1. LAN Update: APM Framework White Paper
January 12, 2016
12:00pm – 1:30pm ET

2. Welcome Mark McClellan, MD Co-chair, LAN Guiding Committee
Robert Margolis Professor of Business, Medicine, and Policy and Director of the Robert J. Margolis Center for Health Policy
Duke University
Mark McClellan
Good afternoon, welcome, and Happy New Year. I am Mark McClellan, co-chair, along with Mark Smith, of the Health Care Payment Learning and Action Network –or LAN for short. The LAN project is led by the CMS Alliance to Modernize Healthcare, known as CAMH, which is operated by the MITRE Corporation on behalf of CMS.
After a substantial amount of effort from the Guiding Committee, the APM FPT Work Group, and each and every LAN participant who took part in our comment period, we are excited to be here today to present the final APM Framework White Paper.
First, I’m going to provide a brief overview of the LAN for those of you who are not familiar with this initiative. Then I will introduce Sam Nussbaum, APM Framework and Progress Tracking Work Group Chair who will provide a summary of the comments that were received on the Draft APM Framework White Paper and shed some light on how those comments were incorporated into the final product.
We will then hear from several panelists who will offer details on a few case studies that exemplify categories in the APM Framework.
Towards the conclusion of this event, we will have a short period in which you will be able to ask any questions that you may have by using the chat window in the bottom-left corner of your screen. Any questions that we are unable to answer during this session will be recorded and answered for public release at a later date.

3. The Health Care Payment Learning and Action Network (LAN) was launched because….
We want better care, smarter spending, and healthier people.
In order to achieve this, we need to improve our payment structure by building one that incentivizes quality and value over volume.
Such alignment requires the participation of the entire health care community. The LAN is a collaborative network of public and private stakeholders.
Mark McClellan
The Department of Health and Human Services launched the LAN in March of 2015 to help advance the work being done across sectors to increase the adoption of value-based payments and alternative payment models. The mission of the LAN is focused on payment reform, and specifically on accelerating the transition already underway by aligning stakeholders across sectors. The LAN is not only about changing health care payment, but also identifying what is needed for an APM to succeed.

4. Goals
Adoption of Alternative Payment Models (APMs)
These payment reforms are expected to demonstrate better outcomes and lower costs for patients.
In 2018, at least 50% of U.S. health care payments are so linked.
2018
50%
In 2016, at least 30% of U.S. health care payments are linked to quality and value through APMs
2016
30%
2018
50%
2016
30%
Mark McClellan
HHS has set a goal of tying at least 30 percent of Medicare payments to quality or value through alternative payment models by 2016 and at least 50 percent by 2018.
The LAN extends those Medicare goals to the private sector and states, and is working on steps toward these goals that can be delivered in the next two years, while establishing a foundation for success well beyond. As a public-private effort involving diverse stakeholders across health care, to date over 5,200 individuals are participating in the LAN.
Better Care, Smarter Spending, Healthier People

5. Work Group Representation
Physicians/Health Care Providers
Private Payers
CMS
Consumer/
Patient groups
Purchasers/
Employers
State Government
Mark McClellan
We now have 3 Work Groups that report to the Guiding Committee which sets strategy for achieving the LAN’s goals. The Work Groups are: (1) the APM Framework and Progress Tracking Work Group; (2) the Population-Based Payment Work Group, and (3) the Clinical Episode Payment Work Group. You can find more information about these on our web site and receive updates on their progress via our semi-monthly newsletter. (Please join the LAN on our website to subscribe to the newsletter).
Guiding Committee and Work Group members represent diverse stakeholder groups, including providers, health plans, purchasers/employers, consumers and patient advocates, and state, regional, and federal perspectives.

6. LAN Update: APM Framework White Paper
Sam Nussbaum, MD
Chair, Alternative Payment Model (APM) Framework and Progress Tracking Work Group
Former Executive Vice President and Chief Medical Officer
Anthem, Inc.
Mark McClellan
Now I’m going to introduce our work group chair:
Sam Nussbaum is the Chair of the APM Framework and Progress Tracking Work Group and the Former Executive Vice President of Clinical Health Policy as well as Chief Medical Officer at Anthem, Inc.

7. Alternative Payment Models Framework and Progress Tracking (APM FPT) Work Group Overview and Charge
A team of 14 public and private stakeholders
Work Group
Charged with assessing APMs in use across the nation and defining terms and concepts essential for understanding, categorizing, and measuring APMs
Charge
Sam Nussbaum (12:05 – 12:30 pm)
The Work Group has been working hard since it began its efforts in July 2015 and has made great progress towards achieving its two objectives:
(1) Provide recommendations and obtain broad agreement across stakeholder groups on a framework for categorizing APMs along with clear and understandable definitions for terms associated with the framework
(2) Develop an approach for tracking the progress of APM adoption across the U.S. health care system, using the established framework
The Work Group has completed its first charge – development of the Framework for categorizing APMs. The Framework is expanded upon in a white paper that describes the approach used to develop the Framework and principles upon which the Framework is based. With these principles in mind, the paper differentiates the categories within the APM Framework, by explaining how the categories are described, and where the boundaries between them lie. 
The Work Group is also considering how to utilize the Framework for measuring progress in APM adoption across the field. Work Group members are currently working to further develop and refine the draft metrics and methods for this measurement effort. The metrics will serve as a roadmap for APM transformation and reporting.
Final APM Framework White Paper released today!
Objective 1

8. Developing the APM Framework APM FPT Work Group Process
Developed principles using CMS Framework as a foundation
Constructed APM Framework based on principles
Solicited LAN input on the draft APM Framework
Finalized APM Framework based on LAN Feedback
Sam Nussbaum(12:05 – 12:30 pm)
As a starting point, the Work Group considered the payment framework established by CMS, as well as ways of measuring the extent of the shift from traditional fee-for-service (FFS) payment and the scope of the payment reform. The work group tested it against private sector models to identify areas where possible further refinement to the CMS payment framework may be needed. The group also reviewed the current measurement environment to understand the range and potential appropriateness of APM definitions that are already in use.
The APM FPT Work Group expanded and refined the four-category HHS framework by:
Articulating key principles to explain what the APM Framework means to convey
Introducing four new categories to account for payment models that are not considered progress towards payment reform
Introducing eight subcategories to account for nuanced but important distinctions between APMs within a single category
Delineating explicit decision rules that can be used to place a specific APM within a specific subcategory
The Work Group's third major step was to solicit input on a preliminary draft of the APM Framework White Paper. The Work Group engaged the LAN and specific stakeholder groups through a variety of channels (LAN Summit, listening sessions, social media, etc.). This item will be discussed in greater detail in the next two slides.
The Work Group spent the last six weeks reviewing and incorporating the LAN's feedback. We are excited to share the final product with you today!

9. APM Framework White Paper Request for LAN Feedback
In an effort to seek input at an early stage, the APM Work Group released a draft version of the White Paper on October 22, The Work Group requested specific input on:
the overall White Paper and proposed framework;
descriptions associated with each category;
the boundaries that differentiate one category from another; and
additional examples and case studies you could provide to illustrate and test each category in the framework.
Over 500 individuals attended the APM Framework presentation and discussion during the LAN Summit on October 26, 2015.
Sam Nussbaum(12:05 – 12:30 pm)
From the outset, one of the Work Group's guiding principles has been that the APM Framework White Paper should reflect the needs of our stakeholders. With that in mind, early in the process we invited diverse stakeholders to review an initial draft and submit their ideas, observations, questions and concerns.
The LAN Summit held on October 26, 2016 provided one of the first opportunities for the LAN to learn more about and provide feedback on the draft Framework. The Work Group presented and facilitated a panel discussion on the APM Framework during this event.
Over a month-long public comment period (Oct 22 – Nov 20), we received 113 comments totaling 285 pages from 79 unique submitters, just over half of whom (51%) represented an organization. We thank everyone who took the time to share their knowledge and expertise with us. The next slide will give you a sense of the types of comments we received.
Written feedback received on the White Paper included:
113 Comments (285 Pages)
79 Unique Submitters
51% of Submitters Acting as
Representative of their Organizations

10. APM Framework White Paper LAN Feedback - Thematic Areas
Commenters focused predominantly on the three pillars of person-centered care and the Framework principles
Many commenters requested additional details about which types of providers would be less likely to accept payments in Categories 3 and 4, and about how big an incentive payment needed to be in order to be “sufficient.”
Many commenters highlighted the risk associated with transitioning to APMs
Commenters representing certain provider types (e.g, primary care physicians, pediatricians, geriatricians) raised questions about where and how their practice might fit into the framework
There was a large number of recommendations (and requests for the Work Group to take a stance) on delivery system and plan design;
Sam Nussbaum
What you see on the slide above are some of the main themes that appeared in the comments submitted to the APM FPT Work Group. The vast majority of comments were positive and in favor of the overall approach and offered suggestions for how to strengthen the paper.
Note: comments numbered below starting in the upper left-hand corner and moving clockwise
Comment Bubble 1: Commenters focused predominantly on the three pillars of person-centered care and the principles.
Patient engagement was a major focus. Expanding the role and influence of patients (e.g., participation in plan design and governance boards), and the scope of patient engagement, and instituting safeguards against discrimination were the primary considerations for the majority of these comments. The Work Group deeply appreciates these comments and the person-centered focus that they add to the White Paper.
We received numerous suggestions about how to change the wording and discussion of the principles. Some of this was fairly substantive – e.g., some suggested edits significantly strengthening the discussion about empowering patients; also: some softening of the language about changing provider behavior in Principle 5. These suggestions are reflected in the final White Paper as appropriate.
Comment Bubble 2: Many commenters requested additional details about which types of providers would be less likely to accept payments in Categories 3 and 4, and about how big an incentive payment needed to be in order to be “sufficient.”
Many commenters noted that it is unrealistic to expect all providers to participate in Category 4 payment models, and that certain markets and provider types are inherently ill-suited for these types of payment arrangements. The Work Group acknowledges that Category 4 payments will not be appropriate for all providers and all markets. The final White Paper now clarifies that movement to Category 4 payments is the goal for the U.S. health care system as a whole, not a goal for each and every provider. The Work Group does believe that Category 4 payments hold tremendous promise, based on foundational principles.
The work Group talked about ways to establish what is and is not sufficient. WG believes more data is needed on appropriate levels for incentives and it is premature to quantify sufficient intensity.
Comment Bubble 3: Many commenters stressed that the transition from fee-for-service (FFS) to alternative payment models (APMs) is complex and financially risky, and may result in negative consequences for patients. The Work Group agrees with these comments and believes that their addition appropriately emphasizes the difficulties (and some of the potential unintended consequences) associated with the adoption of APMs. The Work Group, and the LAN as a whole, continues to believe that alignment across payment models in the public and private sectors will alleviate administrative burdens, incentivize investments in clinical infrastructure, and simplify the transition to APMs. The Work Group agrees that it is important to identify potential pratfalls so that APMs can be designed to avoid or mitigate them; accordingly, the final White Paper now explicitly draws attention to them.
Comment Bubble 4: There was a large number of recommendations (and requests for the Work Group to take a stance) on quality measures, HIT, and delivery system and plan design. The WG appreciates these recommendation and thinks they are worthy of consideration, but these types of recommendations are outside the WG’s charge.
Comment Bubble 5: Commenters representing certain provider types (e.g, primary care physicians, pediatricians, geriatricians) raised questions about where and how their practice might fit into the framework. The Work Group continues to believe that participation in APMs should be an option for all types of providers, and it does not intend to exclude any type of provider from the APM Framework. Although it was not possible to identify how every type of provider could participate in an APM, the Work Group made a significant effort to include examples to address this question.

11. Final APM Framework White Paper
The final version of the White Paper reflects LAN participant comments, as appropriate, and is a much stronger document because of them.
The final APM Framework White Paper may be viewed at:
A Comment Summary is also accessible
Sam Nussbaum(12:05 – 12:30 pm)
The final APM Framework White Paper is now available on the LAN website. In addition, the Work Group developed a separate document, which summarizes the main themes that appeared in the comments we received, and indicates the Work Group's perspective on these comments, and, where appropriate, discusses how the comments were incorporated into the final draft of the White Paper. 
Now, let's spend some time talking about the revised Framework. I will start by introducing the framework and talking though the principles that underlie it. Then, we can circle back and take a more in-depth look at the Framework.

12. APM Framework Summary of Key Principles
Changing providers’ financial incentives is not sufficient to achieve person-centered care, so it will be essential to empower patients to be partners in health care transformation.
The goal is to shift U.S. health care spending significantly towards population-based payments.
Value-based incentives should ideally reach the providers who deliver care.
Payment models that do not take quality into account will be classified within the appropriate category and marked with an "N" to indicate "No Quality" and will not count as progress toward payment reform.
Value-based incentives should be intense enough to motivate providers to invest in and adopt new approaches to care delivery.
APMs will be classified according to the dominant form of payment, when more than one type of payment is used.
Centers of excellence, accountable care organizations, and patient-centered medical homes are examples in the Framework, rather than categories, because they are delivery systems that can be applied to and supported by a variety of payment models..
Sam Nussbaum(12:05 – 12:30 pm)
These 7 principles serve as a scaffolding for the Framework. The principles are summarized above. (read list}

13. APM Framework At-A-Glance
The framework situates existing and potential APMs into a series of categories.
Sam Nussbaum(12:05 – 12:30 pm)
The framework builds on the CMS proposed framework, which includes a trajectory of categories, with category 1, fee for service without a link to quality, being the predominant model today – and a progression to category 4, which includes population based payment models.
It is important when we discuss the framework to understand what the framework “is” and what it “is not.”
The framework is a MODEL for categorizing payment models
The framework is not a tool for establishing categories of delivery systems
It is also not the Work Group’s intention to determine which model is the best model to follow. The framework is meant to allow for evolution and innovation in the field while driving toward value-based payments.

14. APM Framework
Sam Nussbaum(12:05 – 12:30 pm)
Here we show an illustration of the APM framework. Each category includes sub-categories, which further stratify the categories that CMS has already created. For example, within category 3, which includes APMs built on fee-for-service architecture, the Work Group proposes to differentiate between those models which have only upside risk - for example, the ability to obtain a bonus payment for achieving a quality or cost target - from those which include both upside and downside risk - for example, those which have bonus payment opportunities - as well as payment penalties for poor performance.
Category 1: Payment models classified as Category 1 utilize traditional FFS payments (i.e., payments that are made for units of service) that are not adjusted to account for infrastructure investments, provider reporting of quality data, or provider performance on cost and quality metrics.
Category 2: Payment models classified as Category 2 utilize traditional FFS payments (i.e., payments that are made for units of service), but these payments are subsequently adjusted based on infrastructure investments to improve clinical services, providers reporting quality data, and/or providers performance on cost and quality metrics. Category 2 includes four subcategories:
Payments placed in Category 2A involve payments for infrastructure investments that can improve the quality of patient care.
Payments placed in Category 2B provide positive or negative incentives to report quality data to the health plan and (preferably) to the public.
Payments are placed in Category 2C if they provide rewards for high performance on clinical quality measures.
Payments placed in Category 2D reward providers who perform well on quality metrics and penalize providers who do not perform well, thus providing a significant linkage between payment and quality.
APMs Built on Fee-for-Service Architecture (Category 3):
Payment models classified as Category 3 are based on a FFS architecture, while providing mechanisms for the effective management of a set of procedures, an episode of care, or all health services provided for individuals.
Episode-based and other types of bundled payments encourage care coordination because they cover a complete set of related services for a procedure that may be delivered by multiple providers. Clinical episode payments fall into Category 3 if they are tied to specific procedures, such as hip replacement or back surgery. Category 3 includes two subcategories:
Category 3A gives providers an “upside” opportunity to share in the savings they generate.
Payments in Category 3B involve both upside gainsharing and downside risk based on performance on cost measures.
Population-Based Payment (Category 4):
Payment models classified as Category 4 involve population based payments, structured in a manner that encourages providers to deliver well-coordinated, high quality person level care within a defined (4A) or overall (4B) budget. Payments within Category 4 are intended to cover a wide range of preventive health, health maintenance, and health improvement services. Category 4 includes two subcategories:
Category 4A payments are population-based, but they are limited to certain sets of condition-specific services (e.g., asthma, diabetes, or cancer), but they remain person-focused in the sense that they hold providers accountable for the total cost and quality of care related to that condition.
Payments in Category 4B are capitated or population-based for all of the individual’s health care needs.

15. Work Group’s Goals for Payment Reform
Sam Nussbaum(12:05 – 12:30 pm)
The overarching objective of the LAN is to encourage alignment between and within the public and private sectors as the health care system moves away from traditional FFS payment. Consistent with this objective, the Work Group recommends that, over time, public and private health plans should move concertedly towards APMs in Categories 3 and 4. The Work Group recognizes that market forces have led to different levels of delivery system organization and integration, and to differing capabilities with regard to the necessary investments in infrastructure and management to advance to more robust population health payments. Therefore, APMs in Categories 3 and 4 will not be readily achievable in every market and for every patient population, and the Work Group anticipates that some regional markets may be slower to make the transition to Categories 3 and 4.
In the figure above, the size of the various circles represents allocations (either in terms of members/beneficiaries, providers, or dollars) in various types of APMs. As the "bubble chart," as we call it, illustrates, payments shift over time from Categories 1 and 2 into Categories 3 and 4. Additionally, the Work Group expects that over time, APMs within a particular category will increase provider risk and innovation, make a greater impact on quality and cost performance, increase integration and coordination in delivery systems, and, ultimately, result in more patient-centered care. The figure also implies that overall spending will diminish over time. For example, compared with present Category 3B APMs, future Category 3B APMs will employ larger risk corridors and more extensive sets of quality measures; they will offer further opportunities for providers to develop innovative delivery models; and, they will provide additional support for coordinating care across multiple providers. For the reasons discussed above, the Work Group believes that these advancements will also result in more person-centered care.
Caution: Values displayed in the graphic are not precise, nor are they intended to lay out specific targets for health care reform.

16. How the APM Framework helps to achieve LAN and HHS Goals
The framework is a critical first step toward the goal of better care, smarter spending, and healthier people.
Serves as the foundation for generating evidence about what works and lessons learned
Provides a road map for payment reform capable of supporting the delivery of person-centered care.
Acts as a "gauge" for measuring progress towards adoption of alternative payment models
Establishes a common nomenclature and a set of conventions that will facilitate discussions within and across stakeholder communities
Sam Nussbaum(12:05 – 12:30 pm)
The purpose of the LAN is to drive alignment in payment approaches/policies in the public and private sectors, in order to catalyze payment reform in the US health care system.  The first step in this process is establishing a common language, which stakeholders can use to characterize different types of payment models and identify where we stand on the pathway to reform.  The APM Framework White Paper accomplishes this first step towards alignment.

17. Q&A Sam Nussbaum (12:30 – 12:35 pm)
Now it’s your turn, and the floor is open for your comment and questions. What comments do you have on the Framework? You can submit your comments via the chat box and I will facilitate your comments.
The first question/comment I see is……

18. APM Case Studies Jeff Rideout John Pilotte Robert McConville
President and CEO
Integrated Healthcare Association (IHA)
John Pilotte
Director, Performance-Based Payment Policy Group
Center for Medicare, Centers for Medicare & Medicaid Services
Robert McConville
Director of Population Health
Intermountain
Eileen Wood
Senior Vice President, Clinical Integration
Chief Pharmacy Officer
Capital District Physicians' Health Plan, Inc. (CDPHP)
Sam Nussbaum (12:36)
Over the last several months, the APM Work Group has been compiling, with the help of the LAN, examples of APMs that illustrate key characteristics of each of the subcategories. We have planned to share some of these “real-world” examples of APMs today, which we hope will help to bring the Framework to life.
We are delighted to have several respected experts join us today to provide presentations on their case studies and share their experiences with APMs. In addition to walking us through their respective case studies, presenters will talk about their motivation for making the leap to APMs and how they addressed any challenges along the way.
I'll will briefly introduce each presenter before their presentation. Following all of the presentations, we will have time for questions from the audience.

19. California Value Based P4P: A Model 3A Shared Savings Program19
California Value Based P4P: A Model 3A Shared Savings Program
Jeff Rideout
President and CEO
Integrated Healthcare Association (IHA)
Sam Nussbaum
Jeff Rideout is a member of the APM Framework and Progress Tracking Work Group and President and CEO of Integrated Healthcare Association.
Now, I'll turn it over to Jeff to describe this shared savings program…

20. 20
IHA’s Value Based P4P Program Evolution— In 2015 there were 10 participating health plans and 200 participating physician organizations responsible for care delivered to 9 million Californians
First Measurement Year – Quality only
Resource Use measures added
Value Based P4P – Quality and Resource Use integrated into single incentive program
2003
2007
2009
2011
2013
2014
2015
Jeff Rideout (12:35-12:45)
Payment for Improvement added – Quality only
Total Cost of Care measure added
First payments for Value Based P4P
First year Total Cost of Care publicly reported

21. Appropriate Resource Use21
Common Set of Measures— working diligently to align with MA, QRS and Medi-Cal whenever possible
Process and outcomes measures focused on six priority clinical areas
Cardiovascular (2)
Diabetes (7)
Maternity (0)
Musculoskeletal (1)
Prevention (8)
Respiratory (3)
Clinical (50%)
Patient Experience (20%)
Patient ratings of six components, including care overall:
Communicating with Patients
Coordinating Care
Health Promotion
Helpful Office Staff
Overall Rating of Care
Timely Care and Service
Percent of providers meeting intent of CMS Meaningful Use core requirements
Ability to report selected e- measures (2)
Meaningful Use
of Health IT (30%)
Utilization metrics spanning:
Inpatient stays
Readmissions
ED visits
Outpatient procedures
Generic prescribing
Appropriate Resource Use
Average health plan and member payments associated with care for a member for the year, adjusted for risk and geography
Total Cost of Care
Jeff Rideout (12:35-12:45)

22. Value Based P4P Design and Highlights22
Value Based P4P Design and Highlights
Meets minimum Quality Composite Score
TCC trend does not exceed CPI+3%
Of the POs that didn’t pass the performance gates, 14% missed the TCC trend gate and 4% missed the quality gate.
Overall TCC trend continues to slow – showing a decline in 2015
Does the PO qualify?
Resource use compared to prior year
Selected inpatient, outpatient, ED, and prescribing measures
Bed days are the primary driver of PO net share of savings
Did the PO improve or maintain efficient resource use?
Jeff Rideout (12:35-12:45)
Net savings across all ARU measures
Quality determines share of savings
Modeling suggests about 50% of POs earn an incentive
Higher quality magnifies incentive amount
How much is the PO’s incentive payment?
Copyright © 2015 Integrated Healthcare Association. All rights reserved.

23. 23
Medicare Shared Savings Program (MSSP) Centers for Medicare & Medicaid Services
John Pilotte
Director, Performance-Based Payment Policy Group
Center for Medicare, Centers for Medicare & Medicaid Services
Sam Nussbaum
John Pilotte is the Director of the Performance-Based Payment Policy Group, Center for Medicare at CMS.
Now, I'll turn it over to John to describe the Medicare Shared Savings Program…

24. Medicare Shared Savings Program Growing
434 ACOs established to date in the Shared Savings Program
In 2016, 100 new ACOs joining the program and 147 ACOs renewing their agreements
22 ACOs in performance based risk tracks, including 16 in new Track 3
54 new ACOs serving Medicare beneficiaries in rural areas in 2016
Over 7.7 million Medicare FFS beneficiaries receive care from providers participating in Shared Savings Program ACOs
15,000 additional physicians joining Shared Savings Program ACOs in bringing total to over 180,000 physicians and other practitioners in Shared Savings Program ACOs
Physician, practitioner and provider networks most prominent type of ACO
John Pilotte (12:45-12:55)

25. Promising Results Shared Savings Program Quality Results
ACOs that reported in both 2013 and 2014 improved average performance on 27 of 33 quality measures
Quality improvement was shown in such measures as patients’ ratings of clinicians’ communication, beneficiaries’ rating of their doctor, screening for tobacco use and cessation, screening for high blood pressure, and Electronic Health Record use
Achieved higher performance than other FFS providers on 18 of the 22 Group Practice Reporting Option Web Interface measures
Clinicians participating in ACOs in 2015 avoid the PQRS payment adjustment and automatic downward Value Modifier (VM) adjustment in 2017 if their ACO satisfactorily reported quality measures. Physicians also eligible for upward, neutral, or downward VM adjustments in 2017 based on their ACO’s quality performance.
John Pilotte (12:45-12:55)

26. Promising Results Shared Savings Program Financial Results
Performance Year 2014: 92 ACOs (28%) held spending $806 million below their targets and earned performance payments of more than $341 million.
An additional 89 ACOs reduced health care costs compared to their benchmark, but did not meet the minimum savings threshold.
ACOs with more experience in the program were more likely to generate shared savings: 37 percent of 2012 starters, compared to 27 percent of those that entered in 2013, and 19 percent of those that entered in 2014.
Performance Year 1: 58 ACOs (26%) held spending $705 million below their targets and earned performance payments of more than $315 million.
John Pilotte (12:45-12:55)

27. Observations & Lessons Learned
ACOs are engaging in a variety of innovative care coordination and practice redesign activities with local providers in their communities.
ACOs identified physician engagement, patient engagement, care transitions, and post-acute care as key issues and are working on strategies to improve in these areas.
ACOs are receiving Medicare claims data that can assist them in redesigning care and monitor their performance. Many integrate claims data with clinical data systems.
ACOs value communication and learning opportunities, as well as transparency in methodologies.
ACOs are supporting one another with their time and expertise in a learning network and data users group.
John Pilotte (12:45-12:55)

28. Enhanced Primary Care: The CDPHP Medical Home28
Enhanced Primary Care: The CDPHP Medical Home
Eileen Wood
Senior Vice President, Clinical Integration
Chief Pharmacy Officer
Capital District Physicians' Health Plan, Inc. (CDPHP)
Sam Nussbaum
Eileen Wood is the Senior Vice President, Clinical Integration and Chief Pharmacy Officer at Capital District Physicians' Health Plan, Inc.
Now, I'll turn it over to Eileen to highlight CDPHP's Enhanced Primary Care Program…

29. CDPHP Enhanced Primary Care (EPC)
In 2008, EPC was piloted to address the shortage of primary care physicians (PCPs) in our area
Replaces fee-for-service (FFS) with risk-adjusted global payments
Moves physicians to population-based payments
Offers opportunity for significant bonus payments for advancing the principles of the Triple Aim
Rewards doctors for spending more time with sickest patients
In 2012, pilot was moved to a sustainable program, which is now the predominant payment model for our PCP network
Today, EPC includes 245,000 members — more than half our membership
Eileen Wood (12:55 – 1:05)
Payment Reform
Practice Reform

30. CDPHP Enhanced Primary Care (EPC)
Underlying Payment Approach
3(B) - replaces FFS with risk-adjusted global payment
Currently paying 40% more on average than FFS
Opportunity for an average 20% bonus based on goals of Triple Aim
Approaches to Cost Assessment
Cost and efficiency assessed using risk-adjusted utilization in six categories:
Inpatient hospitalization
Emergency room
Medical imaging
Pharmacy
Laboratory
Specialists
Eileen Wood (12:55 – 1:05)

31. CDPHP Enhanced Primary Care (EPC)
Approaches to Quality Assessment
Assessed using HEDIS metrics in four categories:
Population health and prevention
Management of chronic conditions
Antibiotic use
Behavioral health
Assessed using experience of care composite from CAHPS survey
Additional Infrastructure and Operational Investments
Performance management department added to support program
Engagement and training to achieve cultural shift
Support PCPs to achieve NCQA Level 3 PCMH recognition
Provide actionable data
Assist with clinical integration of care management
Assist with transition to value-based payments
Eileen Wood (12:55 – 1:05)

32. CDPHP Enhanced Primary Care (EPC)
Program netted $20.7 million ($17.11 PMPM) in savings in 2014
PCPs received $12.8 million more in reimbursements and bonuses
1.5 fewer primary care visits per 1,000 members
Visits increased for sickest 10% — exactly what we wanted to happen!
Eileen Wood (12:55 – 1:05)

33. CDPHP Enhanced Primary Care (EPC)
Beyond cost, EPC produced impressive quality results:
Quality scores at EPC sites rose from 71% to 77%
Quality scores at non-EPC sites rose from 65% to 68%
Eileen Wood (12:55 – 1:05)

34. Shared Accountability: Intermountain Health34
Shared Accountability: Intermountain Health
Robert McConville
Director of Population Health
Intermountain Health
Sam Nussbaum
Robert McConville is the Director of Population Health at Intermountain.
Now, I'll turn it over to Robert to describe Intermountain Healthcare's shared accountability model…

35. 18 Shared Commitments
Robert McConville (1:05 – 1:15)

36. Shared Accountability Regional Financial Model
Payer
Intermountain Healthcare
“Population
Budget”
Provides Care Process Models
Distributes budgets
Provides Population Health Mgt. Services
Intermountain Hospitals
Intermountain employed Physicians
Contracted
affiliated Physicians
Geographic Committee
18 Shared Commitments Provider Shared-risk Payment
- Productivity
- Quality
- Patient Experience
- Product Performance
Robert McConville (1:05 – 1:15)

37. Payer Strategy Medicare Medicare Advantage – January 2013
ACO – considering
Medicaid
“ACO” model – January 2013
Commercial
– January 2016
Followed by others
Robert McConville (1:05 – 1:15)

38. Q & A
Sam Nussbaum (1:15-1:25)
Thank you Jeff, Eileen, John and Robert. That was very informative. Now it’s our audience’s chance to ask questions. We’ll read the questions you submit through the Question Window of your webinar dashboard.
The first question is…..
Thanks everyone for your participation. Before we close, I want to let you know what we’re working on next.

39. What's Next? Way Forward includes:
Continue building on our set of case studies of payment models
Developing strategy for measuring adoption of APMs
Refining draft metrics
Establishing payer collaborative to define how best to report on APMs
Piloting strategy with a small, diverse group of health plans
Sam Nussbaum (1:25-1:28)
The LAN intends to continue compiling and periodically releasing case studies of payment models. The Work Group believes this is important because it will disseminate lessons learned and provide the nation with models to consider, as public and private plans align around common payment approaches.
The LAN is convening a Payer Collaborative, an offshoot of the APM Work Group, to help further inform our APM measurement approach. This group includes an inclusive and diverse mix of payers. The first session of the payer work group will be held next week.
While the Work Group believes that this Framework identifies and encompasses all models of payment reform and will be enduring, Work Group members hope to return to the White Paper at a later date to take into account new developments in the health care sector.
Revisiting the APM Framework White Paper on the one-year anniversary of its release to take into account new developments in the health care sector

40. Call to Action
We need to continue to work together to move payment towards value and quality in the U.S. Health System
You can help in many ways
Committing to use APMs
Using the Framework to further the discussion on payment reform
Participating in/supporting efforts to report on progress towards national goals
Sharing models and best practices
Staying involved by joining the conversation on Handshake and by participating in future LAN webinars
Sam Nussbaum (1:25-1:28)
So, how can you help as we work together to advance payment reform and improve health? There are many ways. {read list}
Thank you for the opportunity to present the final white paper and for your questions and comments today. I’m now going to turn it back to Mark McClellan to wrap up and close this session.

41. Upcoming LAN Products Sprints Launched Patient Attribution
Population-Based Payment (PBP) Work Group
Sprints Launched
Patient Attribution
Financial Benchmarking
Future Sprints
Performance Measurement
Data Sharing
Clinical Episode Payment (CEP) Work Group
Sprints Launched
Elective Hip and Knee Replacement
Future Sprints
Maternity
Cardiac Care
Mark McClellan
Thanks Sam for this detailed presentation and discussion and for your leadership of the Work Group to date. We look forward to updates on the measuring progress.
I had mentioned the LAN’s two additional Work Groups previously, and want to bring to your attention upcoming opportunities for you to engage as they develop their draft recommendations. Anyone may join the Work Group affiliated communities on Handshake, the LAN collaboration portal, to provide input and feedback on questions and issues raised by the Groups. I’ll indicate how to request an account on Handshake in just a moment, if you don’t already have one.
These two Work Groups will be releasing their first draft products next month with 4-week comment periods. We’ll open a comment period on Patient Attribution in early February and one on Joint Replacement shortly after that. We will be conducting listening sessions for various stakeholder groups and soliciting your comments on the drafts. We look forward to your engagement on these important next steps in the LAN’s work.

42. Get Involved! Register online Visit our site Ask a question
Mark McClellan
If you would like an invitation to create an account on Handshake, please the address you see in the bottom right here. If you haven’t already, visit the LAN website and sign up to get our newsletters and invitations to listening sessions and other events. We would also like to hear from you on any ideas you have and encourage you to forward our newsletters and webinar invitations.
We’re pleased so many of you could participate today, and we look forward to your participation throughout That’s all we have time for today, so thank you for being with us. We appreciate your support and involvement. Have a good afternoon.