DO and
midlevel practitioners
This table illustrates attributed lives for many Value-based Networks in Arizona.
While this list is comprehensive, we know there are other VBN's in Arizona
not accounted for in this report and table.
The data was aggregated by The Hertel Report, sourced from responses directly
from the VBN’s. Summer 2018
Estimated Value-Based Contracted Lives in Arizona
Organization Name Medicare* Medicare Advantage
Commercial Medicaid Estimated Total
Lives
Estimated Number of
PCP's Abacus ACO 28,000 23,200 30,000 7,100 88,300 131
Arizona Care Network 33,000 1,500 105,000 111,000 250,500 1,069
Arizona Connected Care 8,318 5,819 14,021 0 28,158 195
Arizona Priority Care N/A 11,005 0 0 11,005 322
ASPA Connected Community 6,200 0 0 0 6,200 50
Banner Health Network 50,737 90,381 288,644 13200 442,962 1,032 Cigna Medical Group - Not Reporting -
Commonwealth ACO 16,000 24,000 5,000 45,000 97 District Medical Group N/A 0 0 91,500 91,500 60
Equality Health N/A 77,255 77,255 290 Health Choice Preferred N/A 6,000 1,000 31,000 38,000 125 Innovation Care Partners N/A 17,000 0 17,000 300
Iora Health - Not Reporting - Maricopa Integrated Health System - - 19,500 19,500
John C. Lincoln ACO 16,400 N/A N/A N/A 16,400 140 North Central Arizona Accountable Care 14,500 0 0 0 14,500 145
Optum ACO 37,000 65,000 0 0 102,000 600 PathFinder ACO 9,843 0 6,056 0 15,899 78
Phoenix Children's Care Network 2,300 126,000 128,300 359 Scottsdale Health Partners 23,500 N/A N/A N/A 23,500 150
Summit Healthcare NEAR Network 4,500 4,500
TOTAL 243,498 219,905 475,521 481,555 1,420,479 5,143 17.1% 15.5% 33.5% 33.9%
N/A: Not Applicable
WND: Would Not Disclose
Medicare ACO Start Date Ownership/Structure
Service Area 2018 Track
PCP's Attributed
#Beneficiaries
Banner Health Network 1/1/2012 Banner Health & Networks
Maricopa and Pinal Counties MSSP
Track 3 1032 50,737
Arizona Connected Care 4/1/2012 Community Providers, TMC
Southern Arizona MSSP
Track 1 195 8318
Arizona Care Network 1/1/2013 Dignity Health & Abrazo Health
Arizona Next Gen MSSP T1+
1069 33,000
Commonwealth PCACO 1/1/2013 Independent PCP's
Arizona, New Mexico MSSP
Track 1 97 16,000
JC Lincoln ACO 7/1/2013 Honor Health
Maricopa County MSSP
Track 1 140 16,400
Scottsdale Health Partners 1/1/2014 Honor Health
Maricopa County MSSP
Track 2 150 23.500
ASPA-Connected Community
1/1/2015 Independent Physicians (ASPA)
Arizona, New Mexico MSSP
Track 1 50 6200
North Central AZ Accountable Care
1/1/2015 Yavapai RMC, with NEAR-Summit
Apache, Coconino, Yavapai MSSP
Track 1+ 145 14,500
Abacus ACO 1/1/2016 Arizona Community Physicians
Southern Arizona MSSP
Track 1 131 28,000
Optum ACO 1/1/2016 Optum Medical Network
Maricopa County Next Gen 600 37,000
Pathfinder ACO 1/1/2018 Northern Arizona Healthcare
Coconino and Yavapai Counties MSSP
Track 1+ 78 9843
Physicians Performance Network of Arizona
1/1/2018 Tenet healthcare –Carondelet
Pima County MSSP
Track 1+
Arizona’s Medicare ACO’s 2018
ACO Name 2017 Track 2018 Track
Banner Health Network MSSP Track 3 MSSP Track 3
Arizona Connected Care MSSP Track 1 MSSP Track 1
Arizona Care Network MSSP Track 1 and
Next Generation
MSSP Track 1+
and Next Generation
Commonwealth PCACO MSSP Track 1 MSSP Track 1
John C. Lincoln ACO MSSP Track 1 MSSP Track 1
Scottsdale Health Partners MSSP Track 1 MSSP Track 2
ASPA Connected Community MSSP Track 1 MSSP Track 1
North Central Arizona AC MSSP Track 1 MSSP Track 1+
Abacus ACO MSSP Track 1 MSSP Track 1
Optum ACO Next Generation Left Program
PathfinderHealth N/A Track 1+
2018 Arizona ACO Tracks
Arizona ACO 2016 Results
https://www.thehertelreport.com/mssp-aco-2016-arizona-results-scottsdale-health-partners-earns-nearly-9m-in-earned-shared-savings/
ACO Movement/News
• Pathfinder Health leaves NCAAC and starts MSSP Track 1+
• Summit (NEAR network) Joins NCAAC
• NCAAC moves to Track 1+
• Banner Health Network moves from Pioneer to Track 3
• ACN Running MSSP Track 1 and Next Generation
• Scottsdale Health Partners goes to MSSP Track 2
• Optum Care ACO leaves Next Generation Program
• ACC signs management agreement with P3 Health Partners
National MSSP Results To Date
MSSP Results 2012 2013 2014 2015 2016
Earned Shared Savings 29 55 92 125 134
Reduced spending, below threshold 25 60 89 83 107
Increased spending, below threshold 60 88 223 184 187
Owed money back to CMS 0 1 0 0 4
Total 114 204 404 392 432
2018 • 561 ACOs • 101 downside
risk • 21 with no
experience
Have ACOs Been Successful?
• CBO scored MSSP to save $4.9 Billion through 2019
• OIG reported MSSPs have saved CMS $1.7 Billion through 2016
• Quality scores have risen in more mature ACOs
– Better care vs better reporting
23
http://thehealthcareblog.com/blog/2017/12/18/fixing-macra-should-mean-fixing-the-apm-pathway/
CMS Proposes New Risk Tracks for MSSP
Alignment for Maximum Results in Value-Based Contracting
Health Plan & Provider Collaboration
9/26/2018 26
27 9/26/2018 27
David S. Hanekom, MD, FACP, CMPE
Chief Executive Officer & Chief Medical Officer
ACN is a provider
network that improves healthcare and reduces
costs by actively managing care for our
patients.
9/26/2018 28
29
• Medicare
• Medicaid
• Commercial
• Direct to Employer
DIVERSE VALUE-BASED
CONTRACTS Quality outcomes achieving
Care locations
statewide
1,109
Primary
Care
3,964 Community
Specialists
529
Facility/
other
5,602 Providers
Broad Geographic Coverage Improves Access to Care
Provider Type
2013
Today
Primary Care
322
1,109
Specialists: Community Based
771
3,964
Facility & Other
397
529
TOTAL
1,490
5,602
30
Provider Type
Participants
Primary Care 1,109
Specialists: Community Based 3,964
Facility & Other 529
TOTAL 5,602
31
Value-Base Contracting Complex, Evolving, and Targeted to Guarantee Performance
9/26/2018 31
Fair deals require significant collaboration, trust, and transparency between payer and provider
Gainsharing Model may appear straight-forward but details matter.
Member attribution is foundational
Target setting complex and fraught with dangers
Minimum risk corridors can shift savings to payors
Quality Adjustments can be inappropriately biased to payor
Random variation necessitates careful thought about outlier methodologies or stop-loss provisions
Medical inflation and benchmarking populations need careful consideration
UnitedHealthcare & ACN
Shared Values Drives Relationship
ACN’s Quadruple Aim Increased Quality. Decreased Cost. Satisfied Customers
11
Cultural Alignment Integrity, Compassion, Relationships, Innovation, Performance
Leadership alignment around the Quadruple Aim
Quality of care comes first
Ensure patients get the right care in the right care location
Measure and report clinical, financial, utilization, and customer satisfaction outcomes
Patient Satisfaction
Ease of care coordination through N Compass
Aligned commitment where each party understand and “owns” their role
Concierge team trained in warm handoffs to appropriate party
Operational Alignment
Collaboration
9/26/2018 35
1
2
3
4
Improve the health of our patients
Enhance the patient experience
Manage the rising cost of care
Increase provider satisfaction
Data transparency, ID rising risk, Clinical
Leadership, Practice Transformation team, N
Compass care coordination
N Compass care coordination, concierge
line, tools to improve health
Build a broad network, engage providers in
network utilization tools, reward top
performers
Physician-led/governed, data transparency,
tools & resources; provider incentives align
with priorities: clinical outcomes, patient
satisfaction, network utilization
36
Examples
Division of Responsibilities
Transparency
JOCs guide relationship, clarify roles & status
UHC analytics: tools and reports on the patient population helps ACN identify high-priority members to close gaps in care
Collaboration
Combined information systems to drive Quadruple Aim
Alignment of care models to avoid duplication
Collaborative vs. competitive
Disease management – led by physicians, guided by data
9/26/2018 36
Support the Provider Network
Technology tools
Referral management software
Quality data via secure portal
Aligned incentives to drive desired
behaviors
Support team:
Provider Network Consultants
Clinical Performance Representatives
…and they respond
37
10
20
30
40
50
60
70
May
-17
Jun
-17
Jul-
17
Au
g-17
Sep
-17
Oct
-17
No
v-1
7
Dec
-17
Jan
-18
Feb
-18
Mar
-18
Ap
r-1
8
May
-18
Jun
-18
Jul-
18
Au
g-18
Time to First Action (Business Hours)
8
10
12
14
16
18
May
-17
Jun
-17
Jul-
17
Au
g-17
Sep
-17
Oct
-17
No
v-1
7
Dec
-17
Jan
-18
Feb
-18
Mar
-18
Ap
r-1
8
May
-18
Jun
-18
Jul-
18
Au
g-18
Time to Appointment (Business Days)
38
Care Coordination
9/26/2018 38
39 39
40
Innovations to Drive Provider Engagement
9/26/2018 40
Timely resources for providers
Measure and report performance by Network, TIN, NPI –
drives improvement over time
Data available 24/7 via Secure Provider Portal
Practice Transformation Collaboration Meetings deliver
focused performance data, improvement toolkits
N Compass
Aligned Incentives
Annual incentive opportunity
Provider Rewards Program
NEW: ACN Care Wallet for more transparent, timely info
41
High Quality Care is Cost Efficient Care
9/26/2018 41
The ACN Model
Focused metrics for providers
Improved transitions of care
Timely interventions by N Compass team: care coordination embedded in
high-volume practices, customized remote team for other practices
Results for UnitedHealthcare and our Shared Members
$5M Saved in
Total Medical Cost
(2 years)
26.6% Reduced
acute
hospital
admissions
26.2% Reduced
acute
hospital bed
days
25% Increase in
UHC members
Questions?
9/26/2018 42
9/26/2018 43
The Hertel Report is the Source that Connects…. • Local News
– Marketplace plans and premiums; AHCCCS Waiver acceptance and implementation, ACO/VBN, Medicare Advantage data, more value-based deals and risk contracts, innovation.
• National News:
– Trump Budget: Block grants, tort reform, end APTCs, sales across state lines, association plans, short-term plans etc.
– Congressional Action: Pharmacy costs, repeal & replace efforts, Medicare for all, CSRs, reinsurance, state-by-state market reform, etc.
Thank You for Your Attendance and Continued Support!
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www.thehertelreport.com
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“Transactional Services”
• Health Risk Assessments • Gaps in care • Medication reconciliation • Attestations • CCM
– 99490, 99487, 99489
• TCM – 99495, 99496
• Better relationship between patient and provider
• Can uncover multiple conditions leading to better care
• Potential to reduce ER Visits and avoidable admissions
• Potential to reduce cost of care • Right Services, Right Place, Right Time
• Increased Revenue Potential for Risk Entity (Appropriate RAF scoring)
• Increased Revenue Opportunity for Providers
=
WIN for the Patient, Win for the Provider, Win for the Payor Targets the triple aim: Better Care, Better Patient Experience, Lowers the Cost of Care
MSSP Tracks Track 1
Upside Risk only (2012 -)
• APM under MACRA
• Retrospective attribution
• Max sharing rate 50%
• Payment limit 10%
• MSR: 2-4% set by CMS
Track 1+
Upside and Downside Risk (2018 -)
• AAPM under MACRA
• Prospective attribution
• Max sharing rate 50%
• Max loss rate of 4% of benchmark
• Payment limit 10%
• MSR: 0-2% & chosen by ACO
Track 2- Upside and Downside Risk; 2012-
• AAPM under MACRA
• Retrospective attribution
• Max sharing rate 60%
• Payment limit 15%
• Lower MSR and now with choice in MSR/MLR levels
• Loss limit 5%|7.5%|10%
Track 3 Upside and Downside Risk; 2015-
• AAPM under MACRA
• Prospective Attribution
• Max sharing rate 75%
• Payment limit 20%
• More waivers
• Loss limit 15%
