NPG Health Collaborative: Exploring Population Health and Value-Based Healthcare In A Rural Delivery System September 19, 2018

Presentation Objectives Describe background and structure of NPG Health Collaborative Discuss identified barriers, successes, and lessons learned Describe the vision and potential next steps for rural hospitals and clinics to prepare to operate in a value-based environment

Prairie Health Ventures Mission We exist to help hospitals succeed through collaboration Vision To sustain the independence of hospitals in our region through an alliance which improves cost and business performance Alliance of 53 hospitals Owned/directed by hospitals since 1975 Distributed $25M to owners since 2006

Nebraska Purchasing Group, LLC (NPG) Organizational Structure NPG, LLC 37 Hospital Owners GPO 39 Hospitals Premier Inc. PHV, LLC Virtual Services Pharmacy Services Physician & Admin. CHI Health *NPG owns majority of PHV assets and appoints majority of PHV board.

PHV Hospital Owners

NPG Hospital Members * Participating Facilities Annie Jeffrey Memorial Health Ctr. Osceola, NE Boone County Health Center Albion, NE Brodstone Memorial Hospital Superior, NE Brown County Hospital Ainsworth, NE Burgess Health Center Onawa, IA Butler County Health Care Center David City, NE Callaway District Hospital Callaway, NE Chadron Community Hospital Chadron, NE Chase County Community Hospital Imperial, NE Cherry County Hospital Valentine,NE Community Memorial Healthcare Marysville, KS Community Memorial Healthcare Syracuse, NE Cozad Community Hospital Cozad, NE Fillmore County Hospital Geneva, NE Fremont Area Medical Center Fremont, NE Genoa Community Hospital Genoa, NE Gothenburg Memorial Hospital Gothenburg, NE Henderson Health Care Services Henderson, NE Howard County Medical Center St. Paul, NE Jefferson Community Health Center Fairbury, NE Johnson County Hospital Tecumseh, NE Kimball Health Services Kimball, NE *Lincoln Surgical Hospital Lincoln, NE Merrick Medical Center Central City, NE Memorial Community Health, Inc. Aurora, NE MCH and Health System Blair, NE Memorial Health Care Systems Seward, NE *Nebraska Spine Hospital Omaha, NE Nemaha County Hospital Auburn, NE Pawnee County Memorial Hospital Pawnee City, NE Perkins County Health Services Grant, NE Rock County Hospital Bassett, NE Saunders Medical Center Wahoo, NE Shenandoah Memorial Hospital Shenandoah, IA St. Anthony Regional Hospital Carroll, IA St. Francis Memorial Hospital West Point, NE Thayer County Health Services Hebron, NE Warren Memorial Hospital Friend, NE Webster Co. Community Hospital Red Cloud, NE * Participating Facilities

Healthcare Environment FROM TO Single community markets Fragmented, duplicative services and uncoordinated Pluralistic payer strategies Clarity on provider and insurer alignments Provider-centric Inconsistent measurement and opaque Use of data to retrospectively report Treating patients for disease Patient care anchored in bricks & mortar delivery system Star Physicians Large regional markets Highly reliable and more standardized care across the continuum Narrow networks with preferred payers Greater market change and confusion Patient-centric & engaged Measured and transparent Prospective use of data and analytics Routine use of personalized medicine Technology-enabled virtualization of healthcare Star Teams

Accountable Care Organizations (ACO’s) ACO’s are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients Source: www.cms.gov

NPG Health Collaborative Background NPG Health Collaborative, LLC (NPG Health) was formed as a separate legal entity to apply for the CMS Shared Savings Program.  NPG Health is a collaboration of hospitals, rural health clinics and physicians located in the Midwest.    The goal of NPG Health is to improve the health and wellness of the members of our communities.  We intend to improve the quality of care and patient satisfaction, increase preventive health and wellness alternatives, and decrease the costs of healthcare for our Medicare patients. With more than 150 providers across 14 critical hospitals and about 16,000 Medicare beneficiaries, NPG Health will assist CAH’s and their associated RHC’s in creating comprehensive population health management programs to achieve superior patient care, patient engagement and high quality outcomes for their rural community Medicare beneficiaries.

2016 – NPG Health Collaborative, LLC formed with intent to apply to become a CMS Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) 2017: Year One CMS Track 1 MSSP ACO 9 Critical Access Hospitals and associated Rural Health Clinics Approximately 9,000 attributed Medicare lives 2018: Year Two CMS Track 1 MSSP ACO 14 Critical Access Hospitals and associated Rural Health Clinics Approximately 150 Providers Approximately 16,000 attributed Medicare lives

NPG Health Collaborative – 2018 Participants Memorial Healthcare Systems - Seward, NE Pawnee County Memorial Hospital - Pawnee City, NE Jefferson Community Health Center - Fairbury, NE Brodstone Memorial Hospital - Superior, NE Boone County Health Center - Albion, NE St. Francis Memorial Hospital - West Point, NE Kearney County Health Services - Minden, NE Community Memorial Healthcare, Inc. - Marysville, KS Howard County Medical Center - St. Paul, NE Thayer County Health Services – Hebron, NE CHI Health St. Mary’s – Nebraska City, NE CHI Memorial Health Schuyler – Schuyler, NE CHI Health Missouri Valley – Missouri Valley, IA CHI Health Mercy Hospital Corning – Corning, IA

https://mapchart.net/usa-counties.html

Dependencies and Resources 1 Management Participants Providers & Suppliers MSSP 16,000 Lives Data & Technology

NPG Health Collaborative ACO Governing Body

Why Start an ACO Population Health Learning Lab Data Ability to explore new delivery models and continue current reimbursement model (Track 1 Model) Data Claims data on attributed beneficiary's Additional Revenue Opportunities Chronic Care Management Transitional Care Management Wellness Visits Potential of Shared Savings Physician Quality Reporting GPRO – MIPS reporting Automatic Credit Earned in MIPS Scoring Ability for Independent Rural Hospitals to work together to build an Integrated Delivery Network Knowledge Transfer and Group Support Potential to develop Commercial ACO Models

ACO Learning Curve ………….

Historical Benchmark & Aggregate Spend Historical benchmark is a 3 year average (in our case 2014 – 2016) and is risk adjusted. Aggregate ACO expenditure updates are provided on a quarterly basis for comparison to the benchmark. If an ACO’s spending in the program year is less than the benchmark and the ACO meets MSSP quality thresholds, it earns a shared savings payment. Through claims and our technology vendor we are able to analyze the overall ACO spend as well as individual Participant and NPI (provider) level spend on an ongoing basis. www.cms.gov

Our Overall Approach to Success in Value-Based Healthcare We believe that the degree of success we will achieve within the ACO is in large part determined by the degree to which we understand and actively manage these three factors through a thoughtful, balanced and physician-led approach. Quality and Satisfaction – Improve Cost – Lower Risk – Manage

Structure for success Comprehensive care Patient-centered care Includes not only the traditional care of the acutely or chronically ill patient, but also and especially the prevention and early detection of disease. Patient-centered care Active involvement of patients and their families in the decision-making about individual options for treatment and care Coordinated care Organizing patient care (including the patient and family) to facilitate the appropriate delivery of health care services Accessibility of Services The ability to get care and services when they are needed Quality and Safety Degree in which health care services for individuals and populations increase the likelihood of desired health outcomes.

Shared Decision Making Healthier Patients Engaged Providers Lower Costs Better Care Care Coordinators Care Plans Quality Improvement Medical Community Wellness Provider Champion Clinical Data Transformation Clinical Integration Clinical Efficiencies TCM Shared Decision Making Quality Reporting Behavior Change AWV Evidence-Based Medicine Patient Engagement Targeting Physician Engagement Claims Data Waivers Workflows ACP Team-Based Care CCM Risk Stratification

Comprehensive Coordinated Care Eliminate patient care gaps & provide what the patient needs, when they need it, for optimal outcomes. Transitional Care Management Care Coordination Annual Wellness Visits Chronic Care Management In many cases, implementing a comprehensive model requires practice transformation

Creating and Refining a Care Coordination Model Group participation supports buy-in and accountability WE want to implement a new program WE need to design a process How are WE going to be successful?

Transitional Care Management (TCM) Can Impact Total Cost of Care Quality Measures Post-Discharge Outcomes Patient success at home Patient Satisfaction with Care (Hospital to Home) Identify Problems - Provide Interventions Reduce Avoidable Errors & Negative Patient Outcomes Compliance with Discharge Orders Reduce avoidable readmissions Revenue opportunity - TCM Improve Survey Scores Reduce Readmission and Unnecessary ER Use Rates Improve Market Share Program Specific Requirements to bill: Patient has inpatient/observation/partial hosp. stay Pt Discharged & returns to place of residence (home, Assist. Living) Billing provider responsible for pt. care for entire 30 day period Post D/C: Contact with pt. within 2 business day Face-to-face visit with PCP by day 7/14 (r/t complexity) Medication reconciliation anytime on or before face-to-face 30 day service period (D/C day + next 29 days)

Chronic Care Management Program Specific Requirements to bill: Initiating Visit Patient consent for enrollment Two or more chronic conditions 24/7 access to care Patient Centered/Comprehensive Care Plan Certified EMR to record certain patient info Manage Care Transitions - share coordination of care document Successive routine appointments Enhanced communication opportunity 20 min. non-face-to-face activities per month

Chronic Care Management Can Impact SATISFACTION COST OF CARE QUALITY MEASURES Happier with Care Improved Quality of Life – Self Care Ability Provider-Patient Relations Staff Satisfaction Reduce PMPM rates Unnecessary tests/tx Control downstream spend Revenue Opportunity Readmission Rates HCAHPS/CAHPS Scores ER Utilization Rates Coordination to impact other Quality measure rates

ANNUAL WELLNESS VISIT (AWV) CARE COORDINATION: AWV provide coordination of all prevention services AWV considered part of care management Prevention reduces exacerbations Benefits of AWV: Improves overall risk scores through CMS Risk scores Capture Quality measures MEDICARE ANNUAL WELLNESS VISIT: Initial Preventative Physical Examination (IPPE): Billing Code = G0402 “Welcome to Medicare” – once per lifetime benefit Performed within first 12 mos. when benefits begin Not a physical – do not actively treat symptoms Set up preventative tests/screenings for up-coming year Covers once-in-a-lifetime screening electrocardiogram Annual Wellness Visit (AWV) – Initial Visit: Billing Code = G0438 Perform 12 mos. & 1 day after benefits began or after date IPPE was performed (at least) Personalized Prevention Plan of Services (PPPS) Continues same work from IPPE Annual Wellness Visit (AWV) – Subsequent Visit(s): Billing code = G0439 Perform 12 mos. & 1 day after last AWV date (at least)

Care Coordination POPULATION HEALTH - OPTIMAL PATIENT OUTCOMES PROVIDE EDUCATION and VERIFY UNDERSTANDING ELIMINATE PATIENT CARE GAPS ENSURE COMMUNICATION & COLLABORATION EXISTS BETWEEN ALL HEALTHCARE SETTINGS IDENTIFY/SET UP SERVICES & RESOURCES AVAILABLE TO MEET PATIENT NEEDS PRACTICE PREVENTATIVE INSTEAD OF REACTIVE CARE FOLLOW PATIENT THROUGHOUT ALL CARE TRANSITIONS

Hierarchal Condition Categories (HCC) Risk adjustment is the process of modifying payments and benchmarks to reflect the degree of illness. This allows CMS to estimate future spending, and allows providers to understand the health characteristics of their managed population Accurate coding is essential in an ACO to characterize risk, enhance shared savings, and provide patient-centered care.  The CMS-HCC risk-adjustment model was designed to most accurately predict spending at the group level, not the individual beneficiary level. Understanding HCCs – which help to portray patients' conditions and prospective costs – and understanding how CMS uses them to calculate expenditure benchmarks or PMPMs - is extremely important to an ACO's ability to earn shared savings and avoid shared loss. www.aafp.org

ACO Quality www.cms.gov

Quality - GPRO Methodology & Ranking Group Provider Reporting Option (GPRO) CMS Chooses a random sample of each facilities attributed lives, from this sample: Patients are consecutively numerically ranked per measure from 1 to 616 for the maximum sample, and 1 to 248 for the minimum 3 2 4 1 5 Source: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/CMS-Web-Interface-Sampling-Methodology-2.pdf Advancing Healthcare Through Collaboration

Quality – GPRO Reporting Knowledge gaps surrounding the measures and measure specifications Are there processes in place within each clinic to ensure these care measures (or gaps) are addressed? Are these measures able to be documented and captured within a discrete field of each EMR in order to run reports for uploading to our ACO technology vendor? Satisfaction a key component. If not routinely surveying CAHPS, how is patient satisfaction determined outside of the ACO CAHPS survey

What ACO resources needed to be impactful? Education of practice leaders and teams is key Learning Collaborative Webinars Vendor technology training, including care coordination portal Board and Leadership support Informed decision making on resource spend to drive understanding of, and case for, practice-level change Care Coordination organization and support Some practices have – others implementing Practice Transformation Risk adjustment education and support GRPO Quality reporting organization, education and support Data Analysis

Challenges and Barriers Multiple EHR’s Different levels of engagement Regulations Resources Changing governmental rules

Consider a Next Step Determine: What You Have in place vs. Where you want to be

Regardless of which path you take, engage in Population Health and Value-Based Healthcare

An important underlying theme that we instill in our ACO practices: Change is an ongoing process, not an event. Needs talking points listing/describing key lessons.

Questions? . Thank you!

Thank You! Rodney Triplett Anne Hansen MSN, RN-BC, CPHQ CEO Director – Quality and Population Health Prairie Health Ventures Prairie Health Ventures 402.657.5223 712.420.3203 rodney.triplett@phvne.com anne.hansen@phvne.com