Cost and Performance Management Under Alternative Payment Models What are the roles, responsibilities, skills, knowledge and personal attributes of a successful physician leader in a fee for service environment? FFS = V x P What are the roles, responsibilities, skills, knowledge and personal attributes of a successful physician leader in an alternative or value based payment environment? V = Q / C

How Bundled Payments Work

Bundled Payment for an Episode of Care

Components of Episode Pricing All hospital services (Medicare part A) provided during stay are included Patient inclusion criteria must be explicitly defined in advance Physician services (Medicare part B) for Surgeon Anesthesiologist Cardiologist Radiologist Consults Bundle period is defined as 30, 60, or 90 days Days of inclusion: Pre op day, (all preadmission lab work completed prior to admission) In Hospital Stay (number of days based on historical and current practices) Post op follow up, SNF, Rehab Facility, NH, Home Health Care

Bundle Based Payment for Episode of Care Bundle of Care Model Fee for Service Model All Physician Services; billed separately, inpt and outpt; Include PCP, Specialist; Surgeon; Radiologist, etc. All physician services, pre-admit, inpt, and post discharge. Governance Model and method agreed to distribute payments to all physicians, in-patient facilities, hospitals, SNF’s, etc. and all care givers involved in the bundle. Need for metrics, transparency, adjudication of disputes, and stop loss provisions. Separate FFS Physician Payments Single Contracted Payment for all Physician, Hospital and Follow Up Charges All hospital services, Including staff, pharmacy and technical component of radiology and lab. Also ED and readmit. Include all inpatient charges, and any ED or Readmit Charges Hospital Charges Paid Post Discharge Follow Charges Paid All follow up rehab, SNF, NH, Home health and PT Include all Rehab, SNF, NH and PT Charges, either in facility or at home

How Population Health Works

Difference Between a FFS & a Population Health Panel The Sickest Patients Patients with Medical Conditions – “At Risk” In an average non-Medicare population, there is a large number of “healthy patients” In a Population Health Panel, payment or capitation is for the entire panel of patients. In FFS Panel, payment is per unit of service, only for those patients seen in the office or hospital.

The Entire Population Health Portfolio is Required Access Extended hours. Teams. Asynchronous care. Partnering, e.g. retail clinics. Self management. Apps. Patient-Centered Medical Homes Physician directed teams. EMR. Coordination with specialists. Service. Disparities. Care Coordination Care coordination. Health Coaching. Care management. Social work. Clinical pharmacist. Care navigation. Data Analytics/Reporting Connectivity. Aggregation. Analytics. Risk stratification. Dashboards and reporting. Evidence-based Medicine Guidelines/protocols that are created and agreed to by the providers. Wellness and Prevention Technology-apps, portals. Coaching. Automated outreach. Benefits design. Community/govt engagement. “Contemporary nutrition”, eg GMO, pescatarian, vegan. PCMH Does current payer care coordination, case management work?

1 2 3 4 5 Risk Stratification Analytics DEFINE ASSESS STRATIFY ENGAGE MANAGE Population Identification Health Assessment Risk Stratification Enrollment / Engagement Strategies Management / Interventions Tailored Interventions — Care Coordination Disease / Case Management Health Risk Management Health Promotion / Wellness Meeting patients where they are …physically home | school | work | shopping | in the clinic …in the way that works best for them email | text | internet | phone | video | face-to-face

Financial Model for Taking Risk for a Population