Accountable Care Organization April 13, 2011 The Indianapolis - - PowerPoint PPT Presentation

Accountable Care Organization

April 13, 2011 The Indianapolis Association of Health Underwriters

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Drivers of Payment Reform

• Increased attention to regional variation in costs and

quality

▪ Payment for care does not correlate with optimal outcomes ▪ Regional differences in health care supply, delivery and practice lead to variations in spending that do not correspond to health care quality

• Increased efforts to align payment incentives with

performance rather than volume

▪ Current FFS leads to inefficiencies in care ▪ Payment reform alternatives that reward lowest-cost/highest-

• utcome results are needed

Accountable Care Organizations, Deloitte 2010

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Evolution of Reimbursement Strategies

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Payment Innovation – Balanced Approach

Each strategy can include additional rewards and/or penalties related to quality of care goals, efficiency of care goals, other aspects of care or care outcomes

Best Reforms to Pursue May Vary Based on Market Conditions

• Provider organizations
• Other delivery system infrastructure
• Active payment initiatives

Fee-For-Service Enhancement Procedure/Condition/ Episode-Based Payment Population- Based Payment Performance Recognition Programs (P4P) Three Payment Reform Models

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Accountable Care Organizations

The Accountable Care Organization (ACO) model is a local health organization that is accountable for 100%

• f the expenditures and care of a defined population
• f members. The provision of value by ACOs will

require their coordination of care across all continuums of care for the defined population.

Defining WellPoint Principles:

• 5 year relationship
• Transitioning to a global payment over the

term of the relationship

• Development of shared risks over the term of

the relationship

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ACO Criteria for Commercial PPO

WellPoint will contract with provider organizations which meet the criteria to operate as an Accountable Care Organization. These criteria include the following:

▪ A minimum population eligible for membership > 15,000 members ▪ Full complement of medical services with the exception of Transplants ▪ Must have a formal legal structure to receive and distribute reimbursement for member services ▪ An adequate network of ACO professionals to provide total care to the defined population ▪ Defined relationships with hospitals and physicians ▪ Demonstrated plan for reducing the cost of medical care ▪ Deploy an IT platform supporting the capture and electronic exchange of clinical information across the Ambulatory, Inpatient and Ancillary (lab, imaging, eRX, etc.) settings for the high volume ACO Professionals ▪ Electronic medical record system allowing for improved coordination of care ▪ A commitment from the senior leadership regarding the ACO initiative ▪ A willingness to enter a 5 year contractual relationship

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Anthem ACO Model for 2011

All ACO partners will have the following features: Membership

• Defined by Attribution

Provider Network

• Full Network with the

exception of Transplants

Legal

• Structure to receive /

distribute savings

• Management Structure

IT

• IT Infrastructure
• Data Exchanges

Medical Management

• Possible Delegated Medical Management
• Defined Processes to promote quality & coordinate

care

Financial

• FFS & Shared Savings
• Care Management Fee

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Data Exchanges for ACOs

• Membership

▪ Electronic Membership File ▪ Membership additions/deletions

• Census

▪ Hospital Census ▪ Emergency Census

• Claims

▪ Two years of historical ▪ Monthly claims data file

• Medical Management

▪ Utilization Management ▪ Case Management ▪ Disease Management

• Pharmacy

▪ Claims data files ▪ Analytic reports

• Reporting

▪ Series of analytic reports

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ETG Attribution Overview

ETG Product: Symmetry/Ingenix Episode Treatment Group Version 7.0.4.4 Purpose: to attribute members to an Accountable Care Organization Criteria:

▪ High probability of identifying members with a pre-existing clinical relationship with providers ▪ Flexibility in filtering the percentage of members attached to a group Tax ID

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ETG Attribution Overview (continued)

PPO Population for Anthem Two years of PPO claims data

▪ Fully insured PPO lines of business ▪ Members with both medical and pharmacy claims ▪ Excluded members with no claims

ETG Exclusions

▪ Non-episodic Treatments ▪ Ungroupable Services ▪ Episodes assigned to Hospitals

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ETG Attribution Overview (continued)

Episode Matching Logic

Patient A Episode of Care Provider Tax ID Each Episode has a responsible Tax ID Total Episodes Calculate the total number of episodes for each patient Match the total number

• f episodes for each

Tax ID %

• f patient’s

episodes attached to each Tax ID

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Potential Payment Models

Examples Year 1 Year 2 Year 3 Year 4 Year 5 Option 1

FFS with yearly Reconciliation against a medical budget FFS with yearly Reconciliation against a medical budget Global PMPM with increasing risk sharing arrangement Global PMPM with full risk sharing arrangement Global PMPM with full risk sharing arrangement

Option 2

Global PMPM with partial risk sharing arrangement Global PMPM with increasing risk sharing arrangement Global PMPM with increasing risk sharing arrangement Global PMPM with full risk sharing arrangement Global PMPM with full risk sharing arrangement

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Shared Savings – Quality Gate Quality Gate

• Physician Quality

Metrics

• Hospital Quality

Metrics Can participate in upside savings

Note: Points are scored based on both improvement and an attainment threshold

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Quality Metrics - Physician

• Breast Cancer Screening
• Colorectal Cancer Screening
• Childhood Immunization Status (MMR + VZV)
• Chlamydia Screening in Women
• HbA1C Screening
• LDL Screening
• Nephropathy Monitoring
• Cholesterol Management LDL Screening

(Pts with/ Cardiovascular Conditions)

• Use of Imaging Studies for Low Back Pain
• Appropriate Testing for Children with Pharyngitis
• Appropriate Treatment for Children with Upper

Respiratory Infection

• Avoidance of Antibiotic Treatment of Adults with Acute

Bronchitis

• Medication Monitoring (ACE/ARBs, digoxin, diuretics)

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Quality Metrics - Hospital

▪ JC/CMS NHQM – AMI, PN, CHF & SCIP ▪ ACC Metrics for Cardiology ▪ STS metrics for Cardiac Surgery

• Deep Sternal Wound Infection
• Prolonged Ventilation
• Operative Mortality for CABG
• Surgical Re-exploration
• Pre-operative Beta Blockade

▪ National Healthcare Surveillance Network –

• Central line associated bloodstream infections
• Ventilator associated pneumonia
• Catheter associated urinary tract infections

▪ Patient Satisfaction - CAHPS

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Draft Efficiency Score Card

Categories Metrics Points Emergency Department Aggregated total - avoidable visits per 1000 25 Prescription Medications Rx pmpy or Rx/1000 Generic Prescribing rate 25 Imaging Spine MRIs per 1000 Spine CTs per 1000 25 Abdominal CTs per 1000 Inpatient Admits per 1000 Days per 1000 25 HEDIS - all cause readmission rate

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Current State

Initiatives for Jan 2011 implementation

▪ California

• Monarch Healthcare
• HealthCare Partners
• Sharp (Sharp Community & Sharp Rees-Stealy)

▪ New Hampshire

• Dartmouth Hitchcock

Pending Projects for later in 2011

▪ Expansion to other Anthem states ▪ Medicare Advantage ▪ Medicaid ▪ ASO groups

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ACO Process for New Markets

Implementation Team

▪ Leverage SME’s ▪ Time table: 4 months ▪ Established multi-functional workgroups

• IM/IT
• Actuary/Heathcare Analytics
• Medical Management
• Contracting/Network
• Communications
• Product

Maintenance Team

▪ Local PE&C team ▪ PRG team ▪ IM

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ACO Implementation Discussion Items

• Membership

▪ Lines of Business ▪ Member Attribution for PPO members ▪ Narrow focus (chronic disease) vs population focus ▪ Leakage

• Medical Management Opportunities

▪ Delegated Medical Management ▪ Understanding where medical costs can be better managed

• Site of Service
• Pharmacy
• ED
• Readmissions

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• Operation Issues

▪ Communications

• Member Notification
• Employer Notification
• Broker Notification

▪ Electronic eligibility

• Additions/Deletions to

membership

▪ Reporting and Data Exchange

• Payment Methodologies
• Performance Metrics

▪ Quality Metrics ▪ Efficiency Metrics

ACO Implementation Discussion Items

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2012 Draft ACO Products – California

ACO Core

• Only ACO Providers can be accessed
• Regional Offering where ACO presence is strong
• Self Refer Option within ACO network
• Most Aggressively Priced Option

ACO Flex

• 3 Tier PPO offering
• Tier 1 – ACO Providers
• Tier 2 – PPO Providers
• Tier 3 – Non Contracting Out of Network Providers
• Flexibility to move between Tiers when accessing care
• An alternate option to traditional PPO offerings, with the goal to

manage cost more effectively

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Questions