banding together: the future of rural health …...banding together: the future of rural health...

Banding Together: The Future of Rural Health Through Population

Health

9/27/2018

Tim Putnam, CEO Margaret Mary HealthRich Scheinblum, CFO/VP Finance Monadnock Community HospitalTim Gronniger, Senior VP Strategy & Development Caravan Health

Learning Objectives

• Review the experiences of Margaret Mary Health in Batesville, IN and Monadnock Community Hospital in Peterborough, NH and their experiences in a collaborative ACO.

• Understand the collaborative ACO model and benefits rural hospitals and clinics can gain from participation.

• Gain an understanding of the limitations of small-scale ACOs and how rural hospitals and clinics can succeed in scaled-up ACOs.

• Understand CMS’ direction with ACOs and plan next steps for your hospital.

www.CaravanHealth.com | Proprietary & Confidential, Not for Distribution2

Margaret Mary Health

3www.CaravanHealth.com | Proprietary & Confidential, Not for Distribution

Margaret Mary Health

• Batesville, Indiana• 2014 NRACO Founding Member• ~$100 Million Net CAH• SHO2 ACO- AIM Funded

• Margaret Mary Community Hospital

• Henry County Memorial Hospital

• 2 local independent physicians.

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Margaret Mary Health AttributionAttribution Details

State CountyUnique Attributed

BeneficiariesIndiana Ripley County 1,499Indiana Franklin County 1,031Indiana Dearborn County 275Indiana Decatur County 268Indiana Fayette County 27Ohio Hamilton County 23Indiana Jefferson County 18Indiana Jennings County 11Indiana Rush County 9Indiana Bartholomew County 7Indiana Switzerland County 7Indiana Union County 7Indiana Shelby County 5Indiana Hendricks County 4Indiana Marion County 4Ohio Butler County 3Indiana Hamilton County 2Indiana Jackson County 2Indiana Ohio County 2Michigan Wayne County 2Ohio Clermont County 2

MultiCounties with 1 Beneficiary 22

ACO/CIN Benefit Waivers

- Stark Fraud and Abuse- Transportation services- Meal vouchers for AWV

Patients- Carpenter services for fall

prevention- Home health

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Benefits of Access to Medicare Claims Data

Facility Network Utilization Analysis

Setting Total Inpatient OutpatientPost-Acute

CareIn-Network $10,834,803 $3,617,804 $5,703,143 $1,513,856Out-of-Network $20,675,359 $11,665,933 $4,428,330 $4,581,096



Facility Network Utilization AnalysisTop 10 Facilities by Total Payments-Acute

Name

In or Out of

NetworkPatient Count Total Inpatient Outpatient

Margaret Mary Hospital IN 3,432 $9,178,292 $3,617,804 $5,560,488Christ Hospital ON 346 $3,957,047 $3,340,774 $616,272U of Cincinnati Med Center ON 161 $1,731,167 $1,600,358 $130,809Indiana U ON 138 $1,072,981 $894,717 $178,264

Good Samaritan-Cincinnati ON 88 $811,033 $691,234 $119,799Decatur County ON 408 $808,216 $313,981 $494,235Margaret Mary Hospice IN 71 $778,608 $0 $0Margaret Mary Hospital IN 207 $735,248 $0 $0



Facility Network Utilization Analysis

Top 10 Facilities by Total Payments- Skilled

Name

In or Out of

NetworkPatient Count Total Inpatient Outpatient

Non-Swing Bed SNF

ST. ANDREWS HEALTH CAMPUS ON 133 $1,483,337 $0 $118,086 $1,365,252THE WATERS OF BATESVILLE ON 93 $1,216,026 $0 $187,032 $1,028,993

Quality Measures Year to Year Margaret Mary Health


Benchmarks Measure RatesMeasure

2015 2016 2017

2017 Caravan Health ACOs

2015 2016 2017 2016 to 2017 % Change

Clinical Depression Screening/ Follow-Up Plan

60th <30th 40th 50th 24 25.16 46.04 83.00%

Screening for Future Fall Risk 60th 50th 80th 80th 37.25 42.28 70.47 66.67%

Influenza Immunization 50th 70th 80th 70th 56.86 76.56 86.07 12.42%

High Blood Pressure Control 60th 50th 60th 70th 62.3 57.4 63.7 10.98%

HbA1c Control * * * * 18.18 21.94 13.27 29.94 %

Statin Therapy * * * * * 75.37 81.25 7.80%


Suburban Health ACO 2 Results

Final MIPS Score93.64

CMS 2017 Results Released 8/2018

Actual Savings & Losses

Earned Performance Payment

PY Net Earned Performance Payment After AIM

Quality Score

$3,627,190 $1,675,430 $1,401,790 94.27

Monadnock Community Hospital


Monadnock Community Hospital• Peterborough, New Hampshire• 2014 ACO Start• Large CAH• Primary Service Area 13 Towns /

38,000 people• Primary Care Panel 26,500

• 7 primary care practices. About 90% Outpatient.

• Granite One Health13

New Hampshire ACO

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• AIM Funded ACO• 6 hospitals• 3 FQHC’s

Attribution- NH Rural ACO

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Lessons Learned

• Population Health as a strategic initiative• Board• Quality Council

• Pacing• Physician / Clinician / Practice engagement

• Get early buy-in.• IT champion

• Culture• Care Manager

• Success is local• Rapid Cycle Tests• Data• It’s the right thing for your patients.


New Hampshire Rural ACO

Final MIPS Score Quality ACI IA

Payment Adjustment

95.39 96.2 91 100 1.76


CMS 2017 Results Released 8/2018

Performance Year

Quality Score

Savings / (Losses)

Earned PerformancePayment

AIM Repayment

2016 100% $ 1.70M $ 0 $ 02017 96.48% $ 4.96M $ 2.34M $ 2.34M

Total $ left to repay Grant $186K


Q2 2018 ACO Scorecard- NH Rural ACO

A B C D E

Collaborative ACO Model & Limits of Small ACOs


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Helping Providers Navigate the Challenges of Value-Based Payments

CPC+MACRA

150 Employees

38 Accountable Care Organizations

>500 Health Systems

>14,000 Clinicians

>1,000,000 Medicare Lives

MSSP Results (cms.data.gov)

94% Average Quality Score

>2x National Average of Savings

ACOs Practice Transformation

About Caravan Health

www.CaravanHealth.com | Proprietary & Confidential, Not for Distribution

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Consistent Savings Year After Year


Caravan ACOs consistently save >1% per year

Caravan ACOsMSSP National Average

$107$126

$206

Year 1 Year 1 Year 2*

n=52,925

Since 2013 ACOs have improved quality and reduced the cost of care

an average of 0.53% per year

2015 Starts

2016 Starts

2016 Starts

n=221,262($4) ($4)

$26

$131 $127

$3

($29)

$54

$153

$19 $30

$123

$4 $34 $22

Year1

Year2

Year3

Year4

Year5

Year1

Year2

Year3

Year4

Year1

Year2

Year3

Year1

Year2

Year1

2013 Starts

2014 Starts

2015 Starts

2016 Starts

2017 Starts

Savings Per Beneficiary

Why Should You Join The MSSP?

Great for Patients, Great for Providers, More Money, Less Work and SUCCESSFUL IN RURAL

Recover OPPS lossesIncreased MIPS score and adjustments

Decreased MIPS reportingStark and Anti-kickback Statute waivers

Better physician alignmentBetter Quality for patients

Opportunity of Shared SavingsNew Population Health Revenue Streams

Creates fully functional CIN as a side benefit


How Do You Win in the MSSP?Managing your patients better

than fee-for-service Wellness Prevention Chronic Care Management Behavioral/Mental Health Support

Accurately coding chronic conditions every year

Having enough lives to reduce statistical variation

Your path to... … Shared Savings

1

2

3

Empower Your Nurses


Build your primary care capacity.

Utilize nurses and medical assistants to meet patient needs and provide additional support to providers.

Medicare allows important preventive services to be billed under provider supervision.

Physicians get more time to attend acute patient needs, and patients benefit from more attention overall.

Impact Story Knox Community Hospital

Mount Vernon, OH• Improvements in Diabetic patient care stemming directly from ACO

participation-Reduced the rate of uncontrolled high blood sugar among patients 15 percentage points from a measure of 19.6 in 2016 to 4.4 in 2017 -Increased diabetes eye exams from 30.4 percent in 2016 to 35.3 percent in 2017 (increase of more than 16 percent)

• Strategies- Identified uncontrolled diabetes a priority- Clinical staff reviewed the charts of all patients with diabetes, flagging all those with a HbA1c level higher than 7 -Patients were contacted and enrolled in their newly launched chronic care management program-Started a quality subcommittee made up of the medical director, care managers, coding specialists, IT experts, office staff, and others-Practice level education


Diabetes Education Class Turns One Man’s Life Around- Reid Health


• George Eastman- 20 year Type 2 Diabetic• Reid Health- ACO participant, 2015 start• Increasing levels of insulin• ACO related initiatives focused on patients with chronic disease• Doctor recommended taking a class offered by the Reid Health

Diabetes and Nutrition Education Program• George decreased A1C from 9.8 to 7.6, lost 20 lbs, off insulin• “That class turned my life around,” “I have more energy and stamina to

get out and do things.”

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Trained Nurses Excel at Prevention

No AWV(n=15,232)

AWV done by MD/NP(n=446)

AWV done by QMnurse (n=2,863)

Men up to date on AAA screen 70.1% 77.7% 83.8%

Women up to date on mammogram 42.2% 61.1% 74.0%

Women up to date on bone density 45.3% 63.5% 75.1%

Up to date on PCV-23 vaccine 33.4% 57.6% 58.4%

Up to date on depression screening 1.9% 3.4% 94.9%Up to date on Health Risk Assessment 1.9% 2.0% 94.3%Up to date on Fall Risk Screening 1.9% 2.0% 94.3%

Up to date on ADL Assessment 1.9% 2.0% 94.3%

Up to date on Smoking Cessation screen 1.9% 2.0% 94.3%

Up to date on End of Life Plan screen 1.9% 2.0% 93.8%


Source: Hattiesburg Clinic

Population Health Nurses Generate Income

Population Health Nurse

Wellness Visits ($118/yr)

Chronic Care Management ($45-$90/mo)

Advanced Care Planning ($86/yr)

Behavioral Health

Integration ($126/mo)

Cognitive Assessment &

Planning ($238/yr)


Maximize Power of Claims and EHR Data


Analyze your population to understand prevalence of chronic illness, hospitalizations and related costs.

Prioritize areas for improvement and identify where you need additional resources based on which population has the most clinical and financial risk.

Plan early for in-house and outsourced expertise.Ingesting claims data and drawing meaningful reports takes time.

Transparency and Accountability Are Keys to Success

• Determine what activities and processes produce better health Wellness Prevention Chronic care management Mental health support

• Measure process and engagement, not outcomes• Publish process and engagement data by practice quarterly



Keep Score

Practice ABCCategory Metric Points

Points Possible

RN Care Coordinator in place ✓ 6 6Physician Leader in place ✓ 6 6Lightbeam Interface Status as of X/X/XXXX date In Dev. 4 6# Active Medicare AWV Cases - Claims + EHR Interface Data Q1 2017 300 0% of patients with AWV - full credit for over 50% 41.0% 4 6# Active Medicare CCM Cases - Self Reported Q1 2017 140 0% of patients in CCM - full credit for over 10% 17.0% 6 6# Active Medicare TCM Cases - Self Reported Q1 2017 170 0% of patients in TCM - full credit for over 10% 8.0% 4 6Billing AWV ✓ 4 4Billing CCM ✓ 4 4Billing TCM ✓ 4 4Billing Advance Care Planning (ACP) X 0 4Patient Satisfaction Tablet Utilization Rate 27.0% 6 6Quality score 100.0% 6 6Total Cost - full credit for reduction beyond statistical threshold -3.2% 6 6ED utilization - full credit for reduction beyond statistical threshold -2.5% 2 2SNF utilization - full credit for reduction beyond statistical threshold 3.0% 0 2IP utilization - full credit for reduction beyond statistical threshold -1.0% 2 2Representative at Board Meeting ✓ 4 4ACO Champion at Road Map Call ✓ 2 2Practice Manager at Road Map Call ✓ 2 2Care Coordinator at Road Map Call ✓ 2 2Attend QIW ✓ 4 4Attend Care Coordinator Cohort Calls ✓ 4 4Attend Quarterly Steering Committee Meeting ✓ 3 3Attend Cohort Calls ✓ 3 3

TOTAL SCORE 88 100

ACO BOARD SCORECARD ADDITIONS/ADJUSTMENTSAttend EBM Webinars X 0 2Attend Cohort Calls ✓ 2 2Attend Physician Leader Cohort Calls ✓ 2 2

Status

Physician Lead

ACO Medical Director

Key Billing Indicators

Care Coordination

Outcomes

Leading Indicators

Staff Engagement

Use a scorecard to keep focused on goals and pinpoint areas of weakness.

Metrics should be based on efforts towards goals such as AWV percentage rate or cohort meeting participation.

Most ACOs Cannot See True Savings


Small ACOs experience savings and losses +/- 10-20% simply due to statistical variation in health care spend and in HCC coding

73% of MSSP ACOs have fewer than 20,000 lives

-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,0002013 2014 2015 2016

Certainty in Results Increases With Scale


Confidence interval around savings rates in the MSSP program 2014 - 2015 vs ACO attributed lives

CMS RISK CORRIDOR

The Collaborative ACO Model

• Collaboration, with accountability• Attributed lives:

• Accountable for cost and quality• Local governance, community representation• Practice-level support• Not dependent on geography. • The key to success is to implement the tools and tactics and

to do the work!• Maximizes a proven model to take advantage of benefits of

scale

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Caravan Health CompassBundled Payments Overlay

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Caravan Health CompassHome Health Performance Metrics

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Caravan Health CompassNetwork Utilization


Maintain Independence and Control

Every community of providers operate independently and are paid on their own performance.

Independent providers can fully participate in value-based payments while retaining their autonomy.

All health care decisions are kept local.

Significant changes to participation agreements (if any) will be made by July 1 of each year so participants can elect to leave the ACO and form their own in the unlikely event they don’t agree.

Future Directions


Summary of Key Changes

All agreements, both BASIC and ENHANCED would include a path to risk, though retaining the ability to drop out at any time

Propose to eliminate Tracks 1, 1+, 2, and 3 and replace with BASIC and ENHANCED options – making track 1+ and track 3 effectively permanent.

ACOs with high revenue –hospitals – will only be allowed one cycle in the Basic track

Choice of prospective or retrospective attribution

Agreement period extended from three years to five for both options


BASIC Track

The Basic option is available to “new” ACOs or existing

ACOs that are inexperienced with risk (i.e. Track 1)

ACOs have the option of accelerating their risk faster, but this

does not allow them to later move

backwards or remain at any level below E for more than one

year

During the five-year agreement term, the ACO must

advance at least one level every

year, ending with Advanced APM

level risk (Level E)

BASIC & ENHANCED ACO Options


Level A Level B Level C Level D Level E ENHANCED

Risk Upside only Two-sided Two-sided Two-sided Two-sided

Shared Savings 1st dollar savings, rate of 25%

1st dollar savings, rate of 30%




Shared Losses NA

1st dollar losses, rate of 30%, not to exceed 2% of revenue or 1% benchmark

1st dollar losses, rate of 30%, not to exceed 4% of revenue or 2% benchmark

1st dollar losses, rate of 30%, not to exceed nominal risk standard (currently 8% of revenue or 4% of benchmark)

1st dollar losses, rate of 1 minus sharing rate (40-75%), not to exceed 15% of benchmark

QPP Status MIPS APM Advanced APM

Advanced APM

Predecessor Track 1 NA NA Track 1+ Track 3

BASIC


Savings Among Caravan Health ACOs and Other Cohorts

($50) $0 $50 $100 $150 $200 $250

MSSP average among non-CH2016 starts

CH average 2016 ACOs

Savings vs Benchmark $PPPY

2017 2016

$- $50 $100 $150 $200 $250

ACO Investment Model

Track 3

Next Gen ACO

Savings vs Benchmark $PPPY

2017 2016

-$100 -$50 $0 $50 $100 $150 $200 $250

MSSP average among non-CH 2016starts

CH average 2016 ACOs

Savings to CMS $PPPY

2017

$- $50 $100 $150 $200 $250

ACO Investment Model

Track 3

Next Gen ACO

Savings to CMS $PPPY

2017


In SummaryValue-based Payment is Here to StayAugust 9, 2018 CMS MSSP Proposed rule affirms commitment to the ACO program.

Now is the Time to Take ActionAssess your potential ACO options based on the proposed rule. Consider eligibility and risk tolerance.

Stay in touch with the latest information. WWW.Caravanhealth.comSign up for free newsletters and webinars.

Focus on population healthEvaluate workforce and add population health nurses to support physicians.

Get help nowJoin TCPI at https://www.nationalruralaco.com/tcpi-application.shtml

Focus on the futureEvaluate BASIC ACO Tracks

https://www.nationalruralaco.com/tcpi-application.shtml

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leave this session.

Thank you!

Thank Youbringing population health to life

www.caravanhealth.com | [email protected] | 916.542.4582

banding together: the future of rural health …...banding together: the future of rural health...

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