ACOs and CINs — Where Did They Start, How Have They Evolved, and Where Are They Going Next?
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As the types and structures of Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs) continue to evolve, organizations moving into value-based care face an ever-changing landscape. Alternative payment model arrangements have driven provider organizations to hone in on specific tactics to meet their contractual and strategic objectives. Please join Health Catalyst Senior Vice President Dr. Amy Flaster and Population Health Management Consultant Jonas Varnum as they discuss the evolution of the ACO and CIN models, what new tools ACOs employ today to promote success, and lessons learned from organizations that have succeeded in alternative payment models. They will dive deep into lessons learned in addition to providing a primer on what has always been and continues to be vitally important to success in value based care. Specifics they will cover include: - Approaches to simplify quality metric reporting - Enhanced methodology that zeroes in on identifying high-value opportunities to improve patient populations - Key tips to expand your business with new contracts Dr. Flaster and Mr. Varnum’s combined experience make them uniquely qualified to guide you in your ACO or CIN journey. Dr. Flaster comes from a clinical background where she worked as Associate Medical Director at Partners HealthCare - one of the largest ACOs in the country. Mr. Varnum is a professional services strategy leader with demonstrated expertise delivering payment model transformation and helping providers and payers to strategically adjust their operations.
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ACOs and CINs — Where Did They Start, How Have They Evolved, and Where Are They Going Next?
- 1. ACOs and CINs – Where Did They Start, How Have They Evolved, and Where Are They Going Next? Amy Flaster, MD, MBA SVP, Population Health and Management, Health Jonas Varnum Population Health Management Consultant, Health Catalyst
- 2. • Context: Historical and Today • ACOs and CINs: The Basics • Evolution of ACOs and CINs • Key Components of Success: What Has Not Changed • Coming Next: What Has Changed Agenda
- 3. Background & Context Understanding the Landscape for Population Health Management
- 4. © 2018 Health Catalyst The Challenge: Rising Health Spend…. Healthcare spending growth outpaces the growth of the U.S. economy and healthcare prices grow faster than prices in the general economy 4
- 5. © 2018 Health Catalyst …Has Led To The Wave of Clinical Integration Today 5
- 6. • Context: Historical and Today • ACOs and CINs: The Basics • Evolution of ACOs and CINs • Key Components of Success: What Has Not Changed • Coming Next: What Has Changed Agenda
- 7. © 2018 Health Catalyst ACO = Accountable Care Organization • An ACO is a defined by CMS as “a Legal entity recognized and authorized under applicable Federal or State laws comprised of eligible groups of providers that work together to manage and coordinate care for a payer-specific population.” • Defined by CMS in common terms: “ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.” • Defined by AAFP: “An accountable care organization (ACO) is a group of health care providers who agree to share responsibility for the quality, cost, and coordination of care with aligned incentives for a defined population of patients. ” • Defined by ACP: “ACO refers to a legal entity composed of a group of providers that assume responsibility (are accountable) to manage and coordinate care for a defined group of patients in an effective (high quality) and efficient (low cost) manner.” • Unlike the traditional fee-for-service reimbursement model, which pays providers for each care service delivered, an ACO directly ties payment to outcomes and the providers’ abilities to deliver care in an efficient manner. What is an ACO? 7
- 8. © 2018 Health Catalyst ACO Commonalities • Standardize clinical protocols and reduce clinical variation • Meet quality targets • Coordinate care amongst providers • Organize and optimize a broad spectrum of care management • Ensure appropriate site of care and coordinate efforts • Develop patient engagement strategy • Create and monitor governance, partnership operations • Identify solutions for core clinical, analytic, IT, and resource functions • Monitor quality and payment targets • Negotiate and manage contracts • Establish procedures to distribute financial payments to participants Clinical Administrative 8
- 9. © 2018 Health Catalyst Contract Goal: Population-specific reduction of the Total Cost of Care Contract Components: • Benchmarks • Minimum / Maximum Savings Rate • Quality Score • Attribution – Retrospective vs. Prospective • Performance period and ramp up schedule • Data access • Contract review provisions ACOs: What are the Contract Goalposts? 9
- 10. © 2018 Health Catalyst CIN = Clinically Integrated Network • A CIN is “is a structured collaboration between community and employed physicians and hospitals to develop active and ongoing clinical initiatives designed to improve the quality and efficiency of healthcare services. Participation in such clinical integration creates a high degree of interdependence and cooperation among participants. Clinically integrated systems are recognized by the FTC and allow joint managed care contracting in order to accelerate improvements in healthcare delivery.” • A CIN grants the group the ability to negotiate better rates with payers and provides protection against anti-trust laws • A CIN has systems in place to enable their participants to share information about their patient populations. • A CIN allows participating physicians and practices to collectively track a shared patient population in order to optimize quality and cost reduction goals What is a CIN? 10
- 11. © 2018 Health Catalyst The 4 Key Principles of Every CIN • Active participation, engagement, and time committed to enhancing clinical quality (care pathways) and reducing costs. 1. Provider responsibilities • CIN standards of participation create recourse for providers noncompliant in quality and cost reduction policies. 2. Provider accountability • Must demonstrate the CIN improves quality and efficiency over time. 3. Clinical quality standardization • Efforts to meet quality standardization and cost efficiencies include infrastructure investment (IT), efficient network participants (monitored through IT), and clinical improvement tactics (care management and care pathways). 4. Resource Use Clinically Integrated Entity IPA Entity Ind. MDs Hospital(s) / Health System Post-Acute Care 11
- 12. © 2018 Health Catalyst A Level Deeper – the Components of a CIN 12
- 13. © 2018 Health Catalyst Which value-based contracts does your organization currently participate in? (Select all that apply) 1. Upside risk Medicare ACO/product – 40% 2. Downside risk Medicare ACO/product – 18% 3. Medicaid ACO/risk product – 22% 4. Commercial ACO/risk product – 34% 5. Payer/provider partnership – 53% Poll Question 13
- 14. • Context: Historical and Today • ACOs and CINs: The Basics • Evolution of ACOs and CINs • Key Components of Success: What Has Not Changed • Coming Next: What Has Changed Agenda
- 15. © 2018 Health Catalyst Clinically Integrated Infrastructure 15 Clinical Quality Committee Legal Requirement and Operating Agreement Stipulations: • Executive Committee • Compliance • Audit • Management Authority Finance Committee IT Committee Network Management Committee Tasks: • Oversee protocol implementation • Care Management Program • Patient engagement Opt-In and Other Initiatives OperationalPlanning: HowtomakeaneffectiveCIN Example Operational Structure Staff: • 2 FTEs @ 10 hours / month Charter Responsibilities: • Provide PMPM target Staff: • Utilization management Clinically Integrated Entity IPA Entity Ind. MDs Hospital(s) / Health System Post-Acute Care
- 16. © 2018 Health Catalyst Multi-Payer Effort 16 IPA EntityInd. MDs Hospital Post-Acute Care CMS Programs Contract Timeline Self-Insured Product Private Payer Program Intervention Timeline 1. Specialist financial incentives and engagement increase substantially 2. PMPM cost reductions increase 3. Network keepage tightens 1. Utilization management 2. Care Management Pilot begins 3. Other tactics 1. Clinical variation reduction 2. Clinical documentation initiative 1. Develop protocol standards 2. PMPM reductions 3. Post-acute network develops, delivers better quality Year 1 Other Contracts 1. Prevention Tactics Network Value 1. Physician solution to MACRA concerns 2. Physician engagement 3. Clear KPI improvement Clinically Integrated Entity
- 17. © 2018 Health Catalyst Scaled Long-Term Efforts Contract-Specific Participants CIN Participants Narrow Network Super CIN Scaled Infrastructure Contract-specific Services, Participant Agreement Contract-specific Agreement Providers join together with additional networks to expand their opportunities. Providers seek contracting and services support in contracting through interconnected, CI companies CIN / ACO Contract CIN Services Super-CIN 17
- 18. © 2018 Health Catalyst Evolution of ACO Model 18
- 19. © 2018 Health Catalyst • 5,000+ Medicare beneficiaries • One-sided risk (share in up to 50% of savings, not losses, not to exceed 10% of benchmark) • Retrospective attribution • Reduce costs by 2.0 – 3.9% to share in savings 2018 CMS ACOs 19 Level of Risk, Financial Reward MSSP Track 1 • 5,000+ Medicare beneficiaries • Two-sided risk: -30% - +50% • Prospective attribution • Reduce costs by 0.5 – 2.0% to share in savings MSSP Track 1+ • 10,000+ Medicare beneficiaries • Two sided risk (choice of +-80% or +-100%) • Prospective attribution • First-dollar savings (receive what you save) above/below benchmark • 4 payment options from FFS to capitation Next Generation ACO Providers meet MIPS / MACRA requirements 669,000 3,200,000 4,900,000 7,300,000 7,700,000 477,197 9,000,000 10,500,000 ~1,500,000 0 2000000 4000000 6000000 8000000 10000000 12000000 Pioneer MSSP MSSP MSSP MSSP NextGen MSSP NextGen MSSP NextGen 2012 2013 2014 2015 2016 2017 2018 CMS Beneficiaries Per Year
- 20. © 2018 Health Catalyst Innovation and Transformation in Payment “Secretary Azar and I are working for competition and better value by moving away from a fee-for-service approach, to a system that is value-based – and that rewards value over volume…. We also want to think about models that create a true competitive market, where providers compete for patients on the basis of price and quality, and move the government out of the business of setting prices. And in all of our models we will also make sure that our beneficiaries have incentives to seek value when they obtain care.” Government officials are continuing a push for transformation Seema Verma, CMS Administrator: Speech at AHA Annual Membership Meeting; May 7, 2018 https://www.cms.gov/newsroom/fact-sheets/speech-remarks-cms- administrator-seema-verma-american-hospital-association-annual- membership-meeting “It's also (the Centers for Medicare and Medicaid Innovation’s) job to say to folks, 'If you're not cutting it, get out of the way,' because there are others that will come that will cut it ... People will come in and take that risk and do something with it…" Adam Boehler, CMMI Director Speech at the National Associations of ACOs (NAACOS); October 5, 2018 https://www.medpagetoday.com/publichealthpolicy/medicare/75542 20
- 21. © 2018 Health Catalyst Pathways for Success – New Proposed Rule 21 Source: Health Affairs, 2018
- 22. © 2018 Health Catalyst Are ACOs Successful? Current Government Analysis Advocacy and External Analysis 2013-2015: -$358 Million in Net Shared Savings Payments (CMS saved money) 2013-2015: -$541.7 in net Shared Savings Payments (CMS saved money) 22
- 23. • Context: Historical and Today • ACOs and CINs: The Basics • Evolution of ACOs and CINs • Key Components of Success: What Has Not Changed • Coming Next: What Has Changed Agenda
- 24. © 2018 Health Catalyst Know Your End Goal 24 ….To A Contract-Based Focus… “Meeting contractual requirements from commercial insurers, Medicaid and the Centers for Medicare and Medicaid (CMS) related to dollars saved and quality metrics upheld in the context of small but growing at-risk contracts, while remaining successful in FFS contracts.” – Partners Healthcare …To An Aspirational Long-Term Goal “The science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” – C.-E.A. Winslow, Founder, Yale Department of Public Health From The Pragmatic… “The proactive management of the health of a given population by a defined network of financially linked providers in partnership with community stakeholders” -Chilmark Research
- 25. © 2018 Health Catalyst Educate and Engage Physicians and Stakeholders 25
- 26. © 2018 Health Catalyst Let The Patient Be Your Guide 26
- 27. © 2018 Health Catalyst A Framework for Transformation PHM leadership lays groundwork for a high-functioning analytic platform Analytics leadership builds a structure to identify and evaluate opportunities Financial leadership balances risks and helps set a sustainable course forward Clinical leadership identifies and implements appropriate changes in care delivery KEY ACTIVITIES 1. Ensure baseline understanding of current requirements, goals 2. Interview stakeholders for context 3. Assess available data to identify quick wins, long-term focus areas 4. Synthesize and prioritize opportunities 5. Plan for ongoing evaluation, analysis KEY ACTIVITIES 1. Align PHM with financial plans 2. Look to benchmarks to set expectations 3. Ensure you’re paid for value you provide 4. Pace utilization efforts carefully 5. Increase ability to understand true cost of care KEY ACTIVITIES 1. Streamline your approach to quality measures 2. Optimize care management 3. Shore up primary care infrastructure 4. Seek opportunities for inpatient transformation 5. Ensure appropriate site of care 6. Develop patient engagement strategy Near term Meet contractual requirements in FFV contracts Remain successful in FFS business Long term Better quality of care Lower costs Stronger organization Healthier community Create a Framework for Formulaic Success 1 2 3a 3b KEY ACTIVITIES 1. Prioritize data sources, starting with claims data 2. Educate stakeholders on the available data 3. Define supporting logic—like attribution 4. Invest in staffing Transformative activities and investments that grow your ability to deliver the highest quality, most cost-effective, and most care for patients across the continuum 27
- 28. • Context: Historical and Today • ACOs and CINs: The Basics • Evolution of ACOs and CINs • Key Components of Success: What Hasn’t Changed • Coming Next: What Has Changed Agenda
- 29. © 2018 Health Catalyst • Mix various types of contracts for overall strategic impact o Shared Savings, PMPM bonus, Care Management PMPM, Bonus Fee Structure • Depth in contracting operations, benchmarks, attribution o Base benchmark upon clean, transparent historical data o One source of claims data is one source. Understand or define attribution and assignment across multiple payers. • Define upfront expectations on quality measures o Create simple slate of quality metrics across payers o Be purposeful of definitions for trending and maintenance A Shift to Purposeful, Aggressive Contracting 29
- 30. © 2018 Health Catalyst • CINs and provider systems are starting health plans • Compete and/or join with payers to support new clinic structures • Mutual alignment between end goals allows partners to determine who is most efficient at what operations o Network Utilization o Care Management Continuum o Network Design, Products, and Services o Member Services • The Next Frontier: Renewed emphasis of employer-space with a lot of innovation (Amazon, Berkshire, JP Morgan) Increasing Payer-Provider Integration 30
- 31. © 2018 Health Catalyst Enhanced Speed In Defining Impact Populations 31
- 32. © 2018 Health Catalyst Ongoing Expansion of Medicaid Value Based Care Source: Center for Healthcare Strategies 32
- 33. © 2018 Health Catalyst Increasingly Sophisticated Data Components 33 SDoH Data Geomapping Data Genomic Data Wearable Data PROMs Data
- 34. © 2018 Health Catalyst Evolving Care Management Models • Care Management ‘team leads’ tailored to the types of patients they serve • From RNs, to CHWs, to SWs, to MAs • CM Management outsourcing solutions: • AWVs to full-suite of services • Digitization of Care Management: o Patient Stratification with Machine Learning o Risk Identification for targeted interventions o Telemedicine 34
- 35. Q&A
- 36. Thank You!