Slide Deck http:// healthsystemcio.com/presentation/new-models-webinar.pdf TweetChat @ #HSCIOchat Value Proposition: The Building Blocks Needed To Transition To New Care Models A Webinar/TweetChat Combo from healthsystemCIO.com Sponsored by Optum Your Line Will Be Silent Until Our Event Begins at 12:00 ET Jump onto Twitter and Join the Conversation at #HSCIOchat Thank You!
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Value Proposition: The Building Blocks Needed To Transition ......Value Proposition: The Building Blocks Needed To Transition To New Care Models A Webinar/TweetChat Combo from healthsystemCIO.com
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• Webinar Moderated by Anthony Guerra, editor-in-chief, healthsystemCIO.com
• Simultaneous TweetChat Hosted by Kate Gamble, Managing Editor & Director of Social Media, healthsystemCIO.com (@khgamble) • Participate in separate browser or on your phone by using #HSCIOchat
• View in Webex Media Viewer panel on the right of your screen
• Other Webex Panels: Click arrow at top left of any panel to open it • Q&A - Submit questions at any time through the Q&A panel in the lower
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• Value-Based Care (VBC) is described as the transition from a fee for service model to one that provides reimbursement tying payment for quality to the delivery of care: often referred to as shifting from volume to value
Strategy• Given the complexity, the number of programs (instruments),
regulatory ‘opportunities,’ a carefully crafted strategy needs to be created
• It needs to be vetted thoroughly• Address all components• Remain flexible; as things changes modifications will likely be
needed• It needs to have the basic components of VBC including:
• Care Management• Data Analytics & Reporting• A patient-centered approach• Network strength• Data – meaningful data, useful data, data integrated from a
Components• Technology: While true interoperability has not been achieved, it’s vastly
improved. Ensuring that data access and timely delivery is available to care givers is critical to achieving VBC. Integrating claims, clinical data and other data sources is critical. Telehealth strategies that align physicians with patients enhance care delivery and help avoid unnecessary costs.
• Care Management: You need comprehensive care management programs that are robust and can deliver and manage the care necessary to the populations at risk, especially high-risk patients and rising risk patients. Having a robust, post-acute care network and process is critical.
• Data and Analytics: Robust information, data analytics and predictive analysis are all necessary so that you can understand which patients are likely to get sick in the coming year and need management
• Network strength and the alignment of physician incentives to help with the transition are important. Create a value proposition.
Value-Based Programs• Accountable Care Organizations: Accountable Care Organizations (ACO), allow
organizations and groups of physicians to form an entity that will help focus on improving the quality of care delivered to patients. ACOs, governed through CMS offer several tracks with increasing amount of risk to be taken on by the entity. Many utilize a track one Medicare Shared Savings Program (MSSP) which has no downside risk, only the potential for share savings. ACOs who are more advanced and who may have been participating successfully in track one may decide to move to another track with increasing risk, for example track 3, MSSP +1 or the Next Generation ACO. To date however, most hospital and physician groups in an ACO remain in track one (95%).
• Bundle Payments: Bundle Payment programs ‘bundle’ a service together where the reimbursements are set for the entire continuum of treatment. The most prevalent is the Comprehensive Joint Replacement (CJR). This program and other bundle programs offer organizations the ability to manage both the care and the cost of those patients through a specified period, with the goal of improved care while overall reducing the cost of that care.
• Medicaid ACOs: Medicaid ACOs are similar in construct to the Medicare ACO and present other opportunities for organizations to manage a specific population.
Value-Based Programs• Patient-Center Medical Homes (PCMH): PCMH focus on primary care
that is patient centered, comprehensive, team based, coordinated, accessible and focused on quality and safety.
• Self-Insured’s: Management of an organization’s self-insured population represents a low-risk approach to improving the quality of care while managing the cost.
• Direct to Employer strategy. Once and entity establishes a proven track record for management and network strength it can become a value proposition to area employers.
• Medicare Advantage plans: Focused on enhancing the quality of care delivery while controlling and managing the cost of that delivery and offering additional benefits to plan members to help them manage costs and remain healthy.
As organizations decide which clinicians should pursue which path, they often consider the following:
Choosing the right path at the right time: MIPS and APM
• The financial upside and downside of MIPS and APMs may differ significantly, particularly in the 2017 transition year. Financial impact is driven by a number of variables at the individual clinician and TIN level.
• Many of the tools required to be successful in APMs will also support MIPS performance. This allows for organizations to invest in the short and long term simultaneously
• CMS designed MIPS to simulate APM participation which will help organizations to evaluate provider readiness for APMs based on MIPS performance
• The incentive structure in MIPS and APMs are vastly different than traditional fee for service. Support for and commitment to making the necessary changes must exist among both leadership and clinicians in order to be successful
Key Components
Financial Implications Necessary IT Infrastructure
Erik N. JohnsonVice President, Health Management Consulting
Medicare Access and CHIP Reauthorization Act of 2015
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Payment and Delivery ReformsMeasurement
Regimes
Incentive for
Infrastructure Development
CMS has been driving innovation for over a decade
MACRA is intended to help accelerate the transformation to value based care
2006 20092008 2010 2011 2012 2013 2014
Physician Quality Reporting System
CMS Ceases Paying for Hospital Acquired
Conditions
Health Information Technology for
Economic and Clinical Health Act
Affordable Care Act
Meaningful use incentives
First generation of Medicare Shared Savings Program
Hospital Value-Based Purchasing and
readmission penalties
Physician value-based modifier
Merit based incentive payment systemand alternative
payment models
2015
First performance year for MACRA
payments
2017
Setting the foundation…
…Evolution continues
Hospital Inpatient Quality
Reporting (IQR)
2003
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MACRA gives physicians a choice
Merit-based incentive payment system (MIPS)
• Measurement-based regime, replacing PQRS, VBP modifier and MU and creating single reporting framework for physicians
• Four domains: quality, clinical practice
improvement, advancement of care, resource utilization
• Physician discretion in selecting metrics to report to CMS
• Increasing upside/downside risk, depending on relative performance
Advanced alternate payment models (APMs)
• Demonstration of preponderance of patients/revenue in value-based care models, most of which must include 2-sided risk
• Includes MSSP Tracks 2 & 3, Next
Generation ACO, Comp ESRD (2 sided), and CPC+ programs
• Upside bonus of 5% and enhanced fee schedule increases if meet risk requirements
CMS has also created an option for APMs that do not qualify for advanced status (MIPS APM). Benefits include significantly reduced reporting burden and preferential scoring against MIPS only peers.
PQRS =Physician Quality Reporting System
VBP =Value-based Payment
MU =Meaningful Use
MSSP = Medicare Shared Savings Plan
ESRD = Comprehensive End-stage Renal Disease
CPC = Comprehensive Primary Care
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MIPS vs. APM: Financial fee schedule implications
• MIPS positive adjustments have the potential for a 3X adjustment (i.e. +12% for 2019 up to +27% for 2022+).
• For 2019-2024, exceptional performers (top 25th percentile) are eligible for additional payment up to 10% ($500M funding per year).
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