navigating the new era of accountable care organizations and reimbursement daniel c. demarco, md...
TRANSCRIPT
Navigating the New Era of Accountable Care Organizations
and ReimbursementDaniel C. DeMarco, MD
Texas Society for Gastroenterology and Endoscopy
September 19, 2015
Disclaimers
• Chairman of the Finance and Contracting Committee for Baylor Scott & White Quality Alliance Accountable Care Organization
• Vice-chairman of the Board of Managers of Baylor Scott & White Quality Alliance Accountable Care Organization
• Governor of the North Texas Region for the American College of Gastroenterology
PPACA
• Passed in 2009• AKA “Obama care”• Healthcare Reform• Insurance Reform• Alternative Payment Models• Meaningful Use• Quality Metrics
6
Population Health: 2 Mandates
Value
Value = Quality (+Access) Cost
The “Triple Aim”
STEEEP Care
“The overarching goal for providers, as well as for every
other stakeholder, must be improving value for patients”
– Michael E. Porter –
Accountable Care Organizations
• Part of and possible because of the PPACA• Physicians and Healthcare Systems become
accountable for expenditures– Stakeholders– Skin in the game– Accept shared savings– Accept up and down side risk
Why ACO’s?
• Right thing to do?– No longer just spending other peoples money– Spenders (physicians and Healthcare Systems)
now held accountable for delivering high value care
• Last chance for Physician’s to have control over their destiny
• Only way to enhance productivity in the near future
9
ACO Components Built
▪ Mission▪ Vision▪ Culture▪ Strategic financial plan and operating budget developed
Strategic Development
▪ Physician-led Board of Managers▪ Five primary committees activated▪ Twenty-five subcommittees
Governance
▪ Network adequacy▪ Credential verification▪ Regional care needs assessment▪ Exceeded budgeted revenue stream through FY14
Network Development
▪ Informatics infrastructure▪ Data analytics implementation▪ Physician dashboard▪ Member website deployment▪ EMR subsidy program
Information Technology
▪ RN Health Coaches▪ Care Coordinators▪ PCMH Design ▪ Population Health
Care Management
▪ BHCS Employee Health Plan
▪ Aetna MA▪ Humana MA▪ Scott & White
Health Plan▪ Shared
Savings Distribution Model
Contracting/ Compensation
Why should PCP’s join an ACO?
• Ensure a continuous flow of patients• Help with compliance with new regulations
– Meaningful use– EHR– PCMH certification
• Care Coordination• Maintain some control (not autonomy)• Additional revenue
Why should a specialist join an ACO?
• Ensure continued referrals• Participate in care protocols• Additional committee work• Minimal if any additional revenue• Minimal negotiation
– Possible bundles of care?
Shared Savings
• Projected PMPM expenditures minus actual expenditures
• Often adjusted for outliers with stop loss insurance
• Savings is distributed amongst stakeholders according to a mutually agreed upon formula
Shared Savings Distribution
• BSWQA• Others
Distribution to Physicians
• “Shared”• 10% shared equally amongst all those meeting clinical
integration criteria• 70% shared amongst PCP’s according to volume and
PCMH level• 20% shared amongst specialist on a pro rata basis
• If clinical integration criteria are not met, there is no participation in any shared savings!
BSWQA Performance Year 2014 Shared Savings
Trent Hadley
Shared Savings Funds Flow – Based Upon Plan Year 2014
Gross Health Plan Savings
$9,925,983
Net Shared Savings Pool
$8,542,704
50% of Net Shared Savings Pool Applied as a Reduction in Funding
to the Trust in Following Year$4,271,352
Recover Costs of Care Coordination Services
$1,383,279
Repayment of Amounts Paid In Advance by BSW NTX Health
Plan
12.5% of Net Shared Savings Pool to Member
Hospitals $1,067,838
12.5% of Net Shared Savings Pool to
Eligible Physicians$1,067,838
50% of Net Shared Savings Pool To BSWQA
$4,271,352
25% of Net Shared Savings Pool Retained
by BSWQA*$2,135,676
*The percentage retained by BSWQA to cover initial capital contributions by Members and operating losses will be reduced to 0% when operational break-even is achieved and all cumulative losses from prior years have been recovered..
Member
BQA
Calculation of savings is based on Allowed health plan related expenses, including employer related costs, employee related costs, plan design changes, and adjusted for high cost claims considered unmanageable.
For the periods 01/01/2014 thru 12/31/2014
Baylor Scott & White Quality Alliance2014 Shared Savings Calculation – Medicare Advantage
25% Distributed to Member Hospitals (other op. income)
$332,150
25% Distributedto Participating
Physicians$332,150
50% Distribution To BSWQA$1,328,602
50% retained by BSWQA to cover losses*
$664,301
Member
BSWQA
For the periods 01/01/2014 thru 12/31/2014
*The percentage retained by BSWQA to cover initial capital contributions by Members and operating losses will be reduced to 0% when operational break-even is achieved and all cumulative losses from prior years have been recovered..
Baylor Scott & White Quality Alliance2014 Shared Savings Physician Distributions
• Total Shared Savings Distributions to Member Physicians• $1.4 Million – 1,061 Member Physicians Met Clinical Integration Criteria
• Primary Care Physician Pool – 294 Member PCPs Met Clinical Integration Criteria• Average Distribution to PCP - $3,500• Highest Earner - $14,000
• Specialty Pool – 767 Member Specialists Met Clinical Integration Criteria• Average Distribution to Specialist - $500
Baylor Scott & White Quality Alliance2014 Shared Savings Member Hospital Distributions
• Member Hospital Criteria Based on FY2015 AIP Goals• Readmission Performance Goal – 40%• VBP Care Bundle Performance Goal – 28%• Hospital Acquired Conditions Goal – 32%
Member Hospital Shared Savings Distribution
BSW NTx Aetna MA Humana MA SW MA Total
Baylor University Medical Center 14.2% 151,645.72$ 23,173.68$ 13,189.21$ 10,806.43$ 198,815.04$ Baylor Scott & White Medical Center Waxahachie 16.2% 173,002.48 26,437.31 15,046.69 12,328.34 226,814.81 Baylor Regional Medical Center Grapevine 10.8% 115,237.52 17,609.98 10,022.65 8,211.95 151,082.10 Baylor Medical Center Carrollton 16.2% 173,002.48 26,437.31 15,046.69 12,328.34 226,814.81 Baylor Regional Medical Center Plano 3.8% 40,234.61 6,148.44 3,499.36 2,867.16 52,749.57 Baylor Medical Center Garland 16.2% 173,002.48 26,437.31 15,046.69 12,328.34 226,814.81 Baylor Medical Center Irving 6.4% 68,710.29 10,499.94 5,976.00 4,896.37 90,082.60 Baylor All Saints Medical Center 16.2% 173,002.48 26,437.31 15,046.69 12,328.34 226,814.81
100.0% 1,067,838.06$ 163,181.25$ 92,874.00$ 76,095.25$ 1,399,988.56$
Total Distribution %
Clinical Integration Criteria
• Necessary to participate in shared savings and negotiations
• Seemingly onerous and a “waste of time”• Absolutely necessary to receive funds
– If not clinically integrated, What are you being paid for?
– You have already been paid fee for service• Many feel FFS is all one deserves to get!
ACO’s
• Not an Insurance Company– Currently administered through a traditional entity– BSWQA works with:
• Aetna• Humana• United• SWHP• Medicare (MSSP)• Negotiating with the Blues
Reimbursement• Joel Brill, MD, FACP, AGAF, FASGE Faculty and Presenter at GO
2015“The Future of GI Reimbursement: A Shifting Landscape” • “CMS has proposed to reduce payment for diagnostic
colonoscopy, 45378, from 3.69 to 3.29. This 0.40 reduction in RVW represents a cut of approximately 11% across all colonoscopy procedures, which may be magnified by other adjustments to endoscopic reimbursement. In addition, Medicare has laid the groundwork for removing moderate sedation from endoscopic procedures, and revaluing anesthesia for endoscopic procedures, effective in 2017. Along with Medicare’s proposal to reduce ASC facility reimbursement for colonoscopy procedures by almost 3%, Gastroenterology is facing significant and unprecedented threats to our profession.”
Reimbursement
• Cuts to procedures– Proposed 10-20%– Effective Jan 2016
• Separation of sedation component of G-code procedures– Moderate sedation for endoscopic procedures
surveyed with very short notice last July– Transparency????
More on Reimbursement
• Cuts were coming• Actually, we were lucky in that they were
delayed a year• Your societies (ACG, AGA and ASGE) have
people working full time to preserve your revenue stream and ensure the survival of your practice
• Many challenges
Why Bundled Colonoscopy?
• Decreasing Reimbursement• Defined episode of care with a defined
beginning and end.• Extreme variation in charges.• High demand and costs.• It is the only procedure that everybody gets.• Competition with other colon cancer
screening modalities.
Summary
• Join an ACO or two• Consider APM’s• Consider bundles• Expect declines in FFS• Get paid for value, not procedures