Coordinating Care in the Total Cost of Care...

Coordinating Care in theTotal Cost of Care Environment

Stacy Garrett-Ray, MD, MPH, MBAJanuary 9, 2018

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Agenda

• Review Local Landscape with Value Based Care

• Medicare Performance Adjustment and Total Cost of Care

• Care Coordination Strategies to Manage Under Total Cost

of Care

• Lessons Learned

Confidential and Proprietary

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Disclosures

I have no relevant financial or other disclosures.


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Current State of Health Care:

Searching for Value

Sources: M. Bittle, Population Health and Population Health Management: “What it is and What it isn’t” November 2018

Graphic: J. Colmers, Commissioner, Health Services Cost Review Commission, Maryland

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Searching for Value

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Rapid Rise of Healthcare Insurance Premiums

Sources: (left) Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits Annual Surveys, 1999–2012; (right)

authors’ estimates based on CPS ASEC 2001–12, Kaiser/HRET 2001–12, CMS OACT 2012–21.

Projected average family premium as

a percentage of median family

income, 2013–2021

Cumulative changes in insurance

premiums and workers’ earnings,

1999–2012

PercentPercent

180%

47%

38%

Projected

172%

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• Intermittent, episodic care– Fosters fragmentation

• Lack of coordination throughout

continuum of care– No accountability to perform as a

healthcare system

• Systems built to treat the sick

• Rewards utilization/volume

(Traditional Fee for Service)

Reactive, Volume Based

Care

Current State


Searching for Value


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• Coordinated

• Continuous, Proactive

• Connected care – Streamlined, easier to

use and focused on prevention– Utilize technology to monitor, prevent conditions,

and assist with intervention and diagnoses

– Predictive Analytics

– Artificial Intelligence

• Individualized, genomics

• Reimbursement based to value and

management of total cost of care– Lower cost

– Better experience

– Better quality

– Better outcomes

Proactive,

Value Based Care

Future State

Future State of Health Care:

Searching for Value


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Payors Are Implementing New Reimbursement

Models to Influence Health Care Delivery

Maryland’s physician value based contracting models are advancing similar to

other areas of the country where providers have opportunities to assume financial

risk to manage populations.

• Patient Centered Medical Home (PCMH) is a voluntary program and providers who

participate can earn additional reimbursement increases of three types – increased fee

schedules, care plan development/maintenance fees, additional fee schedule rewards

for reduced cost.

• Most dominant value based program in Maryland.

• Other commercial and federal payers and have created Accountable Care

Organization (ACO) models that reward for reduced utilization and increased quality.

• Goal is to move providers toward taking greater financial and clinical risk.

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Maryland’s Medicare Waiver

Phase I (2014-2018)

Controlling and reducing

the rate of growth in

per capita hospital

expenditures for Maryland

residents

Phase 2 (2019-2023)

Controlling and reducing the

rate of growth in total health

care cost per Medicare

Beneficiary in Maryland

Primary Care

Offices

Home


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Highlights of

Maryland Primary Care Program (MD PCP)

UTILIZATION

CMS will assess practice performance on utilization measures. For the 2018 Measurement Period, we will focus on the following two utilization measures

from the Healthcare Effectiveness Data and Information Set (HEDIS®)

•Inpatient hospitalization utilization per 1,000 attributed beneficiaries

•Emergency department utilization per 1,000 attributed beneficiaries

QUALITY AND PATIENT EXPERIENCE

This model aims to improve the beneficiary quality and experience of care and decrease the total cost of care.

To assess quality performance and eligibility for the CPC+ performance-based incentive payment, CMS will require Track 1 and 2 practices to annually report

electronic clinical quality measures (eCQMs) and patient experience of care measures (Consumer Assessment of Healthcare Providers & Systems [CAHPS]).

Performance

Alignment with

Medicare Hospital Goals

Based on CMS

Comprehensive Primary

Care Plus (CPC+) program

Launch- January 2019

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Care Transformation Organizations

Care Transformation Organization (CTO) Design

CTO

Care Management

Data Analytics and Informatics

Practice Transformation

Assistance with Care

Transformation Requirements

Standardized Screening

PCMH

Care Managers

Pharmacists

LCSWs

Transformation Agents

CHWs

Services Provided to PCH: Provision of Services By:

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And

Risk Stratified

Care Management

Behavioral Health Consults and

Telepsychiatry

Pharmacy Expertise and

Medication Management

Practice Transformation

Specialists

LCSWs, Social Risk Assessment

Transitions of Care Support

Quality Improvement

Activities

Data Analytics

Our patient-centered care model uses a team-based approach to work collaboratively with

providers on care delivery transformation that is tailored to their individual needs.


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Definition of Population Health Management

The capability to successfully manage care for a group of

individuals in order to reduce unnecessary utilization and cost

and improve quality, outcomes, and experience.

Key elements:

• A high performing network of providers---community and hospital based

• A “population health bundle” of people, processes, and information technologies that

are utilized by network providers to successfully manage care

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Population Health Management


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Source: Thomson Reuters Marketscan Database

The 70/10 Rule

Major factor in Effectively Managing TCOC

Focus care management on “high cost” populations

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Risk Stratification:

Focus of Interdisciplinary Care Teams


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Appropriate Documentation and Coding is

Necessary to Accurately Reflect Population

Accurate

Documentation and Coding

allows us to provide

appropriate care

management resources for

patientsConfidential and Proprietary

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CMS Hierarchical Condition Category

(HCC) Risk Adjustment Factors

• HCC model is built off the Medicare FFS population –which is

the “denominator.”

• Average risk score of 1.0 and cost an average of $9,367.51 in

2018.

• The RAF weighting can be multiplied against that value to

estimate how much cost is associated with each condition.

Announcement of Calendar Year 2017 MA Capitation Rates and Medicare Advantage and Part D Payment Policies

* - Source:BCHD White Paper: State of Health in Baltimore (Winter 2016)- https://health.baltimorecity.gov/state-health-baltimore-winter-2016

Per ACO Data,

Average Risk Score in Baltimore City is 0.85 in 2017.

“[Baltimore

City] has a

mortality rate

30% higher

than the rest

of the state,

and ranks last

on key health

outcomes

compared to

other

jurisdictions

in

Maryland.”*

RAF Score Expected Expenditures

Diabetes without complications 0.104 $974

Diabetes with complications 0.318 $2,978


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Know the Population:

Coordinating Care Across the Continuum

Community Connect


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- High Utilization (multiple ER visits and/or

admissions in last 12 months)

- Polypharmacy (>10 medications)

- High risk medications (e.g., Warfarin)

- Multiple chronic conditions

- Poorly controlled disease states

- High medical and pharmacy costs

- Problems with adherence to treatment plan

- Multiple providers; multiple caregivers

- High potential for negative outcome within next

year without care management intervention

(Predictive Analytics)

Criteria for Targeting High Risk

Patients for Complex CM Enrollment


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Engage: Interventions to Support Operations

Portfolio MD


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Home Care

High Risk Clinics

Complex Care and Disease Management

Self-Management & Health Education

Programs

Additional

Medical

Management

Infrastructure

Costs (per

patient

treatment per

month)

Home Care ManagementProvides in-home medical care management by specialized physicians, nurse care

managers and social workers for chronically frail seniors that have physical, mental,

social and financial limitations. Chronically disabled patients receive specialized

integrated home care programs

Complex Care and Disease ManagementProvides long-term whole person care enhancement for the

population using a multidisciplinary team approach.

Diabetes, COPD, CHF, CKD, Depression, Dementia, Organ transplant

and Cancer.

Self Management, PCPProvides self-management for people with

chronic disease and prevention services.

High Risk Clinics and Care ManagementProvides one-on-one physician /nurse, and case management for highest risk

population. As risk is reduced, patient transferred to Level 2. Physicians and

care managers are integrated into community resources, physician offices, or

clinics. Chronically mentally ill are directed to specialized medical clinics

Hospice/Palliative Care

Matching the Patient

to the Care That They Need


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Manage: Optimize Performance and Outcomes


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Key Areas of Focus

1. Leadership support and governance

- Culture change for community practices and hospitals to partner together as a

network to enhance quality of care and outcomes

2. Strategy, sustainability, and transformation

- What does it take to develop and maintain a sustainable model (i.e. network vs.

individual practice provided services, SOPs, Training, Onboarding)

- Share promising practices

- Engage providers and practices to actively become necessary change agents for

transformation

3. Network composition and access.

- Ideal network size and provider mix to care for population including community

partners

4. Population health management capability

- Identify and build services including data analytics and

infrastructure required to support the network

- Prioritization process for system approach

Adapted from: Corneliuson et al. Super Clinically Integrated Networks: 8 Components to Consider http://blog.thecamdengroup.com/blog/topic/clinically-

integrated-networks Confidential and Proprietary

http://blog.thecamdengroup.com/blog/super-clinically-integrated-networks-8-components-to-consider

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Key Areas of Focus

5. Clinical care models and coordination

- Identify potential clinical care models to assist with

the management of high cost, chronic disease

patient groups

- Identify gaps and optimal approaches to integrate care to gain

across the network

6. Quality, value and transparency

- Identify quality metrics being measured and tracked and reporting

process and identify gaps and develop communications plan and

strategy to address

7. Financial management and reimbursement

- Develop financial incentives and risk sharing supporting TCOC

goals (i.e. MDPCP, TCOC)

8. Provider/Patient experience and activation

- Develop communications, educational, and community support

programs to engage providers and patients and improve compliance

Adapted from: Corneliuson et al. Super Clinically Integrated Networks: 8 Components to Consider http://blog.thecamdengroup.com/blog/topic/clinically-

integrated-networks Confidential and Proprietary

http://blog.thecamdengroup.com/blog/super-clinically-integrated-networks-8-components-to-consider

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Lessons Learned

• It’s all about execution - People, processes and technology.

• Standardization using best practices is important to operate

effectively.

• Commit to continuous improvement and innovation.

• Allow the data drive your initiatives. The business case is

based on improving outcomes, quality of care and cost

avoidance---building and adhering to sophisticated, rigorous

financial models is important.

• Building population health capabilities takes time!

• It take a team! – Community Providers and Resources

in Collaboration with HospitalsConfidential and Proprietary

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Thank you

Thank you to the

University of Maryland Quality Care Network/

Transform Health MD Team

for your hard work and dedication!


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Questions

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MDPCP Financial Opportunity

• Based on CMS

Hierarchical Condition

Categories (HCC)

• Factors in demographic

factors, chronic

conditions

• Increased care

management fees by risk

score allows providers to

better manage care

• PBPM= Per Beneficiary

Per Month

Track 1 Track 2

Risk TierCriteria

PBPM

CMF Criteria

PBPM

CMF

Tier 1 01-24% HCC $6 01-24% HCC $9

Tier 2 25-49% HCC $8 25-49% HCC $11

Tier 3 50-74% HCC $16 50-74% HCC $19

Tier 4 75-89% HCC $30 75-89% HCC $33

Complex

90+ HCC or

persistent and

severe mental

illness, substance

use disorder or

dementia $50

90+ HCC or

persistent and

severe mental

illness, substance

use disorder or

dementia $100

Care Management Fees

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