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Accountable Care Organizations: Health Care Delivery Redesign Thomas J. Biuso MD, MBA UnitedHealthcare Medical Director Clinical Assistant Professor of Medicine, University of Arizona
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Presentation Goals Understand the reasons why we need new models of care and the implications of the ACA Answer the question: what is population health and what drives its costs? Define accountable care organization and its primary role Appreciate the difficulties for a network to integrate and coordinate care Understand the importance of community involvement
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Why We Do What We Do – Achieving the “The Triple Aim”! Improve population health Improve individual experience Control inflation of per capita costs Triple Aim The Triple Aim: Care, Health, And Cost. Health Affairs, 27, no.3 (2008): 759-769. Donald M. Berwick, Thomas W. Nolan and John Whittington
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Population Health Williams Amy et al. Delivering accountable care to patients with complicated chornic illness. Am J Kidney Dis 2012;59(5):601-603
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Map or revascularization rates, by hospital referral region, from 2003 to 2006. Goodney P et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes 2012;5:94-102
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What Accounts for Variation Patient-level differences Physician-level differences (volume, specialty, and use of endovascular procedures) Hospital-level differences (size, teaching status, financial status) Supply sensitive vs preference sensitive (shared decision making)
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Alignment Drives Value High Quality Low Cost VALUE Care Management Programs Transparency and Premium Designation Program High Performing Preferred Networks Value-based Benefits Value-based Contracting
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Delivery System Transformation Value-based Continuum Level of Financial Risk Degree of Provider Integration Fee-for-service Performance-based Contracts (PBC) Bundled/Episode Payments Shared Savings Shared Risk Capitation Capitation + PBC. Performance-based Programs Centers of Excellence Accountable Care Programs
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What is an ACO? Primary care led, coordinated care organization that accepts a global budget for managing a defined population Facilitate the transformation of the current fee- for-service payment system into one that rewards greater quality and efficiency in care delivery and improved outcomes
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Types Large primary care clinic Multispecialty group Integrated delivery system Physician Hospital Organization Independent Physician Association
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Centers for Medicare and Medicaid Services Pioneer Shared Savings Program Advance Payment Model
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Facts 114 provider groups in Medicare Shared Savings Program Shared Savings ACOs include 2 dozen smaller groups in CMS Advance Payment ACO Model Almost all Shared Savings ACOs chose the 3 year contract model with only 7 that opted for two-sided risk model 32 large provider groups launched Medicare Pioneer ACO 6 large integrated delivery systems in Physician Group Practice Transition Demonstration
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Transformation Health information technology Care management Performance measurement Physician engagement Patient engagement Community involvement
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Prioritizing Care Plan Management & Care Coordination 14 Multiple Chronic Conditions & Complex Patients
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Rules for the Shared Savings Program Performance measures specified by CMS fall into four domains: - patient caregiver experience - care coordination and patient safety - preventive health - at risk population
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Quality 33 quality measures in 4 domains that include patient experience, care coordination/patient safety, preventive care, and at-risk population first 18 months is for reporting must exceed 30 th percentile in 70% of the measures in all domains
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Strategy Consider financial opportunity vs. strategic move Strategy means 3 year commitment with several questions that need to be answered: Will an ACO harm financial performance? Can ACO increase market share? Will an ACO allow better competition for commerical payer book of business?
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Costs Network development and management Care coordination, quality improvement, and utilization management Clinical information systems Data analytics
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Questions
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