7122016 mccabe ppp final - university of arizona · title: 7122016 mccabe ppp final author: paul...
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Accountable Care Organizations
DanielMcCabeMDArizonaConnected Care
Tucson, AZ
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• Accountable Care Organizations arose from the AffordableCare Act
• A group of doctors, hospitals, and other health care providers who work together to provide the patient with better, morecoordinated care by sharing data and resources
• The providers are responsible and accountable for quality, patient satisfaction, and keeping global costs down across thefull spectrum of care
• Majority of shared savings will go back to primary careand much of it will be reinvested in care programs
Accountable Care Organization(ACO)
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Where the Medicare ACOsAre9 Pioneer, 433 Shared Savings Program, and 20 Next Generation ACOs1
as of April 2016
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Why do we need this new approach?
§ Healthcare costs too much
§ It doesn’t do a good job
§ The system is “broken”
§ Current system is still geared to:“The more you do, the more you make”
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Patients are unhappy
Low expectations§ Can’t find a doctor/provider§ Long waits
§ Can’t be seen when they need to be§ High Deducible plans increasing
“I have the best doctor in the world, but I have to waithours to see him.”
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Foundational Principles
Don Berwick and the Triple Aim:
§ Improve the patient experience
§ Improve the health of the population
§ Reduce the per capita cost of health care
Can all three be accomplished at the same time?
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Arizona Connected Careproposes to do just that!
We are a payment-reformand
delivery-reform model …
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Why did AzCC choose to be anACO?
§ Focus is on wellness and prevention along with chronicdisease management
§ Care coordination helps at-risk patients avoid unnecessary hospital readmissions
§ Providers must meet quality measures, patientsatisfaction standards while keeping costs down acrossthe full spectrum of care
§ Majority of shared savings will go back to primary care- and much of it will be reinvested in care programs
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Contractual Quality Measures• MSSP
33 GPRO measures- 4 domains:• Patient/Caregiver Experience• Care Coordination/Patient safety• Preventative health• Clinical Care for at-risk population
• UHC Medicare Advantage• 4 Core measures• 8 HEDIS quality measures (changed for 2017)• Resource Funding• Efficiency Based
• Cigna Commercial• 18 measures
• United Commercial• 15 measures
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Efficiency Metrics
• Admits per 1000• Re Admits per 1000 (not %)• SNF admits per 1000• ER visits per 1000• Specialists visits per 1000• Total Cost of Care per member• Variation Analysis in selected areas
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Investment and Risk
• Primary Care has the largest burden• Significant startup time and capitol• Savings occur 6-9 months after year
end (delayed cash flow)
• Types of risk -one vs. two sided• Collared risk as an alternative• Reserves (Hurricanes)
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Shared Savings
• Range up to 70%, as low as 10%, most 50\50
• Modified up\down by qualityperformance
• Based on Total Cost of Care vs. Budget• Budget based on patient attribution
and benchmarked financial costs
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Medicare Shared Savings ProgramMSSP
• Need 5,000 lives minimum, apply July for the next year• Historical Attribution Model based on claims• Two step attribution model, PCP and specialists• Based on 3 prior years of expense• National increment• Given a PMPM budget (preliminary), quarterly
reports• 3-6 months after year end CMS does reconciliation
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MIPS vs. eAPM’s
Proposed Rule released spring 2016
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MIPS in FFS
• 2017 work product influences 2019payment
• Based on Quality, Cost, EMR, and Ancillary
• 1.0 Composite Score graded on the curve• Starts at +\- 4% growing to +\- 9%• CMS budget neutral.• Win Lose proposition
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Cost’s of MIPS in FFS
• Estimate of 400-800 staff hours per MD• $11,000 to $30,000 per year per MD
• Chance of scoring 1.0 (average) is 35-40%• If bonus\claw back is done by a Bell curve
• In 2019, 2% bonus has a 17% chance ofsuccess
4% bonus has a 2.5% chance
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APM’s with risk
• MSSP track 2 and 3, NexGen ACO• Excluded from MIPS• GPRO reporting continues• Must meet eligibility requirements• Potential 5% bonus (FFS) vs risk of
capitiation
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Cost of eligible APM’s (e-APM’s)
• GPRO - Estimate 10-40 staff hours perMD
• $300 to $16,000 per year per MD
• Cost of ACO per PCP MD per Year percontract $2,000.00 without shared savings.
• Range is $300 to $18,000
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The Hybrid MIPS-APM• CMS writing new legislation for MACRA• Designed for Track 1 MSSP and non qualifying
APM’s• BPCI excluded in proposed rule• Preferential scoring is given in MIPS• Estimates $500 million (6 yrs) set asides for
Composite Scoring (33 quality measures)• All pending the Final Rule from CMS in the fall
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MSSP Track 1.5
• No proposed legislation for Track 1 MSSP
• Camel’s nose is inside the tent.• Consistency of risk is key for eligibility
• Solution maybe collared downside risk(4%)
• Two step process for PCP’s
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APMs vs. CINsAPMs and PCPs
• ACO-based Model• 30% bonus over 6 years• No MIPS, just GPRO• Better for PCP’s• Population based• Risk based• Less anti-trust risk• Profits shared with MDs
• CINS and MIPS
• Specialists-hospital model• 2% raise over 4 years• Burdensome MIPS reporting• FFS based; no utilization focus*• Specialist high cost focus• More paperwork and hoops• Hospital keeps all the money• Takes no risk• •No category 3 and 4 payments• For PPO insurance products• Business as usual !!!!!
*no metrics around inappropriate care
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Questions