2018 arizona winter state-of-the-state...– former az hfma president introduction. the hertel...
TRANSCRIPT
2018 Arizona Winter State-of-the-State
January 2018
BREAKFASTSPONSOR
The Hertel Report
• Trusted & Respected• Impartial & Timely• Solutions Focused• Locally Owned
• Weekly News• Monthly Newsletter• Quarterly Data• Networking & Conferences
• Jim Hammond– Publisher & CEO of The Hertel Report– Managing Consultant, Professional Healthcare Solutions – State-wide Healthplan & Provider Relations Expert– Conference Speaker & Resource to:
AzHHA, AHE, MCMS, HFMA - AZ, CBIZ, ASPA, AMN, HCAA, CMSA, Sonora Quest, Humana, Dignity Health, U of A, CNBC, Money Radio, Wall Street Journal, NPR, Modern Healthcare, Phoenix Business Journal, Arizona Daily Star, Vitalyst Health Foundation, Web AZ, and more
– Former AZ HFMA President
Introduction
TheHertelReportCommunity
• 15FoundingSponsors• 50CorporateMembers• 10CommunityPartners• 1000+IndividualMembers• 11Newsletters• 4DataEditions• 4+StateoftheStateMeetings• More…..
The Source that Connects the Arizona Healthcare Community
GuestSpeakers• PeleFischer
– VicePresident,PolicyandPoliticalAffairs,ArizonaMedicalAssociation• MarcusJohnson
– Director,StateHealthPolicyandAdvocacy,VitalystHealthFoundation• JimWhitfill,MD
– President,Lumetis,LLC.– ChiefMedicalOfficer,InnovationCarePartners
• LisaMead,RN– President,CrowneHealthcareConsulting– Founder,ArizonaWomeninHealthcare
• Welcome, Introductions• Legislative Update with Pele Fischer• Medicare Advantage• AHCCCS• ACA Coverage Update with Marcus Johnson• Value-Based Networks with Jim Whitfill• Quality as a Business Strategy with Lisa Mead• Discussion
Agenda
THANKS for our Programs
FindusonFacebookFollowusonTwitter@thehertelreportTweetusinghashtag#AZSOS2018Survey/Feedback,thanks!TM
Founding Sponsors
Founding Sponsors
Corporate Members
Corporate Members
Corporate Members
Corporate Members
Community Partners
ARIZONAMEDICALASSOCIATIONTheArizonaMedicalAssociationisavoluntarymembership
organizationforallArizonamedicalandosteopathicphysicians.
Mission:
Promoteandprovideleadershipintheartandscienceofmedicine;
PreserveandimprovethehealthofallArizonans;
RepresentArizonaphysiciansinthepublicforum;
DefendArizonaphysicians’freedomandabilitytopracticemedicineinthebestinterestsofyourpatients.
CURRENTPOLITICALCLIMATE• ArizonaPoliticsareinfluxlikeneverbefore…• Uniquedynamics…
• TensePoliticalClimate• NewLegislators• Statewideelections• Termlimitsimpacts• Highprofileissuesanddebates
2018LegislativeOverview• Leadership
• SenatePresident:SteveYarbrough(Chandler)• MinorityLeader:KatieHobbs(Phoenix)• HouseSpeaker:J.D.Mesnard (Chandler)• MinorityLeader:RebeccaRios(Phoenix)
• HealthCommittees• HouseHealthChair:Rep.HeatherCarter(NorthPhoenix- CaveCreek)• SenateHealthChair:SenatorNancyBarto (NorthPhoenix)
• MedicalExpertise?!?!
2018LegislativeForecast- Health• CombattingtheOpioidEpidemic
• GovernorDuceycalledforaspecialsessiontopasslegislationrelatedtocombatingtheopioidcrisis.
• Regulation• CertificationCommunityHealthWorkers• LicensureofDentalTherapists
• AHCCCS• FederalWaiver– implementcapsandworkrequirements• ChiropracticCoverageforAdults• OralHealthCoverageforPregnantWomen
SpecialSession– TheArizonaOpioidEpidemicAct• $10millionforaccesstotreatment(uninsuredorunderinsuredArizonans)• ExpandingaccesstoNaloxoneforlawenforcementandcorrectionsofficers• Regulationofpainmanagementclinicstostop“pillmill”activities• Enactingcriminalpenaltiesformanufacturerswhodefraudthepublicabouttheir
products• Enhancingcontinuingmedicaleducationforallprofessionsthatprescribeor
dispenseopioidsandrequiringopioidrelatededucationformedicalstudents• EnactingaGoodSamaritanlawtoallowpeopletocall911forapotentialopioid
overdose• Mandatinge-prescribingforScheduleIIControlledSubstances• RequiringpharmaciststochecktheCSPMP• RedCapsandWarningLabels• Priorauthorizationreformstoexpeditetreatment• Limitingthefirst-fillofanopioidprescriptiontofivedaysforallopioidnaïve
patientsandlimitingdosagelevelsover90MME(withexceptions)
2018LegislativeForecast- Health• PublicHealth
• Tobacco21• ProhibitIndoorTanningforChildren• RearFacingCarSeats• SchoolRecess
• Administration• CredentialingImprovementsandEfficiencies• VariousBoardReforms
• MoretoCome….
WAYSTOGETINVOLVED
• VOTE!AndVoteEarly!• Primariesarecritical
• JoinassociationsthatareadvocatingfortheissuesthatareimportanttoYOU!
• SupportCandidates• DonatetoaPAC• Attendafundraiser• Gettoknowyourlegislators!
165,415
65,454
59,817
41,922
41,749
23,338
18,583
0
12,345
9758
7173
8169
4720
1577
0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 180,000
UHC/Pacificare/Sierra
BlueAdvantage
Humana
Cigna
UHC- Community
HealthNet
MercyCarePlan…
PhoenixHealthPlan
CareMore
HealthChoice…
UniversityCare…
Aetna
Others
Bridgeway
Membership
MedicareAdvantagePlanEnrollmentMay2017
ArizonaTotalStatewideMedicareAdvantageEnrollment=467,038~39%
Source:CMS
AHCCCSTotalPopulationasofJuly1st(inmillions)2001- 2018*
January20181.89M
• 400,000 • Expansion AdultsRestoration and Expansion by the numbers
Reaching across Arizona to provide comprehensive quality health care for those in need
• 82,000 • Mental Health Service• 47,000 • Substance Use Disorder• 26,700 • Cancer Treatment• 31% each • 20-29 YO and >50 TO• 11,563 • Individuals with SMI• 17.3% to 11.1% • Uninsured 2013-2015
UncompensatedCareTrends
-
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
9.00%
ArizonaHospitalUncompensatedCareTrendsBeforeandAfterMedicaidExpansion
UncompensatedCare% TotalChildlessAdultsCoveredbyAHCCCS
Source: Arizona Hospital and Healthcare Association
ALTCSAwardfor10-1-17Start• North– United• Central(Maricopa,Pinal,Gila)
– University– MercyCare– United• South
– University– MercyCare(Pima)
• Roughly9,000memberstransitioned• Bridgeway(Centene)out
AHCCCSCommittedtoIntegration
ACaseforIntegratingPhysicalandBehavioralHealthServices:
1. Easenavigationofhealthcareservices;
2. Singlepointofaccountability;
3. Alignincentivestoimproveaperson’swholehealth;and
4. Streamlinecarecoordinationtogettobetteroutcomes.
Vision- Integrationatall3Levels
Integrated Acute Care Bid AHCCCS Complete Care
• RFP out November 2, 2017• Integrated Physical and Behavioral Care• For all Adults without Serious Mental Illness• And All children except CMDP (foster kids)• Crisis Services responsibility of RBHA• Move to GSA’s like ALTCS• PROPOSALS DUE JAN 25!
35
Integrated Contractor Geographic Service Areas
Additional zip code exceptions may be considered to allow for further alignment with certain tribal lands.
AHCCCSENROLLMENTBYCONTRACTORJUNE2013TOJUNE2017
AHCCCS Acute Plan Enrollment Shift January 2017 to 2018
HEALTH PLAN MEMBERSHIP YOYCHANGEUnitedHealthcare 507,409 15%
MercyCarePlan 368,137 1%
HealthChoiceAZ 248,971 -1%
Care1stAZ 146,386 31%
UniversityFamilyCare 131,948 -4%
HealthNetAccess 58,567 1%
AHCCCSWaiver’sintheQueue
• AHCCCSWorks– Able-bodiedworkrequirements,5yearmax• Retro-coveragefromACAlevel90days,backto30• Non-EmergencyMedicalTransportationexcludedforable-bodied
• Formulary,rebates
ACACoverageUpdatesMarcusJohnson
Director,StateHealthPolicy&AdvocacyVitalyst HealthFoundation
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0
SloveniaIceland
ItalyPortugal
SpainOECDAVERAGE
NewZealandFinland
AustraliaUnitedKingdom
CanadaDenmarkAustriaBelgiumNorway
NetherlandsJapanFranceSweden
GermanySwitzerland
UnitedStates
HealthSpendby%GDP(2016)
U.S.=17.2%
Average=9%
Source:OECD
76
77
78
79
80
81
82
83
84
85
LifeExpectancybyCountry(2015)
U.S.78.8
Average80.5
Source:OECD
ObjectivesofTheAffordableCareAct• ReduceUninsured
• MandateandExchanges• MedicaidExpansion
• BendtheCost/QualityCurve• Squeezeoutthefat(InsuranceCo.&Provider)• ACOs/Value-BasedNetworks/CareCoordination• ProviderAccountability
MedicaidExpansion
UNINSUREDMIGRATION
Subsidesforlow-incomecitizensONLYavailablethroughMarketplace(www.healthcare.gov)
Commercial
Medicaid
Medicare
Marketplace
1,922,724
140,079
HealthInsuranceCoverageoftheTotalPopulation- Arizona2017
Medicaid
Marketplace
Other
Source:AHCCCSSource:CMS
470,00
0
Who’sCovering Arizona?
*Marketplaceenrollmentreflectseffectuated#sfrom2/17.Totalenrollment=196,291.
Change is Coming
“The primary driver of our national debt is our healthcare programs. There’s no one magic bullet– like pass this and it’s fixed– but, save the healthcare system and you’re saving the country from its debt crisis.”
PaulRyanSpeakeroftheHouse ModernHealthcare
TheSummerofRepealandReplace• AHCA• BCRA• SkinnyRepeal• Graham-Cassidy• BipartisanEfforts• ExecutiveOrders• RegulatoryLevers
TheShowMustGoOn
• Healthcarefacilitiesstillmovingtowardvalue• Insurancecompaniesplanningformarketshifts(MarketplaceOpenEnrollmentandMedicaidIntegratedContract)
• AHCCCScalculatingFedimpacton1115Waiversubmittal
• Consumersdecipheringwhatthisactuallymeans
Summer‘17
ACAOPENENROLLMENT
2018
2018ACAOpenEnrollment
• Enrollmentperiodcutinhalf(November1-December15,2017)
• LessSupportforNavigators(~40%cut,nationally)• MuchLessAdvertising(~90%cut,nationally)• TaxBillZeroes-OutIndividualMandatePenalty• CostSharingReductionsunfunded,unsupportedbyWhiteHouse
CostSharingReductionPaymentsStillUncertain
• 2014:U.S.HouseFiledSuit• Argument:Cost-SharingPaymentsIllegal– NoCongressionalAppropriation
• 2016:DistrictCourtProvidesFavorableRulingtoHouse• DecisionStayedbyJudge– RevisitDecisionPostElection• Fundingcontinueswithuncertainty,monthtomonth
• 2017:TrumpAdministrationdoesnotdefendlawsuits,stopsfunding
• 2018:SusanCollins(R)MEstillbargainingwithSenatetofundCSR’s
Cost-SharingReductionswereavailableforbeneficiariesatorbelow250%FPLor$29,700forasingleperson
WithCostSharingReductions:
WithoutCostSharingReductions:
MarketplacePrices
2016 2017 %ChangeTotalPremiumSticker
Price $324 $611 á88.6%
ConsumerCostafterSubsidies(amongthosereceivingsubsidies)
$120 $104 â13.3%Sources:CMS,CMS
AveragePremiumsforArizonaMarketplaceEnrollees
2014 2015 2016 2017 2018
8 11 8 2 2
NumberofInsurersinArizona’sMarketplace
Source:KaiserFamilyFoundation
MarketplacePremiumVariation(Pre-Subsidy)AZparticularlyvulnerabletomarketdisruption.
DisproportionatelyhighMarketplacepremiumpricesinAZ.
Fortunately,subsidiesbuffermostenrolleesfromhighpremiumcosts.
BUT…enrollees>400%FPLexposedtofullcostofcoverage
Mapbasedon40-yrold,non-smoker,selecting2nd lowestcostsilverplanin2017Source:NationalAcademyofStateHealthPolicy
Arizona’sMarketplaceWho’sBenefiting
• Arizonansearningupto400%FPL,receivingsubsidies
• Largelyprotectedfrompricefluctuations,duetosubsidyformula.
Who’sHurting• Arizonansearningabove
400%FPL,whodon’thave…– EmployerInsurance– AHCCCSorCHIP– Medicare– VA
FamilySize
100% 133% 138% 250% 350% 400%
1 $11,880 $15,800 $16,400 $29,700 $41,580 $47,550
2 $16,020 $21,300 $22,100 $40,050 $56,070 $64,100
3 $20,160 $26,800 $33,600 $50,400 $70,560 $84,650
4 $28,440 $37,850 $39,250 $60,750 $85,050 $97,200
5 $28,410 $37,785 $39,205 $71,100 $89,210 $113,800
HIM Arizona Plans 2018Final Lineup
Maricopa and Pima Counties All Rural Counties
[Averagepremiumincrease1.8%]
[Averagepremiumdecrease0.8%]
2018MarketplaceCosts(39year-old,MaricopaCounty)
Source:CredittoArizonaAllianceofCommunityHealthCenters
Income Silver Premium(Gross)
SilverPremium(Post-Subsidy)
$18,090(150%FPL) $464.88 $20.88
$27,135 (225%FPL) $464.88 $123.88
$45,225(375%FPL) $464.88 $320.88
2018MarketplaceCosts(39year-old,PimaCounty)
Source:CredittoArizonaAllianceofCommunityHealthCenters
Income Silver Premium(Gross)
SilverPremium(Post-Subsidy)
$18,090(150%FPL) $357.40 $62.40
$27,135 (225%FPL) $357.40 $164.40
$45,225(375%FPL) $357.40 $357.40
2018MarketplaceCosts(39year-old,YavapaiCounty)
Income Silver Premium(Gross)
SilverPremium(Post-Subsidy)
$18,090(150%FPL) $713.95 $60.95
$27,135 (225%FPL) $713.95 $162.95
$45,225 (375%FPL) $713.95 $359.95
Source:CredittoArizonaAllianceofCommunityHealthCenters
ACAMarketplaceEnrollmentTrends
National Health Insurance Marketplace Enrollment
20170
2
4
6
8
10
12
14
2014 2015 2016 2017 2018
5.48.8 9.6 9.2 8.7
2.6
2.93.1 3
NationalMarketplaceEnrollment(millions)
Healthcare.gov State-BasedMarketplaces
Arizona Marketplace Enrollment
20170
50000
100000
150000
200000
250000
2014 2015 2016 2017 2018PlanSelections 120071 205666 202295 196291 166961
PlanSelections
2017-2018 HIM Enrollment Statistics2017
• 12.2 million enrollments (9.2M on healthcare.gov platform)
• 69% renewal / 31% new• 83% of all enrollments received financial
assistance• 36% of enrollment is under age 35• 12% earn incomes outside of subsidy range
2018
• 196,291 enrollments (140,079 effectuated)• 74% renewal / 26% new enrollment• 84% of all enrollments received financial
assistance • 41% of enrollment is under age 35 • 18% earn incomes outside of subsidy
range
AZ
• 8.7 million FFM enrollments
• 72% renewal / 28% new
• 166,961 enrollments
• *Detailed 2018 enrollment data not yet made available*
U.S.
Source:CMS
“ThisyearCMStookamorecosteffectiveoutreachapproach,spendingjustover$1perenrolleeonoutreachandeducationforExchangecoveragecomparedtonearly$11
perenrolleelastyear.”– SeemaVerma
TheUninsured
TheUninsuredPOPULATION 1YEAR CHANGE
(%)Non-Hispanic
White +0.7
Non-HispanicBlack +2.3
Hispanic +2.2
Income <$36,000 +2.0
$36,000 to$90,000 +1.4
$90,000+ +0.8
TheUninsured
TheUninsured
CoveragePolicyOutlook• Impactofindividualmandaterepeal?• Alexander-Murray,Collins-Nelson?
– CSRFunding– ReinsuranceFunding– OutreachandEnrollmentFunding
• AssociationPlans?• Short-TermMedicalPlans?• MedicaidBuy-In?• MedicaidPer-CapitaCaps?• MedicaidBlockPayments?• KidsCare Funding?
Coveragereformisonlyonepieceofthepuzzle.Theshifttowardvaluemayholdevengreaterpromise…
Value-BasedCareHowtoGetFromHeretoThere
WithJimWhitfill
Healthcareas%GDPProjected
73
15.5%
16.0%
16.5%
17.0%
17.5%
18.0%
18.5%
19.0%
19.5%
20.0%
20.5%
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html
EmployerandEmployeeCostsRising
Source:Kaiser/HRETSurveyofEmployer-SponsoredHealthBenefits
USLifeExpectancy
TiedtoIncome
JAMA.2016Apr26;315(16):1750–1766.doi:10.1001/jama.2016.4226
HowDoWeAddressIncreasingCostswithInconsistentOutcomes?
It’stheValueBasedNetwork,Stupid
Let’stalkaboutNomenclature• AccountableCareOrganizations– ACO’sarefundedbytheACAandspecificallyaddresstraditionalMedicare
• ClinicallyIntegratedNetworks• PhysicianHospitalOrganizations• IndependentPhysiciansAssociations
– PrimaryCare– Multispecialty
• SingleTINGroups
AllcanbeValue-BasedNetworks
IndicatorsofValue-BasedNetworks• AggregateProvidersintoIntegratednetworks• Contractwithhealthplanswithrewardstiedtotripleaim• Connectelectronically• Trackandreportqualitydata• Trackandreportutilizationdata• Upsideriskagreements(MSSPTrack1,CommercialACOdeals)• Upsideanddownsiderisk(MSSPTrack2-3,NextGen)• PMPMTargets• PercentofPremium
“TransactionalServices”
• HealthRiskAssessments• Gapsincare• Medicationreconciliation• Attestations• CCM
– 99490,99487,99489• TCM
– 99495,99496
• Betterrelationshipbetweenpatientandprovider
• Canuncovermultipleconditionsleadingtobettercare
• PotentialtoreduceERVisitsandavoidableadmissions
• Potentialtoreducecostofcare• RightServices,RightPlace,RightTime
• IncreasedRevenuePotentialforRiskEntity(AppropriateRAFscoring)
• IncreasedRevenueOpportunityforProviders
=
WINforthePatient,WinfortheProvider,WinforthePayorTargetsthetripleaim:BetterCare,BetterPatientExperience,LowerstheCostofCare
Fee-for-service(FFS)
P4PVBM
PerDiemPerCaseBundledPayment
SharedRiskUpsideonlyGainsharingMSSPTrack1
Pioneer
SharedRiskupsideanddownsideNextGenACOTracks1+,2,3
Capitation PercentofPremium
More$ Provequality efficiency Upfrontcosts,
reward FinancialRisk Providerisdecision-maker
Full-RiskIncidenceandprevalence
MoreCases
MoreCases Morecases
AvoidwastepreventionQuality
Measures
Reduceutilization
LessCases ReservesRisktolerance TruePopHealth
ProviderAccountabilityRisk/rew
ard
CMSandthePushforValue
AlternatePaymentMethods
(MSSP/ACO/BPCI)
ManagedMedicare/MA
FeeforService/MIPS/ValueBasedPurchasing
• Choice• Quality• Cost
MIPSbringsthreatsoffeeschedulecutsandincentivesbasedonMIPSscores
• AllprovidersarerequiredtoparticipateinMIPSin2017,proposedrule
• Firstreportingperiod1/1/2017to12/31/2017
• Paymentsadjustedin2019basedonperformanceinthe2017period
• MIPSisbudgetneutralsoanyincentivesarepaidforviacutstootherproviders
• Howeverthereisabudgetexempt$500milliondollarsfor“exceptional”performanceinthefirst5years
May3,2016
TheAdvisoryBoardHealthCareCheatSheetSeriesMACRA:EducationalBriefingforIRProfessionals,April2016
MIPSScore:Components
Quality Category60% of score in year 1; replaces the Physician Quality Reporting System
Advancing Care Information Category*25% of score in year 1; formerly Meaningful Use
Clinical Practice Improvement Activities Category15% of score in year 1
Cost Category*10% of score in year 2; replaces the Value Modifier Program, also known as Resource Use)
*Forclinicianswhodonotmeetthesecategoryrequirements,CMSproposesreweightingthescoreto0andrecalculatingtheothercategories.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf
MIPSParticipantExemptions
ArenewlyenrolledinMedicare;
Have< $90,000inMedicarebillingsORhave< 200Medicarepatients;
AresignificantlyparticipatinginanAAPM.
HasMACRABeenNeutered?• SlowingofimplementationunderObamahascontinuedunderTrump
• 40%ofprovidersnowexemptfromMACRA• MIPSscoreof3willpreventcutsin2019• MeanFFSincreasewillbe0.9%• CosttoreportMIPSnationallyisgreaterthantheadditionalpaymentbyCMSforbestperformers
87
MSSPTracksTrack1UpsideRiskonly(2012-)
• APMunderMACRA• Retrospectiveattribution• Maxsharingrate50%• Paymentlimit10%• MSR:2-4%setbyCMS
Track1+UpsideandDownsideRisk(2018-)
• AAPMunderMACRA• Prospectiveattribution• Maxsharingrate50%• Maxlossrateof4%ofbenchmark• Paymentlimit10%• MSR:0-2%&chosenbyACO
Track2- UpsideandDownsideRisk;2012-• AAPMunderMACRA• Retrospectiveattribution• Maxsharingrate60%• Paymentlimit15%• LowerMSRandnowwithchoiceinMSR/MLRlevels
• Losslimit5%|7.5%|10%Track3UpsideandDownsideRisk;2015-
• AAPMunderMACRA• ProspectiveAttribution• Maxsharingrate75%• Paymentlimit20%• Morewaivers• Losslimit15%
QualifyingAdvancedAPMsfor2017• AdvancedAlternativePaymentModelsvsAlternativePaymentModels:onlytheformerwillcountforincentivesandMIPSexemption
• SharedSavingsProgram- Track2• SharedSavingsProgram- Track3• NextGenerationACOModel• ComprehensiveESRDCare(CEC)- Two-SidedRisk• ComprehensivePrimaryCarePlus(CPC+)• OncologyCareModel(OCM)- Two-SidedRisk• ComprehensiveCareforJointReplacement(CJR)PaymentModel(Track1- CEHRT)
• VermontMedicareACOInitiative(aspartoftheVermontAll-PayerACOModel)
Arizona Medicare ACOs 2018ACO StartDate Ownership/Structure
ServiceArea PCP's Attributedmembers/#Beneficiaries
BannerHealthNetwork* 1/1/2012 BH,BPHO,BMG,AIPMaricopaandPinalCounties 1020 78,000
ArizonaConnectedCare 4/1/2012 CommunityProviders,TMCSouthernArizona 195 6500
ArizonaCareNetwork** 1/1/2013 DignityHealth&AbrazoHealthArizona 1000 30,000
CommonwealthPCACO 1/1/2013 IndependentPCP'sArizona,NewMexico 100 16,000
JCLincolnACO 7/1/2013 HonorHealthMaricopaCounty 126 16,500
ScottsdaleHealthPartners 1/1/2014 HonorHealthMaricopaCounty 107 23.500
ASPA-ConnectedCommunity 1/1/2015 IndependentPhysicians(ASPA)Arizona,NewMexico 35 5200
NorthCentralAZAccountableCare 1/1/2015 YavapaiRMC,withNAH,Affiliates
Yavapai&CoconinoCounties 140 14,600
AbacusACO 1/1/2016 ArizonaCommunityPhysiciansSouthernArizona 131 26,853
OptumACO*** 1/1/2016 OptumMedicalNetworkMaricopaCounty 203 37,000
*MSSPTrack3**NextGenerationandMSSPTrack1+***MSSP Track2 ****NextGenerationAllothersMSSPTrack1
ACO Name 2017 Track 2018 TrackBanner Health Network MSSP Track 3 MSSP Track 3
Arizona Connected Care MSSP Track 1 MSSP Track 1Arizona Care Network MSSP Track 1 and
Next GenerationMSSP Track 1+ and Next Generation
Commonwealth PCACO MSSP Track 1 MSSP Track 1John C. Lincoln ACO MSSP Track 1 MSSP Track 1Scottsdale Health Partners MSSP Track 1 MSSP Track 2ASPA Connected Community MSSP Track 1 MSSP Track 1North Central Arizona AC MSSP Track 1 Track 1+Abacus ACO MSSP Track 1 MSSP Track 1Optum ACO Next Generation Next GenerationPathfinderHealth N/A Track 1+
Arizona ACO Tracks
ArizonaACO2016Results
https://www.thehertelreport.com/mssp-aco-2016-arizona-results-scottsdale-health-partners-earns-nearly-9m-in-earned-shared-savings/
ACOMovement/News
• PathfinderHealth leavesNCAACandstartsMSSPTrack1+• Summit(NEARnetwork)JoinsNCAAC• NCAACmovestoTrack1+• BannerHealthNetworkmovesfromPioneertoTrack3• ACNRunningMSSPTrack1+andNextGeneration• ScottsdaleHealthPartnersgoestoMSSPTrack2
HaveACOsBeenSuccessful?
• CBOscoredMSSPtosave$4.9Billionthrough2019• OIGreportedMSSPshavesavedCMS$1.7Billionthrough2016
• QualityscoreshaveriseninmorematureACOs– Bettercarevsbetterreporting
96
http://thehealthcareblog.com/blog/2017/12/18/fixing-macra-should-mean-fixing-the-apm-pathway/
NationalMSSPResultsToDate
MSSPResults 2012 2013 2014 2015 2016
EarnedSharedSavings 29 55 92 125 134
Reducedspending,belowthreshold 25 60 89 83 107
Increasedspending,belowthreshold 60 88 223 184 187
OwedmoneybacktoCMS 0 1 0 0 4
Total 114 204 404 392 432
2018• 561ACOs• 101downside
risk• 21withno
experience
CostvsACOQualityMeasuresinMSSPs
• CMMIwillbegoingina“newdirection”
• Toomuchhealthcareconsolidation
• “Wemustshiftawayfromafee-for-servicesystemthatreimbursesonlyonvolumeandmovetowardasystemthatholdsprovidersaccountableforoutcomesandallowsthemtoinnovate”
• “Consumersneedmorecontrolovertheallocationofhealth-careresources. ”
VBN’s*Alloftheattributedlivesinthe
MedicarecolumnarethroughtheMSSPorNextGenerationprograms.
**PCPsistotalMD/DOandmidlevelpractitioners
ThistableillustratesattributedlivesformanyValue-basedNetworksinArizona.Whilethislistiscomprehensive,weknowthereareother
VBN'sinArizonanotaccountedforinthisreportandtable.
ThedatawasaggregatedbyTheHertelReport,sourcedfromresponsesdirectlyfrom
theVBN’s.
Value-BasedNetworks- EstimatedCoveredLivesReport2018
OrganizationName Medicare* MedicareAdvantage Commercial Medicaid EstimatedTotal
Lives
EstimatedNumberofPCP's**
AbacusACO 28,000 23,200 30,000 7,100 88,300 131ArizonaCareNetwork 33,000 1,500 105,000 111,000 250,500 1,069ArizonaConnectedCare 8,318 5,819 14,021 0 28,158 195ArizonaPriorityCare N/A 11,005 0 0 11,005 322ASPAConnectedCommunity 6,200 0 0 0 6,200 50BannerHealthNetwork 50,737 90,381 288,644 13,200 442,962 1,032CommonwealthACO 16,000 24,000 5,000 42,200 97DistrictMedicalGroup N/A 0 0 91,500 91,500 60EqualityHealthNetwork N/A 0 0 77,255 77,255 290HealthChoicePreferred N/A 6,000 1,000 31,000 38,000 125InnovationCarePartners N/A 17,000 20,000 0 37,000 300JohnC.LincolnACO 16,400 N/A N/A N/A 16,400 140MIHS N/A 0 0 91,500 91,500 60NCAAC 14,500 0 0 0 14,500 145Optum ACO 37,000 65,000 0 0 102,000 600PathFinder ACO 9,843 0 6,056 0 15,899 78PhoenixChildrens CareNetwork N/A N/A 2,300 126,000 128,300 359ScottsdaleHealthPartners 23,500 N/A N/A N/A 23,500 150
TOTAL 243,498 219,905 488,721 336,055 1,288,179 4,78419.2% 17.3% 37% 26.5%
N/A:NotApplicable
Other Value-Based Networks
• Iora Health• P3 Healthcare Partners• Summit Medical Group• Cigna Medical Group
HowAreVBNsNavigatingThisUncertainty?
• Developingfinancialandoperationalcapabilitiestosupportdifferentvalue-basedpaymentmodelsanddifferentplantypesandmarketsegments
• Engagingproviders• Ensuringthatculture,leadershipandcommitmenttoqualityarealigned
LisaMead,RN,MS,CPHQ
QualityasaBusinessStrategy
Value=Quality/Cost(OverTime)
EnhancingCulture
WorkinginTeams
Training
Planning
PartneringwithSuppliers&Customers
RemovingBarriers
VoiceoftheCustomers
Reward&Recognition
Benchmarking
Outcomes
Data
QUALITY
TheNewParadigmforQualityImprovement• Aimedatcontinuousimprovement• DataDriven• AvoidsBlame• Createsystemsthatpreventerrors• Encourages“thinkingoutsidethebox”
SixImprovementAimsfromIOM:Theprocessofimprovingthelivesofpatients,thehealthofcommunities,andthejoyofthehealthcareworkforceinvolvesfocusingonanambitioussetofgoalsadaptedfromtheInstituteofMedicine’ssiximprovementaimsforhealthcaresystems:
• Safety• Effectiveness• Patient-Centeredness• Timeliness• Efficiency• EquityQualitycareisalsocoordinated,compassionate,andinnovative.(Roper,IOM2006)
ThePlatformforImprovement
• Will,Hope,andOptimism• Transparency:AllTeach– AllLearn• SafeandJustEnvironment• InnovationandImprovementScience• Integrated,Results-OrientedTeams• DesigningCarewiththePatientInvolved• CourageousandAdaptiveLeadership
InstituteHealthcareImprovement
HowFarAlongisYourCompanyintheQuality&ProcessImprovementJourney?
Aligned Acts of ImprovementRandom Acts of Improvement
GOALPerformance Excellence
GOALPerformance Excellence
HowtoDriveExcellence
• Implementmethodstobuildandmaintainperformanceexcellenceinyourhealthcareorganization.
• Executestrategiestoenhanceaccountabilityandachievequalityandpatientsafetyobjectives.
• Utilizemeasurementtoolstotrackclinicalandorganizationalprogresstowardmeetingperformanceexpectations.
RoleofLeadership
• Championofanenvironmentthat“enables”performanceexcellence– Buildsrelationships– Helpstoachieveresults– Leadspeople– Leadsstrategicchange– Allocatestalentandresources
TheLeadershipSystem
AsdescribedbyBoeing
QuestionstoConsider:• Whatwouldyouliketoimprove?• Whataboutyourorganizationcouldbemade:
– Safer– Timelier– MoreEfficient– MoreEffective– MorePatientCentered– MoreEquitable
GettingStarted– Engageyourleaders– Define/Reviewthevision,values,mission,culture– TeachQualityPIprinciples– SetprioritiesforQualityPlanDevelopment– Developpolicyandprocedures– Developa“scorecard”or“dashboard”– Gatherdata– Analyzethedata– Developimprovementplans– Implementationandfollowthrough
FinalThoughts• ACANotDeadYet• Uncertainty• MedicaidisEvolving• CMMICall-outforInnovation• PushtoValue-BasedCareModels• TraditionalNetworkandUtilizationDecisionsShiftingtoVBN’s–Transparency–Thein-crowdhastoearnit!–EssentiallytheTripleAim
QualityCostSatisfaction
MandateMedicaid Expansion
Marketplace Subsidies
Guarantee Issue No Pre-X No lifetime Max Community Rating MLR Rule Dependents to age 26Hospital Cuts Full-time= 30 hrs/wk
MA Plan Cuts Readmission ReductionAccountable Care Organizations Patient Centered Medical Homes
Device Taxes Bundled Payments Pay for PerformanceValue-based modifier
Merit Based Incentives Meaningful Use of EHR
Innovation Funding
TheHertelReportistheSourcethatConnects….• LocalNews
– AHCCCSAwards,Waiveracceptanceandimplementation,ACO/VBN,AHCCCSandMedicareAdvantagedata,morevalue-baseddealsandriskcontracts,innovation.
• NationalNews:– ExecutiveOrder:Salesacrossstatelines,associationplans,etc.– CongressionalAction:CSRs,extenders,reinsurance,statebystatemarketreform,Medicaidblockgrants/percapita,Medicaidbuy-in,shorttermplans,futureenrollmentfunding,etc.
ThankYouforYourAttendanceandContinuedSupport!
Remember to visit our website at:www.thehertelreport.com
Bepartofourmembershipcommunityandsignuptodayfortimely,impartialmarketnews,dataandexclusivereports!
117
http://www.chqpr.org/downloads/WhyVBPIsNotWorking.pdfhttps://www.thehertelreport.com/white-paper-why-value-based-payment-isnt-working-how-to-fix-it/
FailuresofExistingPaymentModels
http://www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf
SharedSavingsModelFailures
• Donotensurehighqualitycareisdelivered• Donotalignpaymentswithcostofcare• MaynotsupportservicesnotcoveredunderFFS• Incentivestonotdothingsmaynotalignwithpatients• Riskadjustmentnotenoughtoencourageservinghighneedpatients
• Providerpaymentnotundercontroloftheprovider• Retrospectivepaymentdesignleadstoprovideruncertainty
119
http://www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf
PatientCenteredPaymentSystem
• PreventativeCare– CMFandbundles
• DiagnosisandTreatmentPlanning– Bundles
• AcuteConditionTreatment– Bundles
• ManagingChronicConditions– BundleandCMF
120
http://www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf