Population Health

1. Population Health Structural “Accountable” Care Approaches for Target Population Lecture a This material (Comp 21 Unit 3) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Structural “Accountable” Care Approaches for Target PopulationLearning Objectives — Lecture a • Describe the integrated and accountable care movements. • Define clinically integrated networks and how they can be used as a strategy for accountable care. • Describe new models of care for population health. • Explain the role of payment reform in the context of population health and accountable care.

3. Accountable Care Movement • Accountable care is a health care reform movement in which improved health outcomes and reduced costs drive health care delivery and payment • Primary purchasers of health care seek to pay for value—not volume • Entities pursuing accountable care adopt financial accountability for the health care needs of a population • To improve health care cost and quality, accountable care organizations (ACOs): • Coordinate care among providers • Access health information technology

4. Affordable Care Act (ACA) • In addition to its expansion and reform of health insurance coverage, the ACA contains numerous provisions intended to resolve underlying problems in how health care is delivered and paid for in the U.S. • Focus on three broad areas: • Testing new delivery models and spreading successful ones. • Encouraging the shift toward payment focused on volume to payment focused on value of care provided. • Developing resources for system-wide improvement. • ACA has spurred activity in public and private sectors and is contributing to the momentum in states and localities across the U.S. to improve health care value. Source: Abrams et al. (2015). The affordable care act’s payment and delivery system reforms: A progress report at five years. The Commonwealth Fund.

5. New Models for Health Care Delivery • Transformation in health care: • Moving away from fee-for-service payment takes time, resources, and experimentation. • A single approach will not work for all providers in all states or in all markets. • ACA encourages the spread of several care models, but two approaches hold promise for improving the effectiveness and efficiency of care delivery: • Accountable Care Organizations (ACOs). • Patient-Centered Medical Home (PCMH). Source: Abrams et al. (2015). The affordable care act’s payment and delivery system reforms: A progress report at five years. The Commonwealth Fund.

6. Accountable Care Organizations • In 2012, the ACA established a new category of provider within the Medicare program: the accountable care organization. • The ACO: an entity formed by health care providers who agree collectively to take responsibility for the quality and total cost of care for a population of patients. Source: Abrams et al. (2015). The affordable care act’s payment and delivery system reforms: A progress report at five years. The Commonwealth Fund.

7. ACA Shared Savings • ACA provides incentives for provider organizations to be accountable for the total care of patients, including population health outcomes, patient experience with care, and the cost of care per person. • Medicare Shared Savings Program (MSSP): • If participating ACOs meet quality benchmarks and keep spending below budget, they receive half the savings that result, with the rest going to Centers for Medicare & Medicaid Services (CMS). • In 2015, more than 400 Shared Savings programs served 7.2 million beneficiaries or 14 percent of Medicare population. Source: Abrams et al. (2015). The affordable care act’s payment and delivery system reforms: A progress report at five years. The Commonwealth Fund.

8. Shared Savings ACO Performance • Results from the program’s first year of operation, 2013, were mixed. • 220 Shared Savings ACOs: • Only 52 were able to meet quality of care benchmarks and keep spending below budget targets. • 60 ACOs kept spending under 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 savings. • 102 did not achieve savings. • 6 achieved savings but did not report quality measures. Source: Abrams et al. (2015). The affordable care act’s payment and delivery system reforms: A progress report at five years. The Commonwealth Fund. 3.1 Chart. Centers for Medicare & Medicaid Services.

9. Evolution Toward Accountable Care 3.2 Figure. The Advisory Board Company. (2010).

10. Primary Care Providers in the ACO • Providers’ participation is voluntary. • ACO is: • Required to have sufficient primary care providers to care for Medicare beneficiaries. • Held accountable for the quality and cost of care for the Medicare patients of those primary care providers. • ACO could consist of primary care physicians, multispecialty physician group practices, or hospitals that employ physicians or partner with physician groups.

11. Organizational Models for ACOs • Three potential organizational models for ACOs: • Advanced primary care practice networks with infrastructure support and associated specialist referral networks. • Multispecialty physician group practices. • Health care organizations with functionally integrated ambulatory, inpatient, and post-acute care services.

12. Primary Care Transformation Through Medical Homes • U.S. has undervalued and underinvested in primary care for decades. • Neglect of primary care is largely due to prevailing fee-for-service reimbursement approach. • Providers have inherent financial incentives to favor high-priced procedures over care management and other cost-savings services. • Result: the care U.S. patients receive is often poorly coordinated and expensive. Source: Abrams et al. (2015).

13. Patient Centered Medical Homes • Considerable evidence that comprehensive, coordinated primary care can improve outcomes and reduce per patient costs. • PCMH: • A model of care that emphasizes care coordination, care teams, patient engagement, and population health management. • The patient-centered medical home seeks to expand patients’ access to primary care, promote prevention, and ensure that care is well coordinated. Source: Abrams et al. (2015).

14. What Is Clinical Integration? • 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. • Improving access to care and the overall patient experience.

15. Clinically Integrated Networks (CINs) • What is clinical integration? • The American Medical Association (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.” • What is a clinically integrated network ? • Physicians working together systematically, with or without other organizations or professionals, to improve their collective ability to deliver high-quality, safe, and valued care to their patients and communities. • Sponsored by hospitals but led by physicians who assemble the resources required to manage care for defined populations.

16. Benefits CINs Provide to Payers and Patients • Ability to deliver improved quality outcomes: • Collaborative education for physicians and staff. • Specific disease management clinics to support practitioners. • Online resources. • Standardized practices and protocols. • Disease registries that track outcomes and outreach to patients when needed.

17. Three Key Areas to Achieve Clinical Integration — 1 • Incentives: • Developing a common, measureable picture of success that delineates clear, tangible (ideally financial) benefits to all stakeholders working together in the clinical care continuum, including hospitals and their employed and affiliated physicians, ambulatory surgery centers (ASCs), independent medical groups, and also labs, pharmacies, radiology, patients, and payers.

18. Three Key Areas to Achieve Clinical Integration — 2 • Knowledge: • Surfacing the right information across multiple systems to the right person at the right time, increasing transparency and clarity, minimizing financial risks, and offering optimal control over business and clinical processes.

19. Three Key Areas to Achieve Clinical Integration — 3 • Behavior: • Using aligned incentives and knowledge to support efficiency and quality, such as the creation of standardized processes and preventive and detective controls, to ensure that caregivers, executives, payers, patients, and other stakeholders can take the right actions when needed.

20. Align Incentives, Knowledge, and Behavior to Achieve Clinical Integration 3.3 Figure. Adapted by Center for Teaching and Learning, Bloomberg School of Public Health, Johns Hopkins University, from athenahealth, Inc. (2013 June).

21. Clinical Integration Necessitates Substantial Quality Improvement Infrastructure 3.4 Table. The Advisory Board Company. (2010).

22. Payment Reform: Care Management Payments • Paying primary care practices with care management payments and utilization-based performance incentives: • A care management payment made to the primary care practice for each patient to support better patient education and self-management, access to physicians by telephone, etc. • Specific targets for reducing utilization of health care services outside of the practice (e.g., non-urgent emergency room visits, ambulatory care–sensitive hospitalizations, and/or high-tech diagnostic imaging). • Bonuses/penalties paid, based on the practice’s performance against the targets.

23. Unbridled Cost Growth 3.5 Chart: Centers for Medicare & Medicaid Services, Office of the Actuary (2012).

24. From Pilot to Policy? 3.6 Figure. The Advisory Board Company. (2013). Used with permission.

25. Overview of Accountable Payment Models 3.7 Table. The Advisory Board Company. (2013). Used with permission.

26. Payment Reform Supports Population Health 3.8 Figure. The Advisory Board Company. (2013). Used with permission.

27. Structural “Accountable” Care Approaches for Target PopulationSummary — Lecture a — 1 • 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.

28. Structural “Accountable” Care Approaches for Target PopulationSummary — Lecture a — 2 • 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.

29. Structural “Accountable” Care Approaches for Target PopulationSummary — Lecture a — 3 • There are several different payment models — value-based purchasing, bundled payments, and accountable care organizations.

30. Structural “Accountable” Care Approaches for Target PopulationReferences — Lecture a — 1 References Abrams, M., Nuzum, R., Zezza, M., Ryan, J., Kiszla, J., & Guterman, S. (2015). The Affordable Care Act’s payment and delivery system reforms: A progress report at five years. Issue Brief (Commonwealth Fund), 12. Retrieved April 27, 2016, from http://www.commonwealthfund.org/publications/issue-briefs/2015/may/aca-payment-and-delivery-system-reforms-at-5-years The Advisory Board Company. (2010). The accountable physician enterprise: Partnering with physicians to transform care delivery. Washington, DC. Retrieved April 27, 2016 from https://www.advisory.com/research/health-care-advisory-board/studies/2010/the-accountable-physician-enterprise The Advisory Board Company. (2013). Path to population health: Payment reform 101. Retrieved March 29, 2016, from: https://www.advisory.com/research/health-care-advisory-board/events/webconferences/2013/path-to-population-health-payment-reform-101 athenahealth, Inc. (2013 June). Clinical integration: 7 myths and a blueprint for success (Whitepaper). Retrieved March 29, 2016, from: http://www.athenahealth.com/whitepapers/clinical-integration-model/

31. Structural “Accountable” Care Approaches for Target PopulationReferences — Lecture a — 2 References Centers for Medicare & Medicaid Services. Retrieved March 29, 2016, from www.cms.gov Centers for Medicare & Medicaid Services, Office of the Actuary. (2012). National health expenditure projections, 2011–2021. Health Care Advisory Board interviews and analysis. Charts, Tables, Figures 3.1 Chart: Shared savings ACO performance. Adapted from Centers for Medicare & Medicaid Services. Retrieved March 29, 2016, from www.cms.gov 3.2 Figure: Evolution toward accountable care. Adapted from The Advisory Board Company. (2010). The accountable physician enterprise: Partnering with physicians to transform care delivery. Washington, DC. Retrieved April 27, 2016 from https://www.advisory.com/research/health-care-advisory-board/studies/2010/the-accountable-physician-enterprise 3.3 Figure: Align incentives, knowledge, and behavior to achieve clinical integration. Adapted by Center for Teaching and Learning, Bloomberg School of Public Health, Johns Hopkins University, from athenahealth, Inc. (2013 June). Clinical integration: 7 myths and a blueprint for success (Whitepaper). Retrieved March 29, 2016, from http://www.athenahealth.com/whitepapers/clinical-integration-model/

32. Structural “Accountable” Care Approaches for Target PopulationReferences — Lecture a — 3 Charts, Tables, Figures 3.4 Table: Clinical integration necessitates substantial quality improvement infrastructure. 3.5 Chart: Projected health care spending: Average annual growth rate. Centers for Medicare & Medicaid Services, Office of the Actuary. (2012). National health expenditure projections, 2011–2021. Health Care Advisory Board interviews and analysis. 3.6 Figure: CMS timeline for accountable payment rollout [Online image]. Used with permission from The Advisory Board Company. (2013). Path to population health: Payment reform 101. Retrieved March 29, 2016, from: https://www.advisory.com/research/health-care-advisory-board/events/webconferences/2013/path-to-population-health-payment-reform-101 3.7 Table: Overview of accountable payment models [Online image]. The Advisory Board Company. (2013). Path to population health: Payment reform 101. Retrieved March 29, 2016, from: https://www.advisory.com/research/health-care-advisory-board/events/webconferences/2013/path-to-population-health-payment-reform-101 3.8 Figure. Payment reform supports population health [Online image]. The Advisory Board Company. (2013). Path to population health: Payment reform 101. Retrieved March 29, 2016, from: https://www.advisory.com/research/health-care-advisory-board/events/webconferences/2013/path-to-population-health-payment-reform-101

33. Population HealthStructural “Accountable” Care Approaches for Target PopulationLecture a This material (Comp 21 Unit 3) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005.