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Rural and Independent Primary Care

www.CaravanHealth.com

Agenda

• 2015 Results from Rural ACO Participants

• Fundamental population health programs.

• Overview of additional rural value-based payments

• Opportunities for free technical assistance in practice transformation.

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Caravan Health

23 MSSP ACO’s

• 6,000 Clinicians

• 55 PPS Hospitals

• 92 Critical Access Hospitals

• 168 Rural Health Clinics

• 39 FQHC’s

• 500,000 Medicare lives

• 32 states

1 Practice Transformation Network

• 11,000 Clinicians

• 800 Independent Practices

3

Caravan Health Services and Programs

• Establish Care Coordination programs

• Establish Wellness and Prevention programs

• Population Health Management software and analysis

• Evidence-based medicine programs

• 24/7 Access program

• Patient Satisfaction program

• Clinically integrated networks

• Advocacy

• Legal and financial services

4

5

Our Triple Aim

Lower Per Capita Cost

Improve Financial

Sustainability

Provide Better Care

Why Quality Matters: Disparities in Quality of Care Between Rural and Urban

2 2 1

13 14

25 15 16

42

17 11 9

0%

20%

40%

60%

80%

100%

Patient Safety(n=19)

Person-Centered Care

(n=16)

EffectiveTreatment

(n=44)

Healthy Living(n=27)

Access (n=25)

Better Same Worse

Key: n = number of measures.

Better = Population received better quality of care than reference group

Same = Population & reference group received about the same quality of care

Worse = Population received worse quality of care than reference group


Source: AHRQ

Disparities in avoidable hospitalizations for all conditions per 100,000 population, by residence location, 2005-2012

800

1,300

1,800

2,300

2005 2006 2007 2008 2009 2010 2011 2012

Rate

per

100,0

00 P

op

ula

tio

n

Total Large Central Metro Large Fringe Metro Medium Metro

Small Metro Micropolitan Noncore

2010 Achievable

Benchmark:938.6 per

100,000 Population

RURAL

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and

Utilization Project, 2005-2011 Nationwide Inpatient Sample and 2012 State Inpatient

Databases quality analysis file and AHRQ Quality Indicators, version 4.4.


Source: AHRQ

Disparities in Life Expectancy Between Rural and Urban are Growing

• 50,000,000 Rural Americans x 2.4 years lost = 120 million years lost by today’s rural residents.

8

Rural vs. Urban Death Rate per 100,000

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Source: AHRQ

9

Rural Value-Based Payments


Rural Value-Based Payments

• Medicare Incentive Payment System (Starts 2017)

• Up to 9% penalty or 27% bonus by 2022

• $3- $9 PMPM

• Medicare Shared Savings Program (Open)

• Average Payment = $7.34 PMPM

• AIM Funding = ~$7.50 PMPM

• Comprehensive Primary Care Plus (Regional-FFS only)

• Average Payment = $16.50-$32 PMPM

• NextGen ACO Shared Savings Program (Open)

• $8 PMPM

• Million Hearts (closed)

• $10 PMPM for 30% of Medicare patients

CONFIDENTIAL | 10

MSSP Program Elements

• All reimbursement stays the same for all providers

• Quality reporting and care coordination is required

• If savings are realized, payor will share savings with the provider

• Bonus payments are adjusted downward based on quality scores

• All claims data is provided to participants

• Waivers of Stark, Anti-trust, Anti-Kickback and Patient Inducement regulations

• MSSP Track 3 also can have 3-day admisssion SNF Waiver

• Patients have full choice on where to go for care.


All MSSP Results – 0.58% Savings


Advanced Payment – 2.28% Savings


Advanced Payment Model Success!

• Note: Total Savings is likely understated due to only accounting for attributed lives and does not reflect savings on patients that were not attributed at the end of the performance year. Typical ACO attribution churn is 20-40% per year. Source: https://data.cms.gov


2015 MSSP Results - COST

• Three out of five of our 2015 ACO starts showed savings, and our 2015 average savings is 2.57 times higher than all other 2015 ACO starts.

• $7,342,984.00 qualifying shared savings

• $3,598,062.00 shared savings paid

Stop = 0

Slow Down = 0

Keep Going = 30

Best Year Ever = 6

30 Hospital CFO’s In Charge

2015 MSSP Results – QUALITY

• Our second year ACO’s quality score went from 68.9% to 96.88% in one year.

• All first year ACO’s reported successfully.

2016 Rural ACO Cost Trends

2016 MSSP Results -- ENGAGEMENT• All but one community has hired a Care Coordinator (145/146) to

do chronic care management (great new rural jobs!)

• 97% are coming to Quality Improvement Workshops to learn how to implement AWVs, CCM and TCM with their patient populations

• 98% (143/146) of communities have begun performing AWVs on Medicare patients and 42,394 have been conducted!

• 4,305 patients currently in CCM

• 6,895 patients been followed for TCM

• 87% of Care Coordinators are regularly attending monthly cohort calls with Caravan Health Coaches to share best practices

• 97% of communities (141/146) now have a 24/7 nurse advice line

• 92% (134/146) are using Lightbeam, Caravan Health’s analytics tool for population health management

• 98% (143/146) are holding quarterly steering committee meetings.

MACRA Proposed Rule: Table 64


CMS says 73% of practices with fewer than 25

clinicians will pay penalties under MACRA

Preparing Clinicians For Value-Based Payments

• Background:

• Spring 2016: ACO Medical Director Summit

• 21 ACO Medical Directors

• 6 Hospital CEOs

• Physician-led discussion on how to align physician compensation with new

payment models.

• Now is the time to begin the conversation


10/3/2016 22

Population HealthCommon Elements of Success

Prevention: • Annual Wellness Visits

• Chronic Care Management

• Advanced Care Planning

• Behavioral Counseling

• Depression Screening

• Mental Health Support

• 24/7 Access

Coding:

• Complete and accurate documentation of all chronic conditions is key to

correct payment under value-based models.

Quality: • Process

• Pre-visit Planning

• Patient Satisfaction

10/3/2016 23

Population HealthCurrent Revenue Opportunities

Fee Schedule: • Annual Wellness Visits

• Chronic Care Management

• Advanced Care Planning

• Behavioral Counseling

• Depression Screening

Value-Based Payments:• Medicare Incentive Payment System

• Medicare Shared Savings Program

• NextGen ACO Shared Savings Program

• Mandatory or Voluntary Bundled Payments

• Comprehensive Primary Care Plus

• Million Hearts

What Are We Trying To Improve?• Quality

• Most practices do not have processes in place to promote wellness and address gaps in care – which are key quality measures.

• We need to establish the processes and workflow to address these issues.

• Cost

• Reduce unnecessary care

• In value-based payments, payments are multiplied times HCC scores.

• We need to improve our coding to get paid what we are worth.

• Practice Economics

• We need to spend an extra hour with each of our Medicare patients each year to address prevention, care gaps and appropriate coding. How do you pay for that?

• We will need to fund the staff to do this work in order to be sustainable.

25

Value of Wellness Visit in Population Health

Gather as much data as possible

on lives

Find patients who are “at risk”

Refer for appropriate follow-

up services

Develop a consistent primary care relationship

Refer patients to Care Coordinator

Example: 25% Wellness Visits


Pre-AWV Post-AWV

Example: Didn’t Do Wellness Visits


Nurses Excel in Wellness Visits


Source: Hattiesburg Clinic

29

CMS Proposes $900 Million Increase for PCPs-- Specialists Pay the Price


2017 Physician Fee Schedule Updates

• Removes 24/7 direct supervision requirement for Chronic Care Management in RHCs and FQHCs

• Allows Advanced Care Planning by telemedicine

• Implements important new programs and payments that are great for patients and providers

• Behavioral Health Integration:

• Psychiatric Collaborative Care Model (GPPP1, GPPP2, GPPP3)

• General Behavioral Health Integration (GPPPX)

• Additional payments for outpatient visits with mobility-related disability patients (GDDD1)

• Cognitive and Functional Assessment and Care Planning (GPPP6)

• Comprehensive Assessment and Care Planning (GPPP7)

• Re-evaluating underpayment for Diabetes Self Management Training


Psychiatric Collaborative Care Model

• Overcomes the lack of psychiatrists, particularly in rural areas.

• Doctors or care coordinators are trained to implement all programs with monthly consultation and review with a psychiatrist.

• More than 80 peer reviewed publications supporting effectiveness.

• New payment model will enable practices to set up program and be successful.


New Diabetes Prevention Program

• 5-10% of pre-diabetic patients develop Type 2 diabetes each year.

• Introducing CDC’s National Diabetes Prevention Program

• 16 “core” group sessions on diet and exercise in six months

• Monthly maintenance sessions

• 7,804 enrolled, saved Medicare $2,650 per enrollee, lost 5% of weight

• Program begins 1/1/2018 for non-clinical staff

• Preventive service – no copay, but providers must bill under Part B

• If patient attends 14 core sessions and loses 5%, provider gets $27.92 PMPM for six months, then $15 PMPM for monthly sessions (50 patients -- $12,876 first year, $9,000 per year afterward.

• Provider can charge non-Medicare patients to participate.

• Can use non-clinical staff but GREAT FIT for care coordinator.

• Great for patients. Synergy with rural needs and rural mission.


33

Physician’s Viewpoint on Value-Based Payments


Payment based on cost and quality is inherently wrong, due to high variability of patients.

Doctors want a program that is measurable and fair. CEOs are very nervous about having this conversation.

Physician Recommendations

• Have a conversation! Everyone’s payments will be affected going forward.

• There is still time to play “Fantasy Football”

• Pay for engagement:

• Percentage of patients who have annual wellness visits

• Percentage of eligible patients in chronic care management program

• Attendance at Steering Committee Meetings

• Attendance at Quality Improvement Workshops,

• Taking Leadership roles

• Viewing evidence based medicine webinars.


35

In Conclusion

• MACRA is the biggest change to physician payments in a generation;

• Don’t fear QPP, there’s decent upside potential;

• Don’t jump to risk;

• Now may be the time to begin discussions on Physician contracts;

• If RHC or FQHC, consider voluntary reporting.

• You don’t want to get left behind, or be perceived as a low-value provider.


What Should You Do Now?• Perform wellness visits on all of your patients.

• Embed a care coordinator in your practice.

• Start a Diabetes Prevention Program.

• Start working on integrating behavioral health.

• Prepare your boards to be flexible. This takes trial and error.

• Join a non-risk bearing Clinically Integrated Network.

• Keep up with your EHR.

• Code Baby Code! Get your HCC scores right.

• Join an ACO.

• Keep up with announcements of new models.

• Get free training, software and support by joining National Rural Accountable Care Consortium Practice Transformation Network.


Join Our PTN:• Set up Care Coordination Services

• Maximize Wellness Visits

• Increase your Medicare revenue by $20 PMPM

• Increase your quality by 20% or more

• Provide 24 hour advice nurses for your patients

• Get help implementing new programs discussed today.

IT’S FREE• Go to www.nationalruralaco.com and click on “Apply Now”

• Or email [email protected]

Learn More

http://www.nationalruralaco.com

mailto:[email protected]

Thank You

www.CaravanHealth.com

http://www.CaravanHealth.com

rural and independent primary care - nmhanet.org - caravan health (1).pdf · •nextgen aco shared...

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