Track 4: Sostenibilidad de los sistemas sanitarios 4.3. Organizaciones orientadas a resultados

1. Accountable Care and
Johns Hopkins Medicine
Accountable Care Organization “ACO”: Early Experiences
MIHealth: Health Management & Clinical Innovation Forum
May 25, 2012
Scott A. Berkowitz, MD, MBA
Medical Director; Accountable Care
Assistant Professor of Medicine, Division of Cardiology
No Disclosures

2. Issues to Cover
• Background. What were the goals of the Affordable
Care Act, and why did it include delivery system
reforms, like creating Accountable Care
Organizations (ACOs)?
• “ACOs”. What is an ACO, who can participate, what
are the “rules”, what is the governance and how is
quality assessed?
• Accountable Care and Johns Hopkins. Why would
an academic medical center like Johns Hopkins
consider accountable care arrangements like ACOs?
Scott A. Berkowitz MD, MBA

3. Background
Health Care Reform
Scott A. Berkowitz MD, MBA

4. Quality is Inconsistent
“The Cost Conundrum” by Atul Gawande (New Yorker, 2009)
$/Pt Technology Med Mal Quality Tests/Devices
McAllen, TX $15K NICU, PET, Same > 2/25 metrics +60% stress; +1-
Cardiac, laws 200% CABG,
#MDs ICD, PM
El Paso, TX $7.5K comparable Same > 23/25 metrics Less utilization
laws
Dartmouth Atlas
Scott A. Berkowitz MD, MBA

5. Costs are Unsustainable
Scott A. Berkowitz MD, MBA

6. Chronic Conditions and Spending
• 5% of beneficiaries (greatest utilizers) consume 50%
of total health expenses; 50% of beneficiaries
(lowest utilizers) consume only 3%.
• Multiple chronic conditions (CC) 7x greater cost
than 1 CC.
• Between 2000 and 2030, the number of Americans
with CC will increase by 46 million.
• Health care spending: 1 CC = 4x greater costs than
without; and >=5 CC = 25x greater costs than
without.
Scott A. Berkowitz MD, MBA

7. United States and
100 Years of Health Reform
• 1912 – Theodore Roosevelt first tries to pass a universal
coverage health care bill.
• 1940’s – Harry Truman fails to enact compulsory health
insurance, and then develops a plan to provide 60 days of
hospital care for Social Security recipients.
• 1965 – Lyndon Johnson signs Medicare and Medicaid.
• 1973 –Richard Nixon signs Health Maintenance
Organization Act.
• 1985 – Ronald Reagan signs COBRA.
• 1997 – Bill Clinton signs the Children’s Health Insurance
Program (CHIP).
• 2003 – George W. Bush signs Medicare Modernization Act
• 2010 – Barack Obama signs Affordable Care Act.
Scott A. Berkowitz MD, MBA

8. Affordable Care Act
Insurance Expansion/Reform
– Coverage expansion - Insured Americans will increase from 83% (of
non-elderly population) to 94% by 2019 (+32 million).
– Preserves Employer-Based System (“If like what have, keep it”).
– Establishes State-based “Exchange” marketplace for coverage.
– Medicaid (and CHIP) eligibility increased to at least 133% FPL.
– Tax credits and premium assistance for those up to 400% of
Federal Poverty Level; substantial assistance for small businesses.
– Individual and employer responsibility requirements (“mandates”)
– No pre-existing condition exclusion (adults/kids).
– Prohibit lifetime limits; Secretary establishes benefits for which
insurers can set annual limits.
– Children up to age 26 can stay on their parents' policy.
Scott A. Berkowitz MD, MBA

9. Affordable Care Act
Financing
• Per Non-Partisan Congressional Budget Office
– <$1T total cost, but Net Deficit Reduction with
offsets
– Deficit Reducing in 1st 10 years and >$1T deficit
reduction in 2nd 10 years (0.5% of GDP)
– “Bends” curve in health spending
– Extends Medicare solvency by 10 years (2016 ->
2026)
– “Offsets” include: Medicare Payroll (HI) Tax, Fees on
Manufacturers/Insurers, High Premium “Cadillac”
Excise Tax, Productivity/MB adjustments, etc.
Scott A. Berkowitz MD, MBA

10. Affordable Care Act
Quality and Delivery System Reform
• Paying for High Value Care. Includes: value-based
purchasing, bundled payments, avoidable
readmissions, accountable care organizations (ACOs)
and investments in primary care.
• Center for Medicare & Medicaid Innovation (CMMI)
Develop, support and expand new patient-centered
care and payment models to encourage evidence-
based high quality care.
• Independent Payment Advisory Board. Starts in 2015.
Present proposals to Congress to reduce cost growth
and improve quality for Medicare beneficiaries.
Congress needs to take or match savings.
Scott A. Berkowitz MD, MBA

11. Program Basics
Accountable Care
Organizations (“ACOs”)
Scott A. Berkowitz MD, MBA

12. Health Reform and ACOs
• Section 3022 of the Affordable Care Act (ACA),
created the Medicare Shared Savings Program.
• Voluntary program that can impact Medicare “fee-
for-service” payments (Parts A and B).
• These are Accountable Care Organizations (ACOs)
under Medicare.
Scott A. Berkowitz MD, MBA

13. What is an “ACO”?
• A provider-based care delivery arrangement, in
collaboration with a payer, where the providers
are accountable for the quality, cost and overall
care of a set of patients. In the MSSP, the payer
is Medicare.
• The goal is to organize and coordinate the end-
to-end delivery of services for each participant
across the care continuum.
Scott A. Berkowitz MD, MBA

14. ACOs: ACA and Rule-making
Affordable Care Act (ACA):
• Basic Framework
• March 30, 2010.
Proposed Rule:
• 400 pages
• March 31, 2011.
Final Rule:
• 700 pages (>1300 Comments)
• October 20, 2011.
• First cycles: Apr 1 and Jul 1, 2012
Scott A. Berkowitz MD, MBA

15. Medicare ACO
Patients and Providers
• 3-year participation agreement.
• Patients. Patients are free to choose any provider
they would like. There is NO network “lock in”.
• >5000 beneficiary minimum.
• Eligible Providers. Includes: ACO professionals in
group practice arrangements, networks of
individual practices of ACO professionals,
partnerships or joint venture arrangements,
hospitals employing ACO professionals, Federally
Qualified Health Centers and Rural Health Clinics.
Scott A. Berkowitz MD, MBA

16. Medicare ACO
Attribution
• Prospective Assignment: 2 Step process:
• Step 1: For beneficiaries receiving at least one
primary care service from an MD, use plurality of
allowed charges for primary care services for
primary care MDs.
• Step 2: If not primary care services by primary care
MD, use plurality of allowed charges for primary
care services by an ACO professional.
• MDs and NP/PAs treated differently.
Scott A. Berkowitz MD, MBA

17. Medicare ACO
Quality Measurement
CMS-1345-F 327
• Phased-in Reporting and Performance
Table 2: ACO Agreement Period Pay for Performance Phase-In Summary
Performance Year 1 Performance Year 2 Performance Year 3
Pay for Performance 0 25 32
Pay for Reporting 33 8 1
Total 33 33 33
• Method of Submission. Survey (7);have modified this finalGPRO
Final Decision: In summary, in response to comments, we
Claims (3); rule
Web Interface (22); EHR Incentive Reporting (1) the
by reducing the measure set to 33 measures total, or 23 scored measures when accounting for
• Measure “Weight”. Each Domain isnothing diabetes and 25%.
patient experience survey modules scored as 1 measure and the all or
Weighted CAD
Each measure iseach. We believe judiciously removing certain redundant, is
measures scored as 1 measure
generally 2 points, except EHR
doubled at 4orpoints. measures would still provide a high standard of quality
operationally complex, burdensome
for participating ACOs while providingScott A. Berkowitz MD,with other CMS and HHS quality
greater alignment MBA

18. Table 3: Sliding Scale M easure Scoring Approach
Quality Points EHR M easure
ACO Performance Level (all measures except EHR) Quality Points
90+ percentile FFS/MA Rate or 90+ percent 2 points 4 points
80+ percentile FFS/MA Rate or 80+ percent 1.85 points 3.7 points
CMS-1345-F 358
70+ percentile FFS/MA Rate or 70+ percent 1.7 points 3.4 points
Quality Points EHR M eas ure
ACO Performance Level (all measures except EHR) Quality Points
60+ percentile FFS/MA Rate or 60+ percent 1.55 points 3.1 points
50+ percentile FFS/MA Rate or 50+ percent 1.4 points 2.8 points
40+ percentile FFS/MA Rate or 40+ percent 1.25 points 2.5 points
30+ percentile FFS/MA Rate or 30+ percent 1.10 point 2.2 points
<30 percentile FFS/MA Rate or <30 percent No points No points
Table 4: Total Points for Each Domain within the Quality Performance Standard
Total Total
I ndividual Potential Domain
Domain Total M easures for Scoring Purposes
M eas ures Points Per Weight
(Table F1) Domain
Patient/Caregiver 1 measure with 6 survey module measures
7 4 25%
Experience combined, plus 1 individual measure
Care Coordination/ 6 measures, plus the EHR measure double-
6 14 25%
Patient Safety weighted (4 points)
Preventative Health 8 8 measures 16 25%
7 measures, including 5 component diabetes
At Risk Population 12 composite measure and 2 component CAD 14 25%
composite measure
Total 33 23 48 100%

19. Medicare ACO
Payment
• Maintains “fee-for-service” but allows for shared
savings if meet high quality standards and reduce
cost versus trend. Eases into the ACO model.
• 2 Tracks:
– “Track 1” (one sided; shared savings; carrots only) for
duration of 1st agreement period (3 years). Max up to
50% shared savings.
– “Track 2” (two sided; shared risk; carrots/sticks) so some
can take on performance-based risk with more reward.
Maximum up to 60% shared savings.
– 1st dollar savings after minimum savings rate.
Scott A. Berkowitz MD, MBA

20. Medicare ACO
Number of Beneficiaries
Scott A. Berkowitz MD, MBA

21. Medicare ACO
Governance and Leadership
• Shared Governance. Board is responsible for the success
or failure of the ACO, and has control over ACO Leadership.
Providers in the aggregate must retain at least 75% Board
control, and the Board is to have at least 1 beneficiary
(applicant can seek exceptions).
• Leadership. The ACO must be managed by an executive.
Clinical management directed by senior-level medical
director (can be part-time) who is board-certified and in
the ACO. Must have a compliance officer. Each ACO
participant/provider/supplier must demonstrate a
meaningful commitment to the ACO.
Scott A. Berkowitz MD, MBA

22. Medicare ACO
Other
• TINs/Legal Entity. ACO is a collection of Tax ID
Numbers (TINs). Any one TIN can only participate
in one Medicare shared savings program. Must
be a Legal Entity Capable of Distributing Shared
Savings.
• Data. De-identified data available. Notify
patients of additional data sharing options with
the opportunity to decline.
• Electronic Health Records Use. Important quality
measure.
Scott A. Berkowitz MD, MBA

23. Medicare ACO
Other
• Indirect Medical Education & Disproportionate
Share Hospital Payments (IME/DSH). Now
excluded from both benchmark and performance
in calculations (important for AMCs).
• No Mandatory Anti-trust Review. Prior was a
requirement depending on the concentration of
providers/services.
• Marketing. Strict requirements with significant
transparency. “File and use” after 5 days and
certify compliance.
Scott A. Berkowitz MD, MBA

24. Other ACO Model
“Pioneer ACO Model”
• Started January 1, 2012.
• 32 participants including: Partners, Beth Israel Deaconess,
Dartmouth, University of Michigan, among others.
• Designed for experienced healthcare delivery entities
more ready to assume risk.
• In year 3, if savings achieved, allowed to transition from a
shared savings model (strictly “fee for service”) to a
population-based payment model (receive monthly
population-based payment and 50% FFS payments).
• More than 50% revenues in outcomes-based contracts (ie.
shared savings) by end of year 2 (MC, Private, etc).
Scott A. Berkowitz MD, MBA

25. Johns Hopkins Medicine and
Academic Medical Centers (AMCs)
Accountable Care:
Challenges And Opportunities
Scott A. Berkowitz MD, MBA

26. Will AMCs form ACOs?
• Yes, some will.
• Pioneer ACOs: University of Michigan, Partners
(MGH/Brigham) and Dartmouth. Others will
apply to the MSSP.
• Although some AMCs may choose to form ACOs
or other accountable care arrangements, there
are challenges and opportunities for AMCs in
considering novel payment and care models.
• Early challenges will be financial and cultural.
Scott A. Berkowitz MD, MBA

27. Accountable Care and JHM
N Engl J Med 2011; 364:e12. Feb 17, 2011.
Scott A. Berkowitz MD, MBA

28. Challenges
Financial
• Shared Savings Dilemma/Opportunity. If
reduce Medicare charges by 10%, and
can keep 50% of difference, you end up
with 95% of current charges. Need
improved efficiency, to back-fill beds, and
reduce costs.
• Risk. How much financial risk will AMCs
be willing to assume?
• Population Health. Need to Coordinate.
• Health IT/Investment. Costs can be
substantial. Scott A. Berkowitz MD, MBA

29. Challenges
Cultural
• AMC culture.
– AMCs contain many “silos” but need integration among
Divisions and Departments.
– JHH #1 for over 20 years. Why change?
– Trainee Education/Autonomy
• Promotion/Advancement.
– Generally based on “scholarship” rather than providing
high quality clinical care.
• “80%/20%” Research/Clinical Care.
– Sufficient numbers of providers to ensure access?
– Motivations and Incentives.
Scott A. Berkowitz MD, MBA

30. Opportunities
Care Delivery
• Clinical Integration and Culture Alignment. Promotes
care coordination and focus on improved quality and
reduced cost across the care continuum.
• Incentivizes Primary Care Access/Expansion. Primary
care expansion improves access, preventive care and
post-acute care. Creates opportunities for more
patients to enter the Hopkins system.
• Payment Models. Shared savings or other payment
mechanisms can allow for more investment in
improved care.
Scott A. Berkowitz MD, MBA

31. Opportunities
Education and Research
• Education. Modernize programs. “Flexner Report 2.0”.
• Become a “Learning Laboratory”. Use research in care
delivery design, study the impact of interventions, and
promote continuous process improvement.
• Measurement. Develop, pilot and disseminate new
patient-centered measures.
• Novel funding mechanisms.
– CMMI ($10B for new models)
– CER ($500M per year by 2015)
– NIH
– AHRQ (Innovation Grants, etc.)
– Others Scott A. Berkowitz MD, MBA

32. Accountable Care and JHM
Bottom Line
• Synergy. Accountable care opportunities (ACOs and others)
allow JHM to build upon new EHR, organizational structure
(“JHM 3.0”), managed care plan, and other transformation
efforts as a modern Academic Medical System (AMS).
• Inter-Dependence and Vision. Accountable care
opportunities are inter-related. Must plan ahead.
• Lead by Example. Accountable care can allow JHM and
other AMCs to lead in promoting “value”, implement
innovative delivery models, modernize medical/nursing
education and expand the research enterprise. This
supports our tripartite mission and our community.
Scott A. Berkowitz MD, MBA

33. The Wisest “Doctor” – Dr. Seuss
Scott A. Berkowitz MD, MBA