Whats Next for Value Based Care? 4.26.19 Introductions Dave - - PowerPoint PPT Presentation
Whats Next for Value Based Care? 4.26.19 Introductions Dave Spalding Erica Maltby 2017 co- Founded TMA 2017 co- Founded TMA Specialty Specialty Services Services CEO TMA Specialty Services VP Operations TMA Specialty
Dave Spalding
Specialty Services
care companies, including TMA PracticeEdge
Erica Maltby
Services
Services
strategies around Value Based Care
developing analytic products
Based Care
Medicare payments
improving quality
payers, providers, device makers, drug manufacturers, etc.
“Never, ever, think about something else when you should be thinking about the power of incentives”
patients should expect Value
with reporting
participation
compliant is forcing out independent physicians
value
25% 25% 50% 50% 75% 75% 20% 20% 35% 35% 50% 50% 0% 20% 40% 60% 80% 2017 2018 2019 2020 2021 2022
Required Payments of Patients Thresholds per Program Year
Payments through APMs Patients in APMs
How is VBC defined?
Fee for Service Performance Bonus (P4P) Shared Savings Shared Risk Pay for Volume Bonuses for hitting Quality targets
successfully meeting clinical improvement thresholds”
Upside-only cost arrangements for beating benchmarks
Upside / downside cost arrangements for beating benchmarks
TRENDS 2015-17
decreased from 63% of payments to 41%
(categories 3 & 4) have increased from 23% to 34% since 2015
adoption with 49.5% of payments in savings / risk models, including 15% in specialty episodes. Category 1 Category 2 Category 3 & 4 20 40 60 80 100 2015 2016 2017
HCP&LAN Payment Categories 2015-2017
Health Care Payment & Learning Action Network Annual Survey
Category 1 – FFS Category 2 – Quality / P4P Category 3 – APM with FFS architecture Category 4 – Population-based risk
The commercial market lagged Medicare with 28% of payments in category 3 & 4 in 2017. Specialty episodes represented less than 8.5% of commercial VBC payments. 2019-20 Cost shifting benefits from high deductible plans are tapped out and employers are accelerating private sector adoption of APMs going in 2019-20. Large employers and purchasing coalitions are contracting directly with providers for specialty episodes and total cost of care deals.
beneficiaries in ACO models
ACOs
in 2019
more broadly in healthcare?
$0 $50 $100 $150 $200 $250 MD-owned Hospital
Savings vs. Benchmark Additional Savings ACO Payments Net Benefit/Loss to Medicare
2016 MSSP Results
10% of total healthcare spend
high costs- and specialists are in the driver’s seat
programs for specialists
team- care & cost containment of an area within specialists’ control
CMS: Chronic Conditions Among Beneficiaries
MEDICARE BPCIA
bundles
acute care re-design and efficiency
downside risk
End Stage Renal “ESCO”
Oncology OCM
participate
COMMERCIAL Currently limited to procedures such as colonoscopy and ortho. Most programs lack scalability and very few organizations are tackling chronic conditions Spotlight on Texas
bundles)
Fusion5, Encompass, Remedy Partners and UnitedHealthcare
MEDICARE
COMMERCIAL
payment from volume to value
episodes- both procedures and chronic conditions- to manage
across the care continuum
PROCEDURE EPISODES CONDITION EPISODES
Objectives
Examples Colonoscopy, Joint Replacement, Coronary Bypass Cost Levers ▪ Unplanned event mitigation ▪ Site-of-service ▪ In-patient utilization ▪ In-network specialists ▪ Tools and techniques Immediate Opportunity Opportunities abound to lower costs by shifting site
and changing clinical workflow patterns. Objectives
management
Examples Heart Failure, Diabetes, COPD, CKD Cost Levers ▪ Care coordination with PCPs ▪ Patient compliance ▪ ER utilization ▪ Standards of care Immediate Opportunity Given the right data, specialists will be able to squeeze out unnecessary utilization of the healthcare system.
Benchmark established by market average
1
Identify cost buckets within a procedure
2
Break down bucket 1: average pathology costs
3
Break down bucket 2: average anesthesia costs
$1,900 $323
4
Break down bucket 3: average facility fees
5
Understand each individual physician’s provider mix for actionable conversations
with anesthesia costs of $250,000
is $662, mostly with MDs
$323
choose efficient provider partners, helping the practice win in Value Based Care models
378 x $662 =
378 patients x $323 =
in potential episode savings
*Guroo ACO has $10,000 to manage this patient’s total cost of care An aligned specialist is beating the Houston benchmark ($2,743*) by $1,000
Colonoscopy Episode
▪ A recent study from the Deloitte Center for Health Solutions found that access to cost information may drive more behavior change toward value-based care among physicians. ▪ The study also found that two-thirds of physicians have access to their own productivity and quality performance data, but cost information is less common.
Source: Deloitte 2018 Survey of US Physicians
Which of the following types of performance information would compel you to reconsider how you practice? For each of the types of information you receive, can you recall an instance when the information made you reconsider or change how you practice?
Not Implemented Implemented My own performance on quality measures 65% 71% My own productivity measures 51% 57% Estimated patient out-of-pocket costs for different treatment options 39% 62% Cost or resource use for attributed patients 36% 53% Performance on quality measures for physicians/ facilities to which I refer 32% 59% Cost or resource use of physicians/ facilities to which I refer 23% 60% None of the above 26% N/A
Specialists ✓ Get on the treadmill ✓ Work with payers and provider partners to obtain your data ✓ Participate in existing opportunities PCPs/ACOs ✓ Identify specialty partners who have aligned incentives ✓ Share data and clinical strategies with specialists Payers ✓ New world- price transparency ✓ Create opportunities for lowering cost and improving quality Hospitals ✓ Leverage data advantage to change clinical workflow models ✓ Use this adoption time to determine new revenue models
Erica Maltby VP, Operations erica.maltby@texmed.org Dave Spalding CEO Dave.spalding@texmed.org