2018 arizona winter state-of-the-state...– former az hfma president introduction. the hertel...

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

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FailuresofExistingPaymentModels

http://www.chqpr.org/downloads/WhyVBPIsNotWorking.pdf

SharedSavingsModelFailures

• Donotensurehighqualitycareisdelivered• Donotalignpaymentswithcostofcare• MaynotsupportservicesnotcoveredunderFFS• Incentivestonotdothingsmaynotalignwithpatients• Riskadjustmentnotenoughtoencourageservinghighneedpatients

• Providerpaymentnotundercontroloftheprovider• Retrospectivepaymentdesignleadstoprovideruncertainty

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PatientCenteredPaymentSystem

• PreventativeCare– CMFandbundles

• DiagnosisandTreatmentPlanning– Bundles

• AcuteConditionTreatment– Bundles

• ManagingChronicConditions– BundleandCMF

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