Value Based Contract Overview and Experience of an Independent - - PowerPoint PPT Presentation

Value Based Contract Overview and Experience of an Independent Physician Practice

Jamie Stevens, MSHS, MBA Administrator/Consultant Clay Platte Family Medicine Clinic, P.C. HQMS

• Recognize necessary for practice transformation that is

needed improve probability of success under value based contracts

• Define the role of physician leadership to succeed

under performance based contracts

• Assess practices capacity to measure and act to

improve risk adjustment in patient populations

• Recognize data available within their practice that can

be used to drive cost and quality improve

• Identify strategic partners in the community that are

essential to success under performance based contracts

Value Based Performance Objectives

• Value-based programs reward health care

providers with incentive payments for the quality

• f care they give to an attributed population of
• patients. These programs are part of a larger

quality strategy to reform how health care is delivered and paid for.

• Value-based programs support the three-part

(Triple) aim:

• Better care for individuals
• Better health for populations
• Lower cost

Value Based Payment Models

Triple Aim and Payment/Delivery Reform

• Accountable Care Organizations (ACOs):
• Groups of physicians, hospitals, and other

providers that agree to be financially responsible for the total cost and quality of care for a defined patient population.

• Provider groups are entering into contractual

agreements with both commercial (or private) payers and public payers, such as Medicare and Medicaid.

Accountable Care Organizations

Recent ACO Trends

• In the first quarter of 2018, commercial ACO contracts accounted

for a little more than half of all ACO covered lives, while Medicare contracts accounted for 37 percent, and Medicaid contracts accounted for the remaining 10 percent.

• The next slide shows the number of ACO contracts over time

broken down by Medicare, Medicaid, and commercial arrangements.

• There are slightly more commercial ACO contracts than Medicare

with Medicaid contracts making up 5 percent.

• Medicare ACO contracts continued to grow, commercial contracts

saw very little net growth in 2017 and 2018, and Medicaid contracts saw a slight contraction as some state demonstration programs were not renewed.

Growth of Commercial and Medicare/Medicaid ACOs

Lives covered by ACOs by Over Time

Emergence of Other Alternative Payment Arrangements

• One impediment keeping providers from making major delivery

system reforms is the limited business case for many of these

• rganizations.
• Most provider organizations that have formed ACOs still have only a

some of their patients covered by alternative payment models and risk-based payments.

• Currently, ACOs see the need to experiment with risk-based payment

models because they want to prepare for a potential future when such models are more prevalent.

• Many are reluctant to undertake major delivery reforms that are not

sustainable under the predominant fee-for-service payment model that still determines their financial success.

• To encourage organizations to change how they deliver care, the

depth of risk is important, but perhaps more important is the breadth

• f risk—what share of revenue is under value-based payment

arrangements.

Limitations of Alternative Payment Models

• Independent primary care practice with 19 FTE

providers practicing at locations in North Kansas City & Lee’s Summit

• High intensity, average volume clinic with a focus
• n preventative care, chronic disease management

and quality

• High staffing model
• 180 FTEs
• 3 floor nurses per physician plus triage, referrals
• Licensed therapist/care managers/diabetic

educator/HEDIS

• 20 business office staff
• 5 of 11 coders are certified as risk adjustment coders

Clay Platte Family Medicine Clinic

• Commitment to value based contract performance as a

strategy in 2012

• Early focus on Medicare Advantage and progressed to PCMH

based patients and Medicare due to MSSP ACO participation

• Today most patients are in value based contracts (PCMH,

CPC+, Medicare Advantage)

• Increase in share of total revenue from value based payment
• ver the past 5 years
• Current standing as:
• Among the highest ranked PMPM by population in the metro area

for major MA plans

• Second highest (out of 32 practices) risk adjusted practice for a

large PCMH agreement

• Significantly higher than average PMPM payment for CPC+

population

Value Based Payment Progression

13 7.9% 3.2% 12.8% 17.7%

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0%

2015 2016 2017 2018

Percent of Revenue from Value Based Payments 2015-18

• Leadership
• Financial commitment (staff, training, provider time)
• Transparency
• Alignment of incentives
• Providers
• Familiarity with value based contracts
• Familiarity with risk adjustment and impactful codes
• Quality measure management-use of preventative care
• Staff
• Increased responsivity of non-physician clinical staff
• Focus on quality
• Alignment of incentives
• Addition of non-traditional primary care staff

Shared Effort by Entire Practice

• Monthly all provider meetings
• Standing agenda items include practice revenue,

quality performance, risk adjustment

• Chart audit for gaps in care and code capture
• Robust flag system for quality measure gaps
• Coding staff with prospectively review charts to flag

codes not yet captured in the calendar year

• Providers review prior history for missing quality and

risk adjustment opportunities

• Use reports provided by health plans

System Approach

• Quarterly team based trainings which include provider,

nurses and administration and billing staff Review documentation trends that lack support for diagnosis

• Review performance on a number of clinical quality

measures

• Evaluate patient population and opportunities for risk

adjustment

• All staff trainings and awareness
• All new staff spend time with coders to learn about

activities that contribute to improved cost and quality

• New nurses and physicians receive more intensive and

frequent training on quality and risk adjustment

System Approach

• Patients with more complicated physical and/or mental

illnesses are at increased risk of potentially serious, even fatal, exacerbations and complications.

• They may benefit from more intensive follow-up and

management than can be done through repeated office visits.

• Implement risk stratification scores to all patients for easy

identification of the highest need patients.

• Evidence suggests that well-organized care management by a

nurse or other health professional can reduce patients' risk

• f deterioration and readmission, and the associated health

care costs.

• One-half of patients readmitted to hospitals within 30 days
• f discharge have not seen a community provider.

Care Management and Primary Care

• Recently transitioned to Northland Health Care Access

program for care management programs in an effort to increase patient satisfaction and improve outcomes, while reducing costs.

• Examples of care management activities and services

include:

• Care plan development and tracking progress
• Patient education
• Social needs assessment
• Transportation
• Food
• Language
• Social support

Care Management Activities

Primary clinical team

• Cares for healthy

population

• Provides routine care
• Controls and stabilizes

chronic disease

• Identifies need for

advanced care management

Primary clinical team + Care Manager

• High risk/acutely ill

patients

• Patients with increased

psychosocial needs

• Patients requiring

support that expands

• utside the practice

Engaging the Care Team

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1. Identify criteria that define risk 2. Assign risk score & record in a discrete, searchable EMR field 3. Develop a strategy or approach for each risk level 4. Define team roles and responsibilities related to care management and coordination support 5. Engage community resources:

• Partner with sub-specialists, ER, hospital and other services
• Maintain real time communications within the medical neighborhood
• Make sure to actively engage family and caregivers

6. Measure to monitor impact

• Internal/External quality measure reports
• Claims based cost management data
• Patient Experience

Six Steps To Risk Stratification

20

High Cost Members-Data to Support Risk Stratification

IP and OP Utilization Practice Trends

RX and ER Utilization Reports to Support Care Management Efforts

Risk Adjustment Role in Value Based Payment Contracts

• Medicare and other payers use risk adjusted factors (RAF)

to determine the anticipated cost of care for beneficiaries based on their documented conditions.

• The higher the RAF the greater the anticipated cost of care

and the greater an opportunity to gain shared savings.

• Health status must be re-determined each year
• Must be assessed, treated and documented in the

medical record annually

• Based on diagnosis reported through claims/encounter

data

• Higher importance to document and code all conditions

that are evaluated at each visit

• Health status is the primary driver of shared savings

Risk Adjustment Factor Scores

• Risk factors or coefficients for a patient add up to equal a risk

adjustment factor (RAF) score in order to give a clinical picture of the patient’s health status

• RAF scores are assigned to a member, but roll up to a

provider based on the member’s assigned primary care provider

• CMS suggests that an average senior who is generally healthy

should have a RAF score on average of 1.00

• RAF scores below 1.00, suggest a healthy patient
• RAF scores above 1.00, suggest a patient with chronic

conditions

Interpreting the RAF

• A lower RAF score may also indicate the following issues
• It may be falsely indicating a healthier population because
• f a lack of adequate chart documentation or complete

and accurate ICD-10 coding

• Patients have not been seen
• Each diagnosis has a RAF score which are cumulative. As

more diagnosis are submitted and documented on a patient, the RAF score increases

• ICD-10 coding to the highest level of specificity and accuracy is

essential in gaining full credit for RAF and to be paid accordingly

Risk Adjustment and Risk Stratification

• Value based payment arrangements require improved

performance on selected quality measures.

• Failure to preform on quality measures often limits the

capacity to access revenue from value based contracts even if shared savings are achieved.

• Strategies to ensure improved performance on quality

measures include:

• Provider quality score cards (intenal/payer)
• Addressing HEDIS gaps
• Access to data that allows for identification of patients

who are past due for services

• High frequency primary care engagement

Quality Measure Performance

CPC+ Sample Results

• Care Management:
• % of all patients with a recorded risk score
• % of high risk patients with a documented care plan
• Improved quality measures
• Chronic disease management measures
• Patient satisfaction
• Cost Reductions:
• Decrease the number of ER visits per year
• Avoidable admission and re-admission rates
• Reduction in total cost of care

Measures Of Success

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