Health Economics Research:
Collaborating with ACOs to Improve Patient Data
Todd Berner MD
Director, Health Economics & Clinical Outcomes Research
Astellas Scientific and Medical Affairs
3rd
Partnering with ACOs Summit
March 18, 2014

“Todd Berner is a paid employee of Astellas. The opinions stated in this
presentation do not necessarily reflect those of Astellas.”

Muller RW, ECRI Institute Conference 11.28.2012

NAACOS Survey of 35 ACOs
First year start-up experience:
“What were your most vexing problems?”
• Meeting implementation schedules
• Finding suitable software
• Delays in getting claims data
• Developing new skill sets to analyze data
• Obtaining addresses of assignees
• Slow stand-up of IT systems
• Data inconsistency from CMS
• Translating data into actionable information for care
managers and providers
NATIONAL ACO SURVEY CONDUCTED NOVEMBER 2013
www.naacos.com accessed 3.12.2014
The typical ACO is risking $3.5
million, plus feasibility and
pre-application costs, until it
can get “cash flow relief”
from possible savings
At least one-third of the ACOs
took out legal debt to finance
their venture
 So many are certainly
banking on recouping
investment costs

Estimated Number of Lives Covered by ACO Contracts
Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013

Total ACOs Over Time
Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013

Physician Led ACOs:
Physician practices have the potential to encourage hospitals to compete
on price and quality for the allegiance of physician sponsored ACOs

Reasons for Slowing in Growth of ACOs
• Reason 1: Tapped Out Market for Trailblazers
• Reason 2: No Proven Model to Follow
• Reason 3: Payer Delays
Leavitt Partners Center for Accountable Care Intelligence in Muhlestein Health Affairs Blog Oct 13,2013

Providers
Assuming
Risk:
• Nationwide, about 120 provider-
sponsored health plans are owned by
hospitals or health systems or are in the
process of applying for license to own
health plans
• Few provider-owned health plans will
participate in exchanges
• About 15% of hospitals had PPOs, 13%
HMOs and 5% fee-for-service products
in 2011, with percentages relatively flat
over a decade, according to AHA’s latest
data
Health Plan Week August 19, 2013 Volume 23 Issue 28
There are limitations for smaller provider
organizations in taking full risk and
becoming an insurance plan, “because
you need large numbers in terms of how
capitated rates are set.”

• North Shore-LIJ began a health plan for its 50,000-some
employees and their families about four years ago
• North Shore is the primary network and UnitedHealthcare
the plan’s administrator, provides the “wrap” network
• More than 85% of inpatient services occur at North Shore-
LIJ facilities
• Benefit design encourages employee base to use their
health system and lowers costs
• The Plan’s experience, coupled with market changes under
the reform law and interest from employers and unions,
allowed the move into fully insured products and to
become an insurance company
Health Plan Week August 19, 2013 Volume 23 Issue 28
North Shore-LIJ:
Started With Own
Workforce
North Shore-Long Island Jewish (LIJ) Health System is marketing an array of commercial products under North Shore-LIJ CareConnect
It will sell individual and small-group options on the exchange and individual and group products off the exchange
The delivery vehicle is an exclusive provider organization (EPO) offering only in-network benefits falling on the low end of 2014 pricing
ranges for various metal levels

Catholic Health Initiatives
(CHI)
• Colorado-based CHI, a nonprofit system, operates in 18 states and includes 86 hospitals; 40
long-term care, assisted- and residential-living facilities; two academic medical centers; and
home health agencies
• CHI has been developing its strategic plan for how it should participate in risk-based
relationships with the payer community
• CHI sponsors health benefits for as many as 70,000 workers, so they are at risk for their own
employees
• CHI purchased Soundpath Health, Inc., a Medicare Advantage (MA) plan in Washington state,
for $24 million in 2012
• CHI also is involved in bundled pricing, the Medicare Shared Savings Program, a couple of
ACOs, and a managed Medicaid globally capitated program in Nebraska
• The health system is involved in a growing number of “value-based relationships” with
insurers —offering financial underwriting gains if CHI demonstrates that it meets certain
quality, cost and service measures
• In 2014 and 2015, CHI will make a significant investment in electronic health records and
informatics for better evaluation of patient data and claims, taking active opportunities to
learn about the populations they’re serving, and how to better manage their care and costs
at the same time
Health Plan Week August 19, 2013 Volume 23 Issue 28

• Anchored by the system's two flagship academic medical centers, with referral volume generated
by a large group of employed and aligned physicians and by multiple community hospitals within
the Partners system.
• Largest non-university based research enterprise in the United States with over $1.6 billion in
research revenue
• Research revenue provides a meaningful source of revenue diversification and contributes to
Partners' ability to recruit physicians
• The system is affiliated with Harvard University for medical training.
• There is significant consolidation and merger and acquisition activity among Boston area hospitals
resulting in the emergence of networks of physicians and hospitals with overlapping geographies
that are competing for similar patient populations
• Multiple academic medical centers in Boston are pursuing similar strategies.
• Partners acquired a moderately sized healthcare insurance company (Neighborhood Health Plan)
in 2013
 NHP generated a 1.0% margin in FY13
 Two thirds of NHP's business is Medicaid managed care, exposing the system to rates dictated by the state
 Focus on cost control has lead to increased government regulation in Massachusetts
 Growth of health insurance products that provide financial incentives for cost control could limit
patient care revenue growth in future years
Moody’s Investors Service Jan 27,2014

Innovation Health Plans:
Inova Health System + Aetna
“Streamlining the process”
• Jointly owned health plan serving Northern Virginia
 Inova provides care to more than 1.1 million Northern Virginia residents annually
 Aetna provides health care benefits to approximately 570,000 members in Virginia
• Aetna
 Health benefits administration and care management capabilities
 Inova
 Health care delivery
• The partnership will promote clinical integration of the health care community
 Health system will engage community physicians to focus on promoting wellness
 Improve patient outcomes through better care coordination
 Streamline access to patient information
 Aetna will support Inova with technology that makes it easier for physicians to exchange information
and track their patients’ care across all settings.
• Commercial and Medicare Advantage HMO and PPO products will be offered in Northern
Virginia as part of the joint venture
 The new products will give employers and consumers access to less expensive, more coordinated
and integrated health care fostered by the partnership and engagement with community physicians.
“Both Inova and Aetna believe that shared
accountability translates into a powerful new value
proposition for consumers,”
Mark T. Bertolini, Aetna chairman, CEO and president

Listening to the Patient Voice in
Research

“When you come to a wall that is too
high to climb, throw your hat over the
wall, and then go get your hat.”
-Old Irish Adage

HECOR Value Evidence Generation
Access

Real World Evidence:
Efficacy vs. Effectiveness
Example-
• RCT data
• Extremely high placebo response rates
• Difficult to show efficacy for drug compared to placebo
• It is essentially all non-pharmacologic therapy compared to
non-pharmacologic therapy + drug
• Real World data
• All of the behavioral, non-pharmacologic intervention
associated with the RCT moves over to the drug side of the
ledger
• This becomes a comparison of activated, engaged Rx
recipients vs. those with just an Rx

Winning under reform:
Critical success factors
 High quality; reduce costs
 Ability to aggregate clinical capabilities and deliver
evidence-based care
 Access to capital
 Ability to aggregate lives
 Physician / Hospital alignment
 Ability to aggregate and analyze data
 Ability to engage consumers
 Manage transition with one foot in FFS and stepping
into risk-based contracting
 Ability to manage risk
 Understand benefit design

Opportunities for ACOs to Better
Manage Costs
• Consider distinctions among medications
• Acquisition costs
• Utilization
• Overall medical costs
• Identify interventions
• Utilization management strategies
• Drug formulations
• Best practices for risk management
• Care coordination

Identifying the various Stakeholders

The Imperative to Remain Relevant
• Forging new types of relationships to answer
questions of relevance to ACOs
• Developing a “Change Package”

Sample Research Project #1:
Primary Nonadherence to Medication within a Health System
• Phase 1
 Retrospective database analysis that will help evaluate the treatment patterns and health care resource
utilization amongst our population of interest. This will build the foundation to understanding the adherence
rates, discontinuation rates and switching rates within this population. This will quantify the burden of both
primary and secondary nonadherence. We will also identify patient and prescriber characteristics for this
population, and evaluate the factors associated with patients being non adherent or discontinuing. Stratification
between age will be conducted to evaluate the Medicare population versus non-Medicare (>=65 y/o versus <65
y/o). We will assess factors associated with the nonadherence or discontinuation of the various therapies. It
would be ideal to evaluate patients newly initiated on therapy and possibly prevalent users. Both primary and
secondary nonadherence will be evaluated. Newly initiating therapy patients will be defined as no prior
history of therapy in the prior 12 months.
• Phase 2
 Study focusing patients newly initiated on therapy. Once we define discontinuation, primary non adherence,
secondary non adherence, we will send them a survey to ask the reasons. This will help examine the real world
reasons for why patients are non adherent or discontinuing. Survey will be designed or a prior validated survey
could be used. We may use an existing instrument since this may be easy for operational purposes.
• Phase 3
 Intervention built from the findings from Phase 1 and Phase 2. Explore which types of interventions would
be needed to help improve care and overall adherence in this population. Phase 1 and Phase 2 findings will be
evaluated with Clinical Leadership to figure out ways to intervene and what the Health System can do as next
steps.

Sample Research Project #2:
Performance Improvement within a Health System with Significant
‘leakage’ of patient care outside the system
• In order to assess treatment approaches, project will explore a number of measures:
 Compare the number of visits during which condition was:

was in the problem list

listed as a diagnosis

drug was prescribed for the condition
 Examine appropriateness of referral patterns:

For purposes of this project, a primary care provider should try at least one drug for this
condition– but only one – before referring to a specialist

Referrals made without trying any drug or after prescribing more than one will be classified
as potentially inappropriate or suboptimal
 We will also distinguish between referrals from the Health System’s primary care
clinic system vs others
 Examine the use of diagnostic testing and imaging
 Examine the use and documentation of validated symptom assessment tools.
 Compare the use of different treatment options among those that we can identify via the EHR

Sample Research Project #2:
Performance Improvement within a Health System with Significant
‘leakage’ of patient care
# Condition specific
Rx’s
# Condition specific
medication classes
Referrals
Use of diagnostic
tools
Treatment Options
Patient Characteristics
Age
<65
65+
Race
Wh
Other
Sex
M
F
Insurance Status
Medicare
Medicaid
Commercial
Provider Characteristics
Primary care physician
Other primary care provider
Specialist
Hospital #1
Hospital #2

Sample Research Project #3:
EHR Based Condition Specific Prompts and HCP Decision Support
National Quality Strategy--The Future of Quality Measurement
ONC, AHRQ, CMS Presentation. September 14, 2012

Sample Research Project #3:
EHR Based Condition Specific Prompts and HCP Decision Support
• Clinical Decision Support (CDS)
− Detect potential safety and quality problems and help prevent them
− Detect inappropriate utilization of services, medications, and supplies
− Foster the greater use of evidence-based medicine principles and guidelines
− Organize, optimize and help operationalize the details of a plan of care
− Help gather and present data needed to execute this plan
− Ensure that the best clinical knowledge and recommendations are utilized to
improve health management decisions by clinicians and patients
Osheroff JA, Pifer EA, Teich JM, et al. Improving Outcomes with Clinical Decision Support: An Implementers' Guide
Chicago: HIMSS; 2005.

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
-Johann Wolfgang von Goethe