Reference Slides US Healthcare in 2016 - namcp

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8/30/2016

Reference Slides • • • •

US Healthcare in 2016 Medicare’s Market Changing Influence Payer-Dominant Market Strategies Provider-Dominant Strategies

Spring Managed Care Forum – Orlando Meeting – April 2016

The Future of Healthcare “Optimization of Value-Based Clinical and Business Models” 1

US Healthcare in 2016 • Marketplace Dynamics Five Years After the Affordable Care Act

Spring Managed Care Forum – Orlando Meeting – April 2016

The Future of Healthcare “Optimization of Value-Based Clinical and Business Models” 2

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Reading the Puck in Healthcare Today and Tomorrow LEVEL OF CRITICAL MASS LEADS MARKET ACCELERATION Critical Mass of and between Physicians/Physician Groups Critical Mass of and between Physicians/Hospitals Critical Mass between Physicians & Hospitals/Payers DIRECTION Declining Reimbursement Increased Clinical Risk Narrow Networks Greater Transparency Enhanced Connectivity EXTERNAL FORCES Consumer Choice and Access Payer Metamorphosis Provider Consolidation Primacy of Primary Care New Care Delivery Options (Th!nk, One, Retail Online)

Spring Managed Care Forum | April 2016

3

Significant Shifts in Value Based Payer Reimbursement Occurring* KEY TAKEAWAY These are preliminary estimates of how payer mix will be changing in the typical market as a result of payment reforms.

ACA “ROLLOUT”

2015 and Beyond

Pre-2014 Commercial ERISA

45%

ERISA | ERISA VBP Cmcl. | Cmcl. VBP, Public/Private Exchange Plans

Public Exchanges VBP

36%

9%

Medicaid

18%

Expanded +/Medicaid VBP/APR DRGs

20%

Uninsured

12%

Uninsured

10%

Medicare FFS Medicare MA

25%

Medicare FFS Medicare VBP MA Products

25%

* Source: Developed from SSB Proprietary Data Base 2014

Spring Managed Care Forum | April 2016

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Physician Leadership and Engagement Essential to CIN Success KEY TAKEAWAY Aligned physicians will need to become engaged in all facets of CIN development and will need to provide significant clinical leadership. PHYSICIAN-SUPPORTED INITIATIVE

Form CIN • Legal structure • Organization/ownership • Governance • Infrastructure development • Budgeting/financial modeling

PHYSICIAN-LED INITIATIVE

Clinical Integration and Performance Improvement • Population Health Management and ValueBased clinical models • Care transformation • Care coordination • Provider compensation • Enabling technology • Performance tracking

Clinically Integrated Network

Specialists

H

PCPs

Medical Staff Collaboration • Staff education and engagement • Integrating/collaborating with CIN quality initiatives • Delegated functionality

Governance and Leadership • Effective governance and management • Member education and engagement • Managing member dynamics and relationships

Spring Managed Care Forum | April 2016

5

Value-Based Contracting Requires FTC-Compliant “Clinical Integration” KEY TAKEAWAY For the hospital and affiliated physicians to engage in joint, value-based contracting, they collectively must meet FTC requirements for “clinical integration,” which cover a combination of organizational and legal touchstones. CIN will need a formal organization structure (usually an LLC) and provider participation agreements that define participation requirements and performance expectations for network service providers.

Hospitals and Employed Physicians H

H

H

H

H

H

Independent Physicians CIN Network Participation Agreements

Organizational Requirements

Legal Considerations

Clinical Scope

Membership

Market Power Concentration

Fraud and Abuse Issues

Encompasses full continuum of care (inpatient, outpatient, alternative care, and collaborative care settings)

Targeted at physicians whose participation has potential to maximize quality and efficient resource utilization

Clinically integrated networks which materially reduce competition may be subject to challenge

Must satisfy Anti-Kickback Statute and Stark rules

Performance Improvement

Capital Requirements

Designed to improve quality and reduce costs through protocols adherence supported by comprehensive data collection and reporting

Significant investment required to develop and deploy technology infrastructure (clinical and financial) to support improved care delivery

Ownership and contractual arrangements must be at Fair Market Value

State Licensing/Regulatory Requirements Must comply with all all state licensing and regulatory requirements with regard to ownership, financial arrangement and other statutes

Spring Managed Care Forum | April 2016

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New Capabilities and Priorities Required by Providers TRIPLE AIM

PROVIDER GROUP/SYSTEM

STRATEGIC AND OPERATIONAL PRIORITIES

Product and Contracting Strategy

Clinical Scope and Model

NETWORK ORGANIZATION/MANAGEMENT - Geographic coverage - Continuum of services - Patient attribution - Performance analytics - Credentialing - Ongoing provider communications

SUPPORTING INFRASTRUCTURE AND TECHNOLOGY CARE COORDINATION - Population health analytics - Deployment of best-practices - Active patient engagement and communications - Care transitions - Quality tracking and reporting - Communication among providers

Spring Managed Care Forum | April 2016

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Evolution of PHM Networks and Associated Capabilities To stay competitive, providers are compelled to move up the curve ahead of changing market so core capabilities are in place to accept value-based Performance contracts Improvement

Quality

Aggregation and Measurement AFFILIATED

ENGAGED

COORDINATED

HIGH PERFORMANCE

Documentation - Implement EHR - Collect data at point-of-care - Focus on episodic care

Organization and Measurement - Aggregate and normalize data - Measure against payer-driven programs - Focus on overall organizational performance

Collaboration and Improvement - Target high-value opportunities - Prioritize high-risk patients - Initiate care management - Identify gaps in care - Patient outreach

Optimize Clinical and Financial Outcomes - Utilize predictive modeling - Assess organizational risk - Manage cost and utilization - Improve the patient experience

Fee for Service

Pay for Performance (Shared Incentives)

Shared Savings Bundled Payments

Shared Risk Capitation

Risk Spring Managed Care Forum | April 2016

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Three Layer Technology Framework Supporting PHM Provider Portal

Patient/Consumer Portal

COMMUNICATIONS

Care Management Coordination

Clinical Applications

Patient Engagement

Analytics/Metrics

APPLICATIONS/TOOL SETS

Parsing – Validation – Routing – Privacy and Security – Filtering – Indexing - Notifications Normalization Semantic Interoperability

Master Patient and Provider Index

HIE

Clinical Data Repository

INFORMATION LAYER

Pharmacy

Lab

Outpatient Imaging

Hospital EMR

Private Practice EMR

Regional HIE

Payer

Spring Managed Care Forum | April 2016

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Critical Infrastructure and Technology Needs for CINs/ACOs Category

Description

Key Capabilities

Population and Clinical Risk Management

Quantify patient risk, input to risk-adjusted payment methods, and ability to predict/tailor care needs and enable greater risk-sharing.

• • • •

Predictive modeling Patient stratification Clinical risk quantification Patient attribution analysis

Financial and Network Management

Facilitate transfer, disbursement, incentive alignment, and contract management of value-based payments.

• • • •

Novel reimbursement model support Network assessment Contract development Patient financial management

Tightly track costs across the care continuum to support operation of a high-performing network. Clinical Model Design and Management

Promote evidence-based care delivery, enable tighter care coordination, support for integrated treatment planning, and cost-effective use of resources and settings.

• • • • •

Clinical process development EBM pathway development Protocol management Bundled payment care management models Care coordination/transitions of care

Core Clinical Technology Infrastructure

Deploy and leverage robust clinical technology infrastructure to create seamless clinical integration across acute and ambulatory settings.

• • • • •

Interoperable EMR Shared clinical and administrative documentation Referral and network management POC decision support Bundled payment tracking and reporting

Integrated Data Exchange

Ensure integrated, secure, timely access to clinical and administrative data.

• Integrated access to clinical, financial, and administrative data – e.g. claims, encounter, cost/quality, EBM guidelines

Performance Management

Enable robust, transparent performance management that allows root-cause identification of cost and quality gaps and ties payment to performance.

• • • •

Performance metric dashboards Integrated cost and quality reporting Provider performance profiling Utilization/quality review

Patient Engagement

Enable patient-focused programs and tools that promote self-management and allow for cost and quality-conscious healthcare decisions, particularly for at-risk and chronically ill patients.

• • • •

Patient navigation and care collaboration Intelligent scheduling/tracking/monitoring/alerts Shared decision making Information portals

Spring Managed Care Forum | April 2016

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Four PHM Purchase Categories for Providers ENTERPRISE DEVELOPMENT PLATFORM

Examples

Integrated data capture, analytics and communications platform to be used by multiple constituencies across the enterprise

Caradigm Health Catalyst Healthcare Data Works Recombinant (Deloitte) IBM

ANALYTICS-AS-A-SERVICE

Explorys Humedica Lumeris Premier (Verisk) Truven

Outsourced PHM analytics and data management to support PHM strategies and benchmarking

POINT SOLUTIONS

Altasoft Medventive Midas+ MedeAnaltyics Cloudera

Standalone components with narrow but deep functionality and subject matter expertise

EMR SUB-MODULE

Epic Cerner MEDITECH AllScripts

Integrated PHM analytic and process routines within the provider’s EMR

Source: Adapted material from the Advisory Board “Overview of the Healthcare Analytics Market” (2014) http://www.slideshare.net/elcid84/phmslideshare2014?qid=331b8a6e-df33-4f6b-8bbf-ee7bc139c465&v=default&b=&from_search=3

Spring Managed Care Forum | April 2016

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Transition from FFS to Value Based Care Accelerates Consolidation – Growth of Healthcare M&A Deals 1995 - 2015 450

Value $425B in 2015

400

24% off total U.S. M&A deals

350

325

300 250 180

180

175

200

175 155 140

120

125

150

130 110

120

100 70 50

45

70

50

70

65

50

40

1995

2000

2005

2010

0 2015

Source: WSJ October 28, 2015

Spring Managed Care Forum | April 2016

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Value-Based Market Dynamics Lead to Healthcare Consolidation Acquisitions targeting U.S. health-related companies are helping drive what could be a record year for M&A transactions PHARMA & BIOTECH Walmart and others have struck more that $240 billion worth of U.S. deals this year

$B 250 200 150 100 50 0

INSURANCE The proposed AetnaHumana and Anthem-Cigna tie-ups leave three U.S. giants

$$

$B 120 90

HOSPITALS Tenet and rival hospital operators are starting to consolidate the still fragmented industry

$B 15 12 9 6 3 0

DRUG STORES Walgreens Boots’ $9.4 billion purchase of Rite Aid would create a chain with over 12,000 U.S. locations $B

20 15

60

10

30

5

0

0

Spring Managed Care Forum | April 2016

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For the 3rd Consecutive Year, the Three Most-placed Providers Were Family Medicine, Internal Medicine And Hospitalists

Placement Specialties 2016. Source: The Medicus Firm

Spring Managed Care Forum | April 2016

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Medicare’s Market Changing Influence • • • •

FFS Medicare Medicare Shared Savings Program (MSSP) “Next Generation” MSSP Medicare Advantage Plan

Spring Managed Care Forum – Orlando Meeting – April 2016

The Future of Healthcare “Optimization of Value-Based Clinical and Business Models” 15

Federal Healthcare Costs Rising

Spring Managed Care Forum | April 2016

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Financial Funds Flow—MSSP Plan Medicare Shared Savings Program $ CMS pays a portion of shared savings to the CIN (ACO) savings achieved based on: • Cost performance for attributed beneficiaries • Meeting quality performance metrics

CIN LLC

CIN (ACO) pays Care Management Fees to PCPs for care coordination

$

$

CMS makes Medicare FFS payments directly to providers

Physicians

CIN distributes Incentive payments and bonuses

$

Hospital

H

Medicare MSSP Revenue Attributes • Medicare pays claims and provides claims data information to CIN (ACO) • Retrospective reconciliation to determine the level of shared savings • CIN Board establishes policies re: reserves, surplus distribution, risk management, etc. Spring Managed Care Forum | April 2016

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MSSP Incentive Award Opportunity Expenditure Reduction Achieved by ACO

×

Track 1: 50% Track 2: 60% Track 3: 75%

×

Performance Score Earned by ACO Patient/Caregiver Experience (7 metrics)

MSSP Shared Savings Award Paid to ACO



ACO Portion of Shared Savings

Care Coordination Patient Safety (6 metrics)

$$$

 ACO Actual $$

ACO Benchmark $$

Savings

=

Preventative Health (8metrics)

 Managing At-Risk Populations (12 metrics)

 

H Physicians

Hospital

33 Total Performance Metrics • Part A and Part B claims for beneficiaries attributed to the ACO • Benchmark projection based on 3 years of CMS data

• In Year 1, requirement is complete and accurate reporting on all measures • In Years 2 and 3, a performance score is calculated for the ACO

Spring Managed Care Forum | April 2016

• Total award is capped at a % of Benchmark expenditures depending upon chose track (Track 1: 10%, Track 2: 15%, Track 3: 20%) • Calculation of award occurs 6-9 months after end of year. 18

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Detailed Example | MSSP vs. Next Generation Quality Score •

• •

What is the same? – The Quality Score for a Next Generation ACO is similar to the methodology used in an MSSP ACO: • Both programs use the same four domains (Patient/Care Giver Experience, Care Coordination/Patient Safety, Preventative Health, At Risk Populations) • The 32 Next Generation ACO quality metrics are the same as those used in the MSSP ACO program • The same methodology is used to calculate the Quality Score across the four domains What is different? The Quality Score for Next Generation ACOs does not include the EHR metric as participants are expected to have met this performance metric – MSSP ACP program applies the Quality Score to the calculated savings while the Next Generation ACO program applies the quality score as a factor in adjusting the baseline costs to the benchmark Quality Score

100%

70%

Total Achieved Savings

$50.0 million

$50.0 million

Available MSSP ACO Share (Track 1 50%)

$25.0 million

$25.0 million

1.0

0.7

$25.0 million

$17.5 million

Quality Score Factor Shared Savings (Available Share X Quality Factor)

Spring Managed Care Forum |

30% reduction in the Quality Score reduces shared savings by 30%. April 2016

Impact: -$7.5 million

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Detailed Example | MSSP vs. Next Generation Quality Score

Quality Score

100%

70%

Baseline PMPM

$1,000

$1,000

PMPM Adj. For Cost Trend (+1.5%)/Risk Score (+2.0%)

$1,035

$1,035

1.0

0.7

Quality Score Quality Discount [2%+(1-Quality Score)]

-2.0%

-2.3%

Benchmark PMPM

$1,015

$1,011

Covered Lives

100,000

100,000

Benchmark

$1.218 B

$1.2132 B

Actual Cost ($50MM savings from Baseline adjusted for risk score/cost trend)

$1.168 B

$1.168 B

Surplus

$50,000,000

$45,200,000

Shared Savings (80% Track)

$40,000,000

$36,160,000

30% reduction in the Quality Score decreases the Benchmark PMPM, which decreases the Shared Savings.

Impact: -$3.84 million

Note: Assumes Regional and National Efficiency adjustments are neutral.

Spring Managed Care Forum | April 2016

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Next Generation ACO Fact Sheet CMS selected 21 organizations to participate in the NGACO model: NGACO Model Name Accountable Care Coalition of Southeast Texas Inc. Baroma Accountable Care, LLC Beacon Health Bellin Health DBA Physician Partners

Location Houston, Texas Miami, Florida Brewer, Maine Green Bay, Wisconsin

Cornerstone Health Enablement Strategic Solutions (CHESS) Deaconess Care Integration Henry Ford Physician Accountable Care Organization

High Point, North Carolina Evansville, Indiana Detroit, Michigan

Iowa Health Accountable Care Optum Accountable Care Organization MemorialCare Regional ACO OSF Healthcare System Park Nicollet Health Services

West Des Moines, Iowa Phoenix, Arizona Fountain Valley, California Peoria, Illinois St. Louis Park, Minnesota

Pioneer Valley Accountable Care

Springfield, Massachusetts

Prospect ACO CA

Los Angeles, California

Regal Medical Group

Northridge, California

River Health ACO

Harrisburg, Pennsylvania

Steward Integrated Care Network

Boston, Massachusetts

ThedaCare ACO

Appleton, Wisconsin

Triad HealthCare Network Trinity Health ACO WakeMed Key Community Care

Greensboro, North Carolina Livonia, Michigan Raleigh, North Carolina

Spring Managed Care Forum | April 2016

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Payer-Dominant Market Strategies • National Perspective • Aetna Example • Optum Example

Spring Managed Care Forum – Orlando Meeting – April 2016

The Future of Healthcare “Optimization of Value-Based Clinical and Business Models” 22

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Ranking of the Top 15 Health Plans by Market Share*

Rank and Insurer 1) UnitedHealth Group 2) Kaiser Foundation Group 3) Anthem Inc. 4) Aetna Group 5) Humana Group 6) HCSC Group 7) Cigna Health Group 8) Highmark Group

9) 10) 11) 12) 13) 14) 15)

Blue Shield of California Group Independence Blue Cross Group Centene Corp Group HIP Insurance Group BCBS of New Jersey Group BCBS of Michigan Group Guidewell Mutual Holdings Group

Source: National Association Of Insurance Commissioners

Spring Managed Care Forum | April 2016

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Aetna Imperative: “Our Business Must Evolve”

Insurance company

Health care company

End user an employee or part of a larger population

End user increasingly an individual with personalized care needs

Managing risk

Spring Managed Care Forum | April 2016

Managing health

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Healthagen Strategy: Enable Transformation of Care Delivery

• Population-based clinical intelligence, decision support and alerts

Cost comparison and transparency tool

• Clinical Data Integration

• Compiles and transforms healthcare data into powerful, meaningful and actionable information

• Secure Data Exchange

• Value-based care models for primary care physicians

• Consumer facing tools for managing health and benefits

Spring Managed Care Forum | April 2016

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Three Pillars of Aetna’s Value-Based Care Model

Plan Design

Cost Structure and Volume Improvements

Clinical/Administrative Efficiencies

• Offer narrow network plans designed to save customers 8-15% in the first year • Employees access care through a tiered plan in which there is a financial incentive to use providers within the ACO

• Providers discount their rates in exchange for Aetna marketing a plan whose preferred tier providers are all participants in the ACO • Competitively priced health plan brings more volume to the provider network

• Technology and care management reduce waste, identify gaps in care, and improve the patient experience • Where needed, Aetna offers providers proven tools and business services for making the transition from volume to value

Spring Managed Care Forum | April 2016

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Aetna’s Provider Collaborations

Aetna reports 200+ negotiations underway with potential ACO partners in markets covering 60% of the US population Spring Managed Care Forum | April 2016

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Aetna Worldview: Future State of Healthcare Current State

Payor and providers largely integrated

Employers and CONSUMER government are the primary decision makers

Consumers are the primary decision makers

Spring Managed Care Forum | April 2016

SOLUTIONS

Payors and providers are largely separate

PUBLIC AND CARE TRANSFORMATION CONSUMER PRIVATE Services and ENGAGEMENT EXCHANGES Technologies Services and Technologies

benefit

Defined contribution / subsidy model

EMPLOYER “Social contract” GOVERNMENT drives defined

PROVIDER

Future State

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Consumer Choice Could Drive Half the Market by 2020 334M 319M

9%

Uninsured

13%

Consumer choice is the fastest growing segment in the marketplace

50% 34%

Consumer Choice • Public / Private Exchanges • Individual MA • Medicare Supplement • Managed Medicaid

16% 16%

Government • Medicare FFS • Medicaid FFS

25%

Employer

38%

2014

Based on Aetna estimates of industry 2014 Aetna Investor Conference| December 11, 2014

2020

37

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Aetna’s Value-Based Contract Spending On track to achieve VBC spend of at least 50% by 2018

50%+ Value Based Contracting Spend as Pct of Total Medical Spend

~25% ~15%

2013

2014E

Spring Managed Care Forum | April 2016

2018P

30

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Aetna Whole Health Product with Banner Banner/Aetna Products Stand Alone or Turn-Key Solutions Aetna Whole Health

Any Payer Any Insurance Segment

Provider Branded Health Plan

Strategy Development and Change Management

Care Management

HIT/HIE CT Suite Team Suite • Care • HIE • CDS Patient PortalPortal • PHR / Pt • Analytics & Reporting • Implementation Services

Physicians

• • • • • •

Telephonic CM Embedded / Embedded Telephonic CMBH, MM UM, DM, CM, DM, UM, Staff CM and Programs Training, Wellness and Lifestyle Senior Programs Clinical / IT Platform Implementation Services

Hospitals

Pharmacy

Health Plan Services • • • • • •

License Claims Member Services Sales and Marketing Actuarial / Underwriting Implementation Services

Outpatient Facilities Home Health

Spring Managed Care Forum | April 2016

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CIN Strategy: Banner Health Moved the Phoenix Market in 2011 and the Arizona Market in 2014 to Become a Statewide CIN CIN

Banner Health Network (“BHN”) with FTC Approval in 2011

Participants

• • • •

Key Payer Relationship(s)

• Medicare (Pioneer ACO), Aetna, BCBSAZ (MA), Humana, HealthNet, United, Cigna • Multiple products and plans including MSSP, global risk, MA, narrow network • No Medicaid product at this time

Attributed Lives

• 200K commercial lives in 2012; 22K MA lives; estimated 500K - 750K lives by end of 2015; U of A Health Plan Members

Org Structure and Governance

• Physicians own 50% and Banner Health owns 50%; shared savings commensurate with ownership • BPHO can engage in risk-based contracting • BHN Board has representatives from all three physician entities and Banner Health; four subcommittees of the BHN Board: Quality/Clinical Integration; Finance; Operations and Contracting; and Information Technology

Key Points

• Aetna partnership is pivotal in building of BHN I/T infrastructure to support utilization management • Arizona Integrated Physicians partnership charged with building clinical infrastructure on ambulatory side owned by DaVita/Healthcare Partners • BHN pushing actively to develop narrow network products consistent with changing payer environment • BHN has tried several types of risk models and plans to offer a capitated arrangement in the third year of the Pioneer program, as well as with several commercial offerings

Banner Health (Hospitals) including U of A’s two hospitals Banner Medical Group and U of A Medical Group/Faculty Practice Plan Banner Physician Hospital Organization Arizona Integrated Physicians (IPA) owned by DaVita Healthcare Partners

Spring Managed Care Forum | April 2016

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Banner Health Network and BCBS-AZ Case Study Key Elements of the BHN Partnership

JV #1: Banner Health Network (50/50 JV Between Banner Health and Physicians)

• “Win/win” structure • Terms are acceptable to AIP • Formation of new company for all VBP contracting

Banner Medical Group 25%

Banner Health 25%

Banner Hospitals

• 50/50 ownership • 50/50 governance

800+ Physicians 120 PCPs

• AIP has leadership role • AIP is exclusive to BHN for VBP contracts • Banner is exclusive to BHN for VBP contracts • Alignment of incentives

600 Physicians 150 PCPs

900+ Physicians 170 PCPs

Banner PHO* 25%

• 50/50 sharing of incentives and risk

Arizona Integrated Physicians 25%

Banner * Banner Health owns 50% of Banner PHO

Spring Managed Care Forum | April 2016

JV #2: BCBS-AZ and Banner Health Network (50/50 JV) • Purpose is joint development of value-based products • Mutual exclusivity for value-based

33

Banner and AZ Care Network (Dignity/Tenet/PCH) – Opposing Provider CIN/Networks in Phoenix and Tucson HMO

Los Ninos H. Phoenix Indian MC Phoenix VAMC St. Luke’s MC Thunderbird VA

Arizona Heart H. Maryvale H. Paradise Valley H. Phoenix Baptist H. Phoenix Children’s St. Joseph’s

PPO

Banner Estrella MC Banner Good Samaritan

Kindred Hospital Arizona - Phoenix Select Specialty Hospital - Phoenix Select Specialty Hospital - Phoenix Downtown

Arizona Care NetworkDignity/Tenet/ PCH Powered by Aetna Whole Health

Banner Health Network Powered by Aetna Whole Health

Source: Aetna DocFind directory

Spring Managed Care Forum | April 2016

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Structural Overview of Optum

Care management, integrated care delivery, and consumer solutions, including financial services

Delivers technology, operational and consulting services across healthcare industry

PBM Services

Collaborative research and innovation partnership between Optum and Mayo focused on improving patient care

Spring Managed Care Forum | April 2016

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UnitedHealthcare Has Formed ACOs Across the Country $30B of UHC provider spend is tied to ACPs, projected to grow to $65B by the end of 2018 Atlantic Health ACO to provide services for 16,000 UHC employersponsored plan participants in northern New Jersey ACP partnership with Optum Health

Sources: http://accountablecareanswers.com/ http://accountablecareanswers.com/newsroom/

Spring Managed Care Forum | April 2016

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Provider-Dominant Market Strategies • Memorial Hermann Example • Summit Medical Group Example • Academic Medical Centers

Spring Managed Care Forum – Orlando Meeting – April 2016

The Future of Healthcare “Optimization of Value-Based Clinical and Business Models” 37

Largest For Profit and Not-For-Profit Health Systems in US by Operating Revenue 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Kaiser (NFP) HCA (FP) Ascension (FP) CHS (FP) Tenet (FP) CHI (NFP) Trinity (NFP) Providence (NFP) UPMC (NFP) Partners Healthcare System Dignity (NFP) Sutter (NFP) Mayo (NFP) University of CA (NFP) Adventist Health System/FL (NFP)

Spring Managed Care Forum | April 2016

$56.4 B $36.9 B $20.1 B $18.6 B $16.6 B $13.8 B $13.6 B $12.4 B $11.4 B $10.9 B $10.6 B $10.2 B $9.7 B $8.5 B $8.3 B

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The Market Leader – Emphasizing Retail Expansion and Critical Mass

$4.9B Total Assets $4B Net Operating Revenue 22,000 Employees; 5,000 Medical Staff

Inpatient Market Share

211 Locations

Market Share Ranking 1st: Aggregate Market Share 1st: Burns 1st: Cardiology 1st: ENT 1st: General Medicine 1st: General Surgery 1st: Neurology 1st: Neurosurgery 1st: Ophthalmology 1st: Orthopedics 1st: Rehab 1st: Thoracic Surgery 1st: Urology 1st: Vascular 2nd: Gynecology 2nd: Obstetrics 2nd: Neonatology 2nd: Spine 2nd: Oncology

Memorial Hermann

HCA

St. Luke’s Methodist

Greater Houston MSA 6.36 million population, projected to 6.9 million by 2018 Spring Managed Care Forum | April 2016

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Memorial Hermann Accountable Care

COMMERCIAL

MEDICARE Gr Houston >11,000

211 Locations

MHMD 3,500 CI 2,900 ACO 2,700 PCMH 304

• Clinically Integrated IPA • Private, Employed & Faculty Integration Commercial • Exclusive Contracting DOJ/FTC Protections • 260,000 covered lives • BCBS, Aetna, Humana

CMS Shared Savings • 45,000 attributed beneficiaries • Focus Patient Centered Medical Home

Medicare Advantage • 19,600 covered lives

Year 1 CMS Shared Savings $57,800,000 Savings (#1 ACO in the US) Spring Managed Care Forum | April 2016

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Memorial Hermann Health System CIN is Organized for Population Health Management Around Service Lines and Specialties

MHMD Board of Directors Clinical Programs Committee

H&V

Neuro

Women Children

Surgery

Medicine

Cardiology

Neurology

Neonatal

Anesthesia

CV Surgery

Neurosurgery

OB Gyn

Oncology Oncology

Contract Contract

Critical Care

Medical

Radiology

Adult PCP

Bariatrics

Emergency

Radiation

Pathology

Peds

Orthopedics

Hospital Medicine

ENT

Post Acute

Primary Care

Spring Managed Care Forum | April 2016

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New Dimensions of Retail Medicine • Critical to recognize the retail medicine goes far beyond clinic carve outs in drugstores or big box retailers • Also encompasses population health management and array of retailer sponsored specialty services and analytics Consumer-Centered Care at Walgreens

Walgreens Physician Support

• Health screenings and testing

• Patient referrals

• Immunizations

• Comprehensive Medicare member assessments coding support

• Medication therapy management • Bedside RX delivery for inpatients

• Medicare wellness exams

• Inpatient discharge solutions (Well Transitions)

• Site of care optimization

• Adherence counseling • HIV centers of excellence • Broad access to specialty medications

• Care gap closure • Consumer engagement programs • Physicians education and alignment materials

Back Office Data and Analytics • Direct reporting/tracking of consumer interventions - Immunizations - Health testing - Gap closure - Infusion and respiratory services • Analytics and predictive modeling for gap closure and working with targeted high-risk population

• Adherence reporting

• Infusion and respiratory services

Spring Managed Care Forum | April 2016

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Growth of Retail Clinics •

2013 survey estimates that one-third of Americans visited a retail clinic for clinical services



Estimated 1,800+ clinics in 2014 anticipated to grow to 3,000 in 2016/17



Staffed by NP, core menu of services generally includes: – Minor illnesses and injuries – Skin conditions – Common health screenings – Vaccinations and injections – Selected lab tests

Top 6 Participants account for 90+% of the Retail Clinic Market



Regional clinic networks often linked or aligned with individual health systems, with intent to connect and data share



Growing support for retail clinics by payers due to reduced cost of care vs. physician office

Source: Robert Wood Johnson Foundation, “The Value Proposition of Retail Clinics”, April 2015

Spring Managed Care Forum | April 2016

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Proposed Service Model of Summit Health Management SHM model for optimizing performance during transition from Fee-for-Service to Fee-for-Value CULTURE

PEOPLE

Operations Management

Revenue Management

Infrastructure

CLIENT

Physician Management

PROCESS Spring Managed Care Forum | April 2016

Infrastructure

Governance & Leadership

Population Management

TECHOLOGY 44

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A Multidisciplinary SHM Approach Matching Patients and Interventions Interventions High-Cost Patients

Trade high-cost services for lowcost management

Centralized Care Management PCMH: Assign to embedded care manager

Rising-Risk Patients Avoid unnecessary higher-acuity, highercost spending

Office Care Team

At-Risk Patients

Keep patient healthy, loyal to the system

Connect with risk modification services Patient or portal/mobile outreach for preventive care

Healthy Patients •

Clinical Risk

Social Risk

Behavioral Risk

Source: Health Care Advisory Board interviews and analysis.

45

Spring Managed Care Forum | April 2016

45

Integrated SHM Programs Interventions

Reducing “Circles of In-Accountability”

Hospitalist Program and UCC Programs

Hospital

Ambulatory Clinic/UCC

Inpatient Physiatrist

Rehab

Transitions in Care Coordinator

Cost Escalation

Care Management Telemonitoring Home visits NP

Home

ED

Geriatric Services

Nursing Home

Behavioral Risk

Spring Managed Care Forum | April 2016



Source: Health Care Advisory Board interviews and analysis.

46 46

23

8/30/2016

Progression of SHM Service Delivery Model

Systems Redesign Training

?

Business Process Outsourcing Operational Risk Sharing

Performance Tracking and Improvement

Diagnostic Assessment

Change Management Services

Organizational evaluation to define issues, opportunities and a the path forward

Working with client, facilitate and oversee critical practice changes and upgrades

Enterprise Management Assume operational management of revenue cycle and related services, either by hiring local staff as SHM employees or centralizing functions in SHMadjacent location

Demonstrating expertise and performance Building trust

Spring Managed Care Forum | April 2016

47

24

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Reference Slides US Healthcare in 2016 - namcp

8/30/2016 Reference Slides • • • • US Healthcare in 2016 Medicare’s Market Changing Influence Payer-Dominant Market Strategies Provider-Dominant Str...

NAN Sizes 6 Downloads 12 Views

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