Accountable Care Organizations: Health Care

Delivery RedesignThomas J. Biuso MD, MBA

UnitedHealthcare Medical Director

Clinical Assistant Professor of Medicine, University of Arizona

Presentation Goals

Understand the reasons why we need new models of care and the implications of the ACA

Answer the question: what is population health and what drives its costs?

Define accountable care organization and its primary role

Appreciate the difficulties for a network to integrate and coordinate care

Understand the importance of community involvement

Why We Do What We Do –

Achieving the “The Triple Aim”!

Improve population

health

Improve individual experience

Control inflation of per capita costs

Triple Aim

The Triple Aim: Care, Health, And Cost. Health Affairs, 27, no.3 (2008): 759-769. Donald M. Berwick, Thomas W. Nolan and John Whittington

Population Health

Figure 1 Relationship between chronic disease complexity (number of comorbid diagnoses) and health care spending in Medicare recipients. Population health 2010 data from the Mayo Clinic Health Services Evaluation Research (HSER) program. Fifty pe...

Amy W. Williams , Robert E. Nesse , Douglas L. Wood

Delivering Accountable Care to Patients With Complicated Chronic Illness: How Does It Fit Into Care Models and Do Nephrologists Have a Role?

American Journal of Kidney Diseases Volume 59, Issue 5 2012 601 - 603

http://dx.doi.org/10.1053/j.ajkd.2012.02.318

Williams Amy et al. Delivering accountable care to patients with complicated chornic illness. Am J Kidney Dis 2012;59(5):601-603

Map or revascularization rates, by hospital referral region, from 2003 to 2006.

Goodney P et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes 2012;5:94-102

What Accounts for Variation

Patient-level differences Physician-level differences (volume,

specialty, and use of endovascular procedures)

Hospital-level differences (size, teaching status, financial status)

Supply sensitive vs preference sensitive (shared decision making)

Alignment Drives Value

High Quality

Low Cost

VV

AA

LL

UU

EE

Care Management Programs

Transparency and Premium Designation Program

High Performing Preferred Networks

Value-based Benefits

Value-based Contracting

Delivery System Transformation

Value-based Continuum

Lev

el o

f F

inan

cial

Ris

k

Degree of Provider Integration

Fee-for-service

Performance-based Contracts (PBC)

Bundled/Episode Payments

Shared Savings

Shared Risk

Capitation

Capitation + PBC.

Performance-based Programs

Performance-based Programs

Centers of ExcellenceCenters of Excellence

Accountable Care

Programs

Accountable Care

Programs

What is an ACO?

Primary care led, coordinated care organization that accepts a global budget for managing a defined population

Facilitate the transformation of the current fee-for-service payment system into one that rewards greater quality and efficiency in care delivery and improved outcomes

Types

Large primary care clinic Multispecialty group Integrated delivery system Physician Hospital Organization Independent Physician Association

Centers for Medicare and Medicaid Services

Pioneer Shared Savings Program Advance Payment Model

Facts 114 provider groups in Medicare Shared

Savings Program Shared Savings ACOs include 2 dozen

smaller groups in CMS Advance Payment ACO Model

Almost all Shared Savings ACOs chose the 3 year contract model with only 7 that opted for two-sided risk model

32 large provider groups launched Medicare Pioneer ACO

6 large integrated delivery systems in Physician Group Practice Transition Demonstration

Transformation

Health information technology Care management Performance measurement Physician engagement Patient engagement Community involvement

Prioritizing Care Plan Management & Care

Coordination

14

Multiple Chronic

Conditions &

Complex Patients

Rules for the Shared Savings Program

Performance measures specified by CMS fall into four domains:

- patient caregiver experience - care coordination and patient

safety - preventive health - at risk population

Quality

33 quality measures in 4 domains that include patient experience, care coordination/patient safety, preventive care, and at-risk population

first 18 months is for reporting must exceed 30th percentile in 70% of the

measures in all domains

Strategy

Consider financial opportunity vs. strategic move

Strategy means 3 year commitment with several questions that need to be answered:

Will an ACO harm financial performance? Can ACO increase market share? Will an ACO allow better competition for

commerical payer book of business?

Costs

Network development and management Care coordination, quality improvement,

and utilization management Clinical information systems Data analytics

QuestionsQuestions