Accountable Care Organization April 13, 2011 The Indianapolis Association of Health Underwriters
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- outcome results are needed Accountable Care Organizations, Deloitte 2010 2
Evolution of Reimbursement Strategies 3
Payment Innovation – Balanced Approach Three Payment Reform Models Procedure/Condition/ Population- Fee-For-Service Episode-Based Payment Based Payment Enhancement Performance Recognition Programs (P4P) 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 4
Accountable Care Organizations The Accountable Care Organization (ACO) model is a local health organization that is accountable for 100% of the expenditures and care of a defined population of 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 5
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 6
Anthem ACO Model for 2011 All ACO partners will have the following features: Membership Legal • Defined by Attribution • Structure to receive / distribute savings Provider Network • Management Structure • Full Network with the exception of Transplants Financial IT • FFS & Shared Savings • IT Infrastructure • Care Management Fee • Data Exchanges Medical Management • Possible Delegated Medical Management • Defined Processes to promote quality & coordinate care 7
Data Exchanges for ACOs • Membership • Medical Management ▪ Electronic Membership File ▪ Utilization Management ▪ Membership additions/deletions ▪ Case Management ▪ Disease Management • Census • Pharmacy ▪ Hospital Census ▪ Emergency Census ▪ Claims data files ▪ Analytic reports • Claims • Reporting ▪ Two years of historical ▪ Monthly claims data file ▪ Series of analytic reports 8
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 9
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 10
ETG Attribution Overview (continued) Episode Matching Logic Patient A Episode of Care Each Episode has a responsible Tax ID Total Provider Episodes Tax ID Calculate the total number of episodes for each patient Match the total number % of episodes for each of patient’s Tax ID episodes attached to each Tax ID 11
Potential Payment Models Examples Year 1 Year 2 Year 3 Year 4 Year 5 FFS with FFS with Global PMPM Global PMPM Global PMPM Option 1 yearly yearly with with full risk with full risk Reconciliation Reconciliation increasing risk sharing sharing against a against a sharing arrangement arrangement medical medical arrangement budget budget Global PMPM Global PMPM Global PMPM Global PMPM Global PMPM Option 2 with partial with with with full risk with full risk risk sharing increasing risk increasing risk sharing sharing arrangement sharing sharing arrangement arrangement arrangement arrangement 12
Shared Savings – Quality Gate Quality Gate • Physician Quality Can participate Metrics in upside savings • Hospital Quality Metrics Note: Points are scored based on both improvement and an attainment threshold 13
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) 14
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 15
Draft Efficiency Score Card Categories Metrics Points Aggregated total - avoidable Emergency Department 25 visits per 1000 Rx pmpy or Rx/1000 Prescription Medications Generic Prescribing rate 25 Spine MRIs per 1000 Imaging Spine CTs per 1000 25 Abdominal CTs per 1000 Admits per 1000 Days per 1000 25 Inpatient HEDIS - all cause readmission rate 16
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 17
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 18
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 19
ACO Implementation Discussion Items • 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 20
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 21
Questions 22
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