Accountable Care Organizations and Integrative Health/CPMs

1. Accountable Care Organizations and Integrative Health/CPMs Karen Milgate, Health Policy Consultant National Association of Certified Professional Midwives July 10, 2014

2. Overview of presentation • What are ACOs? • Why were they established? • How will their success be measured? • How likely are they to succeed? • How can integrative healthcare (CPMs) help?

3. What are ACOs? • Groups of providers—primary care professionals must be sufficient to care for the number of beneficiaries assigned to them. • Willing to take accountability for the overall cost and quality targets established for the aligned population • Willing to do this even as beneficiaries still in FFS Medicare and can go to any provider they so choose—essentially a virtual network

4. Why were ACOs established? • Cost concerns— • Health care represents 18 percent of GDP: and growing—faster than the rest of the economy • Medicare is single largest payer thus often impacts other payer policy • Medicaid catching up fast and may surpass Medicare • Both together are crowding out other priorities • In the future, fewer workers to pay, increasing share of per worker income necessary

5. What are the options for addressing cost concerns? • Price X Volume=Cost • Historically congress has tried to control the price; medical system left in charge of volume • More and more difficult, so how to create incentives for less volume to counteract FFS incentives for greater volume • Volume? • Are all of these services necessary/appropriate? Huge variation in utilization patterns across the country and for similar populations suggest some care (as much as 30 percent) may be unnecessary • Some care, such as preventable admissions, c-sections, etc may be indicators of poor quality care and increase costs • Need to change the FFS incentives for volume • Bottom line: Provide incentives for FFS providers to better manage care. Set targets for cost and quality and allow providers to share in savings achieved.

6. How will success be measured? Cost. • Define population for which ACO accountable—aligned beneficiaries. Done through primary care providers. • Establish baseline per capita—mix of historical with and without aligned beneficiaries • After measurement period, determine whether ACO better than expected trend or not (benchmark) • If better, calculate and share savings based on quality metrics

7. How will success be measured? Quality. Four target areas (33 total metrics), reporting vs. pay for performance: • Patient/caregiver – 7 metrics, 4 points, 25 percent of score • Care coordination/patient safety – 6 metrics + HER metric, 14 points, 25 percent of score • Preventative health—8 metrics, 16 points, 25 percent of score • At-risk population – 12 metrics, 14points, 25 percent of score

8. How likely to succeed? • In Medicare, 323 Shared Savings Program and 23 Pioneer ACOs as of January. 5.3 million lives • Total, including all payers: 626 with over 20 million lives. Several states with Medicaid ACOs. • Other payment models support: Patient-Centered Medical home, bundled payment, value-based payment • Is the right thing to do • But…..it is hard • Sets up dualing incentives in same organization • Not easy to coordinate care and savings thresholds are tough

9. How can integrative healthcare (CPMs) help? • Goal is better outcomes leading to lower acute exacerbations and lower overall spending • CPMs are still proving themselves, but this allows for demonstrating on a large population without intervention by intervention study. Less need for RCT, more for observational results • Less expensive alternatives, such as CPMs, nutritionists, community health workers, nurse practitioners encouraged

10. Ask, Answer, Make the case: • How would CPMs fit into this model? • What are the potential savings for an ACO if a higher percentage of births were attended by CPMs? At home? At birth centers? • What are the potential quality improvements that might result for an ACO if a higher percentage of births were attended by CPMs? At home? At birth centers? • Focus on Medicaid and commercial payers. • Find out whether there are payers in your region—either Medicaid or commercial insurers-- that have created a payment stream for ACOs. • Make the case.