Payment Reform to Transform Advanced Illness Care 11.2.17 Khue Nguyen, Chief Operating Officer Payment Reform to Transform Advanced Illness Care 11.2.17

Current State Mean per capita medical spending (in 2014 US dollars) in 9 countries in the last 12 months of life, by category of spending. Eric B. French et al. Health Aff 2017;36:1211-1217 ©2017 by Project HOPE - The People-to-People Health Foundation, Inc.

Care Fragmentation 8.4 Days in the Hospital, Last 6 months 9.4 Days in SNF, Last 6 months 8 Home Health Visits, Last 6 months 10.5 Physicians, Last 6 months Families & providers must choose between comfort or curative care 32% of Medicare costs in the final 2 years; 25% in the final year

ACTsm But…

Interdisciplinary Team: What if we Coordinate care across settings: hospital, post-acute, offices/clinics Extend practice of PCPs and specialists into the home setting Support transition from “curative” to palliative care Inpatient Patient’s Home Advanced Illness Care and Payment Interdisciplinary Team: Med. Dir., RN, SW + Ambulatory

Goals of the ACM Payment Structure Pay for improvement in quality at equal or lowered cost Convert palliative care provider’s fee schedule to a team-based, population health payment structure that rewards quality Utilize a pay-for-quality payment structure that incentives quality Set appropriate incentives and financial risk

Impact Coordinated care, aligned with patient preferences High patient and family satisfaction Improved clinical quality outcomes Ability to be layered with and support other APMs 2.5% ($5 billion) cost savings for Medicare FFS program

Eligibility: Advanced Illness Population One or more chronic conditions 11 chronic conditions associated with high mortality risk Represents over 90% of all Medicare decedents Recurrent or extensive disease Quantified acute care utilization , functional decline and/or values High 1-year mortality risk Evidence-based combination of quantified clinical values and clinician prognostication

Primary Care Physicians & Specialists Model Services Primary Care Physicians & Specialists Advanced APM incentives for participation Enhanced, additional team-based resources for all physicians Palliative care provider valued-based payment Beneficiaries Dedicated team-based resources: palliative care provider, nurse, social work and others Comprehensive care coordination Advance care planning over time Concurrent integrated curative and palliative treatments 24/7 Clinician access Caregiver support Model Entities Same opportunities for small independent vs. large physician practices APM can be supported by multispecialty physicians or specific specialty All Medicare provider types can participate: physician practices, health systems, hospitals, home health or hospice Voluntary all-payer participation

Pay for Quality Metrics 13 relevant, established patient- and family-centered measures; currently used in QPP or CMMI Models Domain Metric Access ACM Team Visit within 48 hours of hospital discharge Timeliness of advance care planning: Yes/No Measure Description: Advance care planning conversation with patient and or their health care agent representative must include exploration of goals, values and preferences and discussion of disease process and prognosis within 14 days of enrollment. Clinical Process/ Effectiveness Getting Help for Symptoms: Pain: Did your family member get as much help with pain as he or she needed? Getting Help for Symptoms: Anxiety and Sadness: How often did your family member get the help he or she needed from the ACM team for feelings of anxiety or sadness? Getting Help for Symptoms: Trouble breathing: How often did your family member get the help he or she needed for trouble breathing? Person-and Caregiver-Centered Experiences and Outcomes Minimum Quality Standard Measure: ACM provider attestation that patient’s care plan is consistent with preferences: Yes/No Effective Communication Composite: How often did this provider explain things in a way that was easy to understand? Effective Communication Composite: How often did the ACM team listen carefully to you when you talked with them about problems with your care or condition? Effective Communication Composite: How often did this provider show respect for what you had to say? Care Coordination: How often did the provider (ACM team) seem informed and up-to-date about the care you got from specialists?

ACM Payment Components Wage-adjusted $400 PMPM of indefinite duration, to be included in ACM episode costs Cover care management and ambulatory palliative care provider E&M visits Ends at death, hospice enrollment, or beneficiary’s request Replace ACM entity’s palliative care provider E&M, Chronic Care Management, Complex Chronic Care Management, Transitional Care Management, and Advance Care Planning payments Years 1-2: Quality bonus funded by shared savings Year 3: Quality bonus funded by shared savings & shared loss Minimum savings or shared loss rate of 4% An upside bonus for quality funded by shared savings and downside risk Quality bonus capped at $250 PMPM and the loss amount capped at $100 PMPM. Upside quality bonus payment in years 1-2; shared loss in year 3

Example of Success: Sutter AIM® Program ACTsm Example of Success: Sutter AIM® Program Most Impactful Model within CMMI, Health Care Innovation Awards Round 1 $1 Billion Portfolio Savings in the last month of life: $5,700 Patients reach over 3 years: 9,400 https://innovations.ahrq.gov/node/4958

Our Partners: A Diverse Alliance of 140+ A national non-profit, non-partisan alliance of patient and consumer advocacy groups, health care professional and providers, private sector stakeholders, faith-based organizations, and health care payers

ACTsm Start.

Thank You khuen@thectac.org Contact Information khuen@thectac.org