Welcome to Population Health, structural quote Accountable end quote Care Approaches for Target Population. This unit is divided into three lectures, lecture a covers the accountable care movement and discusses clinically integrated networks, models of care and payment reform. Lecture b covers population based care management and discusses the challenges of chronic care management. The roll of social and community factors and how Health IT can be effective for improving population based care management. And lecture c covers the business of population health, the value proposition, sustainability, and key stakeholders of the business of Population Health. This is lecture a, the accountable care movement. The objectives for this session are to, one, describe the integrated and accountable care movements. Two, define clinically integrated networks and how they can be used as a strategy for accountable care. Three, describe new models of care for population health. Four, explain the role of payment reform in the context of population health and accountable care. So what is accountable care? If you Google it, you'll find many definitions. Accountable care is a healthcare reform movement in which improved health outcomes and reduced cost drive healthcare delivery and payment. In this movement, primary purchasers of healthcare. For example, the centers for Medicaid and Medicare, private insurance companies, and employers prefer to pay for value of service, not volume of service. Organizations and agencies who seek accountable care adopt financial accountability for a population's healthcare needs. They manage that population's care across the healthcare continuum. These organizations and agencies are sometimes referred to as accountable care organizations or ACOs. ACOs coordinate care among providers and access health information technology to improve healthcare cost and quality. In addition to expanding and reforming health insurance coverage, the Affordable Care Act of 2010, ACA, also contains numerous provisions. That are intended to resolve underlying problems in how healthcare is delivered and paid for in the US. The ACA focuses on three broad areas, number one, testing new delivery models and spreading successful ones. Number two, encouraging the shift away from volume payment to value of care payment. And number three, developing resources for system-wide improvement. The Affordable Care Act has spurred activity in public and private sectors. And is contributing to the momentum in various states and localities across the US to improve healthcare value. In terms of new models for delivering healthcare, transformation in healthcare is essentially moving away from fee-for-service payment. Though that takes time, resources and experimentation, we know that a single approach will not work for all providers in all states or in all markets. And so the Affordable Care Act is encouraging the spread of several different models. Two approaches hold promise for improving the effectiveness and efficiency of care delivery. And those two approaches are Accountable Care Organizations or ACOs, and the Patient-Centered Medical Home or PCMH. ACOs began in 2012, when the Affordable Care Act established a new category of provider within the Medicare program called the Accountable Care Organization. The ACO is essentially an entity that's formed by healthcare providers. They agree collectively to take responsibility for the quality and total cost of care for a population of patients. The Affordable Care Act provides incentives for providers of health care organizations to be accountable for the total care of patients. Including population health outcomes, patient experience with care and the cost of total care of a patient or a person. This is sometimes referred to as the triple aim or the three-part aim. Improving outcomes in population health, patient experience of care, and cost of care. In particular, the Medicare Shared Savings Program refer to sometimes as MSSP. Requires participating ACOs to meet quality benchmarks and keep spending below a particular budget or target. If they do that, the MSSP ACOs receive half of the savings that would result. With the rest going to the Centers for Medicare and Medicaid Services or CMS. In 2015, there were more than 400 MSSP Shared Savings programs, serving 7.2 million beneficiaries across the US or 14% of the Medicare population. Now how are the Medicare Shared Savings programs performing? Results from the program's first year of operation which was 2013 were mixed. There were 220 Shared Savings ACOs, only 52 were able to meet the quality benchmarks and keep spending below the target. 60 ACOs kept spending under the target, but did not fulfill their requirements to measure the quality of care delivered. Or did not reduce spending enough to meet the criteria to share in the savings. Remember that there are two criteria, achieve quality benchmarks and spending or budget benchmarks. So 60 ACOs were not able to meet either one or the other of those criteria. Of the shared savings ACOs,102 did not achieve savings. Six achieved savings, but did not report quality measures. In other words, the shared savings bonus was only delivered to 24% of the 220 shared savings ACOs. Only 52 of the 220 were able to meet both the reduced spending and the quality metrics. The rise of new accountable payment models shifts financial risk for cost and quality to providers. And they place a premium on primary care providers as a means to affect more efficient and coordinated consistent care. To survive in this emerging environment of ACOs, hospitals and physicians need to assume a level of functional integration which is far deeper and broader than what most have in place today. Physician alignment then is now taking on an even greater sense of urgency in today's market of accountable care organizations. Hospitals and health systems must make critical decisions regarding relationships with physicians and primary care providers moving forward. And in this new accountable payment paradigm, accountable care where providers jointly take risk for the total cost of care for a population of patients. Means that the health systems must assemble an accountable physician enterprise. And is represented in this graphic in terms of degree of population health management. Step one is assembling that physician enterprise. That can be a group of primary care physicians and a hospital, multi-specialty physicians, any number of different kinds of models. But first, in an ACL, we must assemble the physician enterprise. Then we must organize for performance within that ACL. And finally, we accept total cost of care accountability for a population of patients. So, as the degree of population health management rises, so does the financial risk to physicians. This all happens over a period of time. The journey to accountable care for primary care providers in the ACO, their participation is voluntary. The Accountable Care Organization is required to have a sufficient number of primary care providers to care for Medicare beneficiaries. And they are held accountable for the quality and the cost of care to those Medicare patients of those primary care providers. The ACO could consist of primary care physicians, multi-specialty physician group practices, or hospitals that employ physicians or partner with physician groups. For example, Johns Hopkins has a Medicare shared savings program called the Johns Hopkins Medicine Alliance for our Patients, or JMAP. Many of the the primary care providers are employees of the Johns Hopkins Health System, but there are several who are not. And who are independent physician groups not affiliated with Johns Hopkins. There are three potential organizational models for ACOs one is that there are advanced primary care practice networks with infrastructure support and associated specialty referral networks. Another, is that there are multispecialty physician group practices. And yet another model, is that healthcare organizations with functionally integrated ambulatory, inpatient, and post-acute care services form an accountable care organization. So, our first model, accountable care organizations, can be made up of primary care physicians. Can be made up of speciality practices, or can be made up of hospitals in a network of physicians who form an enterprise to improve quality and decrease cost of care in a population. A second model is the medical home medical, and we can achieve transformation in healthcare through primary care or patient centered medical homes. In the United States, we have undervalued and underinvested in primary care for decades. And that neglect of primary care has largely been due to the prevailing fee-for-service reimbursement approach. in which providers have an inherent financial incentives to favor high-priced procedures over care management and other cost-saving services. The result is that the care US patients receive is often poorly coordinated and expensive. However, in patient-centered medical homes, we now have considerable evidence that comprehensive coordinated primary care can improve outcomes, and reduce patient costs. In the patient-centered medical home, we developed a model of care that emphasized care coordination, care teams, patient engagement and population health management. Different models of patient centered medical homes and multidisciplinary teams that support the medical home are explored in other units of this component. But the patient-centered medical home seeks to expand patients' access to primary care, promote prevention, and ensure that care is well coordinated across specialist hospitals, home care, and different settings of care. Our next objective is to explore clinical integration. What is clinical integration? Clinical integration is a continuous process of alignment across the care continuum that supports the Triple Aim of care, which we have discussed in previous slides. The Triple Aim seeks to improve the quality of care to reduce or control the cost of care, and to improve access to care and the overall patient experience. We'll now explore clinically integrated networks, sometimes referred to as CINs or CINs. What is clinical integration and how is it defined. The American Medical Association, the AMA describes clinical integration as the means to facilitate the coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused, end quote. What is a clinically integrated network then? A clinically integrated network is a network of physicians who are working together systematically with or without organization or professionals to improve their ability to deliver high quality, safe, valued care to their patient and communities. The clinically integrated networks are generally sponsored by hospitals. But lead by physicians who assemble the resources required to manage care for a defined population of patients. Clinically integrated networks can have many benefits to payers and to patients because they improve the ability to deliver improved quality outcomes. So there could be collaborative education for physicians and staff across the clinically integrated network. There are often specific disease management clinics that support practitioners, online resources, standardized practices, and protocols across multiple physician groups, and across multiple settings of care. And often there are disease registries that track outcomes and outreach to patients, when it is needed and necessary. In order to achieve clinical integration there are three areas that must be addressed. There need to be incentives, there needs to be knowledge and there needs to be behavior change in order to achieve clinical integration. The first key area is incentives. And in clinically integrated networks, we need to develop a common, measurable picture of success that delineates clear and tangible Ideally financial benefits to all the stakeholders that are working together in a clinical care continuum. That includes hospitals and their employed and affiliated physicians, ambulatory surgery centers, or ASC's, independent medical groups, and also labs, pharmacies, radiology, patients, and payers. In other words, there have to be clear tangible benefits for all providers and physicians in order to want to develop a clinically integrated network. The second key area is in the area of knowledge. And that is that the right information should be surfaced across multiple systems to the right person at the right time, increasing transparency and clarity, minimizing financial results, and offering optimal control over business and clinical processes. And finally, behavior using aligned incentives and using knowledge to support efficiency and quality, such as the creation of standardized protocols and prevention and detective controls. We need to ensure the caregivers, executives, payers, patients and all stakeholders can take the right actions when needed. And those are three key areas that must be met, in order to achieve clinical integration. This graphic explains that, align incentives, align knowledge and align behavior are all necessary to achieve clinical integration. At the base of the diagram, the foundation is the incentives which have to be aligned and coordinated. Knowledge must be shared across the clinically integrated network, with insights from behaviors and finally actions will produce better results in the triple aim of reduce cost improving quality outcomes and improving access and patient experience. But clinical integration is not easy to achieve and so this factors must be in place. Now clinical integration necessitates that there be a substantial quality improvement infrastructure. Because there are several aspects of programs that were touched on briefly in the previous slide that lead to clinical integration. For example, the use of evidence-based medicine. In Clinically Integrated Networks, there has to be a categorical approach to selecting which conditions and regular addition of new guidelines. For example, across multiple physicians and multiple hospitals how will we care for patients with joint replacements in terms of position infrastructure investment, there needs to be a significant expenditure. Simple collaboration is different than clinical integration in that there is minimal resource investment in simple collaboration. But in clinically integrated networks, and clinical integration, there's significant expenditure to build that position infrastructure. There has to be a human resource commitment, significant staff in addition to physicians, such as case managers, staff who handle training, staff who handle protocol development, technology maintenance and contracting. And if it's just simple collaboration where clinical integration is not necessarily a stated focus there's really minimal human resource expenditure. In terms of IT utilization in a simple collaborative network, there's little emphasis on IT tools. But in a clinically integrated network, there has to be widespread utilization of disease registries, IT for data tracking, and IT for protocol dissemination, monitoring of performance, and communication for continuous quality improvement. Generally, in a clinic integrated network IT is usually mandated as condition for participation. With electronic medical records and the ability to create disease registries as the typical requirements. Data collection and monitoring in clinically integrated networks are much more sophisticated. Often, there is a data warehouse where data are shared among multiple institutions. And it's often a very key piece of infrastructure, even to create a clinically integrated network. There are often are processes to collect patient data from claims, billing data, and other physician reports. In a simple collaborative network, where physicians are loosely collaborating often there is just data gathered from a physician's office. There are not the significant investments in a data warehouse or other pieces of infrastructure In terms of physician commitment, in a simple collaboration, that commitment may be variable. There may be no penalties for under utilizing tools or IT. There may not be penalties for under performing. There may not be incentives for improving performance. But the physician commitment in a clinically integrated network says that there are stated expectations for guideline. But the physician commitment in a clinically integrated network says that there are stated expectations for guideline adherence and program management. There are clear action steps for addressing underperformance. So often there are continuous quality improvement run charts and performance metrics that are shared back with physicians. And they're clear actions if they are not meeting expected targets. In Clinically Integrated Networks, positions are generally given quality incentives and are asked to improve quality beyond what the positions may be able to do on their own. So when there are multiple physician groups forming a multiple enterprise with hospitals and ambulatory surgery centers for example, there is absolutely an expectation that physicians will perform and compare data with one another so that they can increase quality and decrease costs. In clinically integrated networks, there are substantial quality improvement infrastructure as compared to simply a collaborative or an affiliated group of physicians. Now we move to the topic of payment reform and what CMS in particular is doing to address care management payments. In accountable care organizations, often times with positions hiring additional case managers, enabling IT, having some expenditure, there should be a payment for primary care practices so that care management activities and care management costs can be incentivized. A care management payment is generally made to the primary care practice for each patient who is engaged in better supporting education, self-management support, and additional access to physicians by telephone or online. Often, there are specific targets for reducing utilization of healthcare services outside of the practice, such as for non-urgent emergency room visits and for ambulatory care, sensitive hospitalizations, which hospitalizations that may have been avoided had the patient received the right care at the right time. The ambulatory care is what is necessary to prevent hospitalization, high tech and diagnostic imaging. There are specific targets set for appropriate use and utilization of high tech diagnostic imaging, as well as sometimes pharmaceuticals and specialty drugs. Bonuses and penalties are sometimes paid to the practice, based on its performance against this targets payment Reform. While physicians are trying to achieve better population health and better outcomes, they also may be incentivised by the centers for Medicare and Medicaid services or by private pairs. Like private insurance companies to achieve better outcomes in a population by performing care management services. We know that there has been an unbridled cost growth in the US, and that it's taking its toll. Are we on the path to insolvency? This graph shows that while our gross domestic product is expected to grow 4.8% from the year 2010 to 2021, the national health expenditure projections panel projects health care expenditures to increase at an annual growth rate of 5.6%. With Medicare increasing by 5.9% and Medicaid increasing by 7.5%. Without any kind of payment reform and without any substantial savings, we may be on the path to insolvency. CMS provided a timeline for the Accountable Payment Rollout that was part of the Affordable Care Act. Now we're going essentially from pilots to policy. Let's begin in 2010 with a passage of the Affordable Care Act. There were some Medicaid capitation pilots that were evaluated and now are in Nation Rollout The Medicare Shared Savings Program, Early Adopters,started in 2012 with shared savings programs projected to expand in 2016 and beyond. Phase one, quality of hospital value-based purchasing, began in 2012 expanding to phase two, which is payment for efficiency in 2014. Readmission penalties for poor performers also began in 2012 and are continuing. The pediatric ACO with shared savings pilot is estimated to enter a valuation in 2016 followed by a national rollout. Integrated care demonstration, medicated episodic bundling is also in pilots. With demonstrations to be evaluated, and then rolled out as national policy. National episodic bundling pilot is projected to be evaluated and rolled out in 2018. And payment adjustment for hospital acquired conditions begin in 2015. The darker bars had been officially announced by CMS. The lighter bars indicate that the advisory board company estimates that this evaluations and national rollouts may become policy after the pilots are completed and evaluated. So these are estimations from the advisory board company only. There are several different payment models, value based purchasing, bundle payments, and accountable care organizations. Value based purchasing is essentially pay for performance programs that reward or punish hospitals based on performance against predefined process and outcome metrics measures. And the purpose of them is to create a link between reimbursement, quality, and patient's satisfaction, moving away from being reimbursed for volume of services or fee for services to value-based reimbursement or value-based purchasing. Bundled payments are where purchaser, whether the purchaser is the centers for Medicaid and Medicare services, or if the purchaser is a private insurance company will disperse a single payment to cover a combination of hospital, physician, post acute and other services that are provided across an episode of care. So joint replacement is a good example of a fee that would be disbursed for caring for a patient who is receiving a knee replacement. The purpose is to incentivize multiple types of providers to coordinate care and reduce expenses across associated care episodes. Payment reform helps support population health and care management goals. This graphic from the Advisory Board Company demonstrates how having effective care providers, efficient care Providers and population health managers. Moving from efficient providers of acute care to population health managers in our physician and health care system really supports population health. In terms of the cost of care, the quality of care, and the volume of care, the cost care bundle payments definitely support population health in that the bundle payments are seeking to improve care. Pay for performance, value base purchasing, readmission penalties, and quality based commercial contracts incentivize providers to provide higher quality services. Providers do not get paid unless services reached a level of value, quality and cost. And finally, in shared savings, removing more to population health management with Medicare shared savings programs, ACO programs and commercial ACOs. In shared savings, the incentives are definitely with the physicians to become population health managers as opposed to just being efficient providers of acute care. This concludes Lecture A of Structural, quote, Accountable, end quote, Care Approaches for Target Population. In summary, you have learned that accountable care is a health care reform movement in which improved health outcomes and reduced cost drive health care delivery and payment. Clinical integration is a continuous process of alignment across the care continuum that supports the Triple Aim of health care: improving quality of care, reducing or controlling the cost of care and improving access to care and the overall patience experience. Continuing our summary, you have also learned that a clinically integrated network is a network of physicians who are working together systematically, with or without organization or professionals, to improve their ability to deliver high-quality, safe, valued care to their patients and communities. There are three key areas to achieve clinical integration: incentives, knowledge, and behavior. And finally, you learned that there are several different payment models. Value based purchasing, bundled payments, and accountable care organizations.
