1. NPG Health Collaborative: Exploring Population Health and Value-Based Healthcare In A Rural Delivery System
September 19, 2018

2. Presentation Objectives
Describe background and structure of NPG Health Collaborative
Discuss identified barriers, successes, and lessons learned
Describe the vision and potential next steps for rural hospitals and clinics to prepare to operate in a value-based environment

3. Prairie Health Ventures
Mission
We exist to help hospitals succeed through collaboration
Vision
To sustain the independence of hospitals in our region through an alliance which improves cost and business performance
Alliance of 53 hospitals
Owned/directed by hospitals since 1975
Distributed $25M to owners since 2006

4. Nebraska Purchasing Group, LLC (NPG)
Organizational Structure
NPG, LLC
37 Hospital Owners
GPO
39 Hospitals
Premier Inc.
PHV, LLC
Virtual Services
Pharmacy Services
Physician & Admin.
CHI Health
*NPG owns majority of PHV assets and appoints majority of PHV board.

5. PHV Hospital Owners

6. NPG Hospital Members * Participating Facilities
Annie Jeffrey Memorial Health Ctr. Osceola, NE
Boone County Health Center Albion, NE
Brodstone Memorial Hospital Superior, NE
Brown County Hospital Ainsworth, NE
Burgess Health Center Onawa, IA
Butler County Health Care Center David City, NE
Callaway District Hospital Callaway, NE
Chadron Community Hospital Chadron, NE
Chase County Community Hospital Imperial, NE
Cherry County Hospital Valentine,NE
Community Memorial Healthcare Marysville, KS
Community Memorial Healthcare Syracuse, NE
Cozad Community Hospital Cozad, NE
Fillmore County Hospital Geneva, NE
Fremont Area Medical Center Fremont, NE
Genoa Community Hospital Genoa, NE
Gothenburg Memorial Hospital Gothenburg, NE
Henderson Health Care Services Henderson, NE
Howard County Medical Center St. Paul, NE
Jefferson Community Health Center Fairbury, NE
Johnson County Hospital Tecumseh, NE
Kimball Health Services Kimball, NE
*Lincoln Surgical Hospital Lincoln, NE
Merrick Medical Center Central City, NE Memorial Community Health, Inc. Aurora, NE
MCH and Health System Blair, NE
Memorial Health Care Systems Seward, NE
*Nebraska Spine Hospital Omaha, NE
Nemaha County Hospital Auburn, NE
Pawnee County Memorial Hospital Pawnee City, NE
Perkins County Health Services Grant, NE
Rock County Hospital Bassett, NE
Saunders Medical Center Wahoo, NE
Shenandoah Memorial Hospital Shenandoah, IA
St. Anthony Regional Hospital Carroll, IA
St. Francis Memorial Hospital West Point, NE
Thayer County Health Services Hebron, NE
Warren Memorial Hospital Friend, NE
Webster Co. Community Hospital Red Cloud, NE
* Participating Facilities

7. Healthcare Environment
FROM TO
Single community markets
Fragmented, duplicative services and uncoordinated
Pluralistic payer strategies
Clarity on provider and insurer alignments
Provider-centric
Inconsistent measurement and opaque
Use of data to retrospectively report
Treating patients for disease
Patient care anchored in bricks & mortar delivery system
Star Physicians
Large regional markets
Highly reliable and more standardized care across the continuum
Narrow networks with preferred payers
Greater market change and confusion
Patient-centric & engaged
Measured and transparent
Prospective use of data and analytics
Routine use of personalized medicine
Technology-enabled virtualization of healthcare
Star Teams

8. Accountable Care Organizations (ACO’s)
ACO’s are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients
Source:

9. NPG Health Collaborative
Background
NPG Health Collaborative, LLC (NPG Health) was formed as a separate legal entity to apply for the CMS Shared Savings Program.  NPG Health is a collaboration of hospitals, rural health clinics and physicians located in the Midwest. 
The goal of NPG Health is to improve the health and wellness of the members of our communities.  We intend to improve the quality of care and patient satisfaction, increase preventive health and wellness alternatives, and decrease the costs of healthcare for our Medicare patients.
With more than 150 providers across 14 critical hospitals and about 16,000 Medicare beneficiaries, NPG Health will assist CAH’s and their associated RHC’s in creating comprehensive population health management programs to achieve superior patient care, patient engagement and high quality outcomes for their rural community Medicare beneficiaries.

10. 2016 – NPG Health Collaborative, LLC formed with intent to apply to become a CMS Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO)
2017: Year One CMS Track 1 MSSP ACO
9 Critical Access Hospitals and associated Rural Health Clinics
Approximately 9,000 attributed Medicare lives
2018: Year Two CMS Track 1 MSSP ACO
14 Critical Access Hospitals and associated Rural Health Clinics
Approximately 150 Providers
Approximately 16,000 attributed Medicare lives

11. NPG Health Collaborative – 2018 Participants
Memorial Healthcare Systems - Seward, NE
Pawnee County Memorial Hospital - Pawnee City, NE
Jefferson Community Health Center - Fairbury, NE
Brodstone Memorial Hospital - Superior, NE
Boone County Health Center - Albion, NE
St. Francis Memorial Hospital - West Point, NE
Kearney County Health Services - Minden, NE
Community Memorial Healthcare, Inc. - Marysville, KS
Howard County Medical Center - St. Paul, NE
Thayer County Health Services – Hebron, NE
CHI Health St. Mary’s – Nebraska City, NE
CHI Memorial Health Schuyler – Schuyler, NE
CHI Health Missouri Valley – Missouri Valley, IA
CHI Health Mercy Hospital Corning – Corning, IA

13. Dependencies and Resources1
Management
Participants
Providers & Suppliers
MSSP
16,000 Lives
Data & Technology

14. NPG Health Collaborative
ACO Governing Body

15. Why Start an ACO Population Health Learning Lab Data
Ability to explore new delivery models and continue current reimbursement model (Track 1 Model)
Data
Claims data on attributed beneficiary's
Additional Revenue Opportunities
Chronic Care Management
Transitional Care Management
Wellness Visits
Potential of Shared Savings
Physician Quality Reporting
GPRO – MIPS reporting
Automatic Credit Earned in MIPS Scoring
Ability for Independent Rural Hospitals to work together to build an Integrated Delivery Network
Knowledge Transfer and Group Support
Potential to develop Commercial ACO Models

16. ACO Learning Curve
………….

17. Historical Benchmark & Aggregate Spend
Historical benchmark is a 3 year average (in our case 2014 – 2016) and is risk adjusted.
Aggregate ACO expenditure updates are provided on a quarterly basis for comparison to the benchmark.
If an ACO’s spending in the program year is less than the benchmark and the ACO meets MSSP quality thresholds, it earns a shared savings payment.
Through claims and our technology vendor we are able to analyze the overall ACO spend as well as individual Participant and NPI (provider) level spend on an ongoing basis.

18. Our Overall Approach to Success in Value-Based Healthcare
We believe that the degree of success we will achieve within the ACO is in large part determined by the degree to which we understand and actively manage these three factors through a thoughtful, balanced and physician-led approach.
Quality and Satisfaction – Improve
Cost – Lower
Risk – Manage

19. Structure for success Comprehensive care Patient-centered care
Includes not only the traditional care of the acutely or chronically ill patient, but also and especially the prevention and early detection of disease.
Patient-centered care
Active involvement of patients and their families in the decision-making about individual options for treatment and care
Coordinated care
Organizing patient care (including the patient and family) to facilitate the appropriate delivery of health care services
Accessibility of Services
The ability to get care and services when they are needed
Quality and Safety
Degree in which health care services for individuals and populations increase the likelihood of desired health outcomes.

20. Shared Decision Making
Healthier Patients Engaged Providers Lower Costs Better Care
Care Coordinators
Care Plans
Quality Improvement
Medical Community
Wellness
Provider Champion
Clinical Data
Transformation
Clinical Integration
Clinical Efficiencies
TCM
Shared Decision Making
Quality Reporting
Behavior Change
AWV
Evidence-Based Medicine
Patient Engagement
Targeting
Physician Engagement
Claims Data
Waivers
Workflows
ACP
Team-Based Care
CCM
Risk Stratification

21. Comprehensive Coordinated Care
Eliminate patient care gaps & provide what the patient needs, when they need it, for optimal outcomes.
Transitional Care Management
Care Coordination
Annual Wellness Visits
Chronic Care Management
In many cases, implementing a comprehensive model
requires practice transformation

22. Creating and Refining a Care Coordination Model
Group participation supports buy-in and accountability
WE want to implement a new program
WE need to design a process
How are WE going to be successful?

23. Transitional Care Management (TCM) Can Impact
Total Cost of Care
Quality Measures
Post-Discharge Outcomes
Patient success at home
Patient Satisfaction with Care (Hospital to Home)
Identify Problems - Provide Interventions
Reduce Avoidable Errors & Negative Patient Outcomes
Compliance with Discharge Orders
Reduce avoidable readmissions
Revenue opportunity - TCM
Improve Survey Scores
Reduce Readmission and Unnecessary ER Use Rates
Improve Market Share
Program Specific Requirements to bill:
Patient has inpatient/observation/partial hosp. stay
Pt Discharged & returns to place of residence (home, Assist. Living)
Billing provider responsible for pt. care for entire 30 day period
Post D/C: Contact with pt. within 2 business day
Face-to-face visit with PCP by day 7/14 (r/t complexity)
Medication reconciliation anytime on or before face-to-face
30 day service period (D/C day + next 29 days)

24. Chronic Care Management
Program Specific Requirements to bill:
Initiating Visit
Patient consent for enrollment
Two or more chronic conditions
24/7 access to care
Patient Centered/Comprehensive Care Plan
Certified EMR to record certain patient info
Manage Care Transitions - share coordination of care document
Successive routine appointments
Enhanced communication opportunity
20 min. non-face-to-face activities per month

25. Chronic Care Management Can Impact
SATISFACTION
COST OF CARE
QUALITY MEASURES
Happier with Care
Improved Quality of Life – Self Care Ability
Provider-Patient Relations
Staff Satisfaction
Reduce PMPM rates
Unnecessary tests/tx
Control downstream spend
Revenue Opportunity
Readmission Rates
HCAHPS/CAHPS Scores
ER Utilization Rates
Coordination to impact other Quality measure rates

26. ANNUAL WELLNESS VISIT (AWV)
CARE COORDINATION:
AWV provide coordination of all prevention services
AWV considered part of care management
Prevention reduces exacerbations
Benefits of AWV:
Improves overall risk scores through CMS
Risk scores
Capture Quality measures
MEDICARE ANNUAL WELLNESS VISIT:
Initial Preventative Physical Examination (IPPE):
Billing Code = G0402
“Welcome to Medicare” – once per lifetime benefit
Performed within first 12 mos. when benefits begin
Not a physical – do not actively treat symptoms
Set up preventative tests/screenings for up-coming year
Covers once-in-a-lifetime screening electrocardiogram
Annual Wellness Visit (AWV) – Initial Visit:
Billing Code = G0438
Perform 12 mos. & 1 day after benefits began or after date IPPE was performed (at least)
Personalized Prevention Plan of Services (PPPS)
Continues same work from IPPE
Annual Wellness Visit (AWV) – Subsequent Visit(s):
Billing code = G0439
Perform 12 mos. & 1 day after last AWV date (at least)

27. Care Coordination POPULATION HEALTH - OPTIMAL PATIENT OUTCOMES
PROVIDE EDUCATION and VERIFY UNDERSTANDING
ELIMINATE PATIENT CARE GAPS
ENSURE COMMUNICATION & COLLABORATION EXISTS BETWEEN ALL HEALTHCARE SETTINGS
IDENTIFY/SET UP SERVICES & RESOURCES AVAILABLE TO MEET PATIENT NEEDS
PRACTICE PREVENTATIVE INSTEAD OF REACTIVE CARE
FOLLOW PATIENT THROUGHOUT ALL CARE TRANSITIONS

28. Hierarchal Condition Categories (HCC)
Risk adjustment is the process of modifying payments and benchmarks to reflect the degree of illness. This allows CMS to estimate future spending, and allows providers to understand the health characteristics of their managed population
Accurate coding is essential in an ACO to characterize risk, enhance shared savings, and provide patient-centered care. 
The CMS-HCC risk-adjustment model was designed to most accurately predict spending at the group level, not the individual beneficiary level.
Understanding HCCs – which help to portray patients' conditions and prospective costs – and understanding how CMS uses them to calculate expenditure benchmarks or PMPMs - is extremely important to an ACO's ability to earn shared savings and avoid shared loss.

29. ACO Quality

30. Quality - GPRO Methodology & Ranking
Group Provider Reporting Option (GPRO)
CMS Chooses a random sample of each facilities attributed lives, from this sample:
Patients are consecutively numerically ranked per measure from 1 to 616 for the maximum sample, and 1 to 248 for the minimum 3 2 4 1 5
Source:
Advancing Healthcare Through Collaboration

31. Quality – GPRO Reporting
Knowledge gaps surrounding the measures and measure specifications
Are there processes in place within each clinic to ensure these care measures (or gaps) are addressed?
Are these measures able to be documented and captured within a discrete field of each EMR in order to run reports for uploading to our ACO technology vendor?
Satisfaction a key component. If not routinely surveying CAHPS, how is patient satisfaction determined outside of the ACO CAHPS survey

32. What ACO resources needed to be impactful?
Education of practice leaders and teams is key
Learning Collaborative Webinars
Vendor technology training, including care coordination portal
Board and Leadership support
Informed decision making on resource spend to drive understanding of, and case for, practice-level change
Care Coordination organization and support
Some practices have – others implementing
Practice Transformation
Risk adjustment education and support
GRPO Quality reporting organization, education and support
Data Analysis

33. Challenges and Barriers
Multiple EHR’s
Different levels of engagement
Regulations
Resources
Changing governmental rules

34. Consider a Next Step
Determine: What You Have in place vs. Where you want to be

35. Regardless of which path you take, engage in Population Health and Value-Based Healthcare

36. An important underlying theme that we instill in our ACO practices:
Change is an ongoing
process, not an event.
Needs talking points listing/describing key lessons.

37. Questions? .
Thank you!

38. Thank You! Rodney Triplett Anne Hansen MSN, RN-BC, CPHQ CEO
Director – Quality and Population Health
Prairie Health Ventures
Prairie Health Ventures