1. Home-Based and other Primary Care APMs for the Elderly
April 13, 2016
12:00 – 1:15 pm ET
Home-Based and other Primary Care APMs for the Elderly

2. CMS Alliance to Modernize Healthcare (CAMH)
Welcome
Anne Gauthier
LAN Project Leader,
CMS Alliance to Modernize Healthcare (CAMH)
Anne Gauthier:
Good afternoon and welcome. I am Anne Gauthier, Project Lead for the Health Care Payment Learning & Action Network, or LAN. The LAN project is led by the CMS Alliance to Modernize Healthcare, known as CAMH, operated by the MITRE Corporation on behalf of CMS.
I’m delighted to be here with you today for this important discussion about APMs for home-based and other geriatric medical homes for the elderly.

3. Agenda Time (ET) Topic 12:00 – 12:05 pm Opening remarks
Eric De Jonge, MD, Director of Geriatrics and co-founder of the Medical House Call Program at MedStar Washington Hospital Center
Steven Phillips, MD, founder and CEO/President of Geriatric Specialty Care (GSC); Medical Director of the Sanford Center for Aging at the University of Nevada
Alan Lazaroff, MD, Medical Director, Physician Health Partners; member of the Board of Directors of the American Geriatrics Society
12:50 – 1:10 am
Facilitated Discussion
1:10 – 1:15 pm
Upcoming LAN Activities and Closing Comments
Anne Gauthier:
As you can see from our agenda, we’ve devoted this entire session to today’s topic. A member of our Guiding Committee will provide his own welcome and walk you through what you can expect to get out of today’s session. Then we have several panelists who will share examples of alternative payment models for geriatric care.
We’ll look forward to your questions for our panelists during our Q & A at around 12:50. As always, you can submit your questions via the chat window at any time.

4. Guiding committee welcome
Thomas Buckingham, BSN, MBA
Member
LAN Guiding Committee
Executive Vice President
Select Medical
Anne Gauthier:
It is now my pleasure to introduce Tom Buckingham, the Executive Vice President of Select Medical and member of the LAN Guiding Committee. Tom will host the panel and moderate our Q & A after the presentations. Tom?

5. Session Objectives Learn:
Learn how several home-based and primary care-based programs for the frail elderly have effectively implemented alternative payment approaches to help achieve the Triple Aim, and hear advice for ‘graduating’ to a higher-level APM
Learn from three practicing geriatricians, with over 80 combined years of experience, about what you can do to be successful implementing APMs
Learn how one provider moves payments from the risk-adjusted global payments to individual physician practices, in a process that includes fee-for-service (FFS), quality metrics, participation level, and financial performance, and about its success in participating in risk or accountable environments
Discuss the challenges, value proposition, and lessons learned of data capture, analytics, and IT system support to ensure success with APMs within this changing environment
Tom Buckingham:
Thank you Anne. We’re excited to bring you today’s panel. Our session objectives today are as follows: [READ SESSION OBJECTIVES]
We have panelists who will share their home-based and primary care based programs for the frail elderly, including results they’ve seen and challenges they’ve encountered using APMs. You’ll also hear from them how their models fit within the LAN’s APM Framework that we use to categorize payment models.

6. Poll Question #1 Who is in the audience Anne Gauthier:
At this time I think it would be very interesting to see who is in our audience today to hear about this topic. Let’s do an online poll. Please select the category that best represents you. ….
[we use our list of stakeholder types]
{comment on results]

7. Poll Question #2
What types of payment models do you have experience with? Choose all that apply.
Tom Buckingham:
Thanks for your responses. Let’s follow with one more question at this time. What types of payment models do you have experience with? Make sure that you choose all options that apply to you. Your options are:
[read each option]
FFS with shared savings based on quality and cost
FFS with upside and downside financial risk                             FFS with infrastructure payment (for example: PMPM for care coordination) Full capitation (no FFS) with no link to quality Full capitation with reward for quality Other (write in the text box)
[comment on results]

8. Panel speaker Eric De Jonge, MD Director of Geriatrics,
MedStar Washington Hospital Center
Tom Buckingham:
It is now my pleasure to introduce the first of our three panel speakers. The first speaker is Dr. Eric De Jonge who is co-founder of the Medical House Call Program and the Director of Geriatrics with MedStar Washington Hospital Center. Dr. De Jonge, who currently teaches at both Georgetown and Johns Hopkins School of Medicine, will discuss his organization’s excellent work in the area of geriatrics. Eric, the floor is yours.

9. Home-Based Primary Care (HBPC) and the Independence At Home (IAH) Payment Model
Eric De Jonge, M.D.
Director of Geriatrics
MedStar Washington Hospital Center
NOTE: This work does not involve any CMS-sponsored analyses. The content is the responsibility of the author, and no scientific review, corroboration or verification by CMS should be inferred.

10. Overview Context IAH Payment Model Results Lessons Learned
Define patient population and home-based primary care model (HBPC)
Why do we need APM?
IAH Payment Model
Results
Effect of HBPC on patient/CG experience and per capita Medicare costs
Recent studies / IAH Demonstration project
Lessons Learned
September 19, 2018

11. Context- HBPC and IAH Highly Targeted: Mobile Service: Goals:
2 million ill and high-cost patients (age )
5% with severe, chronic illness  expend nearly 50% of budget
Mobile Service:
Interdisciplinary, home-based primary care
24/7, care across settings, coordinate ALL medical and social services
Goals:
Enhance health and dignity of frail elders, peace of mind for CGs,
Lower per capita costs  Scalable model

12. Expenditures -- MC Beneficiaries CBO Report 2005$
Source: Congressional Budget Office Report

13. Patient- Carolyn B.
69 year old with liver and heart failure, depression, falls, caregiver burden
SIX admissions in 2011 in CO/AZ (6 admits/ patient year)
2011: Daughter moved Mom to D.C. zip code to gain entry to HBPC program
2011 to 2016:
Terminal diagnosis of Liver CA reversed
Over 150 house calls, social services, home aides
Urgent same-day visits, Home X-rays, EKG, Echo, and wound care
Life-saving Radiology procedure in ICU in August, 2014
TWO admissions in 4.5 years (0.4 admits/patient year)

14. IAH Model- “APM 3A” Focus on most ill elders with persistent high-cost
2 or more permanent chronic illnesses
Hospital admission and post-acute skilled services in past 12 months
2 or more deficits in Activities of Daily Life (ADLs)
Shared Savings Payment Model
Operate within Medicare FFS only
6 Relevant Quality Metrics linked to savings
Compare actual costs of IAH patients with “expected costs”, fully-risk adjusted
Pay savings only after 5% reduction- 80% to provider if 6/6 on metrics
Retroactive payment of savings after 2 years
“Downside risk”-- Removed from participation if fail to meet goals
September 19, 2018

15. HBPC Services?
Home-based primary care (HBPC) -- Routine and urgent visits
ER: Coordinate transitions
Coordinate subspecialty and mental health care
Direct Hospital Care
24/7 on-call medical staff
Inpatient acute and subacute rehab
Hospice services
Mobile Phlebotomy
Home Radiology, EKG, Echo
Pharmacy/DME Delivery
Skilled Home Health - PT/ OT/RN
Transportation- Ambulance or Wheelchair van
Mobile Electronic Health Record (EHR) / Health Information Exchange
Social Services- Coordinate aides, daily supports, Caregiver support and training

16. Results: Patient / Family Experience
“The House Call Program saved my mom’s life and mine. It restored my faith in the health care system, and gave my mom and me encouragement and support every day. The good days, hours, and moments I have with my mother are the result of the excellence, tireless passion, and commitment of those who created, support, and sustain the House Call Program” – Sylvia Trujillo (Dtr.)
*Permission granted from patient and family

17. Results- VA, FFS, IAH Demo
VA (n = 9,425) (Oct JAGS)
Highest satisfaction in VA- 83% outstanding
VA + Medicare costs- 12% lower per capita
FFS Study- D.C. (722 cases, 2161 controls) (Oct JAGS)
High similar mortality (16.2 vs months)
Medicare cost reduction of 17% ($4,200/patient year)
IAH Medicare Demo present (n= 8,400) (CMS, June, 2015)
Mid-Atlantic Consortium- 20% cost reduction ($1,016/ pt/month)
9 of 17 programs paid savings (6-31% per capita)
Year 1- $25M saved, $12M to providers
September 19, 2018

18. Potential IAH Patients in the U.S.

19. Lessons / Keys to Success
Skilled Workforce
Recruit, train, and pay talent  Team culture
Grow teams to serve 1 Million over next 10 years
1 medical provider / 200 patients
Practice capacity to support HBPC teams
Service partners, Mobile IS, Daily Operations, Data Analytics
Health Systems/ CMS commit to value-based mode
Target ill and high-risk patients - Persistent high-cost
Link savings to relevant quality metrics-- For this population
Rigorous criteria for new IAH practices  Preserve quality
Use fully risk-adjusted methods for outcomes/cost analysis
September 19, 2018

20. MWHC House Call Team- Questions?
September 19, 2018

21. References
Retrieved from:
KE De Jonge et al. Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders. J Americ Geri Soc. 62: Oct Retrieved from:
B Leff, P Boling. Comprehensive Longitudinal Health Care in the Home for High-Cost Beneficiaries: A Critical Strategy for Population Health Management. J Americ Geri Soc. 62:
Retrieved from:
T Edes et al. Better Access, Quality, and Cost for Clinically Complex Veterans with Home-Based Primary Care. J Americ Geri Soc. 62: Oct. 2014
Retrieved from:
Retrieved from:
Video retrieved from: :

22. Panel speaker Steven L. Phillips, MD
CEO/President of Geriatric Specialty Care
Medical Director,
Sanford Center for Aging
University of Nevada, Reno
Tom Buckingham:
Thank you, Eric. Next, I am pleased to introduce our second speaker today, Dr. Steven Phillips. Dr. Phillips is the CEO and President of Geriatric Specialty Care in Northern Nevada, serves as the Medical Director for the HealthInsight Nevada Enhanced Care Coordination Program, and is the Medical Director of the Sanford Center for Aging at the University of Nevada School of Medicine. He will discuss more about the payment models his organization is using and how they fit into the APM framework. Steve?

23. Prepare for Success Value Based Payment
Steven L. Phillips, MD
Jeremy V Phillips

24. The FEMR Philosophy F – Familiarize E – Educate M – Manage
R – ReEvaluate

25. Familiarize Analyze and Evaluate
Discover Gaps in Care, Capture, and Efficiency
Organization
Site
Provider
Patient

26. Educate Gaps of Care Measures Gaps of Capture Gaps of Efficiency
Physician Quality Reporting System (PQRS)
Clinical Quality Measures (CQM)
Accountable Care Organization (ACO)
Gaps of Capture
Hierarchical Condition Categories (HCC)
Burden of Illness
Gaps of Efficiency
Perform at the top of one’s scope

27. Manage Team approach Proactive Tools Inform team members of necessity
Showing gaps
Identifying level of outreach
Dashboards/Reports
Inform team members of necessity

28. ReEvaluate Are the strategies working? Change APM level?
Do you need/want to drop down? If so why?
Do you want to “graduate” to a higher level?
Are you ready?
Follow the FEMR Philosophy

29. Geriatric Specialty Care (2D)
Familiarize
Analyzed data to better understand which Measures to report
Educate
Gaps of Care – Consisted of the 9 measures we report against
Tools – Created reminders to help providers and staff
Manage
Real time Dashboards/Reports
ReEvaluate
After three years of successful reporting we have decided to join an ACO

30. ACO/IAH (3A)
ACO 30,188 members
IAH 4,977 members
Other 20,771

31. ACO/IAH (3A)

32. Health Information Exchange
Helps with Closing
Gaps in Care
Gaps in Capture
Gaps in Efficiency
Disparate EMR’s
Real Time Alerts

33. Chronic Conditions Unique Patients seen 2016 – 908 CCM January 130
February 158
March 196

34. Panel speaker Alan Lazaroff, MD Medical Director,
Physician Health Partners
Board of Directors,
American Geriatrics Society
Tom Buckingham:
Thank you, Steve. Finally, I am pleased to introduce Dr. Alan Lazaroff. Dr. Lazaroff is the Medical Director of Physician Health Partners and also sits on the Board of Directors of the American Geriatrics Society.
Dr. Alan Lazaroff will speak about the opportunities and challenges he has experienced with implementing APMs with the frail elderly population. Alan?

35. Geriatric Medicine in Accountable Care
Alan Lazaroff, MD

36. Paying for Value: Delivering quality care while maintaining financial sustainability
Medicare Advantage Health Plan
IPA with an associated management company
Geriatrics group practice
Learn how payments move from the risk-adjusted global payments to the individual provider, in a process that includes FFS, quality metrics, participation level, and financial performance.
Hear a case study that demonstrates the value of geriatric care by participation in risk or accountable environments.
Global Risk of 30,000 MA beneficiaries

37. Getting Paid for Value Secure fair distribution of value created
Measure and demonstrate value
Create value

38. Optimal Care of Higher-Risk Seniors
Geriatric Medical Home
Performance Measurement
Risk-adjusted Performance Standards

39. Geriatric Medicine Associates (GMA)
Since 1991
12 Geriatricians, 3 Nurse Practitioners
Hospital and IPA Relationships
Geriatric Medical Home
Medicare, PACE, MA, PACO/MSSP
Results: Demonstrates high levels of both quality and financial performance and receives meaningful financial rewards

40. PHPprime IPA Principal owner of PHP Medicare Advantage PACO/MSSP
30,000 lives
PACO/MSSP
Commercial
125,000 lives
FP, IM and Geriatricians (about 200 PCP’s)

41. Physician Health Partners
Since 1996
IPA/Network Management
PHPprime
185,000 lives
Medicaid Regional Care Collaborative Organization (RCCO)
125,000 lives

42. Sharing Resources
PHP employs resources and deploys resources in the practices that they cannot afford on their own:
Care Managers
Practice Quality Coaches
In the case of the MA plan, the IPA at risk - not PHP
PHP is paid a percentage of premium for its services to the IPA
PHP provides financial and business services, but GMA and other physician practices are independently owned and operated

43. Generating Value and GMA’s role

44. After Capitation Pool all capitation dollars Fund reserves
Pay all claims
(hospital, medical, DME, SNF, HH, excludes part D)
Fund reserves
Reserve money for R&D
Designate bonus pool(s)
After Capitation

45. Divide available funds into two equal pools
Paying for Value
Divide available funds into two equal pools
Quality Pool
Efficiency Pool
Calculate share by membership TIN
Apply any quality deductions
Loss practices excluded
Prorated share of net saving

46. Pay for Value and Unpredictability
Clinical situation
(e.g., bad flu year)
Payment rules
Market behavior

47. Parting Advice This is a payment structure and model that can work:
Aggregate the patients of primary care practices with all sorts of business models into "ACO" products
Share resources with and across practices that they cannot afford on their own
Measure the value each practice creates and distribute some of it back
Practices can remain independently owned and operated, yet succeed in value-based care.
If you're not at the table, you might find yourself on the menu

48. Panel q&A Tom Buckingham:
Thank you. That was excellent. Now it’s our audience’s chance to ask questions and we look forward to our dialogue with you. At this time I’m going to address the questions you submit through the Question Window of your webinar dashboard.
The first question is…..[questions and discussion here]…
Thanks everyone for your participation, that’s all we have time for. We will post the presentation on the LAN website in a few days. Thanks again to our speakers and to those on the call for your thoughtful questions.

49. pring, 2016 Spring LAN Summit April 25-26, 2016 Sheraton Hotel
8661 Leesburg Pike Tysons, VA 22182
Join hundreds of payment reform innovators
Over 40 Breakout and Plenary sessions
Includes sessions on 7 WG Products
Preliminary data from Payer Collaborative measurement effort
Session on Payment Reform Evaluation Hub
Listening session on Primary Care
Tom Buckingham:
Before we close this session, I want to draw your attention to some upcoming events of interest. We hope you will plan to join our next in-person meeting. The spring LAN Summit will be April 25 & 26 in Virginia at Tyson’s Corner, just outside DC. At the October 2015 Summit, 450 people attended the one-day event to learn about APM models that are succeeding and to meet other innovators. The spring Summit will be an expanded meeting, with 2 days of learning and connecting, and room for 800 people to attend. Please visit lansummit.org to register, where you can find the full agenda and speakers posted - and sign up if you are available.
Also note we will release two new draft white papers that will be open for comment beginning April 22. The papers include the CEP Work Group’s draft recommendations on maternity, and the PBP Work Group’s draft recommendations on performance measurement. There will be sessions on these and other Work Group recommendations at the Summit, and if you are not attending the Summit, you may access archives of these presentations on the LAN website after the Summit. We look forward to your comments on these drafts, which you can submit on the LAN website or on Handshake, or via to

50. ENGAGE, LEARN, AND ACT
The LAN will only succeed with robust stakeholder engagement across the field
Tom Buckingham:
Outside of the conference, the LAN has an array of tools for your learning, engagement and sharing, and we look forward to your continued contributions to this dialogue.
We also encourage you to enlist your colleagues – please share the LAN registration page with them. We appreciate your support and involvement.
That’s all we have time for today, so thank you for being with us. We’re pleased so many of you could join us today, and we look forward to your participation throughout the year.
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