What to look for in an Accountable Care Organization.

Presented By:

Lerla G. Joseph, MD,CEO and Chair, Central Virginia Coalition of Healthcare Providers, LLC

108 t h ODMS Annual Meet ing

June 07, 2013Virg in ia Beach,

Vi rg in ia

What to look for in an

Accountable Care Organization

2

CVCH i PBackground

In 2000, Congress via legislative mandates directs the Centers of Medicare and Medicaid Services to test models of care that share savings with physicians.

The Innovation Center was established by section 1115A of the Social Security Act(as added by section 3021 of the Affordable Care Act)

In 2006, researcher, Elliot Fisher of Dartmouth introduced the concept of “extended hospital medical staff”.

In 2002, the Physician Group Practice Demonstration Design Report was submitted to CMS

Physician Group Practice Demonstration implemented from 2005-2010

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CVCH i PThe Patient Protection and Affordable Care Act Passage in April 2010 CMS issues the final rule for the ACO

concept October 2011 Pioneer ACO’s awarded in January

2012 The Supreme Court upholds the

constitutionality of the now infamous “Obamacare Act” July 2012

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CVCH i PWhy Are We Here?

Increasing numbers of uninsured or underinsured Americans

Medical bills a leading driver of personal bankruptcies

Skyrocketing cost: with cost rising at the present rate medical cost will be 19.3% of GDP by 2019

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CVCH i PNational Healthcare Spending Projections CY 2003-2018

As the cost of health care continues to rise, averaging $20,728.00 per American family, and as the cost consumes more of the GDP Payers (Commercial and Public) are looking for more value for each dollar spent.

$1,735 $1,855$1,981

$2,113

$2,241$2,379

$2,510$2,624

$2,770$2,931

$3,111

$3,313

$3,541

$3,790

$4,062

$4,353

15.8%15.9% 15.9%

16.0%

16.2%

16.6%

17.6%17.7%

17.9%18.0%

18.2%

18.5%

18.9%

19.3% 19.8%

20.3%

15.0%

16.0%

17.0%

18.0%

19.0%

20.0%

21.0%

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

$5,000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

National Health Expenditures (billions)

National Health Expenditures as a Percent of Gross Domestic Product

CMS Projections for National Healthcare SpendingCY 2003 - 2018(Amount in Billions)

Source: Centers for Medicaid & Medicare Services - NHE Projections 2008-2018, Forecast Summary and Selected Tables

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CVCH i PLosing Ground on Quality

The World Health Organization ranks the United States of America 37th among industrialized countries

5% of the patients drive 44% of the healthcare expenditure

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CVCH i PHow the Performance of the U.S. Health Care System Compares Internationally,Source: The Commonwealth Fund 2010 Updated Chart

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CVCH i PIron Triangle of Health Policy

Access to Care

Cost Containment Quality of Care

Value

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CVCH i PAccountable Care Organization

Groups of Physicians, hospitals, SNF, Providers/Suppliers, etc. who agree to work together to achieve improved individual health, improved population health, reduced expenditures for health care in an Evidence-based approach Legal Entity Governing Body with 75% Physician

Representation Willing and able to distribute Shared Savings

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CVCH i PThe Medicare Shared Savings Program

Qualified legal entity 3 year contract with CMS for a

minimum of 5,000 Medicare A&B and dual eligible recipients

Achieve the triple goal of better care, better health, and lower cost

Pioneer ACO’s, Advance Payment Model, Shared Savings (one-sided or two-sided model)

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CVCH i P

The Landscape of Healthcare Delivery and Reimbursement has changed Fee for Service continues to decline

with physicians trying their best to keep up by volume business.

Bundled Payments Chronic Disease Management or

Intensivist Carve-Outs Shared Savings Arrangement

(Medicare and Commercial)

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CVCH i PCan accountable care organizations save the independent medical practice

PayrollStaffingOffice

Overhead

EHRBilling and Manageme

nt

MeaningfulUseChronic

Disease Manageme

nt

Care Coordinati

on

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CVCH i PACO as the Integrator

CVCHiPHealth IT

Health AnalyticsPopulation

ManagementCare Coordination

Business DevelopmentCMS Liaison

Outreach

MD

MD

MD

SNF

MD

HOSPITAL

MD

Provider

Supplier

RN NP

PASTAFF

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CVCH i PWhat to look for in an Accountable Care Organization

Governance (will you have a seat at the table?)

Mission Policy and design input IT, Quality Improvement, and

Reporting support Shared Savings

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CVCH i PEarly Experience from Coastal Carolina Health Care, PA

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CVCH i PEarly Experience from Coastal Carolina Health Care, PA

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CVCH i PEarly Experience from Coastal Carolina Health Care, PA

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CVCH i P

ACO’s Provide the Cover for UrbanPractices

• Health IT• Care Coordination• Population Management• Health Analytics

Accountable Care Organizations, ACO’s

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CVCH i PReference

Centers for Medicare and Medicaid Services website

Medicare Shared Savings: A Practical Path to Accountable Care, sponsored by Medical Economics whitepaper

Commonwealth Fund 2010, Exhibit ES-1. Overall Ranking

Health Affairs, Volume 31 No.11, November 2012

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CVCH i PCentral Virginia Coalition of Healthcare Providers

Thank You