How to Achieve the Competencies of Successful Value-based Contracting Delivery Systems
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This webinar will review the evolution of the value-based contracting world, identifying key insights into impactable contract levers, and delineating systematic steps that lead to sustainable value-based contracting success. Health Catalyst team members Bobbi Brown, SVP, a healthcare finance executive with over 40 years’ experience, and Jonas Varnum, a population health and value-based care strategic consultant expert, will present on many of their battle-scarred experiences working with the financial, clinical, analytical, and operational components of value-based contracting delivery models including: 1) Shared qualities of successful value-based contracting delivery systems. 2) The intensifying need for robust data to drive success. 3) Refining and optimizing core competencies. 4) Increasing sustainability by impacting key contract levers.
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How to Achieve the Competencies of Successful Value-based Contracting Delivery Systems
- 1. March 14, 2018 How to Achieve the Competencies of Successful Value-based Contracting Delivery Systems
- 2. 1. Shared qualities of successful VBC delivery systems 2. The intensifying need for robust data to drive success 3. Refining and optimizing core competencies 4. Increasing sustainability by impacting key contract levers Agenda
- 3. © 2018 Health Catalyst It’s March! and Since Value-based Contracting is Madness… • Live in Phoenix and Park City • Part of Health Catalyst’s Population Health team • Background in finance with Intermountain Health Care and Kaiser • Attended Final Four in 2017 • From Kansas – Live in North Carolina • Part of Health Catalyst’s Population Health and Care Management team • Started on ACOs during Medicare’s first round of Shared Savings Program applications • Kansas City BBQ and basketball fan Bobbi Brown Jonas Varnum
- 4. © 2018 Health Catalyst ….To a Contract-Based Focus… “Meeting contractual requirements from commercial insurers 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 Defining Population Health 4 …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 (social workers, visiting nurses, hospice, patient, caregivers/family, etc.)” -Chilmark Research
- 5. © 2018 Health Catalyst HCPLAN Payment Model Framework 5 “To achieve the goals of better care, smarter spending, and healthier people, the U.S. health care system must substantially reform its payment structure to incentivize quality, health outcomes, and value over volume. Such alignment requires a fundamental change in how health care is organized and delivered, and requires the participation of the entire health care ecosystem.” Health Care Payment and Learning Action Network Source: Health Care Payment Learning & Action Network Alternative Payment Model APM Framework. Refreshed for 2017. The MITRE Corporation. Available at: http://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf
- 6. © 2018 Health Catalyst The Fee-for-Service to Fee-for-Value Curve 6 ProviderReimbursement Time Your Local Market FFS reimbursement Call to Action: 1. Five competencies for Value-based Contracting success 2. Data organization for intelligence is paramount 3. Roll out scalable initiatives that impact contract performance
- 7. © 2018 Health Catalyst Where Are We In Our Value Journey? 7 62% 43% 23% 29% 15% 28% 2015 2016 PAYMENT CATEGORIES FFS APM P4P 19% decrease Source: Health Care Payment Learning and Action Network Report Over half of respondents said they had less than 10% of their revenue tied to a true risk-based contract. , Sage Growth Partners, Getting to Value Based Care: Are EHRs up to the task? Value-based payments Measure quality improvement Collect and analyze data
- 8. © 2018 Health Catalyst Alternative Payment Models 8 Program Government Marketplace ACO Accountable care organization 562 Medicare, 88 Medicaid contracts- 13 million covered lives 715 contracts, over 19 million lives BPCI Bundle payments for care improvement 315 acute care hospitals, 567 skilled nursing facilities, 228 physician groups, 76 home health agencies Central conversation for commercial work CPC+ Comprehensive Primary Care Plus 2,188 providers servicer 410,000 beneficiaries Same providers served over 2 Million commercial members
- 9. © 2018 Health Catalyst Models 9 Source: MedPac Oct 2017 ACO Payment Systems Fee for service Pay for Performance Bundled payment Capitation Health plan Lowest risk Highest risk 2015 MSSP Financial Results Benchmark $ 73,298 Actual spend $ 72,868 Difference $ 430 Paid to ACOs $ 646 Net $ (216) Dollarsinmillions MSSP Track 1 Track 2 Track 3 Risk One-sided Two-sided Two-sided Shared savings 50% 60% 75% 2017 Count 438 6 36
- 10. © 2018 Health Catalyst Medicare Value-based Programs Programs 10 Value-based Care Programs MACRA BPCI - Voluntary CRJ Mandatory bundle Advanced BPCI- Voluntary
- 11. © 2018 Health Catalyst Medicare 11 Source: Enrollment- Dept of Health & Human Services FY 2019 President’s Budget Trends: MedPAC June 2017 A Data Book 18 20 22 24 26 28 30 32 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 NumberofEnrollees(inmillions) Year Medicare Advantage Enrollment Projected to Increase by 50 Percent from 2017 to 2028 0.0% -0.9% -2.0% -5.7% -8.1% -10.0% -13.9% -16.9% -19.8% -19.5% 0.0% 5.8% 9.3% 14.2% 19.2% 25.4% 32.1% 39.0% 44.2% 47.4% -30.0% -20.0% -10.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Medicare Trends Inpatient Admits Outpatient Visits
- 12. © 2018 Health Catalyst Medicaid 12 Source: Center for Health Care Strategies Fact Sheet Feb 2018 12 States with active ACO programs 10 States pursuing ACO programs WA OR CA NV ID MT WY COUT NM AZ TX OK KS NE SD ND MN WI IL IA MO AR LA AL TN MI PA NY VT GA FL MS KY SC NC MD OH DE IN WV NJ CT MA ME RI VA NH AK HI DC States with active Medicaid ACO programs States pursuing/exploring Medicaid ACO programs
- 13. © 2018 Health Catalyst Ability to model future projections Market Volume/cost/payment Financial Competencies 13 48% 93% 17% 13% 5% 16% 12% 2% 14% CA LI FORNI A A LA B A MA NE W Y ORK INSURANCE MARKET LARGE EMPLOYER Source: KFF -5% -4% -3% -2% -1% 0% 1% 2% 3% 4% 5% 6% 2016 2017 2018 2019 2020 2021 2022 2023 PROJECTION Projection- no risk Projection- risk California Alabama New York Kaiser 47% BCBS of AL 93% Lifetime 17% Anthem 13% Viva 5% Emblem 16% Blue Shield of CA 12% United Health Grp 2% United Health Grp 14%
- 14. © 2018 Health Catalyst The FFS to FFV Curve 14 ProviderReimbursement Time Your Local Market FFS reimbursement
- 15. © 2018 Health Catalyst During your PHM program’s first year, where did your organizationconcentrate most of its efforts? 1. Quality measurement and improvement 2. Care coordination and/or patient stratification 3. Lever identification (e.g. HCC analysis, patient utilization in/out network, care management interventions) 4. All of the above 5. Not applicable 15
- 16. © 2018 Health Catalyst Clinical Integration Standards Clinically Integrated Networks: Legal framework for single signature contract that promotes quality outcomes and efficiencies in care. •Activate participation, engagement, and time committed to enhancing clinical quality (care pathways) and reducing costs Provider responsibilities •CIN standards of participation create recourse for providers noncompliant in quality and cost reduction policies Provider accountability •Must demonstrate the CIN improves quality and efficiency over time. 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). Resource Use Clinically Integrated Entity IPA Entity Ind. MDs Hospital(s) / Health System Post-Acute Care Key Principles:
- 17. © 2018 Health Catalyst Population Health Vehicle 17 Clinically Integrated Entity IPA Entity Ind. MDs Hospital(s) / Health System Post-Acute Care Governance Clinical Transformation 1. Educated constituency 2. Operational documents 3. Clear authority and responsibility 4. Provider performance monitoring 5. Meet regulatory stipulations 1. Patient Population Identification 2. Protocol Adoption 3. Quality Measurement 4. Data sharing for performance improvement 5. Care coordination tactics Must Have Competencies
- 18. © 2018 Health Catalyst Population Health Vehicle 18 Clinically Integrated Entity IPA Entity Ind. MDs Hospital(s) / Health System Post-Acute Care IPA Entity Ind. MDs Post-Acute Care Hospital(s) / Health System Ind. MDs Hospital(s) / Health System Cross continuum relationships 1. Partners 2. Vendors 3. Services Organizations Color Relationship CIN JV / Ownership Varied partnerships
- 19. © 2018 Health Catalyst The Data Operating System Data Ingest Real-time Streaming Source Connectors Catalyst Analytics Platform Fabric Data Services Real-time Processing Health Catalyst Applications Data Quality Data Governance Pattern Recognition Hadoop/ Spark Data Export Population & Registry Builder Leading Wisely Care Management Atlas Client-built Applications NLP Touchstone Benchmarks CORUS Cost Accounting Patient Safety Measures Manager ACO Financials Patient Engagement HL7 Data Pipelines Metadata Data Lake Reusable Content AI Models Third-party Apps Artificial Intelligence Pipelines Marketplace SAMD & SMD Fabric Application Services Terminology & Groupers EMR Integration Security, Identity & Compliance Patient & Provider Matching Value Sets & Measures Standard, Extensible Data Models RegistriesFHIR HL7 Analytic Accelerators
- 20. 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 • 50+ analytic accelerators in high-opportunity areas (readmissions, sepsis, COPD, joint replacement, CLABSI, CAUTI, labor & delivery, CABG, C. diff, diabetes, SSI, etc.) • Expert guidance on care & payment transformation strategies • Data Operating System (DOS) • 150+ data sources (EMR <10% of data needed) • Measure Business Library (MBL) • Population Explorer • Patient Stratification • CAFÉ: collective analytics • PMPM Analyzer • HCC Insights • CORUS: Activity-based Cost Insights • Care Management • Community Care • Leading Wisely executive monitoring Population Health Management 1 2 3a 3b Build vehicle for clinical, financial, and patient-focused decisions 0 Educated constituency Operational documents Clear authority and responsibility PHM goals align with entity goals Performance improvement minimum standards Meet regulatory stipulations Purchasing and partnership evaluation Competency Scorecard Governance Enterprise Data Warehouse, data storage, and data structuring Data sources and stewardship Clinical quality measurement and monitoring Technology tools (e.g. remote patient monitoring) Resource needs and capabilities Advanced specifics (e.g. attribution) Competency Scorecard Patient stratification Validating organizational initiatives Prospective intervention analysis Partnership due diligence Incorporating varied data sources into structure Competency Scorecard Define financial landscape for cross-continuum participants Align to local market trends and opportunities Billing, collections, and payment model systems Prospective financial performance Utilization management Performance incentive design Competency Scorecard Streamline quality approach Routine population assessment and multi-tiered stratification Clinical variation measurement and improvement Care management tactics across population Ambulatory transformation tactics Specialty transformation tactics Patient engagement tactics Competency Scorecard
- 21. Data Acquisition and Transformation 21
- 22. © 2018 Health Catalyst Ingest the Right Data – What Do You Need? 22 Claims data • Historical PMPM • Network leakage • Historical acuity tracking 1 Clinical data • ADTs, daily patient statistics • EMR • With claims, can provide complete clinical picture 2 Costing data • Activity-based data • Link with quality metrics • Specialty-based statistics 3
- 23. © 2018 Health Catalyst Which data sources has your organization integrated to inform value-based strategic and operational planning? (Choose all that apply) 1. Claims 2. Clinical 3. Costing 4. None of the above 5. Not applicable Poll Question 23
- 24. © 2018 Health Catalyst Ability to Know/Influence Cost Structure 24 What are the drivers of cost? Does my organization know costs across the continuum? Can my organization analyze variation?
- 25. © 2018 Health Catalyst Analyze Spending Trends and Utilization 25
- 26. © 2018 Health Catalyst Partnerships 26 52.3% 18.8% 13.6% 45.5% 21.2% 16.9% Home SNF Home with home care Discharge Disposition FFS Medicare 2006 2015 Consumers / Beneficiaries Community Organizations Physicians Payers Post Acute Care
- 27. © 2018 Health Catalyst Quality Metrics 27 Patient/caregiver experience Care coordination/ patient safety Preventative health At risk population CMS measures quality in four domains
- 28. © 2018 Health Catalyst Where are members receiving care? What is going outside your network? Network Analysis 28 In Millions In-Network payments Out-of-Network Payments Total Payment In-Network % Out-Of-Network % Inpatient Acute: $ 77,584,940 $ 27,606,258 $ 105,191,198 73.8% 26.2% Cardiovascular $ 15,975,143 $ 3,252,836 $ 19,227,979 83.1% 16.9% Respiratory $ 7,243,002 $ 3,429,435 $ 10,672,437 67.9% 32.1% Musculoskeletal $ 12,602,281 $ 3,246,495 $ 15,848,776 79.5% 20.5% Professional Office $ 62,371,870 $ 43,911,623 $ 106,283,493 58.7% 41.3% Cardiovascular $ 5,077,166 $ 2,512,301 $ 7,589,467 66.9% 33.1% Respiratory $ 2,870,447 $ 1,003,531 $ 3,873,978 74.1% 25.9% Musculoskeletal $ 9,139,489 $ 7,656,674 $ 16,796,163 54.4% 45.6%
- 29. © 2018 Health Catalyst Medicare continues to pay the “old” way and do a reconciliation at the end for ACO/Bundled Payment Hospital paid based on IP MSDRG and OP APC, fee schedules. Physician paid on fee schedule. Must save more money than savings threshold. New Programs and Payment 29 Cost Trend Benchmark Actual Potential Savings
- 30. © 2018 Health Catalyst Revenue Cycle 30 Apply interventions to monitor and improve revenue cycle results $$$ Avg Days to First Payment % of First Payment Denied Avg Days to Denial resolution % of AR > 90 Days % of AR > 35 Days, No Response Billed Claim Resolved #/$ Denials Starting Balance #/$ Denied this Month #/$ Resolved #/$ Break out by days 0 to 30#/$/% Over 120 #/$/%
- 31. © 2018 Health Catalyst Coding – Hierarchical Condition Category (HCC) 31 Recognize models care for complex patients Account for changes in patient severity
- 32. © 2018 Health Catalyst Standard & Poor’s Rating Scores 32 Enterprise Profile Source: U.S. and Canadian Not-for-profit Health Care Organizations, Standard and Poors 20% Economic fundamentals 20% Industry risk 50% Market position 10% Management & governance Financial Profile 40% Financial performance 30% Liquidity, financial flexibility 30% Debt
- 35. © 2018 Health Catalyst Contract Components • Regulatory framework • Attribution-based experience • Chronic events and life-style management • Narrow network patient management • Premium on total cost of care reduction, quality measures • Market dynamics framework • Member-coordination experience • Episodic events • Narrow network patient management • Premium on consumer access, navigation, experience, satisfaction Government Payers Private Payers Interventions should be as agnostic as possible, allowing successful scale
- 36. © 2018 Health Catalyst PHM Vehicle Revenue Opportunities 1. Contracts (no-risk or risk) 1. Self-Insured 2. Government Payers (Medicare, Medicaid, Medicare Advantage) 3. Commercial 2. Accountable Care Organizations 3. Episodes of Care / Bundled Payments 4. Population Health Initiatives • Examples: Telemedicine, Centers of Excellence, Community Care Program 1. Care Management Program 2. Utilization Management 3. Pharmacy, Care Transitions, and Coordination Programs 4. Clinical Documentation Improvement 5. Network management / leakage 6. Clinical Variation Programs 7. Prevention and Community Care Programs Initiatives Intervention Examples 36
- 37. © 2018 Health Catalyst Health Catalyst Client-tailored Stratification Model 37 Answer key level-setting questions to align stratification with governance, resources, data, payment models, and appropriate clinical delivery 1 2 3a 3b Stratify patients per population or panel Improve and refine over time using feedback loop, machine learning, and additional tactics Populations: Next Gen ACO, BCBS, At-risk Plans Acuity Level Utilization Condition SDOH Score Provider Referral Yes No CM Program 1* *to be refined in 3 months OR
- 38. © 2018 Health Catalyst When building Care Management program, identify structural fits that allow for billing of Care Management codes Annual Wellness Visits + • Transitional Care Management, Chronic Care Management, Advanced Care Planning, Complex Chronic Care Management, Behavioral Health Codes Use Data Systems to Drive Efficiencies • Patient engagement platforms that help patients sign up and stay engaged • Tools that allow Care Managers and staff to track time in a billable system FFS Care Management Codes 38 AWV Increase Programs are growing and have considerable snowball effect to finance broad Care Management Infrastructure 7.50% 15.60% 19.80% 2011 2014 2016 • BPCI Findings: An effective transitional care management program can enhance partner relationships, improve care, and reduce costs. TCM • 684,000 beneficiaries from 2015-2017 • Majority received 4 to 10 months on averageCCM Use • Can include PMPM payments for programmatic efforts (e.g. chronic care program, PCHM, etc…) where codes align well Medicare Advantage Incentives
- 39. © 2018 Health Catalyst Revenue Categories Time to value Financial Impact Internal Cost Savings Care management (spectrum) 18 months - 2 years. Scale for value. Medium-High Utilization management Pace as data directs to minimize FFS reduction Medium Clinical variation reduction Quick internal savings. If applicable, distribution payments take 9-18 months. High Activity-based costing intelligence 12-24 months High Quality penalty avoidance 24 months Medium Contract Revenues Shared Savings Distribution payments take 18 months Medium-High Per Capita Increases 12 months High Lever Revenues FFS Care Management Codes Immediate Low; Can help finance Care Management Network management / leakage 0 – 6 months High Clinical documentation improvement Annual High Halo Effect 18 months – 2 years. Medium Intervention Revenue Opportunities 39
- 40. Thank You
- 41. © 2018 Health Catalyst Does your organization conduct thorough competency and operational planning reviews? 1. Yes 2. No 3. N/A Poll Question 41
- 42. © 2018 Health Catalyst Contact Us: Bobbi Brown – bobbi.brown@healthcatalyst.com Jonas Varnum – jonas.varnum@healthcatalyst.com Join Us for our Next Webinar: A Health Catalyst Overview: Learn How a Data-first Strategy Can Drive Increased Outcomes Improvements Tuesday, March 27 at 1:00 EDT 42