Total Cost of Care vs. Member P & L (PPDR) for State · SFY 2018 PPDR SFY 2018 TCOC PPDR vs. TCOC (SFY 2018 -Pilot Year 2) Shared Savings Pool 147,235 PPDR Member Months 124,786 TCOC

Total Cost of Care vs. Member P & L (PPDR) for State Fiscal Years 2017 & 2018

1994 – RI Medicaid beneficiaries move into Managed Care Health

Plans; RI Health Centers form Neighborhood

Health Plan of RI with approval of every community health

center’s Board

2012 – With Board approval BVCHC

establishes clinical data warehouse for population health reporting; BVCHC

scores very highly in Health Care Innovation

Challenge

2016 – Accountable Entity (AE) Pilot Program

Year 1 commences; BVCHC Board apprised

of opportunity and agrees to engage

2017 – AE Pilot Program Year 2; Rhode Island

begins receiving first of four payments that will total $129M ($80M for

AEs) for AE infrastructure

2018 – BVCHC certified as an AE; Board

recognizes governing authority of BVCHC’s AE Governance Committee to run concurrently with the Board for strategic

accountable care vision and planning

The Journey to Value-Based Care

MM PMPM MM PMPM MM PMPM MM PMPM MM PMPM33,980 $311.05 35,686 $310.93 36,896 $315.30 37,772 $314.09 144,334 $312.90

$11,701,814 $344.37 $12,073,325 $338.32 $12,489,081 $338.49 $12,807,028 $339.06 $49,071,248 $339.98

Expenses$469,338 $13.81 $481,668 $13.50 $492,910 $13.36 $498,902 $13.21 $1,942,818 $13.46

$4,232,849 $124.57 $3,642,368 $102.07 $3,955,405 $107.20 $3,669,876 $97.16 $15,500,498 $107.39$2,136,870 $62.89 $2,107,866 $59.07 $2,176,785 $59.00 $2,221,933 $58.82 $8,643,454 $59.89$1,429,638 $42.07 $1,619,964 $45.39 $1,604,677 $43.49 $1,468,559 $38.88 $6,122,838 $42.42$1,412,489 $41.57 $1,341,809 $37.60 $1,417,517 $38.42 $1,298,360 $34.37 $5,470,175 $37.90($139,565) ($4.11) ($66,414) ($1.86) ($71,631) ($1.94) ($81,614) ($2.06) ($359,224) ($2.49)$9,541,619 $280.80 $9,127,261 $255.77 $9,575,663 $259.53 $9,076,016 $240.28 $37,320,559 $258.57$2,160,195 $63.57 $2,946,064 $82.56 $2,913,418 $78.96 $3,731,012 $98.78 $11,750,689 $81.41

Reinsurance SubtotalTotal ExpensesMedical Margin

Pilot Year 1 ‐ SFY 2017Practice Performance Data Report (PPDR)

Quarter TotalBirths ‐ Premium SubtotalTotal Premium

Primary Capitation PaidInstitutional SubtotalProfessional FFS SubtotalBH SubtotalPharmacy Subtotal

$1,132,326 $977,478 $855,579 $943,008 $3,908,391

2016 Q3 2016 Q4 2017 Q1 2017 Q2 SFY 2017

2016 Q3 2017 Q12016 Q4 SFY 20172017 Q2

$0

$2,000,000

$4,000,000

$6,000,000

$8,000,000

$10,000,000

$12,000,000

$14,000,000

BVCHC PPDR Medical Margin

Sum of Premium

Sum of Expenses

2-per. Moving Avg (Premium)

2-per. Moving Avg (Expenses)

Medicaid Expansion Added to PPDR

$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

$400.00

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

PMPM

Mar

gin

BVCHC PPDR Medical Margin (with PMPM) Per Quarter

Medical Margin Premium PMPM Expense PMPM

$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

$400.00

$450.00

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

PMPM

Mem

ber M

onths

BVCHC PPDR Member Months Per Quarter

Member Months Premium PMPM Expense PMPM

$-

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

$160.00

BVCHC Quarterly PPDR PMPM Margin (Premium Minus Expense)

Pilot Year Pilot Year 2

$11,

701,

814

$12,

073,

325

$12,

489,

081

$12,

807,

028

$9,5

41,6

19

$9,1

27,2

61

$9,5

75,6

63

$9,0

76,0

16

33,980 35,686 36,896 37,772

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

$-

$2,000,000

$4,000,000

$6,000,000

$8,000,000

$10,000,000

$12,000,000

$14,000,000

2016Q3 2016Q4 2017Q1 2017Q2

Mem

ber M

onth

s

Prem

ium

/Exp

ense

s

BVCHC PPDR Med. Margin (SFY 2017 - Pilot Year 1)

Premium Expenses Member Months

Shared Savings Pool = Predicted Minus Actual Costs104,554 Member Months

$2,140,834 Savings Pool $20.47 PMPM($4.80 PMPM) Claw-Back

$1,638,847 $15.67 PMPM Net Savings Pool

($819,423) ($7.84 PMPM) Share to NHPRI$819,423 $7.84 PMPM Share to BVCHC

($204,856) ($1.96 PMPM) Quality Penalty$614,567 $5.88 BVCHC Shared Savings

$37,320,559

$27,642,818

$11,750,689

$2,140,834

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

$-

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

SFY 2017 PPDR SFY 2017 TCOC

PPDR vs. TCOC (SFY 2017 - Pilot Year 1)

144,334 PPDR Member Months

104,554 TCOC Member Months

$20.47 PMPMShared Savings Pool

$284.86 PMPM

$264.39 PMPM

Predicted Costs

Margin

Expenses

Actual Costs

$81.41 PMPM

$258.57 PMPM

$2,140,834

$1,638,846

$819,423

$614,567

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

NHP TCOC Model – Pilot Year 1

TCOC Margin

Less: EOHHS Expected Savings

Less: NHP Adjustment (50%)

QualityMultiplier (0.75)

$20.47 PMPM

- $4.80 PMPM

- $7.84 PMPM

$15.67 PMPM

$7.84 PMPM - $1.96 PMPM

$5.88 PMPM

NHPRI BVCHC

PPDR $81.41 $0

TCOC $14.59 $5.88

104,554 Member Months

MM PMPM MM PMPM MM PMPM MM PMPM MM PMPM36,889 $312.90 36,437 $310.39 36,974 $310.59 36,935 $310.84 147,235 $311.18

$12,279,413 $332.87 $12,292,089 $337.35 $12,318,663 $333.17 $12,374,629 $335.04 $49,264,794 $334.60

Expenses$483,332 $13.10 $472,006 $12.95 $465,330 $12.59 $456,744 $12.37 $1,877,412 $12.75

$4,063,523 $110.15 $3,821,080 $104.87 $4,305,178 $116.44 $3,647,315 $98.75 $15,837,096 $107.56$2,124,048 $57.58 $2,162,268 $59.34 $2,239,668 $60.57 $2,274,359 $61.58 $8,800,343 $59.77$1,172,675 $31.79 $1,358,495 $37.28 $1,453,488 $39.31 $1,688,472 $45.71 $5,673,130 $38.53$1,206,824 $32.71 $1,082,004 $29.70 $1,380,849 $37.35 $1,408,799 $38.14 $5,078,476 $34.49($228,297) ($6.19) ($9,175) ($0.25) ($40,622) ($1.10) ($43,018) ($1.16) ($321,112) ($2.18)$8,822,105 $239.15 $8,886,678 $243.89 $9,803,891 $265.16 $9,432,671 $255.39 $36,945,345 $250.93$3,457,308 $93.72 $3,405,411 $93.46 $2,514,772 $68.01 $2,941,958 $79.65 $12,319,449 $83.67

Pilot Year 2 ‐ SFY 2018Practice Performance Data Report (PPDR)

2017 Q3 2017 Q4 2018 Q1 2018 Q2 SFY 2018

Quarter TotalBirths ‐ Premium Subtotal $736,725 $982,300 $834,955 $3,447,873Total Premium

Primary Capitation PaidInstitutional SubtotalProfessional FFS Subtotal

2018 Q1 SFY 20182018 Q2

$893,893

Pharmacy SubtotalReinsurance SubtotalTotal ExpensesMedical Margin

2017 Q42017 Q3

BH Subtotal

$12,

279,

413

$12,

292,

089

$12,

318,

663

$12,

374,

629

$8,8

22,1

06

$8,8

86,6

77

$9,8

03,8

91

$9,4

32,6

71

36,889 36,437 36,974 36,935

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

$-

$2,000,000

$4,000,000

$6,000,000

$8,000,000

$10,000,000

$12,000,000

$14,000,000

2017Q3 2017Q4 2018Q1 2018Q2

Mem

ber M

onth

s

Prem

ium

/Exp

ense

s

BVCHC PPDR Med. Margin (SFY 2018 - Pilot Year 2)

Premium Expenses Member Months

Shared Savings Pool = Predicted Minus Actual Costs124,786 Member Months

$3,861,155 Savings Pool $30.94 PMPM($7.19 PMPM) Claw-Back

$2,964,035 $23.75 PMPM Net Savings Pool

($1,482,018) ($11.88 PMPM) Share to NHPRI$1,482,018 $11.88 PMPM Share to BVCHC

($370,504) ($2.97 PMPM) Quality Penalty$1,111,513 $8.91 BVCHC Shared Savings

$36,945,345 $28,258,295

$12,319,449

$3,861,035

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

$-

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

SFY 2018 PPDR SFY 2018 TCOC

PPDR vs. TCOC (SFY 2018 - Pilot Year 2)

Shared Savings Pool

147,235 PPDR Member Months

124,786 TCOC Member Months

$83.67 PMPM

$250.93 PMPM

$30.94 PMPM

Predicted Costs

Margin

ExpensesActual Costs

$226.45 PMPM

$257.40 PMPM

$3,861,155

$2,964,035

$1,482,018 $1,111,513

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

NHP TCOC Model - Pilot Year 2

TCOC Margin

Less: EOHHS Expected Savings

Less: NHP Adjustment (50%) Quality

Multiplier (0.75)

$30.94 PMPM

- $7.19 PMPM

$23.75 PMPM

$11.88 PMPM

$8.91 PMPM

- $2.97 PMPM

- $11.88 PMPM

NHPRI BVCHC

PPDR $83.67 $0

TCOC $22.04 $8.91

124,786 Member Months

At Jessie Trice Community Health System, Inc.

Accountable Care Organizations

A Health Center’s Board Member Perspective


MISSIONThe Mission of Jessie Trice Community Health System, Inc. is to improve health equality for our diverse South Florida community by providing and increasing access to quality comprehensive primary care services.


VISIONJessie Trice Community Health System, Inc., is recognized as a health system of excellence and is the choice for health and wellness of our diverse community.


42.48%57.51

%

Patients by Gender

Male Female

68.27%

28.29%

3.42%

Patients by Age

Under 1-19Age 20-64Age 65 to 85 and over

42.20%

3.82%1.33%2.73%

49.89%

Patient Characteristics

100% and below 101-150%151-200% Over 200%Unknown*

Total Patients Served in 2018: 44,471

*Includes pediatric population

58.88%

29.79%

4.60%Patients by Race

Asian/Native/Other Pacific IslanderBlack/African AmericanAmerican Indian/AlaskanWhiteUnreported/Refused


Why join an ACO? Strong base to draw on for transformation

Care is moving from volume to value

Options on risk

Permits FFS payments

Allows for payment of savings

Ties to Center’s journey to excellence

Supports Quadruple Aim

But, before you do…….


Obtain full understanding of the ACO model and requirements:

ACO Board requirements Provider Majority - 75%

Member representative

Minimum of 5,000 Attributable

Centers can only participate in 1 ACO

ACO Overview


Ensure understanding of the ACOmodel in consideration

Risk Shared savings only Commitment to meeting: Financial performance – must achieve minimum

savings rate to receive savings Thresholds for 31 quality measures must be met to

receive achieved savings

ACO Overview


Must report on 31 quality measures Patient/Care Giver Experience (8) Care Coordination/Patient Safety(10) – 3 via claims,

1 via EHR Incentive program Preventive Health (8) At Risk populations (5)

Each domain will be weighed equally at 25%

Must achieve quality performancestandards on 70% of the measures ineach domain to receive savings

QualityMeasures


1. Participation in ACO’s IT Analytics & QI Program

2. Implementation of care management program

3. Annual Wellness Visits4. Integrating ACO’s management tactics5. Choosing the ACO that is aligned with

Center’s mission6. Center’s level of involvement: Governance /decision making

Financial investment – Capital calls

Level of risk

CenterConsiderations


Challenges

Assignment of Center Champion/Care Team Buy-in for limited population

Membership: retention and focused/targeted care management

Importance of data: knowing what to monitor and identifying key areas of focus – quality, utilization, determining key strategies

Financial perspective needed to sustain the organization; looking ahead


Accountable Care for Boards: Learning from Health Center CEOs and

Boards that Have Joined Accountable Care Organizations

Policy & Issues ForumFriday, March 29, 2019

3:30pm – 5:00pm

Session Objectives

1. Gain insight as to why some health centers are joining ACOs;

2. Gain insight as to the type of education and questions boards have undertaken to inform their health centers’ decisions to join an ACO; and

3. Identify relevant session information or questions to share with your board.

Resources

Check out the National Health Center Resource Clearinghouse! www.healthcenterinfo.org

Session SpeakersSherwood DuBose

Board MemberJessie Trice Community Health System, Inc.

Raymond LavoieExecutive Director

Blackstone Valley Community Health Care

Jennifer NoltyDirector, PCA and Network Relations

NACHC Training & Technical Assistance Department

Who Is In the Room?• Do you represent:

• a Health Center?• a Primary Care Association?• a Health Center Controlled Network?

• Time as a Board Member:• less than one year• 5 – 10 years• more than 15 years

• Organization participates in an ACO?• thinking / talking about it• just joined an ACO• have been part of an ACO (or ACOs) for a number of years• no

Setting the Scene• Have you heard of any of the following?

• Value Based Payments

• ACOs

• MSSP ACO

• Attribution

• Risk

Role of the Board• Expectations of the Board in ACOs:

• Fiduciary• having the duty and trust to provide oversight and act for the good of the

health center, rather than personal benefit• protect the health center’s assets

• Understand what is happening in the Community

• Understand what is happening at your Health Center

• Asking Questions / Getting Information / Training• work closely with your CEO

Table DiscussionAt your tables take about 5 minutes to discuss these two questions:

1. Is your health center in an ACO or similar organization?

2. What tips would you share related to board education or critical questions your board asked?

Q & A

Resources

Check out the National Health Center Resource Clearinghouse! www.healthcenterinfo.org

Thank You!Sherwood DuBose

Board MemberJessie Trice Community Health System, Inc.

Raymond LavoieExecutive Director

Blackstone Valley Community Health Care

Jennifer NoltyDirector, PCA and Network Relations

NACHC Training & Technical Assistance Department

Documents

Total Cost of Care vs. Member P & L (PPDR) for State · SFY 2018 PPDR SFY 2018 TCOC PPDR vs. TCOC (SFY 2018 -Pilot Year 2) Shared Savings Pool 147,235 PPDR Member Months 124,786 TCOC