Negotiating Pharmacy's Role From a Position of Strength

1. Negotiating Pharmacy's Role From a Position of Strength

2. Objectives • Define Accountable Care Organizations (ACO) • Define Pioneer ACO • Define Transitions of Care • Determine the Opportunities for implementation of the Pharmacy Practice Model Initiative in an ACO setting

3. What are the core elements of ACO’s? • Accountable for health, quality, and costs of care over the full continuum of their patients’ care • Collaborate, share information and manage patient health for a population of patients (physicians, acute care hospitals, wellness, home care, long term care, pharmacies, et al) • Focus on improving health and reducing overall costs for a population of patients • Able to measure and report improvements in patient health and overall costs • Integrate financially to accept and distribute bundled payments and incentive payments or penalty retractions

4. Health Care Reform formalizes the Accountable Care Organization (ACO) model • Beginning 1/1/2012, hospitals-physician entities may provide ACO services • Beginning in 2013, Voluntary bundled payment pilot programs • FTC expected to waive restrictions that prohibit effective formation of ACOs. • 5 guiding principles: • ACOs have a strong foundation of primary care • ACOs report reliable measures to support quality improvement and eliminate waste and inefficiencies to reduce cost • ACOs are committed to improving quality, improving patient experience and reducing per capita costs • ACOs work cooperatively towards these goals with stakeholders in a community • ACOs create and support a sustainable workforce

5. Accountable Care Objectives • Create efficient teams of hospitals, primary care physicians and specialists • Reduce or eliminate duplication of services and fragmented care • Reduce costs – Shared savings • Improve quality • Bundle payments

6. Care Transitions Infrastructure P U B L I C H E A L T H

7. Are you on the Road to Accountable Care ?a. ACO Pioneer b. Commercial ACO c. Don’t know Efficient Delivery System Transformation Synchronizing change Inadequate physician alignment. High cost pathways. Poor analytics for measurement Accountable Payment at Risk Lower unnecessary utilization for the ACO population. Have sufficient ACO population. Careful not to undermine non- ACO revenues. Care Delivery Financial Care Transformation

8. Some Elements of Care Common to Most of the Transitions Models • Medication Management • Assessing Patient's Understanding/Ability to Follow Care Plan • Discharge Support • Coaching for Primary Care Physician Visit • Use of Home Visits Screening for cognitive ability • Use of Centralized Health Record • Involving Family and other Caregivers • Arranging Community-Based Support Services From: The Lewin Group, December 16, 2009 Care Transitions Workgroup and ASHP Ambulatory Practice Group

9. What is the Pioneer Program? • Patient Protection and Affordable Care Act (2010) • Center for Medicare and Medicaid Innovation (CMMI) • Separate from Medicare Shared Savings Program • Accountable Care Organizations (ACO) • Triple Aim • Quality and cost efficiency = value • Steward’s community care model is considered an ACO

10. What is the Pioneer Program? (cont’d.) • Pioneer ACOs will be held financially accountable for the care provided to their aligned beneficiaries • The Pioneer program begins on January 1, 2012 and continues for three, one-year performance years. There is an option to extend for two additional years. • 60-day termination provision and no settlement if effective within first 6 months of performance year

14. ACO Pioneer Project • Demonstration project for certain entities to start Pioneer ACO in 2012 • More flexibility than traditional ACO program • Assignment of patients, for example • Quality reporting measures similar to ACO • CMS named 30 Pioneers – 5 in Massachusetts

15. Institution A as a PioneerAccountable Care Organization • Health Care Reform (Insurance Reform) • Treat patients in best location • Avoid unnecessary admissions • Requires physician groups and hospitals to collaborate • Focus on chronic care • Focus on preventative care • Refer internally • Experience with transitions of care model • Reduces cost and adds value

16. Institution A as a Pioneer ACO - Infrastructure • Physician groups and hospital are in the same pool together for all risk contracts • Institution A - 10 hospitals (1,980 beds) • Institution A - 149 physician sites (2,200 physicians) • Institution A • Owned physicians • Institution A • Non – owned, affiliated physicians • Treat 1.2 million Patients Annually

17. Commercial ACO Model Contracts • Blue Cross Blue Shield (BCBS) 66,000 members choosing Steward - BCBS AQC – Since 2009 • 5 year AQC design based on total costs • Member opt in • Quality Measures • X Health Plan 30,000 members that choose a PCP – Since 2012 • Based on PMPM • Quality Measures • XX Health Care 38,000 members that choose a PCP – Since 2012 • Based on PMPM • Quality Measures

18. Institution A’s Business Strategy Where We Are Today 7 - 10 5 - 6 Redefine “Health Care” & shift the focus to VALUE 4th year Utilization Per Unit Cost Infrastructure • Value: Quality, Access and Costs (TME –Time & Materials Estimate) • Lower annual rate of TME (unit price and utilization) • Drive provider efficiency • Coordinate care and keep it “in the community” • Improve quality, enhance patient experience • Keep cost trend low, affordable • Build scale: enhance services, apply efficiencies across entire delivery system • Create better value for patients and employers • Creative disruptions in the market, where needed • Budget as Medical Loss Ratio

19. Value: keep care in right place, at right time, at right cost • Academic / Tertiary / Quaternary • Community Hospital • Physician office / Clinic • Home There is a 20% -- 25% drop in cost as you move care from high cost, to low cost settings 19

20. Community Care Model:The Role of Payment Reform • Value is the new paradigm • Keep appropriate care local • Payment Reform is a tool not the goal • Move away from FFS (volume) • Alignment of Key Stakeholders: CI and FI • Hospitals, LTAC*s, Rehab, FQCHC • Providers • Payers • Employers • Consumers / Patients • The role of risk contracts • Commercial: BCBS, THP, HPHC all risk contracts • Pioneer • Avoids mixed mode and aligns key stakeholders Value Quality Affordability Access *LTAC Long Term Acute Care

21. Key Strategies for Success: Population Health Management Population Identification and Stratification • Analyze population to identify patients health status and drive the most appropriate and effective care interventions Deliver Care Interventions • Evidence based clinical pathways and protocols to define and deliver the most appropriate intervention for all patients based on their identified health status Optimize Care & Physician Communication • IT and communication infrastructure to enable improved care delivery Measure & Track Performance • Improve ability to measure population health to the patient level, disease/condition level and physician level Community & Patient Engagement • Primary prevention initiatives including cultural compatibility and community education outreach

22. Distribution of Complexity and Costs • Biggest opportunity is managing medical costs for complex and complex prevention categories

23. Focus Area: Patients with Heart Failure And Its Co-morbidities

24. Initial Analysis and Identification Population Identification and Stratification • Population is analyzed to identify patients and group by health status: • High Risk($) Impactable • Facility based care, re-admissions, etc • Active, high current claims • At Risk Patients • Diabetes, CHF, CAD, COPD, IVD, HBP etc. • All Beneficiaries • Quality, wellness, prevention • Palliative Care and/or End of Life Care

25. Key Strategies for Success • Quality • Pioneer ACOs who fail to achieve certain minimal quality standards may be terminated from the program • High quality scores can mitigate potential losses and maximize sharing in successful performance years. • The Quality Score is based on 33 measures comprising four domains, weighted equally at 25% each • ACOs must meet minimum attainment level of the 30th percentile or 30 percent to earn points on given quality measure • ACOs not eligible for savings unless achieve the quality performance standard on at least 70% of measures within each domain • Exception: Meeting the EHR measure is required in order to be eligible

26. Pioneer Quality Measures (N=33): Four Domains • Patient/Caregiver Experience (N=7) • Care Coordination/Patient Safety (N=6) • Includes meaningful use of Electronic Health Record • Preventive Health (N=8) • At-Risk Populations (N=12, 5 are “all-or-nothing”) • Diabetes • Hypertension • Ischemic Vascular disease • Heart Failure • Coronary Artery disease

27. Top Down and • Bottom Up Approach to Readmission Prevention

29. CHF Care map

31. Percentage Re-admission Rates - Medicare

32. Percentage Re-admission Rates –All Payers

33. Percentage Re-admission Rates -AMI

34. Re-admits by MSDRG

35. Pay For Performance

36. Pay For Performance

37. HCAHP’s Inpatient Hospital

38. HCAHP’s Inpatient Hospital Pharmacist Role

40. STAAR Initiative Effective Interventions to Prevent Readmissions • RED – Re-Engineered Discharge • Education, Discharge Follow-up, Med plan • Transitional Care Model • Pre, post discharge coordinated care for high risk – Steward Healthy Transitions • Care Transitions Program • Self management skills training – “Red Zones” • Evercare™ - Care Model • Aimed at LTC, Chronic conditions, hospice, palliative care • Care in home setting • Phone follow-up

41. Patient Discharge Informationin Nine Languages

42. Conclusions • Evaluation of ACO readiness is critical • ACO organizations must have sufficient numbers of risk patients • Value proposition of ACO differs from FFS • Pharmacists are part of the care team • Pharmacist reimbursement for services is part of the bundle not FFS • Pharmacists have a role in the success of the ACO in both inpatient and outpatient settings

43. Appendix • Readiness as an ACO • Strategies for Success • Re-Admission Prevention • Care Maps • Data collection

44. Barriers to Effective Care Transitions • Structural • Lack of integrated care systems • Lack of longitudinal responsibility • Lack of standardized forms and processes • Incompatible information systems • Lack of care coordination and team-based training • Lack of established community links • Procedural • Ineffective communication • Failure to recognize cultural, educational or language differences • Processes are not patient-centered nor longitudinal • Performance Measurement and Alignment • Underuse of measures to indicate optimal transitions • Compensation and performance incentives not aligned with care coordination and transitions • Payment is for volume of services rather than outcomes

45. Initial Analysis and Identification Population Identification and Stratification • Population is analyzed to identify patients and group by health status: • High Risk($) Impactable • Facility based care, re-admissions, etc. • Active, high current claims • At Risk Patients • Diabetes, CHF, CAD, COPD, IVD, HBP, etc. • All Beneficiaries • Quality, wellness, prevention • Palliative Care and/or End of Life Care

46. Key Strategies for Success • Population Health Management (cont’d.) • Develop a real-time understanding of physicians who are managing the populations effectively in terms of quality and cost efficiency • Cluster patients with chronic disease and co-morbidities with physicians and care teams who demonstrate expertise in management • Team based care and practice redesign • Care management tool enables the development and delivery of evidence based clinical pathways and protocols based on the health status of all patients

47. Key Strategies for Success • Ambulatory-driven care management program • Improve care coordination and care management through disease management for complex and chronic conditions, ER readmissions, homecare VNAs, SNFs, hospice and palliative care programs • Since the ACO is responsible for the total cost of care of aligned beneficiaries, it is essential that Steward look to improve coordination along the entire continuum of care • One of the largest opportunities for achieving shared savings arises from enhanced post-acute care that reduces readmissions • Medically complex beneficiaries also offer significant opportunities to improve care coordination and realize immediate savings • Telephonic and embedded case management

48. Readmissions

50. Pneumonia Care Map