Value-Based Payment for Patients Living with Chronic Illness

1. Value-Based Payment for Patients Living with Chronic Illness • February 24, 2016 • 12:00 – 1:15 pm ET

2. Welcome • Anne Gauthier • LAN Project Leader, • CMS Alliance to Modernize Healthcare (CAMH)

3. Agenda

4. Guiding committee welcome Mark McClellan Guiding Committee Co-Chair Robert Margolis Professor of Business, Medicine and Policy Director of the Robert J. Margolis Center for Health Policy, Duke University

5. Session Objectives • Learn About • Identifying the high-need, high-cost patient population • Basic features of successful care management programs • Current payment arrangements for care management services • The move from fee-for-service to value-based payment for care management services • Value-Based Payment for Patients Living with Chronic Illness

6. Panel facilitator Jeff Micklos Executive Director, Health Care Transformation Task Force (HCTTF)

7. LAN Learnings: Value-Based Payment for Patients Living with Chronic Illness A Perspective from the Health Care Transformation Task Force February 24, 2016

8. HEALTH CARE TRANSFORMATION TASK FORCECommitted to 75% of all business activity in value-based contracts by 2020 Patients, Payers, Providers and Purchasers: Committed to Better Value Now

9. The Task Force’s guiding principles outline a financially and operationally viable and sustainable approach Design programs that provide reasonable returns to deliver the triple aim of better health, better care and reduced total cost of care at or below GDP growth Shift 75% of our respective businesses to be under value-based care contracts by 2020 Equip market players with all tools necessary to compete in new market focused on people-centered primary care Encourage multi-payer participation and alignment to create common targets, metrics, and incentives Share cost savings with patients, payers, and providers to ensure adequate investment in new care models Foster transparency of quality and cost metrics in a manner that is accessible to, and easily understood by, consumers Support the needs of disadvantaged populations and help strengthen the safety net providers who serve them

10. TF Work Groups are driving rapid-cycle product development, starting with improving the ACO model and transforming payment models for caring for high-cost patients Improve the ACO Model Develop Common Bundled Payment Framework New Model Development - Improving Care for High-cost Patients Develop aligned public-private action-steps and recommendations to improve the design and implementation of the ACO model Create detailed principles and tools to align and evaluate episode definitions/pricing for public/private payer bundled payment programs. Create, test and recommend a delivery/payment model that allows a wide range of provider organizations, including in rural areas with little to no current MA/ACO penetration, to engage in population health by starting with highest-cost patients (top 5%).

11. Panelists Diane Stewart Senior Director Pacific Business Group on Health (PBGH) Greg Jones Government Affairs Aetna Ginger Hines Director of ACO Operations and Model of Care Providence Health & Services

12. Panelist Diane Stewart Senior Director Pacific Business Group on Health (PBGH)

13. Payment to Support High Need, High-Cost Patient Care Models Diane Stewart, Sr. Director Pacific Business Group on Health dstewart@pbgh.org

14. HCTTF’s Improving Care to High-Cost Patient Work Group: Three White Paper Series • Identifying the high need, high cost patient population (2 mins) • Proactively Identifying the High Cost Population (July 2015) • Common care model elements (2 mins) • Developing Care Management Programs to Serve High-Need, High-Cost Populations (February 2016) • Supportive payer-provider relationships (10 mins) • Payment to Promote Sustainability of Care Models for High-Need, High-Cost Patients (Expected Spring 2016)

15. Paper 1: Identifying the High Cost Patient Population A. Stratifying the High Need, High Cost population: • Persons with Advanced Illness • 28% of Medicare spending in last 6 months of life • Persons with persistent high spending patterns • Medicaid – 60% in Top 10% in one year are Top 10% in the next • Medicare – 40% in Top 10% in one year are Top 10% in the next • Patients with episodic needs B. Methods used to predict individuals in Group 1 and 2

16. Paper 2: Common Care Model Elements

17. Paper 2: Lessons Learned • Ensure meaningful patient and caregiver engagement • Measure patient-reported outcomes and satisfaction • Tailor model to context and patient • Overcome resistance with education and patience • From Providers and Patients

18. Paper 3: Payment to Promote Sustainability of Care Models for High Need, High Cost Patients • Goals: • Summarize how existing programs are reimbursed to support high need, high cost patient programs • Methods: • Qualitative interviews with 10 provider organizations and health plans both inside and outside the task force • Review case studies in the literature

19. Continuum of Payment Models: Examples of Payment Methods for High Cost Patient Programs

20. Provider View: Patchwork of Payment Models

21. Payer-Provider Relationships: What Works? • Preference for shared risk within categories (e.g., 3A to 3B) and population-based payment across categories (e.g., 3B to 4A) • Flexibility with covered services • Support for coordination across care settings • Investment in infrastructure • Can “get by” with a mix with lower category payments • Weekly program management calls between payers and providers • Careful review of delegation agreements to avoid doubling up/waste • Mission driven organizations making investments because “it’s the right thing to do”

22. Payer-Provider Relationships: Opportunities to Move the Needle • Spread common set of payer-provider best practices • Harmonize efforts • Delineate common care model elements and create model delegation agreements and/or RFIs • Requires alignment on definition of target population • Modified MA rules could provide starting point for key issues • Risk adjustment when it matters • Standardized Measurement to streamline administrative burden • Policy Advocacy • Promote patient-reported outcome measures (important to focus on patient goals/experience) • Push for Category 3 and 4 Payment models

23. HCTTF’s Improving Care to High-Cost Patient Work Group: Three White Paper Series • Proactively Identifying the High Cost Population (July 2015) • White Paper: Proactively Identifying the High Cost Population • Developing Care Management Programs to Serve High-Need, High-Cost Populations (February 2016) • White Paper: Developing Care Management Programs to Serve High-Need, High-Cost Populations • Payment to Promote Sustainability of Care Models for High-Need, High-Cost Patients (Expected Spring 2016) • And.. a summary of evidence from the Commonwealth Fund: • Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis

24. Panelist Greg Jones Government Affairs Aetna

25. Aetna Presentation to the Health Care Payment Learning and Action Network

26. Aetna’s Mission: Build a Healthier World I can’t get an appt! How long a wait? What’s covered? Payer Specialist Lab Hospital Diagnostic imaging The “Old Model” The “New Model” How far is this place? Pharmacy High cost Why somuch? Primary care doctor Clinic How much? • Complex products • Confusing to access • Limited price discovery • Uncoordinated care • Varied outcomes • Simple products • Engaging technology • Price & quality transparency • Coordinated care • Better outcomes

27. Aetna’s Vision for Improving Care for High-Need, High-Cost Medicare Beneficiaries *Avalere Analysis Performed on Behalf of Aetna, November 19, 2013.

28. Overview of Current Medicare Legislation • Both Bills Establish: • Three year pilot program • Conducted in at least four service areas • Up to 2 organizations per service area • HHS can extend duration and expand pilot to additional areas if quality and savings targets are achieved • Additional Provisions: • More Benefits: Enhanced benefits such as transportation, meals, and personal care • Lower Out-of-Pocket Costs: VBID component allowing reduced or eliminated cost sharing • Integrated Care Model: Includes best-in-class providers and mandatory health risk assessment/care plan • Risk Adjusted Payments: Risk adjusted capitated payment set at 98 percent of Medicare FFS program • Preserves Part D - Preserves Part D payment, benefits, beneficiary protections and non-interference

29. Successful Model of Care Requires Regulatory Flexibility

30. Case Study: Aetna Compassionate Care Program for Advanced Illness

31. Panelist Ginger Hines Director, Operations and Model of Care Providence Accountable Care Services

32. A Snapshot of Providence Data is consolidated for Providence and its affiliates based on financial reporting. >650,000 lives across the System in accountable care risk contracts

33. Care Management Models Providence has a variety of arrangements in place across a wide range of patient populations and payer types – from CMS programs for seniors, to commercial insurers and direct to employer, to Department of Defense, Medicaid and our own health plan

34. Focus on Two Models Today • Primary care based model for care management that supports our direct to employer contracts • Providence Elder at Home program that supports our Providence Health Plan Medicare Advantage population

35. Primary Care Based Model for Direct to Employer Contracts Our philosophy: care management is best done close to the patient • Patient centered medical home approach • Elements of IOCP model: intake visits, care plans, routine touchbase with patient in the office or via phone • Plus: transition calls, frequent ED utilizer outreach, pharmacy support and reporting, behavioral health models • Accountable Care Services helps with data feeds, work flows, training, tools, working groups and reporting

36. How is Care Management Different in an Accountable Care Model? • Data and shared risk/reward help prioritize the work • Merging claims and electronic medical record data to create a better picture • Data feeds and tools to care management teams in the clinic • Who are the patients we are accountable for? • Inpatient, Emergency Department census lists daily (inside/outside our hospital system) • Transition calls after discharge • Emergency Department follow up for high utilizers • Practice variation – diagnostic imaging, pharmacy, specialty referrals • Opportunity analysis

37. Reporting is Key to the Program • High level utilization metrics/1,000 • Clinical and process metrics: • Outreach and engagement (#, %) • Transition calls completed (#, %) • Patients with care plans created (#, %) • Clinical metric performance changes: • A1c • blood pressure • PHQ9 scores • Statin adherence, … etc • Number of calls to our next day appointment lines (from ED to avoid IP admission as appropriate)

38. What Are We Working On?

39. Elder at Home, a Providence Model

40. Elder at Home Background • High-acuity patients • consume the majority of resources • have unmet needs in traditional clinic-based care model • Providence providers entered into a shared savings / full risk contract with Providence Health Plan to deliver care in the home for a cohort of MA patients who meet specific clinical and utilization criteria • payment structure includes PMPM for care management

41. Program Features that Distinguish Elder at Home

42. Key Findings Based on 6+ Months • Many patients are very sick and in inappropriate care setting • Key to savings is providing quality care for greatest needs, not necessarily the total number of participants • Dual eligibles present greatest needs, yet are not always the best match for program • Payer partnership relationship is critical • Don’t underestimate demand – must be able to quickly scale • Recruitment of skilled providers and nurses is happening in a challenging, competitive environment

43. Quote from Primary Care Provider about Elder at Home “…Elder at Home providers are a window on what is going on back home with patients, which becomes increasingly valuable when deciding with family and patients what the goals of care are, and facilitating patient choices. Honestly, with this program, I rest easier about my frail elderly patients, knowing they are extensions of our caring, in a way we can’t provide without them. My wish: that we could extend and expand the program to cover all the frail elderly for whom transportation is a challenge, and for whom consistent in home medical care can make the difference between comfort and repeated health care crises resulting in emergency visits to the hospital.”

44. Panel q&A

45. UPCOMING WEBINARS Opportunities for LAN Participants to Learn, Engage and Act • LAN Updates • No Events Currently Scheduled • LAN Learnings • March 14, time TBD • Listening Sessions • March 1 @ 1:00 – 2:00 PM • Providers: Preliminary Recommendations on Patient Attribution and Financial Benchmarking

46. LAN SUMMIT • https://www.lansummit.org • Spring LAN Summit • April 25-26, 2016 • Sheraton Hotel • 8661 Leesburg PikeTysons, VA 22182Tysons, VA • Save the Date • Presentations Planned from Work Groups on Work Group Products • Call for Sessions Coming Soon! (end of February)

47. ENGAGE, LEARN, AND ACT The LAN will only succeed with robust stakeholder engagement across the field Visit the Website Join the Discussion Follow Us Attend Webinars Access Resources Submit Comments Attend LAN-wide Meetings