Nebraska HIMSS 2019 Spring Meeting

1. Nebraska HIMSS 2019 Spring Meeting Impact of ACOs on Rural Healthcare Facilities • Todd Searls, Regional Vice President • Caravan Health Nebraska HIMSS 2019 Spring Meeting

2. Agenda • - Medicare Challenges Are Rural Health Challenges / Opportunities • - Review of Medicare Shared Savings Program ACO (MSSP ACO) • - Impacts of an ACO On: • People • Process • Technology • - Closing Nebraska HIMSS 2019 Spring Meeting

3. Medicare Challenges Are Rural Challenges MSSP Opportunities are opportunities for CAHs/RHCS Nebraska HIMSS 2019 Spring Meeting

4. Projected Federal Spending on Medicare and Medicaid INDUSTRY AND MARKET TRENDS Source: Kaiser Family Foundation, Congressional Budget Office Nebraska HIMSS 2019 Spring Meeting

5. Chronic Conditions Drive Cost Nebraska HIMSS 2019 Spring Meeting

6. Physician Fee Schedule Increases Will Not Keep Pace With Inflation 2022 2026 and later 2024 2023 2020 2018 2021 2019 2017 2015 and earlier 2016 2025 Fee Schedule Updates 0.75% QAPM 0.5% 0.5% 0.5% 0.5% 0 0 0 0 0 0 0.25% Non-QAPM Risk Required To Capture 0.75% Raise Medicare payments include fee schedule reimbursement, MIPS adjustments and shared savings. NEHIMSS 2019

7. As A Result – More Physicians Joining ACOs https://www.medscape.com/slideshow/compensation-2017-overview-6008547#1 Nebraska HIMSS 2019 Spring Meeting

8. Heightened Challenges in Rural Settings Increased / Inappropriate ED Usage Limited Access to Behavioral Health Providers Geography Limited Capital / SME Resources Rural Social Determinants of Health vs Urban Controlling ‘out of network’ costs (ie, downstream facility spend) Lack of Specialists RHC Billing setup Lack of Post-Acute Care Facility & CAH/RHC Communication & Care Planning Nebraska HIMSS 2019 Spring Meeting

9. Benefits of Rural Participation in ACOs • All healthcare is local • Rural healthcare is primary care – the very thing that Medicare wants to encourage through ACO participation • Partnering / collaborating with a large number of peer facilities • Better access to Subject Matter Experts (SMEs) • Reduced costs of shared analytics platforms • Executive, Physician, and Population Health RN cohort building / learning networks • Improved ACO performance: more facilities = more covered lives = better ACO scoring • Improving / increasing preventative care services • Adds financial stability • Increases patient engagement & satisfaction scores • Improves Quality Reporting / MIPS participation • Better care coordination with specialists and post-acute settings of care Nebraska HIMSS 2019 Spring Meeting

10. “The ACO has just been a catalyst for care coordination. Before the ACO model, we knew that we had partners that existed, but we didn’t call on one another.” “You don’t have to be in an ACO to offer these programs, but one benefit of being in an ACO is the resources, structure, and support to effectively implement programs that positively impact patients and care.” - MAY 30, 2018, Relationships and Partnerships: How ACOs Are Improving Treatments for Super-Utilizers, by Allee Mead https://www.ruralhealthinfo.org/rural-monitor/acos-and-super-utilizers/ Nebraska HIMSS 2019 Spring Meeting

11. https://rupri.public-health.uiowa.edu/publications/policybriefs/2018/ACO%20Spread%202018.pdfhttps://rupri.public-health.uiowa.edu/publications/policybriefs/2018/ACO%20Spread%202018.pdf ACOs – Coming To A CAH Near You! Secretary of Health and Human Services Alex Azar talks tough to hospitals: “…make no mistake: we will use these tools to drive real change in our system. Simply put, I don’t intend to spend the next several years tinkering with how to build the very best joint-replacement bundle— we want to look at bold measures that will fundamentally reorient how Medicare and Medicaid pay for care …. ….As just one example, we are looking at our efforts regarding Accountable Care Organizations. The program was intended to give providers three years to learn how to accept risk and share savings, but the results have been lackluster.…. ….as costs continue to skyrocket, the current system simply cannot last. As of January 2018: 1,210 RHCs & 421 CAHs participate in MSSP ACOs Nebraska HIMSS 2019 Spring Meeting

12. Review of the Medicare Shared Savings Program Our Focus today is the mssp ACO Nebraska HIMSS 2019 Spring Meeting

13. Forming an ACO • ACO professionals in grouppractice arrangements • Networks of individual practices of ACO professionals • Partnerships or joint venture arrangements between hospitals and ACO professionals • Hospitals employing ACO professionals • Federally qualified health centers • Rural health clinics Eligible Participants Must serve at least 5,000 Medicare fee-for-service patients. Agree to participate for at least 5 years, meet other program requirements such as a governing body, processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost measures and coordinate care. ACOs enjoy waivers of Stark, Anti-Kickback Statute and Patient Inducement regulations. They are deemed to be Clinically Integrated Networks by the FTC. Nebraska HIMSS 2019 Spring Meeting

14. Most ACOs Cannot See True Savings Small ACOs experience savings and losses +/- 10-20% simply due to statistical variation in health care spend and in HCC coding 73% of MSSP ACOs have fewer than 20,000 lives Nebraska HIMSS 2019 Spring Meeting

15. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/SSP-2018-Fast-Facts.pdfhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/SSP-2018-Fast-Facts.pdf Nebraska HIMSS 2019 Spring Meeting

16. 2020 – Pathways MSSP Model Nebraska HIMSS 2019 Spring Meeting

17. Why Take Risk? • ACO participants taking risk will get 5% lump sum payments that are not counted in shared savings and are exempt from MIPS reporting – making your clinicians happier and more attractive to others in value-based payments. • CMS is steadily increasing incentives for risk-takers • Higher rewards for MSSP performance • Reduce risk corridor to 0.5% or lower • Direct admissions to SNFs • Telehealth to patients homes as a billable visit • Exempt from MIPS and Meaningful Use • 0.5% higher annual increases in Part B starting in 2026 that will accumulate over time to the clinicians NPI. • It will be difficult to recruit physicians if you do not take risk. Beginning in 2026, every year a clinician does not take risk his lifetime earning potential decreases by 0.5%. Nebraska HIMSS 2019 Spring Meeting

18. Should We Worry About Being Pushed into Risk Too Early? There is no reason to panic CMS is proposing to continue low or no downside risk for the early ACO years We have seen that the longer ACOs stay in the program, the stronger the results Large Collaborative ACOs are in a great position to take on risk in future years If your ACO has a strong population health focus, routinely performs PDSA improvement activities, and has robust data analytics, you are well positioned for Risk Nebraska HIMSS 2019 Spring Meeting

19. People Right person / right seat Nebraska HIMSS 2019 Spring Meeting

20. The ACO Core Team Clinical & Ancillary Administrative / HIM / IT - Physician Champion - Population Health RN - RN Champion - Pharmacy Lead - ACO Champion Nebraska HIMSS 2019 Spring Meeting - Executive Sponsor(s) (CEO / CFO / COO) - ACO Champion - IT Lead - Coding Lead - Analytics Super User - Compliance Lead

21. Solidify Provider Relationships Ensure your physician contracts encourage a collaborative work environment Keep an open line of communication so PCPs, specialists and facilities can most effectively work together Establish a level of trust between providers to leverage each other’s strengths Nebraska HIMSS 2019 Spring Meeting

22. Empower Your Nurses Build your primary care capacity. Utilize nurses and medical assistants to meet patient needs and provide additional support to providers. Medicare allows important preventive services to be billed under provider supervision. Physicians get more time to attend acute patient needs, and patients benefit from more attention overall. Nebraska HIMSS 2019 Spring Meeting

23. Trained Nurses Excel at Prevention Source: Hattiesburg Clinic Nebraska HIMSS 2019 Spring Meeting

24. Population Health Nurses Generate Income FFS Sites RHC Sites Don’t forget billing for the IPPE (PA / APRN), Home Health Supervision, & Other Screenings! Nebraska HIMSS 2019 Spring Meeting

25. Case Study: Caravan Health MSSP ACO ~17,000 Attributed Lives (Predominantly CAH/RHCs) ACO Clinics CY 2018 CY 2017 CY 2018 CY 2017 Total: 5512 4900 $821,117.55 ACO Sites: CY2017 CY2018 39% Services $784,138.25 Nebraska HIMSS 2019 Spring Meeting

26. Process Plan, Do, Study, ACt Nebraska HIMSS 2019 Spring Meeting

27. Have a Plan to Execute Focus on Execution Don’t just have a plan – focus on the end result Identify New Resources Dedicate new resources and technologies to project planning, management and tracking above and beyond clinical staff and technology investments. Adapt to New Processes Even if you are a high-performing health system, there is always room for improvement. Nebraska HIMSS 2019 Spring Meeting

28. Meet Practices Where They Are Nebraska HIMSS 2019 Spring Meeting

29. Build on Performance Implement Expertise & Compliance Teach Guidance through the complex regulatory environment and governance procedures Practice Transformation Drive clinical and non-clinical transformation initiatives Clinical Excellence Lead the physician engagement aspects of value-based care Intelligence & Analytics Healthcare data experts delivering mission-critical insights Report Improve Nebraska HIMSS 2019 Spring Meeting

30. Get Your Coding in Order • Ensure you receive credit for the sicker patients you treat • Appropriate HCC coding is required for value-based payments. • Numerous ACOs have found that inattention to HCC-coding workflows has been the difference between collecting shared savings and falling below the minimum savings rate. • Integrating coding best practices into your workflow can help you get credit for caring for sicker patients without driving your clinicians crazy. Nebraska HIMSS 2019 Spring Meeting

31. Documentation & Coding Affect Reimbursement Nebraska HIMSS 2019 Spring Meeting

32. Technology 2015 cEHR is just the starting point Nebraska HIMSS 2019 Spring Meeting

33. Does Your EHR Make ACO Workflows Easier? • - HCC Module? • - AWV Templates? • - CCM Time Capture? • - Patient Self-Scheduling? • - Patient Self-Reported Health Information? • Blood Pressure • Blood Sugars • Assessment Forms Nebraska HIMSS 2019 Spring Meeting

34. Attribution Maps • ACO Analytics Platforms Should Be Able To Track Your Attributed & Assignable Lives. • Attribution drives shared savings! • Do you know where your patients live? • What community support services are available to assist patients in keeping to their care plan? Nebraska HIMSS 2019 Spring Meeting

35. Why Is Attribution Important? • Total Opportunity • Shared Savings Earned (PBPY) • # of Medicare Beneficiaries (Attribution) • 30% of ACO shared savings are distributed on pure attribution • 60% based on attribution and local PBPY savings • 10% goes to the top quality performers Nebraska HIMSS 2019 Spring Meeting

36. Analytics: Internal & External Data Nebraska HIMSS 2019 Spring Meeting

37. Be Sure To Keep Score Use a scorecard to keep focused on goals and pinpoint areas of weakness. Metrics should be based on efforts towards goals such as AWV percentage rate or cohort meeting participation. Nebraska HIMSS 2019 Spring Meeting

38. Please Note: RHCs / CAHs and the ACO As expected – similar, but different Nebraska HIMSS 2019 Spring Meeting

39. Why Does RHC/FQHC Status Matter? • RHC/FQHC billing differs substantially from fee-for-service (FFS) • Unique billing codes are required to allow your facility to receive reimbursement for important care management services • Claims billed under the All-Inclusive Rate (AIR) do not contain the same information as FFS • Alternative methodology is used to determine ACO patient attribution • Certain FFS policies have become intertwined with the Shared Savings Program • You may be required to participate in additional programs to support your FFS ACO partners Nebraska HIMSS 2019 Spring Meeting

40. Shared Responsibility in the ACO • When participating in a Shared Savings ACO, your TIN(s) will be scored with the APM entity (the ACO); • Because of participation in the ACO, RHC/FQHC participants are not exempt by virtue of the low volume threshold; • All members of the ACO will receive an identical MIPS score (for their ACO TIN(s)); • Failure of an RHC/FQHC to participate in MIPS will negatively impact all of their fee-for-service ACO partners. Nebraska HIMSS 2019 Spring Meeting

41. CAHs – Something to Consider… • Advanced Alternative Payment Models (Advanced APMs) • Advanced APMs are APMs that meet these 3 criteria: • 3/4 majority use of certified EHR technology; • Provides payment for covered professional services based on quality measures comparable to those used in the MIPS quality performance category; and • Either: (1) is a Medical Home Model expanded under CMS Innovation Center authority OR (2) requires participants to bear a significant financial risk (ie, Track E & Enhanced Track under Pathways to Success MSSP model). • Advanced APM Potential Benefits (for Qualified Participants (QP)): • 5 percent bonus on all Medicare Part B Charges (Method II Billing anyone? But follows provider…) • APM-specific incentives (ie, shared savings payment if achieved) • Exclusion from MIPS (all QP providers within ACO) • Waivers, waivers, waivers! (3 Day rule, beneficiary incentive, telehealth to home, etc.) Nebraska HIMSS 2019 Spring Meeting

42. QP Status: It’s All About That Billing, ‘bout That Billing… QP Status Determination: Using the 2018 MSSP Track 2 & Track 3 example: A provider would be considered a QP if their total Medicare Part B charges (attributed lives / attribution-eligible lives) were equal to or greater than 25%. Question: - Does this help or hurt your CAH Method II and RHCs? https://qpp-cm-imp-content.s3.amazonaws.com/uploads/811/QP-Methodology-Fact-Sheet.pdf Nebraska HIMSS 2019 Spring Meeting

43. In Summary Nebraska HIMSS 2019 Spring Meeting

44. Maximize Power of Claims and EHR Data 1 Analyze your population to understand prevalence of chronic illness, hospitalizations and related costs. 2 Prioritize areas for improvement and identify where you need additional resources based on which population has the most clinical and financial risk. 3 Plan early for in-house and outsourced expertise. Ingesting claims data and drawing meaningful reports takes time. Nebraska HIMSS 2019 Spring Meeting

45. The Collaborative ACO Model 5k, 10k, 25k lives are just not enough to succeed in an ACO, especially when considering Risk. Large-scale collaboration is key to MSSP Success! • Collaborative ACO Models are a great option for smaller facilities – especially when Partnering with other facilities within a region (similar patients, similar challenges) • The Mississippi Hospital Association created the first State-wide ACO • Master core competencies for provider-based risk • Value-based Purchasing • MACRA • Medicare ACO risk • Medicare Advantage • Medicaid Managed Care • Employer plans Nebraska HIMSS 2019 Spring Meeting

46. In Summary Value-based Payment is Here to Stay More than a third of all providers will participate in these programs. Reducing healthcare cost growth is critical for our future. Get maximum upward adjustments of Part B payments and shared savings to supplement frozen fee for service revenue. Now is the Time to Take Action Early adopters reaped the benefit of risk-free participation. The move to risk is accelerating and it is important to gain experience and prepare for the future reimbursement system. Statistical Variation will Hurt your ACOThe effects of statistical variation create unreliable and spurious results that can wrongly penalize or reward providers. Strengthen Provider Reputation MIPS scores will be much higher for APM participants. CMS will post this data on Physician Compare in 2018 and publish for third-party use. Maximize Value-based Reimbursement Joining a 100,000+ life ACO increases the likelihood of predictable shared savings, higher MIPS adjustments, reduces risk and sets the stage for future success in value-based payments, clinical integration and provider-based health plans. Nebraska HIMSS 2019 Spring Meeting

47. Todd Searls, RVP | tsearls@caravanhealth.com | 816.945.6341 Nebraska HIMSS 2019 Spring Meeting

48. About Caravan Health Helping Providers Navigate the Challenges of Value-Based Payments MACRA CPC+ ACOs Practice Transformation • Founded in 2013 • 38 Accountable Care Organizations • >14,000 Providers • >1,000,000 Patient Lives • Results (cms.data.gov) • 95%- 97% Quality Scores • >10x National Average of Savings