Why ACOs are Good for Your Patients… PEAK Leadership Summit March 2014 © 2014 Franciscan...

Why ACOs are Good for Your Patients…

PEAK Leadership SummitMarch 2014

© 2014 Franciscan Alliance, Inc.

Presented by:

Kimberly S. Hodge, PhD(c), MSN, RN, ACNS-BC, CCRN-CMC

Clinical Operations Manager & Clinical Nurse Specialist

Franciscan Alliance Pioneer ACO

Indianapolis, IN

©2013 Franciscan Alliance ACO

Carmel

Franciscan Alliance

• Has a rich history of serving local communities for over 135 years

• Operates in 4 regions throughout Indiana and Illinois with 13 hospitals and several healthcare support companies

• Employs over 600 providers (Franciscan Physician Network)

• Completed transition to the Epic Electronic Medical Record system during 2013 in all regions

http://www.ssfhs.org/


Franciscan Alliance: Accountable Care Journey

ACOs originated from the Patient Protection and Affordable Care Act (Healthcare Reform) which was signed into law on March 23, 2010. One of the goals of healthcare reform was to find ways to deliver care that resulted in better quality at lower costs.

The Centers for Medicare & MedicaidServices (CMS) was the first to pilot ACOs with the Pioneer ACO program.

3


What is an Accountable Care Organization (ACO)?• Groups of doctors, hospitals, and other health care providers, who

come together voluntarily to give coordinated high quality care to their Medicare patients.

• Goal: coordinated care is to ensure that patients, especially the chronically ill, get THE RIGHT CARE AT THE RIGHT TIME, while avoiding unnecessary duplication of services and preventing medical errors.

• When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.


Different Types of ACOs

• Medicare Shared Savings Program (MSSP)• Advance Payment ACO Model• Pioneer ACO Model


Pioneer ACO Model (Demonstration Project)

• Designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings.

• It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Services Program.

• It is designed to work in coordination with private payers by aligning provider incentives, which will improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers and patients.


Pioneer ACO

• Payment Arrangement Options: 5 (core plus 4 alternatives)– Varying degrees of shared savings/losses, which are capped

across performance years– Alternatives 1 and 2 have capitation options for Part B only or

all Part A and B services– Function like MSSP first 2 years and transition to population-

based payment approach in year 3• Beneficiary alignment

– CMS assigns prospectively if there are 12 months of fee-for-service coverage under Part A and B

– Two-step assignment: PCP and Specialist/FQHC


Pioneer ACO

• Interim Payment Methodology– First 2 years: continue to receive payments under fee-for-service

program; savings/losses compared to benchmark using retrospective reconciliation at end of each performance year

– Beginning year 3: Core and Options A and B begin receiving combination of fee-for-service reimbursement and population-based payments for aligned beneficiaries

• Fee-for-service paid at 50% of usual allowable fee and [opulation-based payment estimated as 50% of ACO’s expected fee-for-service costs (at 100% allowable amounts)

• Eligible for shared savings/losses but must have 3% reduction in costs before sharing savings


Pioneer ACO

• Benchmark Methodology– Compared to 3-year historical claims benchmark– Provision: limits the benchmark increase in areas of high

costs or high cost trends and increases the benchmark more rapidly in areas of low cost or low cost trends

– Calculated retrospectively– Recalculated in 4th performance year for remaining 2 years

of program– Adjusted to include claims for beneficiaries no longer

aligned with ACO in the performance period


Pioneer ACO

• Benchmark Methodology– Choices

• Benchmark that caps expenditures at 99th percentile of national Medicare fee-for-service Part A and Part B expenditures (reduces variation from catastrophic claims)

• Uncapped benchmark and the requirement to purchase their own reinsurance

– Capping done separately for ESRD and non-ESRD beneficiaries– National reference population

• No state-specific expenditures• Adjusted using same age, sex, and eligibility distributions across

prospectively aligned beneficiaries


Pioneer ACO

• Trending Methodology– ACO-specific baseline expenditure

• Base year one and base year two are trended to base year three using trends for beneficiaries residing in the same state and having the same age, sex, and eligibility

• Trends developed separately for trending base year one to base year three and from base year two to base year three

– ACO-expenditure benchmark• Trends ACO-specific baseline expenditure to the performance year

using national growth rate and absolute amount of growth, blended 50%/50%


Pioneer ACO

• Calculation of Shared Savings/Losses– Determined using retrospective reconciliation at the end of each

performance year against the Pioneer ACO’s benchmark for the first two performance years

• Performance year expenditures < applicable benchmark in a given year AND quality performance metrics are met = ACO will share in portion of savings

• Performance year expenditures > applicable benchmark in a given year = ACO required to pay back a portion of the losses

– Must achieve savings AND meet quality standards and other program requirements to move to population-based payment

• CMS determines whether participating ACOs will be able to move to population-based payment for years 3–5


Pioneer ACO

• Calculation of Shared Savings/Losses– Minimum savings/loss: 1%

– Savings/losses based on difference to the benchmark rather than only the excess over the benchmark plus the minimum savings rate / minimum loss rate (MSR/MLR)

– Potential gains/losses are greater for Pioneer ACOs under ALL program options


Franciscan Alliance Accountable Care Journey

In October 2011, Franciscan Alliance was awarded Pioneer ACO status by Medicare, along with 31 other organizations across the country. The program began January 1, 2012.

Franciscan is the only Pioneer ACO in Indiana and was officially the first Medicare ACO in the state.


Medicare ACO Initiatives: 2014


Why Franciscan Alliance Chose To Participate In An ACO

As the state’s largest Catholic-based health-care system, the Franciscan Alliance worked diligently to become an ACO. We recognize the vital role our hospitals, staff and partnering providers will play in health care reform. Our goal is to become a model for the future of health care!


Why Franciscan Alliance Chose To Participate In An ACO

The concept of ACOs aligns with our corporate values:

– Respect for Life: ACOs allow patients to play a more active role in directing their own care.

– Joyful Service & Compassionate Concern: ACOs offer better quality of care with personalized care coordination.

– Fidelity to Mission & Christian Stewardship: ACOs provide the opportunity to significantly reduce costs associated with duplicative testing and medical waste while benefiting from shared savings.


Franciscan Alliance ACO at a Glance

Franciscan Alliance (FA) Central Indiana Region (CIR) hospitals & physicians partnered with other organizations in the Pioneer ACO. These partners include:• Major Health Partners• Indiana Internal Medicine Consultants• Fairbanks Hospital• Rush Memorial Hospital• WindRose Health Network• Franciscan Visiting Nurse Service• Advanced Healthcare Associates



Participating providers include:

• Made up of over 1,000 providers across Indiana and serves nearly 50,000 Medicare beneficiaries with 600+ Franciscan Physician Network physicians

• Non-Franciscan Alliance affiliated health care providers, hospitals, and other entities



2014 Population: • Approximately 50,000 fee-for-service Medicare beneficiaries• Approximately 22,000 of those located within CIR

Medicare Status

Aged Non-Dual 75.8%

Disabled 16.9%

Aged Dual 6.5%

ESRD 0.8%

Chronic Conditions

19+ 19.2%

15-18 10.4%

11-14 15.2%

7-10 21.5%

3-6 23.2%

0-2 10.6%

66.3%



Medicare Status Summary

Total Population Beneficiaries

High Emergency

Department Utilizers

Clinical Condition Prevalence

CHF COPD Diabetes

Aged Non-Dual

16,580(75.8%)

293(1.8%)

2,435(14.7%)

4,002(24%)

6,061(36.6%)

Aged Dual 1,431(6.5%)

65(4.5%)

486(34%)

644(45%)

709(49.5%)

Disabled 3,690(16.9%)

216(5.9%)

411(11.1%)

1,320(35.8%)

1,379(37.3%)

ESRD 168(0.8%)

42(25%)

108(64.3%)

85(50.6%)

133(79.2%)


Focused on the Triple Aim

There are 3 main goals of an ACO, often referred to as the “Triple Aim:”

1. Better health for the population2. Higher-quality care3. Lower costs of care


Changes in Care Delivery

To meet the goals of an ACO, we must change the way we deliver and provide care. Because patients can still go anywhere for care, ACO providers and facilities must work together to help coordinate care for the patients we serve.


Changes in Care Delivery & Reimbursement

ACOs focus on improving care through change in two main areas:

1. Care delivery – the way care is delivered across different providers along the care continuum.

2. Reimbursement• Providers are still paid by fee-for-service.• In order for providers to receive shared savings from

the ACO, they must be focused on AND meet quality goals.


Quality Measures

Quality is an important piece in the ACO. There are 33 quality metrics that CMS uses to rate the quality of care the ACO is providing to patients.

If the ACO does not meet certain quality metrics, it cannot receive shared savings. Some of the quality metrics include:

• Patient satisfaction scores• Preventive health measures• Depression screenings• Fall risk assessments• Electronic Health Records (EHR)/Meaningful Use


Accountable Across the Care Continuum

Primary Care Physician

Long Term Acute Care

Hospital: Inpatient & Outpatient Visits

Specialist

Home

An ACO is responsible for overseeing the cost and quality of a patient’s healthcare across all

healthcare provider settings regardless of where the patient seeks care. This includes facilities

not in the ACO.


Accountable Across the Care Continuum

TRUE coordination of care requires communication across the entire continuum of care and at every transition, which requires that many approaches be used. Communication vehicles and approaches include:

• Electronic (e.g., Epic, MIE, ADVantis)• Verbal (e.g., medication reconciliation by pharmacists prior to

hospital discharge, visit by complex care coordinator, ACO champion and stakeholder meetings)

• Written (e.g., provider update letters)


How do we traverse the care continuum?



• Complex Case Management: Registered Nurses, Advanced Practice Nurses (NP and CNS), Social Workers, and Respiratory Therapist

– Post-ED visit calls– Home visits– Provider office visits– Health coaching– Care coordination– Disease management



• Medication Reconciliation– Inpatient pharmacists perform prior to discharge home– Post-acute care teams address across care settings– Providers perform during first visit after discharge

• Advance Care Planning– Palliative team visits beneficiary during inpatient visit and discusses care

planning options followed by documentation and communication with the healthcare team

– Palliative team available to Complex Case Managers for consultation• Franciscan VNS

– Preferred home health provider– Health coaching provider


Integrating Care Across the Continuum: Continuing Care Networks• Transitional / post-acute care (launched 2/2013)

– Registered Nurse (RN) facilitates beneficiary transition from inpatient to home/post-acute setting (long-term acute care, subacute rehabilitation, inpatient rehabilitation or home health)

• Renal (launched 8/2013)– Adult Nurse Practitioner and Social Worker facilitate transitions across

settings for the beneficiary with end-stage renal disease

• Behavioral Health (launched 3/2014)– Social worker facilitates transitions across settings for the beneficiary with

behavioral health concerns (e.g., depression, anxiety, addictions, etc.)


Franciscan Alliance 2012 Results

• In 2012, via care management and care coordination programs, the Franciscan Alliance Pioneer ACO saved Medicare over 13 million dollars

• Ranked 4th out of 32 Pioneer ACOs

• 50% ($6.6 million) of those dollars were returned to the ACO, which in turn were:

– Distributed to ACO participants, and– Reinvested into new ACO care management programs


Why are ACOs good for your patients?

• Quality-focused• Cost-effective• Optimizes communication• Creates a continuum of coordinated, integrated care

Because it’s the RIGHT thing to do!

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