2/5/2018
Alternative Payment Models
for Chronic Pain and
Substance Abuse
2/5/2018
1. Empower Patients to be Partners
2. Drive Delivery System Improvements
3. Shift to Population-Based Payments
4. Incentives Should Reach Providers
5. Payment Models & Quality
6. Motivate Providers
7. Dominant Form of Payment
8. Examples in the Framework
Key Principles
2/5/2018
APM Framework
2/5/2018
APM Goals
2/5/2018
• Traditional FFS payments
– No infrastructure investments, provider
reporting of quality data, nor provider
performance on cost and quality metrics
– Includes DRGs unless linked to quality or value
Category 1
2/5/2018
• Traditional FFS payments PLUS payments for:– Infrastructure investments to improve care or
clinical services
– Providers reporting quality data
– How well providers perform on cost and quality metrics.
• Can drive the development and expansion of health information technology (HIT)
• Should be used to smooth the transition into Category 3 and 4 APMs
Category 2
2/5/2018
• Payments are based on cost performance
against a target
• Structured to encourage providers to deliver
effective and efficient care
• Must hold providers accountable for
performance on measures of “appropriate
care”
Category 3
2/5/2018
• Avoids wasteful tests and procedures that provide no benefit to patients
• Involves a high degree of care coordination to ensure efficient delivery
• Encompasses everything patients need to achieve their personal goals
• Essential to ensure that providers are only incentivized to reduce/eliminate care that is wasteful and potentially harmful for patients
Measures of “Appropriate
Care”
2/5/2018
• Prospective, population-based payments
• Structured to encourage providers to deliver
well-coordinated, high-quality, person-
centric care
• Must hold providers accountable for
performance on measures of “appropriate
care”
Category 4
2/5/2018
Begin with the end in mind
2/5/2018
If you can’t measure it,
you can’t improve it
2/5/2018
• Align incentives to drive toward common
goal
• May include process measures initially
• Consider NQF endorsed measures
• Best determined in collaboration
• Need very clear baseline and benchmarks
• KISS
Quality Measures
2/5/2018
Who’s gonna get you
there?
2/5/2018
Who are the people in your
neighborhood?
2/5/2018
• PCP
• Specialist
• Hospital (both ED and inpatient)
• Pharmacy
• PT/Chiro/Yoga
• CBT/EMDR
• Peer Support
• Lab
• Health Plan
Medical Neighborhood
2/5/2018
• Project ECHO
• eConsults
• Telemedicine
• Telehealth
What’s missing?
2/5/2018
Who’s your quarterback?
2/5/2018
You need a coordinator
2/5/2018
• Traditional FFS payments PLUS payments
for infrastructure investments to improve
care or clinical services
– Used for care coordination
– Used for non-capitated services like yoga
– Can be used in conjunction with shared savings
or shared risk
Option 1
2/5/2018
• Traditional FFS payments PLUS payments
for high performance on clinical quality
measures (Pay for Performance)
– Same measures could be used in conjunction
with shared savings or shared risk
– Could incentivize multiple ”neighbors” to align
goals
Option 2
2/5/2018
• Total Cost of Care Shared Savings/Risk
– PCP or Specialist
• Chronic Episode of Care Shared
Savings/Risk
– PCP or Specialist
Option 3
2/5/2018
• Cost performance compared to a target
(“budget”)
– Any APM with “neighbor” counted toward cost
• Percent of savings shared back
• Higher risk = greater upside
• Always tied to quality
TCC SS/SR
2/5/2018
2/1/2018 Glenn Wood PA - Dashboard
https://www.treoservices.net/portal/dashboard.aspx?personaViewID=network&userPkey=ntwk&userPkeyValue=48&entranceToken=ProspectiveEntrance&clientAcce… 1/1
Glenn Wood PA (Claims paid through 3/31/2017)
Total Cost of Care
Potentially Preventable Events
Utilization
Value Index Scores (VIS) Percentile
Budget Basis
Base risk score 0.4
Current risk score 0.4
Base budget $101.
Current budget $106.
VIS Target 37.
Population Data04/201603/2017
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Reports
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Supporting Resources
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Rolling 12 months01/201612/2016
Program YTD01/201612/2016
N/A ($5.87)
$100.42 $100.42
N/A $0.17
N/A ($3.64)
N/A $2.48
N/A ($4.25)
Key Performance Measure
Variance from Budget (PMPM $)
Allowed (PMPM $)
Variance IP Allowed (PMPM $)
Variance OP Allowed (PMPM $)
Variance PR Allowed (PMPM $)
Variance RX Allowed (PMPM $)
Rolling 12 months01/201612/2016
Program YTD01/201612/2016
$17.84 $17.84
0.3 0.3 Member List
(1.5) (1.5) Member List
(143.1) (143.1) Member List
97.4 97.4 Member List
Key Performance Measure
Allowed Preventable (PMPM $)
Variance PPR Admits PKPY
Variance PPA Admits PKPY
Variance PPV Visits PKPY
Variance PPS PKPY
Rolling 12 months01/201612/2016
Program YTD01/201612/2016
7.2 7.2 Member List
(104.9) (104.9) Member List
(327.5) (327.5) Member List
74.23 % 74.23 % Member List
Key Performance Measure
Variance IP Admits PKPY
Variance ER Visits PKPY
Variance Rx Scripts PKPY
% Rx Generic Scripts
Rolling 12 months01/201612/2016
61.0
57.7
54.4
51.5
79.1
51.6
28.7
Key Performance Measure
Value Index Score Percentile
Primary and Secondary Prevention Percentile
Tertiary Prevention Percentile
Panel Health Status Change Percentile
Continuity of Care Percentile
Chronic & Followup Care Percentile
Efficiency Percentile
© 2018 3M Company All Rights Reserved. 3M Company 575 Murray Blvd | Murray, UT 84123 1 518 426 4315
Data Updated : 5/30/2017 LoHelp
Home Dashboard
David Harmon
Example
2/1/2018 Glenn Wood PA - Dashboard
https://www.treoservices.net/portal/dashboard.aspx?personaViewID=network&userPkey=ntwk&userPkeyValue=48&entranceToken=ProspectiveEntrance&clientAcce… 1/1
Glenn Wood PA (Claims paid through 3/31/2017)
Total Cost of Care
Potentially Preventable Events
Utilization
Value Index Scores (VIS) Percentile
Budget Basis
Base risk score 0.4
Current risk score 0.4
Base budget $101.
Current budget $106.
VIS Target 37.
Population Data04/201603/2017
Loading...
Reports
Loading...
Supporting Resources
Loading...
Rolling 12 months01/201612/2016
Program YTD01/201612/2016
N/A ($5.87)
$100.42 $100.42
N/A $0.17
N/A ($3.64)
N/A $2.48
N/A ($4.25)
Key Performance Measure
Variance from Budget (PMPM $)
Allowed (PMPM $)
Variance IP Allowed (PMPM $)
Variance OP Allowed (PMPM $)
Variance PR Allowed (PMPM $)
Variance RX Allowed (PMPM $)
Rolling 12 months01/201612/2016
Program YTD01/201612/2016
$17.84 $17.84
0.3 0.3 Member List
(1.5) (1.5) Member List
(143.1) (143.1) Member List
97.4 97.4 Member List
Key Performance Measure
Allowed Preventable (PMPM $)
Variance PPR Admits PKPY
Variance PPA Admits PKPY
Variance PPV Visits PKPY
Variance PPS PKPY
Rolling 12 months01/201612/2016
Program YTD01/201612/2016
7.2 7.2 Member List
(104.9) (104.9) Member List
(327.5) (327.5) Member List
74.23 % 74.23 % Member List
Key Performance Measure
Variance IP Admits PKPY
Variance ER Visits PKPY
Variance Rx Scripts PKPY
% Rx Generic Scripts
Rolling 12 months01/201612/2016
61.0
57.7
54.4
51.5
79.1
51.6
28.7
Key Performance Measure
Value Index Score Percentile
Primary and Secondary Prevention Percentile
Tertiary Prevention Percentile
Panel Health Status Change Percentile
Continuity of Care Percentile
Chronic & Followup Care Percentile
Efficiency Percentile
© 2018 3M Company All Rights Reserved. 3M Company 575 Murray Blvd | Murray, UT 84123 1 518 426 4315
Data Updated : 5/30/2017 LoHelp
Home Dashboard
David Harmon
2/5/2018
• Risk adjusted budget for all assigned
patients
– Traditional FFS structure
– Project ECHO payments count toward budget
– Infrastructure payments count toward budget
– Incentives to “neighbors” count toward budget
• Percent savings paid tied to quality
benchmarks
PCP Attribution
2/5/2018
• Risk adjusted budget for all attributed members
– Traditional FFS structure
– Infrastructure payments count toward budget
– Attributed members removed from PCP budget
– Incentives to PCP count toward budget
– Incentives to “neighbors” count toward budget
• Percent savings paid tied to quality benchmarks
Specialist Attribution
2/5/2018
• Cost performance compared to a target
(“budget”)
– Might be counted toward TCC SS/SR
• Percent of savings shared back
• Higher risk = greater upside
• Always tied to quality
Chronic EOC SS/SR
2/5/2018
Episode Template
2/5/2018
Episode Example
2/5/2018
• Prospective, population based payment
• Full risk
• Always tied to quality
Option 4
2/5/2018
• Chronic EOC triggered by diagnosis and
attributed to specialist (quarterback)
• No pre-trigger services
• Post-trigger services measured for 6 months
– Includes PMPM for infrastructure
– Includes incentive payments to “neighbors”
• Episode Cost compared to “budget” with
shared savings/risk contingent on quality
Hypothetical Urban
2/5/2018
• TCC SS/SR attributed to assigned PCP
(quarterback)
– Includes PMPM for infrastructure
– Includes Project ECHO
– Includes incentive payments to “neighbors”
• Actual costs compared to budget with
shared savings/risk contingent on quality
Hypothetical Rural
2/5/2018
The common enemy