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H E A L T H W E A L T H C A R E E R

V A L U E B A S E D P U R C H A S I N G

E M P L O Y E E B E N E F I T S P L A N N I N G A S S O C I A T I O N

MARY KAY O’NEILL, MD, MBA FEBRUARY 25, 2016

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C O S T

Reduce health care costs Deliver care

more efficiently

W H A T A R E T H E G O A L S O F A C O S A N D V B C S ?

PAT I E N T E X P E R I E N C E

Improve the patient experience

Q U A L I T Y

Improve the quality of the care

THE TRIPLE AIM OF VALUE-BASED CARE

•  A fundamental shift in how health care delivery is organized, paid for and received.

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V A L U E B A S E D C A R E A N D A C C O U N T A B L E C A R E O R G A N I Z A T I O N S C H A N G E P R O V I D E R P A Y M E N T S

FEE-FOR-SERVICE PROVIDER-CENTRIC

ACUTE CARE FOCUSED

TECHNOLOGY TO INCREASE PROFITS

NO ALIGNMENT OF INCENTIVES

CARE COORDINATION

FEE-FOR-VALUE PATIENT-CENTRIC

PREVENTION FOCUSED

TECHNOLOGY TO IMPROVE CARE AND PATIENT EXPERIENCE

REWARDS FOR QUALITY AND EFFICIENCY, SHARED RISK

CARE INTEGRATION

…with most employers caught in the transition

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T R I P L E W I N F U N D A M E N T A L S

Employer Wins Employees Win Clinical Win •  Includes one or more major

health systems to improve quality, enhance member experience and reduce cost

•  Healthier, more engaged and productive population

•  Community leadership – setting direction and expectations for transforming care

•  Organization and employee savings

•  Enhanced, personalized service

•  Improved access to and coordination of care

•  Improved health outcomes

•  The highest level of customized care – in return for provider options limited to just the selected health care system

•  Enhanced program relative to traditional option

•  Increased patient volume •  Rewarded with a share in the

resulting savings, if able to demonstrate improved outcomes while effectively managing costs

•  Success will likely translate to expansion into other employer relationships

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H I S T O R Y O F V A L U E B A S E D C A R E

•  Medicare Data 1967

•  Managed Care early 1990’s in response to medical inflation

•  Leapfrog report 1998, Business Roundtable funding 2000

•  Institute of Medicine: To Err is Human/100K lives program 1999

•  Care Focused Purchasing 2003 convened by Mercer

•  CMS Medical Home Demonstration project 2006

•  “Triple Aim” in Health Affairs 2008 by Institute for Healthcare Improvement

•  McAllen, Texas, article in the New Yorker 2009

•  ARRA passage with “Meaningful Use” language for EHRs 2009

•  ACA passage 2010, includes provisions for models of VBC

•  CMS Pioneer ACO demonstration 2012

•  ACO shared savings and investments model 2016

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N E C E S S A R Y I N N O V A T I O N S F O R V B C

–  Data -  Accurately and completely connected -  Timely -  Distributed -  Actionable

–  Delivery System Integration -  Governance -  Oversight -  Innovation -  Prospective Population Management

–  Patient/employee/member engagement -  Access -  Communication

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P A Y M E N T A N D C A R E D E L I V E R Y M O D E L S S P A N A C O N T I N U U M

Shared risk

Integrated delivery systems

Shared savings

Bundled payments

All costs for an episode of care (such as a knee replacement) are grouped together to create a fixed payment to the provider

Payments tied to specific measures, such as the percent of members receiving certain screenings

Performance based payments

Fee-for-service

Provider payment model that pays providers for the number of services delivered

Capitations

Patient Centered Medical Home (PCMH)

Delivers integrated primary care to the patient by monitoring and coordinating patient care across all providers and services

Accountable Care Organization (ACO)

Delivers integrated care to the patient by bringing together groups of doctors, hospitals, and other health care providers, with providers taking responsibility for results

INCREASING DEGREE OF CLINICAL INTEGRATION REQUIRED AS PAYMENTS ARE BASED ON RESULTS

TRANSACTIONAL EPISODIC VALUE BASED

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N A T I O N A L C A R R I E R M O D E L S

AETNA ACO AETNA PCMH

CIGNA COLLABORATIVE CARE (CCC)

V B C D E L I V E R Y M O D E L S & M E M B E R S H I P

60 ACOs and 600k members

16 PCMHs and 1M members

145 VBC delivery systems and 1.4M members (year-end 2015)

S T E E R A G E Aetna offers separate “Product Model” and “Attribution Model” ACOs

Passive: “Attribution Model” ACOs are embedded in broad networks with no directed steerage opportunity

Directed: “Product Model” ACOs offer directed steerage via 3 Tier and / or narrow 2 Tier networks

Passive: providers participate in all Aetna networks

Passive: all CCC provider systems are embedded in broad networks that offer no directed steerage opportunity

Directed: some limited provider participation in narrow networks that allow directed steerage

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N A T I O N A L C A R R I E R M O D E L S

UNITED HEALTHCARE

ANTHEM ENHANCED PERSONAL CARE (EPC) BLUE SHIELD CA HCSC

V B C D E L I V E R Y M O D E L S & M E M B E R S H I P

30 ACOs and 862k members, 6 PCMHs and 215k members

120 contracts and 4.2M members (includes Medicare)

32 ACOs and 257k members, 6 PCMHs (PCMH membership not disclosed). Accessed via 24 HMOs and 8 PPOs

8 ACOs, 12 PCMHs, 17 IMHs (Intensive Medical Home), 1 CPCi (Joint Government & Commercial Initiative) and 855k combined members

S T E E R A G E Passive: All PCMH and ACO providers accessible via broad national networks

Directed: Most ACO providers available via UHC’s Navigate Networks, featuring narrow networks with a gatekeeper

Passive: All EPC providers participate in Anthem’s National PPO and AltNet networks

Directed: No directed steerage available at this time

Passive: Small number of PPO solutions built on traditional broad networks

Directed: HMO solutions offer directed steerage, some with and some without a gatekeeper. Handful of narrow network PPO solutions

Passive: Vast majority of Value-Based Care providers participate in broad PPO networks

Directed: Modest availability of directed network options including 2 Tier narrow networks, 3 Tier high performing networks, and HMO models

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T H E I M P A C T T O E M P L O Y E R S

•  VBC is changing the way care is delivered and how providers get paid. As a result, provider contracts and networks are beginning to change too.

NEW ALTERNATIVES

CHANGES TO YOUR HEALTH AND WELLNESS PROGRAMS

CHANGES AT YOUR CURRENT CARRIER

HOW DO THESE CHANGES IMPACT YOU NOW, AND SHOULD YOU ADAPT YOUR STRATEGY GOING FORWARD?

•  Changes to current networks

•  New contracts with different payment structures

•  Whether changes (or lack of) warrant a broad market evaluation

•  Integrating with

new provider models

•  Data exchange and collaboration

•  What you will need to turn on/off

•  New networks with traditional carriers or emerging specialty vendors

•  Employer-direct to provider

•  Steering employees through designs or contributions

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H E A L T H C A R E E C O S Y S T E M

–  Healthier Washington -  CMS Innovation grant -  Accountable Communities of Health -  Medicaid waiver -  Bree Collaborative

–  Government Programs -  CMS payment policies and demonstration projects -  Medicaid innovations

–  Private Sector Innovations -  Commercial carriers -  Employers

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K E Y I S S U E S F A C I N G V B C G R O W T H

•  Need sufficient enrollment or attributed patients to create the economies of scale to achieve desired goals

•  Care management systems and tools for high-cost/high-risk patients for proactive identification and management

•  EHR systems and information exchanges to exchange information across the continuum of care.

•  Focused set of cost and quality measures and their calculations

•  Alliances with behavioral health, post-acute care, and community-based health and social providers

•  Expanded role of patients and their families in their care

•  Roles for transparency and consumerism in the new model

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