Accountable Care Organizations and Integrative Health/CPMs Karen Milgate, Health Policy Consultant National Association of Certified Professional Midwives July 10, 2014

Overview of presentation What are ACOs? Why were they established? How will their success be measured? How likely are they to succeed? How can integrative healthcare (CPMs) help? 2

What are ACOs? Groups of providers—primary care professionals must be sufficient to care for the number of beneficiaries assigned to them. Willing to take accountability for the overall cost and quality targets established for the aligned population Willing to do this even as beneficiaries still in FFS Medicare and can go to any provider they so choose—essentially a virtual network 3

Why were ACOs established? Cost concerns— – Health care represents 18 percent of GDP: and growing—faster than the rest of the economy – Medicare is single largest payer thus often impacts other payer policy – Medicaid catching up fast and may surpass Medicare – Both together are crowding out other priorities – In the future, fewer workers to pay, increasing share of per worker income necessary 4

What are the options for addressing cost concerns? Price X Volume=Cost – Historically congress has tried to control the price; medical system left in charge of volume – More and more difficult, so how to create incentives for less volume to counteract FFS incentives for greater volume Volume? – Are all of these services necessary/appropriate? Huge variation in utilization patterns across the country and for similar populations suggest some care (as much as 30 percent) may be unnecessary – Some care, such as preventable admissions, c-sections, etc may be indicators of poor quality care and increase costs – Need to change the FFS incentives for volume Bottom line: Provide incentives for FFS providers to better manage care. Set targets for cost and quality and allow providers to share in savings achieved. 5

How will success be measured? Cost. Define population for which ACO accountable— aligned beneficiaries. Done through primary care providers. Establish baseline per capita—mix of historical with and without aligned beneficiaries After measurement period, determine whether ACO better than expected trend or not (benchmark) If better, calculate and share savings based on quality metrics 6

How will success be measured? Quality. Four target areas (33 total metrics), reporting vs. pay for performance: Patient/caregiver – 7 metrics, 4 points, 25 percent of score Care coordination/patient safety – 6 metrics + HER metric, 14 points, 25 percent of score Preventative health—8 metrics, 16 points, 25 percent of score At-risk population – 12 metrics, 14points, 25 percent of score 7

How likely to succeed? In Medicare, 323 Shared Savings Program and 23 Pioneer ACOs as of January. 5.3 million lives Total, including all payers: 626 with over 20 million lives. Several states with Medicaid ACOs. Other payment models support: Patient-Centered Medical home, bundled payment, value-based payment Is the right thing to do But…..it is hard – Sets up dualing incentives in same organization – Not easy to coordinate care and savings thresholds are tough 8

How can integrative healthcare (CPMs) help? Goal is better outcomes leading to lower acute exacerbations and lower overall spending CPMs are still proving themselves, but this allows for demonstrating on a large population without intervention by intervention study. Less need for RCT, more for observational results Less expensive alternatives, such as CPMs, nutritionists, community health workers, nurse practitioners encouraged 9

Ask, Answer, Make the case: How would CPMs fit into this model? What are the potential savings for an ACO if a higher percentage of births were attended by CPMs? At home? At birth centers? What are the potential quality improvements that might result for an ACO if a higher percentage of births were attended by CPMs? At home? At birth centers? Focus on Medicaid and commercial payers. Find out whether there are payers in your region— either Medicaid or commercial insurers-- that have created a payment stream for ACOs. Make the case. 10