session 15 accountable care organizations– carewell (in partnership with umass and lahey) –...

Practicing Medicine in the Era of Health Reform

Session 15

Accountable Care Organizations

Richard Lopez, MD

August 12, 2015

Tufts Health Care Institute1

Accountable Care Organizations

Richard Lopez, MD – Chief Medical OfficerAtrius HealthAugust 12, 2015

[email protected]

2

Today’s Discussion

• Introductions• Health Care Crisis• Reactions to Rising Cost of Healthcare• ACO Concept as a Provider Solution• Global Payments in support of ACO’s• ACO Model: BCBSMA AQC• ACO Model: Pioneer ACO• ACO Results

3

4

Atrius Health

.

The Northeast’s largest nonprofit independent multi-specialty medical group. A national leader in delivering high-quality, patient-centered coordinated care.

Dedham Medical AssociatesGranite Medical GroupHarvard Vanguard Medical AssociatesVNA Care Network

Providing care for ~ 675,000 adult and pediatric patients with 750 physicians across more than 35 specialties

Atrius Health 2015. All rights reserved

Atrius Health Core Competencies

5

Corporate Data Warehouse integrates single platform, electronic health record data with multi-payer claims data

Widespread Extensive Population Health Management including disease-based and risk-based rosters, population managers

Long history with and majority of revenue under Global Payment across commercial and public payers

Sophisticated development and reporting of Quality and Performance Measures leading to high achievement

Patient-Centered Medical Home foundation, achieving level 3 NCQA across all primary care practices

© 2015 Atrius Health, Inc. All rights reserved. Not for distribution.Atrius Health 2015. All rights reserved

US Health Care Costs as Compared to Gross National Product

6

National Healthcare Perspective: Spending vs Life Expectancy

MA

9000

CT

8000

The U.S. is off the charts when it comes to health expenditures per capita, but this extensive spending is not performance-based and is not correlated to longer life expectancy.

7

Workers Are Paying a Greater Share of Health Care Premiums as Employers Strive to Reduce Their Costs

8

State Healthcare Perspective: Burden of Healthcare Expenditures

Massachusetts State Budget ($ Billions), FY 2001 vs. 2011

SOURCE: Massachusetts Budget and Policy Center

FY2011FY2001

+$5.1 B(+59%)

‐38% ‐33%

‐15%

‐23%

‐13%

‐50%

‐11%

-$4.0 B(-20%)

Health Care Coverage(State Employees/GIC;

Medicaid/Health Reform)

PublicHealth

MentalHealth

Education Infra-structure/Housing

HumanServices

LocalAid

PublicSafety

Growing healthcare expenditures are putting enormous pressure on state budgets throughout the country, forcing budget cuts in most other areas to make room for the growing healthcare component.

© 2013 Atrius Health, Inc. All rights reserved.

Response of Commercial Payers and Employers

• Consumer Driven Products (cost sharing)– High deductables– Higher copays– Defined contribution

• Tiered physician and hospital networks– GIC– Tufts Navigator– HPHC Independence

• Limited networks • Increased pre-authorization programs

– Imaging– High cost drugs– Sleep studies

• Increased risk sharing with providers (ACO)• Employers: Employee Wellness Programs

11

Response of Government – Part One

• Federal– Accountable Care Organizations

• Shared Savings Program (CMS)• Pioneer ACO Program (CMMI)• NexGen ACO (CMMI)

– Payment• Decreases for hospitals and physicians• Penalties for hospitals for re-admissions and “never

events”

– Bundled Payments• Bundle Payment for Care Improvement Initiative

12Atrius Health 2015Atrius Health 2015. All rights reserved

Response of Government – Part Two

• State– Chapter 224 passed in August 2012

• Limits rate of increase in health care costs to the State’s Gross Product

• Requires payers and providers to provide performance improvement plans if rates exceed SGP

• Regulates ACO’s• Requires transparency in pricing by both payers and

providers

– Municipalities• Conversion from traditional high cost BCBSMA plans to

lower cost Group Insurance Commission (GIC) plans with higher copays and deductibles


Marketplace Response: Disruptive innovation?

• Limited service and retail clinics– CVS MinuteClinics and Walgreens Take Care Clinics– Doctors Express (franchise)– CareWell (in partnership with UMASS and Lahey)– MedSpring (in partnership with Partners Health Care

• Best Doctors – expert opinion program• Video visits, e.g. American Well, • Find a doctor when needed: ZocDoc• Potential use of out-of-state MDs for telemedicine • Employee wellness companies


Response from Providers (Hospitals, Health Systems, Physician Groups)

• Heavy pressures on reimbursement rates are resulting in shifts towards accountable care and risk based contracting models

– Tighter network management of leakage across the spectrum – hospital, SNF, outpatient, specialty

– Stronger care management models- PCMH, High Risk Management• Healthcare delivery systems are integrating across the spectrum to optimize

care management– Hospitals acquiring physicians– Physician groups acquiring hospitals– Systems acquiring insurance companies– Insurance companies acquiring delivery systems

• Consolidation of health systems, with scale providing significant advantages– Access to capital– Efficiencies of scale both clinical and administrative– Opportunity for “white label” insurance products– Opportunity for direct-to-employer contracting


The concept of an Accountable Care Organization is not new

“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”

Dr. Robert Ebert, Founder, Harvard Community Health Plan, 1967

© 2015 Atrius Health, Inc. All rights reserved


Definitions of “Accountable Care Organization”

• Academic: Devers & Berenson in RWJ Brief: The ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care; The capability of prospectively planning budgets and resource needs; and Sufficient size to support comprehensive, valid, and reliable performance measurement.

• Federal Law: PPACA: an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.

• Certification: NCQA: provider-based organizations that take responsibility for meeting the health care needs of a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capita costs.

• MA State Law: Health Policy Commission will define ACO through its certification process and Model ACO certification

Providers

Migration Towards Accountable Care

CommercialPayors

Regulators

The act of providers assuming responsibility and

financial risk for the quality and total cost of care of a

defined population

This means a radical transformation from the perspective of providers, who will need to develop the capabilities to manage a population’s health, as well as payors, who will need to transition to risk-based contracting models.

18

From Fragmented Care Systems…

…Towards Integrated Care and Population Health Management

Implications for Providers

Managing a population’s health, and remaining financially viable in a risk-based contracting environment, requires healthcare delivery systems to be truly integrated across the spectrum of care.

Massachusetts is a Leader in Medicare ACOs

• Pioneer ACOs:– Atrius Health– BIDPO– MACIPA– Partners– Steward

– Of total 22 nationally

• Medicare Shared Savings:– Accountable Care Clinical Services– Accountable Care Org of NE– BMC Integrated Care Services– Cape Cod Health Network– Circle Health Alliance, LLC– Collaborative Health ACO– Emerald Physicians– Harbor Medical Associates, PC– Lahey clinical Performance ACO LLC– NEQCA Accountable Care– Physicians Accountable Care– Pioneer Valley Accountable Care– Southcoast ACO– UMASS Memorial ACO– Winchester Community ACO– Of total 404 nationally


Impact of ACO’s: Consolidation

• The Massachusetts market is rapidly moving towards consolidation

• It is widely predicted that in 3-5 years, a large percentage of healthcare in the Commonwealth will be provided by 5-6 large health care systems:– Partners– Stewart– BIDCO– Atrius Health– UMass– ???


First Year Results of Medicare Shared Savings ACO Program – the numbers

• Number ACO’s Participating: 114

• Number of ACO’s that saved money: 54

• Number of ACO’s that saved enough money to collect a bonus: 29

• Amount saved: $126M

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Accountable Care is driving fundamental change in health delivery

• Increase in population management – registries, outreach• Increased use of data to manage cost and quality• Use of nurses to coordinate care for high-risk patients• Use of community health workers • Creation of preferred post-acute provider network (SNF and

VNA) • Connecting with local community elder service agencies to

provide community-based supports• Systematic ways to honor, across the care continuum, patients’

wishes around end of life care• Delivery of a proven post-discharge “bundle” of services to

prevent readmission• Increase in disease management programs• Patient engagement in shared decision making


Global Payments provide financing model for an Accountable Care Organization• Infrastructure can be

– Planned and maintained without dependence on patient activity

– Provided even if not funded in under Fee-for-Service payment

• Provides stimulus for more efficient use of physician and office time with more convenience to the patient.

• Funds innovations such as e-portals, text messaging, phone calls and new roles necessary to “be with” the patient where life is actually being lived by the patient.

• Fosters use of diverse medical teams working at “top of license”

Atrius Health 2015Atrius Health 2015. All rights reserved

BCBSMA Alternative Quality Contract was Early Model for ACO

• Accountability for quality and resource use across full care continuum Long-term (5-years) Annual inflation tied to Consumer Price Index

• Improved quality, safety & outcomes as compared with traditional Pay-for-Performance

• Robust performance measure set (60+ measures) creates accountability for quality, safety & outcomes across continuum and over time

• Substantial financial incentives for high performance


Experience with AQC helped us step up our game

• Early adopter based on prior managed care experience

• Investments made to “retool factory” include Lean, Leadership Academy, Patient Centered Medical Home

• Quality framework provided focus and common language across Atrius Health groups

• Established strong precedent for joining Medicare Pioneer ACO Program

• Other Mass payers have followed suit


Lean is an important Foundation for our work

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Why Participate in Pioneer ACO? “Reason for Action”

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High quality, high –value care for allMedicare‐eligible patients across the care continuum with

spillover for commercial risk

Unique opportunity to be accountable for quality and costs for a PPO population

Further Atrius Health position as a market leader in payment reform, moving towards 100% global payment

Achieving Triple Aim Goals

.Atrius Health 2015Atrius Health 2015. All rights reserved

Three year contract effective January 2012 with two additional year options; accountable for all Medicare A and B benefits

Partnership with Center for Medicare and Medicaid Innovation (CMMI)

Medicare FFS beneficiaries aligned with ACO based on their historical claims data

Global budget: performance

measured against national

benchmark

Upside & downside risk sharing with

CMS

Incentives rewards to

achieve high quality

performancemeasurements

Accountable to Pioneer ACO Obligations

Key Features of Pioneer & Performance Measures


Financial Measures: Shared saving/loss

BaselineBased on Actual Claim for ACO

population

BenchmarkThink Global Budget

Based on Growth Rate from National Matched Cohort

Atrius Health Goal:To beat the Benchmark


Quality Measures: Key Features

33 Quality Measures:

many new, or with new features

• Patient/caregiver experience, measured by CG-CAHPS

• Care coordination/patient safety using claims data (eg. Readmission rates)

• At Risk Population, using EHR measures • Diabetes• IVD• CAD• Heart Failure• Hypertension

• Preventive Health


Pioneer ACO Strategies Address Gaps

Quality & Safety

Internal Communication

& Structure

Regulatory

PATIENT‐CENTERED MEDICAL HOME

Data Analytics &Reporting

Hospital Strategy Geriatric Care Model

Care Management Strategy

Post-Acute Strategy

Electronic Health Records & Health

Information Exchange

Medicare/MedicaidDual Population

Strategy

Costs: Beat the TrendQuality:100% Reporting201290th Percentile2013


ACO = Medicare Population Health Strategy

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Approximately 52,000 Medicare Beneficiaries in• Outcomes-Based Contracts with• Triple-Aim Accountability

30,000

21,000

1000

Pioneer Aligned

MedicareAdvantageDuals HMOs


Accountable Care = Population Management

• What is the target population? – How is the cohort defined?– How is accountability defined?

• What population outcomes do we want & how are they measured?

– What conceptual framework links potential care processes to target outcomes?– What are the overall key indicators? What are interim process/operational indicators?

• How do we support the key processes required to achieve outcomes?

– Which of these processes are most effective, efficient, and patient centered?– What infrastructure is required to ensure reliable frontline process execution?

34. Atrius Health 2015Atrius Health 2015. All rights reserved

Medicare Population Health Approach

• Close medical management at end of life • Tight coordination of 5% highest risk• Medical Management of chronic conditions • Preventative Care for “well” patients

» Local Implementation – Practices at different starting points.

» Central support to reach goals, manage CMS relationship and obligations.

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Advanced Illness Management - Top 2%

Chronic Care Management -Next 15%

Population Management- Remaining 80%

Other High Risk/Acute - Another 3%


Focus One: High Risk Patients, High Cost Events

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• Advance Care Planning• High Risk Roster Review • Care Transitions• Post Acute Episode Mgmt• CKD • Community Support for

Dual Eligibles






Focus Two: Health Risk Prevention

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• Falls Risk/Fractures• Depression Screening• Med Reconciliation






Keep Working the Medicare Population Pyramid

38

2015 Focus:

• Custodial Nursing Home program

• Palliative Care/Hospice • Care Transitions• COPD• Expanded home tele-

monitoring• New ACO Quality

Measures






The Triple Aim

ExperienceOf Care

Per Capita Cost

Population Health

Source: IHI.org

The root of the problem in health care is that the business models of almost all US health care organizations depend on keeping

these aims separate. Society on the other hand needs these three aims optimized (given appropriate weightings on the components)

simultaneously. Tom Nolan, PhD.

Atrius Health 201539


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TripleAim

Outputs: Population Health Initiatives

IdentifyGaps

DesignProgram

Develop Tools Implement

Track & Measures

Continuous Improvement

Inputs: Quality Measurement and Improvement, Data Analytics, Medical Management, Clinical Champions, Internal Best Practices,

External Peer AccomplishmentsAtrius Health 2015Atrius Health 2015. All rights reserved

Key ACO Initiatives: Our Investments

Acute/Post Acute Preferred Providers Strategies • Preferred SNF Network with service

standards/facility expectations• SNF Provider Expectations• Preferred Hospital strategy• Preferred ambulance strategy

Care Management (“Post Acute Home”)• VNACNH Integration• Local Elder Services Agencies• Programs for Dual-Eligibles• Shared standards and best practices

Geriatric Care Model • Patient Risk Stratification• Multidisciplinary Roster Reviews• Advance Care Planning• Chronic Kidney Disease

Data Analytics & Reporting• Ongoing Support for Workgroup

Initiatives• Trackers to monitor performance

against goals

Electronic Health Record and Health Information Exchange• Tools to Support ACO Quality

Metrics & Workflow

Quality & Safety• ACO Quality Metric Reporting• Performance Improvement/Best

Practices

41Atrius Health 2015. All rights reserved

Medicare High Risk Model:Patient Risk Stratification Tool

Using both claims and Electronic Health Records databases, the tool allows to identify members at risk of hospitalization, poor health outcomes, high costs

The model consists of five key factors:Likelihood of HospitalizationHospital admissions or ED visitsBehavioral Health diagnosisCHF or COPD>= 15 medications

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Patients ACO TME

% DECEASED

% ALIVE H/VH Risk

% OTHERS

20% of patients

60% of costs

Proportions of High Cost (Atrius Health ACO) Patients & attributable to them Costs

(Aug 2012)

Factor Pts

DxCG Likelihood of Hospitalization Score (Model 71)

3

Hospital Admissions or ED Visits 3

Behavioral Health (Psychiatric, Substance Abuse, Dementia)

2

CHF or COPD or CKD 1

Poly-pharmacy (Excludes Topical & Supplies)

1

Maximum Score 10


High Risk Patient Roster Review

Confirm diagnoses Review medications Address quality measures

Confirm diagnoses Review medications Address quality measures

Social assessment Care needs assessment

Social assessment Care needs assessment

Advance directives Palliative care discussion

Advance directives Palliative care discussion

Care plan documentation & orders

Care plan documentation & orders

PCP-Led Team

PCP-Led Team

43. Atrius Health 2015Atrius Health 2015. All rights reserved

High Risk Roster Participants

“Each site may choose to have any number or combination of participants so long as the goals of high risk roster reviews are being met.”

Typical participants include:• PCP• Primary Nurse or Medical Assistant• Population Manager• Care Manager• Geriatric Champion or Palliative Care Specialist• Social Worker• VNA representative• Clinical Pharmacist

44.Atrius Health 2015Atrius Health 2015. All rights reserved

Geriatric Care Model: Multidisciplinary Roster Reviews

Review and confirm accuracy of diagnosis

Review appropriateness of medications

Perform a care needs assessment

Create a clinical summary of the patient

Perform a social assessment

Review applicable diseases related quality measures

Confirm existence and need for advance directives

Update the patient’s care plan and document next steps

Adopted common standards for High Risk Patient Roster Reviews

Early adopters of HRRR saw greater reductions in TME


Advance Care Planning Initiatives

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Description: • Developed advance care planning (ACP) curriculum with CME/CEU credits.

• Established site‐based ACP champions to train and provide ongoing ACP support locally

• Developed new tools in Epic to track and document advance care planning

Expected Outcomes:• Improve PCP knowledge and comfort with ACP

• Increase end of life conversations and collection of patient’s care wishes, advance directives and proxy information

• Minimize use of aggressive curative care when not aligned with patient’s care wishes

82%86%

0%10%20%30%40%50%60%70%80%90%

100%

2013 ACP and 2014 MOLST Trainings

ACPMOLST


Advance Care Planning: Results

47

Implemented EMR checklist


Geriatric Care Model:Chronic Kidney Disease

ResultsIn first 5 months, 66% of patients with lab defined criteria were diagnosed with CKD triggering clinical interventions.

Description• Clinical guidelines• Provider education & training• Patient education and engagement• Keeping services in‐house when

appropriate• Expectations for outside nephrologists• Epic tools• Risk score modification

Expected Outcomes• Improve diagnosis• Slow progression of CKD


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Kidney International, Jan 2013; Supplement 3 KDIGO Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: 1 - 150Approved by the Atrius Health Accountable Care Organization’s Geriatric Care Model CKD Workgroup, which includes the Harvard Vanguard Chief of

Nephrology; February 2013

Stage (eGFR) Albuminuria? (≥30mg/g)

Serum eGFR and Urine

Microalbumin

Hgb, 25-OH Vit D, Phos, PTH, Lipids, Ca

Electrolytes

Initial Renal

Ultrasound

Nephrology Consult

Stage 3a (45-59) No Annually* Annually* Consider

Stage 3a; (45-59) Yes Q6 Month* Annually* Consider Recommend

Stage 3b; (30-44) No Q6 Month* Annually* Consider Recommend

Stage 3b; (30-44) Yes Q4-6 Month* Annually* Consider Recommend

Stage 4; (15-29) N/A Q3 Month* Annually* Consider Recommend

* Might require more frequent monitoring if abnormal and/or if undergoing changing treatment strategies

CKD: Clinical Guidelines

Atrius Health CKD Guidelines for Primary Care

.Atrius Health 2015Atrius Health 2015. All rights reserved

CKD Dashboard/Roster

50

Primary Care Dashboard: Merge of EPIC and Claims Data- Lab Result Based Total CKD Population- Laboratory Screening (Ca, Phos, CBC, UA, Vit D, PTH)- Clinical Outcomes (BP, LDL, HgA1c)- Referral to Nephrologist Specialist- Visit to Nephrologist


CKD: Impact

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Patients w/EGFR<60

CKD Dx No CKD Dx

. 51Atrius Health 2015Atrius Health 2015. All rights reserved

Post-Acute Home Workgroup: Stronger Collaboration with VNACN

Developed Standard Work for referrals to and communication with VNACNH during episode of care.

Care plan transmitted to EPIC within 48 hours of admission, including: ‐ Advance care planning forms‐ Follow up appointment with PCP within 7 days of hospital discharge‐ Collection of ACO quality metrics

* Fall risk assessment * Medication review * Depression screen (PHQ) 2

© 2013 Atrius Health, Inc. All rights reserved.

We see a decrease in VNA $pmpm and a decrease in readmits during VNA episode 52


PAH Tracker: By Medical Group

Post Acute Home (by Medical Group) YTDJan 2014 thru October 2014 YTD(Claims paid through December 2014)

VNACNF Episodes as % total HHA Episodes ‐ PION

VNACNF Episodes as % total HHA Episodes ‐

TMP

ED visit/K during VNACNF Episode ‐ PION

Readmit Rate during VNACNF Episode ‐ PION

% Patients with VNACNF

Episode with ACP in Epic ‐

PION% Duals Enrolled

DMA 53% 72% 84 17% 86% 15%GRN 40% 64% 92 20% 67% 15%HVMA 32% 65% 101 10% 67% 20%RMG 42% 68% 109 16% not available 50%SMG 35% 61% 288 18% 75% 22%


PAH 2015 Q1

TMP PIONA. ED Visit per 1000 during NON‐VNACNF episode/admission

NA 103 97

B. ED Visit per 1000 during VNACNF episode/admission

VNACNF lower than NON‐VNACNF 97 78

C. Readmit rate during NON‐VNACNF episode/admission

NA 22% 11%

D. Readmit rate during VNACNF episode/admission

VNACNF lower than NON‐VNACNF 17% 11%

E. VNACNF episodes/admissions as % of all home health episodes/admissions

37% 68% 37%

Quality% of patients admitted to VNACNF who have Falls Risk Assessment (FRA) scanned in EPIC within the episode/admission

94% 95% 88%

% of patients admitted to VNACNF who have Depression Screening scanned in EPIC within the episode/admission

94% 93% 87%

% of patients admitted to VNACNF who have ACP form (MOLST, Adv Dir, or HCP) in EPIC

watch until Q4 79% 75%

VNACNF Pre‐op Joint visits completed (all payers)

watch

% of total joint replacement discharges going home with VNA

Q1 watch 20% 37%

RPM Program (began May 2015 ‐ all payers)

a. # of referrals Q2 & Q3 watchb. accepted to program Q2 & Q3 watch

Acute hospital admissions during an RPM episode

Q2 & Q3 watch

VNACNF Patient ExperienceA. % of referrals with timely initiation of care

95% 94%

B. AH complaints ‐ % of investigations initiated within 48 hours

92%100% (12/12)75%(9/12)

53

0

Utilization 2015 PION Goal Atrius YTD thru PION YTD

65

C. AH complaints ‐ % resolved within 30 days

92%

2015 YTD thru May

Tracking VNA Performance


Post-Acute Home Workgroup: Integrate Local Elder Services (ASAPs)


Adapted from Slides presented by Robert Mechanic, Brandeis University, with permission

Variation in 2010 Medicare Average Length of Stay for Skilled Nursing Facilities

0

10

20

30

40

50

60

Quartile 1 Quartile 2 Quartile 3 Quartile 4

ALOS

Source: Adapted from Office of HHS Inspector General December 2010.

2929

3434

61

24

24

5

Difference Between Top & Bottom Quartile10 Days = $4,000

56

Adapted from Slides presented by Robert Mechanic, Brandeis University, with permission

Variation in 2009 Risk Adjusted Readmission Rates from Skilled Nursing Facilities

14.4%18.1%

22.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

25th Percentile Median 75th Percentile

Readmissions

Source: MedPAC Report to Congress, March 2012.57

58

Development of Preferred SNFs Network

Created preferred SNF network to enhance the delivery and

coordination of care

Meet service

standards

Atrius Health team

on‐site

History of positive

relationship

Geographic needs

Good metrics*

SNF willingness

to collaborate

*Good Metrics: Medicare Compare; State survey; Readmission during SNF stay; LOS


Managing SNF Events

Developed expectations and tools to manage length of stay

• Facility‐level expectations

• Provider‐level expectations

• Discharge workflow

• EHR documentation

• Monitoring & reporting

• Use of preferred discharge providers

↓2.0 LOS = $2M↓2% Readmit Rate = $.5M


Still Lots of Opportunity

PreferredNon-Preferred


CHARTINGPatient ChecklistVisit InfoAllergiesVitals

Patient Care Checklist● Advance Care Planning documents are not on file● A Falls Risk Assessment has not been completed in the current calendar year● A PHQ-2 or PHQ-9 has not been completed in the current calendar year● Tobacco use has not been reviewed in the current calendar year● BMI has not been updated within the past 6 months

EHR tools to support ACO: Standard Checklist and Shared Workflows

Tools were developed to facilitate:• Advanced Care Planning• Fall Risk Assessment• Depression screening• Medication Reconciliation

61

Patient Care Checklist● Advance Care Planning documents on file● A Falls Risk Assessment has been completed in the current calendar year● A PHQ-2 or PHQ-9 has been completed in the current calendar year● Tobacco use has been reviewed in the current calendar year● BMI has been updated within the past 6 months


Depression Screen & Fall Risk Assessment

Implemented EMR checklist

Reset FRA, PHQ Checklist


Data Analytics and Reporting providesOngoing Support for Workgroup Initiatives

64

#1 ACO in New England; #2 Pioneer Nationally


First Year Pioneer Results: 2012 ACO Quality Metricswww.medicare.gov/physiciancompare/aco/search.html

Atrius Health compared to Pioneer ACO Range

• A1c = % of diabetic patient population with blood sugar (hgba1c) control < 8• BP = % of hypertensive patient population with blood pressure control <140/90• Tobacco = % of diabetic patient population who do not currently smoke• Aspirin = % of diabetics with ischemic vascular disease (IVD) who are currently taking aspirin• ACE/ARB = % of patients with coronary artery disease (CAD) who are also diabetics OR have left ventricular systolic dysfunction

(LVSD) and are on an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB)


Independent “Near Market” Evaluation, May 2015

Association of Pioneer Accountable Care Organizations vs Traditional Medicare Fee for Service With Spending, Utilization, and Patient Experience

JAMA. 2015;313(21):2152-2161. doi:10.1001/jama.2015.4930.

• Pioneer ACOs saved $384M over two years– Atrius Health saved $36M compared to near market

• Ten of 32 Original Pioneers had statistically significant savings in both years– Atrius Health was one of the ten– Atrius Health noted as one of three Pioneers accounting for

70% of savings in 2013

66

Pioneer Financial Performance

2012 (PY1) = 1% loss, in the noise• Atrius Health expenditure $10,700 vs. • Massachusetts Pioneer Expenditure $12,000+

2013 (PY2) = 1% savings, in the noise* $3M saved for Medicare

2014 (PY3) = Projecting 1.4% savings, would be:* $4.5M saved for Medicare* $2.8M share to Atrius Health

Year over Year Improvement


From the JAMA Article

68

Atri

us H

ealth

Par

tner

s

BID

CO M

AC

IPA

Ste

war

d

http://jama.jamanetwork.com/article.aspx?articleid=2290608

Side by Side Settlement: Beat the Trend

69.


Keys to Success

Leadership and Facilitation • Create the data-based

hypothesis • Identify evidence-based best

practice• Develop standards & tools to

close gaps• Measure and track

Outcomes Fidelity to Process

Core Competencies• Small team with operational

credibility• Diverse clinical expertise • Share resources clustered

together (no silos)• Home for shared values • Exploratory mindset • Laser focus on triple aim


Lessons Learned

Internal

• MD engagement key to driving change

• Wide adoption of Lean problem solving methodology created strong foundation for change

• “ One Model, One Contract” provided burning platform

• Making long-lasting change takes time

• Our ability to partner effectively is key

CMS

• More unknowns = more risk• It’s bigger than CMS - many

federal agencies have a stake• Engagement of other Pioneers

– big opportunity, but differing priorities

• CMS is moving up the learning curve too


We will challenge “Simple rules”

“I am accountable” “We are accountable”This image cannot currently be displayed.

This image cannot currently be displayed.

From Accountable Care Organizations, Marc Bard and Mike Nugent, 2011

74

Two Kinds of Change

Technical• Problem is well-defined• Solution is known, can

be found• Implementation is clear

Adaptive• Challenge is complex• To solve requires

transforming long-standing habits and deeply held assumptions and values

• Involves feelings of loss, sacrifice (sometimes betrayal to values)

• Solutions requires learning and a new way of thinking, new relationships

From Jack Silversin, Amicus

75

Reflections…

“We shall not cease from exploration. And the end of all our exploring will be to arrive where we started and know that place for the first time.” T.S. Eliot

76

Charles HandyThe Age of Unreason

The future we predict today is not inevitable. We can influence it, if we know what we want it to be…

We can and should be in charge of our own destinies in a time of change.

Reflections…

77

session 15 accountable care organizations– carewell (in partnership with umass and lahey) –...

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