Value-Based Care

1. Value-Based Care Volume to Value Lecture c – Advanced Alternative Payment Models This material (Comp 23 Unit 6) was developed by Normandale Community College, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0003. This work is licensed under the Creative Commons Attribution-Noncommercial-Share Alike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Volume to Value Learning Objectives • Describe alternative payment models. • Outline state level initiatives for payment reform, including private payer models.

3. Terms and Definitions • Episode of care • Bundled payments • Shared-risk • Population

4. General Features of ACOs • Contract based on an assigned population • Payments based on the performance on negotiated metrics • Shared-risk

5. Overview of Payment Models 6.6 Table: Payment Taxonomy Framework Source: CMS, January 2016.

6. Category 3 and 4 APMs 6.7 Table: Category 3 & 4 Payment Models. Source: CMS, January 2016.

7. Care and Payment Chain in ACOs

8. Population Attributions – Prospective or Retrospective

9. Accountability in APMs • Works best for Medicare where people tend to stay in the same payer for years • Works less well for private insurers, where people frequently shift insurance plans.

10. ACO Model Review

11. What are the Goals for APMs? Image: created for use in lecture CC NC-BY-SA 4.0

12. MSSP Performance 6.8 Table: Performance Year 2, MSSP ACOs Sources: Introcaso, D. & Berger, G., 2015.

13. Medicare Advance Payment ACO Program Performance Source: CMS, 2016

14. Pioneer ACOs Performance Source: CMS, 2016

15. Next Generation ACOs Source: CMS, 2016

16. CPC+ • Comprehensive Primary Care Plus • Announced spring of 2016 • 20 regions in the country; 5000 practices in two tracks • Category 3 model • Built on FFS with incentive payments based on quality and utilization measures • Includes payment for care management • Health IT core component • CEHRT use required • Track 2 providers prove vendor support of Health IT needs, including reporting Source: CMS, 2016

17. What about States and Private Insurers? • Value-based contracts account for over 40% of payments in commercial market in 2014 • States face issues similar to Medicare ACOs • Cost reductions not coming as quickly as hoped • Patients mostly unaware of ACOs

18. State Innovation Models Source: CMS, October 5, 2015

19. Volume to ValueLecture c - Summary • Rapid rise of APMs • Ambitious goals by CMS • Variety of models range from very limited risk/reward to 100% non-FFS • Jury still out on ACOs

20. Volume to ValueLecture c – References 1 References Advance Payment ACO Model. (February 19, 2016). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ Comprehensive Primary Care Plus (February 19, 2016). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ Defining an Episode Logic for the Medicare Physician Resource Use Measurement Program: Background Paper for the November 10, 2009 Listening Session. (March 19, 2016). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ Earl, J. (2015, December 16). Four considerations when moving to value-based payment. Retrieved from http://managedhealthcareexecutive.modernmedicine.com/ Health Reform Minnesota: About. (2015, July 20). State of Minnesota. Retrieved from http://mn.gov/dhs/ Introcaso, D., & Berger, G. (2015, September 24). MSSP Year Two: Medicare ACOs Show Muted Success. Retrieved from http://healthaffairs.org/blog/ Next Generation ACO Model: Frequently Asked Questions (FAQ). (April 5, 2016). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/

21. Volume to ValueLecture c – References 2 References Shared Savings Program. (November 2, 2015). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ Smith, V. K., Ph.D., Gifford, K., Ellis, E., Rudowitz, R., Snyder, L., & Hinton, E. (2015, October). Medicaid Reforms to Expand Coverage, Control Costs and Improve Care: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2015 and 2016 (Publication No. 8785). Retrieved from http://kff.org State Innovation Models Initiative: General Information. (October 05, 2015). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ Tables and Charts 6.6 Table: Payment Taxonomy Framework. (2015, January 26). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ 6.7 Table: Category 3 & 4 Payment Models. (2015, January 26). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ 6.8 Table: Introcaso, D., & Berger, G. (2015, September 24). MSSP Year Two: Medicare ACOs Show Muted Success. Retrieved from http://healthaffairs.org/blog/

22. Volume to ValueLecture c – References 3 Image Slide 7: Care and Payment Chain in ACOs, created for use in program Slide 8: Prospective and Retrospective Population Attribution, created for use in program Slide 10: Category 3 & 4 ACO Model Review, created for use in program Slide 11: Timeline for APM Adoption, created for use in program Slide 13: Advance Payment ACO Model [Digital image]. (February 19, 2016). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ Slide 14: Pioneer ACO Model [Digital image]. (April 22, 2016). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ Slide 15: Next Generation ACO Model [Digital Image] (May 5, 2016). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/ Slide 18: Round One Awards [Digital image]. (October 5, 2015). Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/

23. Volume to ValueLecture c This material was developed by Normandale Community College, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0003