Steven E. Wegner, MD JD Chair, NCMS Accountable Care Task Force Paul Cunningham, MD NCMS Accountable Care Task Force 1

Steve Wegner (919)

What is this? … and why should I care? 3

4 - Peter Orszag, N Engl J Med, 2007

5 - Baicker et al. Health Affairs web exclusives, October 7, 2004

“ Even if federal health overhaul is rejected by the Supreme Court or revamped by Congress, the market must continue to change. The system that brought us to this place is unsustainable. Employers who foot the bill for workers’ health coverage are demanding that BlueCross identify the providers with the highest quality outcomes and lowest costs.” - Brad Wilson, President of BlueCross BlueShield of North Carolina 6

“ACOs consist of providers who are jointly held accountable for achieving measured quality improvements and reductions in the rate of spending growth.” - Mark McClellan, Director of the Engleberg Center for Health Care Reform at the Brookings Institution 7

8  ACOs are not gate keeper; ACOs do not require patient enrollment.  ACOs do not require changes to benefit structures.  Can provide or manage continuum of care as a real or virtually integrated delivery system.  Are of a sufficient size to support comprehensive performance measurements.  Are capable of internally distributing shared savings payment.

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10 More doctors are joining hospitals and health systems rather than go into private practice.

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12  Triple aim: ◦ Population health status and outcomes of care ◦ The care experience ◦ Total cost of care – Delivering the outcomes

 Tightly aligned physician network  Contracting capability  Large enough population base  Willingness to accept common cost and quality metrics  Sufficient data infrastructure 13

1. People-centered foundation 2. Health Home 3. High-Value network 4. Population health data management 5. ACO leadership 6. Payer Partnership 14

 Fee-for-service plus bonus  Bundled payments plus bonus  Global capitation  Partial capitation 15

These Principles are: 1. Stakeholders should identify specific targets that reduce cost. 2. Evaluate objectively whether these targets were met. 3. They should share success financially. 4. Should engage in a process of continued monitoring. 16

1. Quality 2. Cost effectiveness 3. Care-coordination 17

ACO Impact ACOs have access to medical, pharmacy, and Laboratory claims from payers Care Effectiveness/ Population Health Cancer Care Screenings Diabetes Care (LDL and H1c tests, eye exams, etc.) Coronary Artery Disease Care (LDL test) Safety High-risk medication for the elderly Appropriate testing for patients using high-risk medications Patient Engagement Overuse/ Efficiency Imaging for low back pain (in absence of “red flags”) during first 30 days Inappropriate antibiotic prescribing Utilization rates of select services (e.g., C-section) 18

ACO Impact ACOs use specific clinical data (e.g., electronic laboratory results) and limited survey data Care Effectiveness/ Population Health Immunization rates for children and adolescents Patients with diabetes whose blood sugar (H1c) is in control Patients with diabetes or ischemic vascular disease whose lipids (LDL) are in control Patients with hypertension whose blood pressure is in control Safety “Never events” in hospitals Patient Engagement Physician instructions understood (CAHPS) Care received when needed (CAHPS) Overuse/ Efficiency Episode-based resource use – linked to quality measures for common medical (e.g. diabetes, AMI) and common surgical conditions (e.g. hip replacement) 19

 Reduced hospitalizations and other wastes.  Care coordination and care transition for chronic disease and complex patients.  Internal process improvement.  Informed patient choices.  Prevention and wellness. 20

 Coordination between PCPs and specialists.  Support for preventing complications in specialty care and reducing costs.  Successful ACOs will promote more effective specialists care and PCP- specialists coordination and higher-value specialty care. 21

1. Quality 2. Cost effectiveness 3. Care-coordination 22

1. Quality 2. Cost effectiveness 3. Care-coordination Culture of teamwork X 2

 Best practices for specialty coordination with medical homes  Best practices for all specialty procedure registries/patient tracking for improving care-and supporting meaningful performance measurements 24

 Improved professional working environment  Realization that at some point volume and intensity will not be able to be increased further  Understanding that the care currently being delivered is not in the best interest of our country or patients  Knowledge of continued reform attempts by all healthcare stakeholders to improve quality and bend the cost curve 25

Steve Wegner (919)