changing'us'healthcare'market,'acos' …...2015/11/06 · acos will look...
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Changing'US'Healthcare'Market,'ACOs'and'the'Role'of'Pharmacy'
Spokane(Pharmacists(Associa2on(Mee2ng(November(6,(2015(
Spokane,(WA((
Sean(D.(Sullivan,(PhD(
Professor(and(Dean(
School(of(Pharmacy(University(of(Washington(
1(
Disclosure(
• I(have(no(financial(or(other(conflicts(of(interest.(
Objec2ves(
• Cri2cally(discuss(recent(health(care(changes,(par2cularly(related(to(delivery(and(financing.(
• Describe(the(key(features(of(ACO(design(and(financing.(
• Examine(the(role(of(pharmacy(and(pharmaceu2cals(in(a(future(where(integrated(delivery(and(global(budgets(are(widespread.(
Key(Trends(–(A(Tale(of(Two(Responses(
• Unprecedented(Rate(of(Change(
• Disrup2on(in(the(health(care(system(
• Role(of(the(Pa2ent(as(a(Customer(for(Health(Care(Delivery(Systems(
• The(ACO(
Global PMA Trends 5
The economies of the developed world markets—and that of the rest of the world—are climbing out of a v-shaped recession on a slow path to recovery
8 Mature Markets GDP Growth Economic Crisis
• All of the mature markets were in recession in 2009
• US, UK and Germany impacted first and most deeply
• Results for 2009: Japan: -5.9% contraction; US: -3.1% contraction
• U.K., Spain and Germany contracted into 2010 and beyond
-4%
-3%
-2%
-1%
0%
1%
2%
3%
4%
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Jun 2008 outlookEmbedded March forecastLatest outlook*
Global Macroeconomic Dynamics & Current Economic Environment
Source: Economist Intelligence Unit, GDP forecasts Mar 2009; US, Japan, Canada, France, Germany, Italy, Spain, US
Disrup2on(in(the(US(health(care(system(
(• Boeing(and(Cleveland(Clinic(
• Intel(Corpora2on(
• Washington(State(Public(Employee((
Affordable(Care(Act(• Expand(access(to(insurance((exchanges(and(subsidies)(and(other(payment(
mechanisms((Medicaid)(to(achieve(near(universal(coverage.(– Reduces(uncompensated(care(that(drives(higher(costs(
• Adopt(and(Incent(the(Triple(Aim(in(Health(Care(– Improve(the(pa2ent(experience((quality(and(sa2sfac2on)(– Improve(the(health(of(popula2ons(– Reduce(per(capita(costs(
• Reform(Payment(Mechanisms(– Move(away(from(FFS(– Toward(bundles,(shared(savings(and(global(budgets(– Transfers(risk(to(the(health(care(system(
What'is'an'Accountable'Care'OrganizaAon?'
• Provider(mix(dependent(on(whether(federal(or(commercial(ACO(structure(
Healthcare'organizaAon'with'a'coordinated'set'of'providers…'
• Clinical(accountability(–(Quality(of(care(• Financial(responsibility(–(Cost(of(Care(
Who'share'responsibility'and'accountability'for'the'conAnuum'of'care…'
• Increase(quality(• Decrease(costs(
By'providing'the'highest'possible'value'of'care…'
• Value^based(payments(• Reimbursement(for(achieving(cost(and(quality(goals(
For'financial'incenAves'or'“shared'savings”…'
• Public(Payors((e.g.,(Medicare,(Medicaid)(• Commercial(Payors((e.g.,(BCBS(of(MA)((
From'parAcipaAng'payors.'
�The$Promise$of$ACOs�$Accountable$Care$Organization$Learning$Network,$http://www.acolearningnetwork.org/whyBweBexist/theBpromiseBofBacos;$�Essential$Guide$to$Accountable$Care$Organizations:$Challenges,$Risks,$and$Opportunities$of$the$ACO$Model,�$The$Healthcare$Intelligence$Network,$2011.$$
Key'Principles'and'Elements'of'ACOs'
• Ability(to(provide(and(manage(con2nuum(of(care((• Responsible(and(accountable(for(quality(and(cost(of(care(• Incen2vize(providers(for(quality(–(not(quan2ty(
Local(Accountability(
• Legal(en2ty(and(governance(structure(that(allows(receiving/distribu2ng(shared(savings(payments(
• Invest(shared(savings(in(delivery(system(improvements((• Capable(of(financial(and(resource(planning((
Shared(Savings(
• Ongoing(metrics(to(obtain(evidence(of(meaningful(outcome(improvements(and(cost(impacts(
• Measurements(must(be(transparent(and(accessible((• Essen2al(cost(savings(are(result(of(meaningful(improvements(
Performance(Measurement(
�AC0$Model$Principles,�$The$Accountable$Care$Organization$Learning$Network,$http://www.acolearningnetwork.org/whyBweBexist/acoBmodelBprinciples$(Accessed$09/16/2011)$
ACOs will look very different, but a few characteristics are essential
10(
Can provide or manage continuum of care as a
real or virtually integrated delivery
system(
Are of a sufficient size
to support comprehensive performance measurement (
Are capable of prospectively
planning budgets and
resource needs(
1( 2( 3(
How are patients assigned to the ACO?
11(
Providers(sign(agreement(to(par2cipate(with(ACO/ACN((
(PCPs(must(be(exclusive(to(one(ACO;(Specialists(can(be(part(of(mul2ple(ACOs)(
Pa2ents(are(assigned(to(their(PCP(based(on(the(majority(of(their(outpa2ent(E&M(visits(
12(
1. Local accountability
• We know that cost growth is a major challenge to health reform • Local decisions (MRI purchases, ICU wings, high-tech devices) are a
first step in the chain to more-intensive practice patterns and the overuse of services
• ACO-level measures of quality and costs would bring the impact of such decisions to light
• The effects of expansions of acute care facilities or recruitment of additional specialists would be more easily identified – The good and the bad – Not just a vague pass-through that is built into future premiums
13(
2. Performance measurement
• Oregon�s development of All Payer All Claims database provides rich set of opportunities for measurement
• Focus: population health and per capita costs – Not just outcomes & costs for a selected procedure
• Measures and promotes coordination between physicians, clinics, and hospitals – Not just silos
• Opportunities for comparing outcomes different regions (and learning best practices)
• Broad, diverse set of measures possible (public health, too!)
3. Shared savings
14(
• The(principal(features(of(a(�shared(savings�(model(include:(– Payers(and(ACOs(establish(budget(targets(for(the(total(health(spending(of(ACO�s(members.(
– Payers(may(con2nue(to(make(payments(on(a(fee^for^service(basis.(
– At(the(end(of(the(year,(the(actual(and(target(spending(are(reconciled.(
– If(the(actual(spending(is(less(than(the(target,(and(if(the(ACO(has(performed(adequately(on(access(and(quality(metrics,(the(ACO,(payers,(employers,(and(consumers(share(the(difference((�shared(savings�).(
Shared savings based on spending targets
!3 !2 !1 0 1 2 3
Expe
nditu
res
Year
Projected(Spending(
Actual(Spending(
Shared'Savings'
Target(Spending(
ACO Launched
15(
Changing incentives
16(
• Current focus: revenue growth – Often driven by large capital investments with high fixed costs – Incentives for more use
• Extra MRI means more revenue • Foregoing MRI means NO revenue • Only way to make margins is to use more or charge more
– Always leads to greater health care spending • ACO Focus: spending targets & shared savings
– Eliminate wasteful and low value care – Provides incentive to avoid increases in capacity (and to reduce capacity
where feasible); and to improve care in domains previously ignored: care coordination, end-of-life
– Promotes use of data to evaluate cost and quality
PotenAal'ACO'Structure'Commercial*ACOs*
The(UW(Medicine(ACN(• UW(Medicine(
– Harborview,(Northwest,(UWMC,(Valley,(UW(Physicians(
• UW(Network(Partners(– Mul2care((South(King(and(Pierce(County)(
– Overlake((Bellevue)(– Cascade((Arlington)(– Skagit((Mt(Vernon)(
– Island((Anacrotes)(– PeaceHealth((Bellingham)(
– Capital((Olympia)(
The(UW(Medicine(ACN(• How(are(pharmacists(deployed(in(the(ACN(
– Gehng(more(involved(in(customer(service(orienta2on(–(par2cularly(at(discharge(
– Expanding(CDTA’s(in(the(inpa2ent(sehng(
– Ac2ve(in(managing(pa2ents(during(the(transi2ons(of(care((– Deploying(pharmacists(in(the(primary(care(clinics(and(u2lizing(them(as(primary(care(providers(for(certain(condi2ons(that(are(heavily(treated(with(drugs((HTN,(COPD,(Diabetes,(CHF,(etc)(
– Strategy(team(to(reduce(30^day(admissions(
'But'Concerns'About'ACOs'• Most(ACO’s(and(Bundled(Payments(Use(“Shared(Savings”(Approach(and(Not(“Fixed(Budgets”(
• Pa2ents(Have(The(Right(to(Opt(Out(of(ACO’s(• Both(ACO’s(and(Bundled(Payments(are(Voluntary(• First(Genera2on(“Pioneer”(ACO’s(Have(Thus%Far%Had(Only(Limited(Success(
• The(Need(for(Big(Systems(Which(Have(Used(Their(Market(Power(to(Extract(Higher(Prices(That(Could(Outweigh(Efficiency(Benefits(
How'Will'ACOs'be'Successful?*• Aggressively$reduce$low$value$care.$• Help$standardize$high$value$care$using$“Care$Pathways”$
• Integrate$teams$of$providers$that$practice$at$the$“Top$of$their$License”$
• Lead$and$participate$in$care$innovations$–$– Reducing$admissions$– Reducing$‘never$events’$– Shared$decision$making$
• Develop$leadership$teams$
�Medicare$Program;$Medicare$Shared$Savings$Program:$Accountable$Care$Organizations$and$Medicare$Program:$Waiver$Designs$in$Connection$With$the$Medicare$Shared$Savings$Program$and$the$Innovation$Center;$Proposed$Rule$and$Notice�$Federal$Register,$Vol.$76,$No.$67$(April$7,$2011),$p.$19643.$
How'Will'We'be'Successful?*• Integrating$seamlessly$into$the$healthcare$team$–regardless$of$our$practice$setting.$
• Helping$reduce$inefaiciency,$waste.$
• Improving$the$patient$experience.$
• Stepping$up$to$broader$leadership$opportunities.$
• 5557$B$$
Conclusion(• Mul2ple(and(significant(health(care(changes,(par2cularly(related(to(delivery(and(financing.(
• ACO(design(and(financing(varies.(
• Pharmacy(and(the(delivery(of(pharmaceu2cals(in(a(future(where(integrated(delivery(and(global(budgets(are(widespread(will(be(cri2cal(to(success.(