How Supporting Risk-based Agreements Can Advance Value-based Care - Joseph Nicholson, DO, Chief Medical Officer, CareAllies Timothy Irvine, MD ...
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How Supporting Risk-based Agreements Can Advance Value-based Care Joseph Nicholson, DO, Chief Medical Officer, CareAllies Timothy Irvine, MD, President at IKP Family Medicine and Board Member at Renaissance Physicians IPA
Learning objectives
► Examine how physicians can advocate for risk-based contract implementation
Understand the challenges that exist to improve social determinants under
►
competing models
Develop tactics necessary to help providers find health plans willing to share the
►
data needed to improve quality metrics
CareAllies 2
Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAllies
What makes an organization an ACO?
National Association of ACOs A group of doctors, hospitals, and/or other health care providers that work together
(NAACOS) with a goal of giving you better care at lower cost.1
ACOs are groups of doctors, hospitals, and other health care providers, who come
Centers for Medicare & Medicaid
together voluntarily to give coordinated high-quality care to their Medicare
Services (CMS)* patients.2
Rather than focusing solely on Medicare requirements, we build upon the Medicare
Utilization Review Accreditation
framework of clinical integration to include total population health and care
Commission (URAC)* coordination, truly putting the patient at the center of service delivery.3
National Committee for Quality The patient-centered medical home is a model of care that puts patients at the
Assurance (NCQA)* forefront of care.4
*Formal accreditation entity
1 https://www.naacos.com/what-is-an-aco-
2 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO
3 https://www.urac.org/accreditation-cert/accountable-care-accreditation/
4 https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAllies
ACO landscape
ACOs and Covered Lives Over Time Accountable Care Contracts Over Time
https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAllies.U.S. health care payments that flowed through more
advanced models (shared savings/risk or capitated)
35.8%
Total
30.1% 53.6% 40.9% 23.3%
Commercial Medicare Traditional Medicaid
Advantage Medicare
(MA represents 39% of
total Medicare population)
https://hcp-lan.org/workproducts/apm-infographic-2019.pdf
https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in-2020/ CareAllies 5
Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesThere is still opportunity to participate in risk-based
agreements
2%
Only a small 7%
Percent Annual Revenue
in Risk-based Agreements
percentage of 7%
1-20%
organizations
21-40%
have the majority 18%
66% 41-60%
of their revenue at
61-80%
risk
81-100%
https://info.nai-consulting.com/acton/attachment/5655/f-0033/1/-/-/-/-/Numerof%20Population%20Health%20Survey%20Report%20-%20August%202020.pdf
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesThe pandemic
Ambulatory provider visits fell almost 60% by early April
Baseline Week (3/1/20)
10%
0%
0%
-10%
-20%
-30%
-40%
Total Visits
-50%
-60%
Feb Mar Apr May Jun Jul Aug Sept Oct
Ateev Mehrotra et al., The Impact of the COVID-19 Pandemic on Outpatient Care: Visits Return to Prepandemic Levels, but Not for All Providers and Patients (Commonwealth Fund, Oct. 2020). CareAllies 7
Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesThe need for flexibility
Motivating factors for IKP Family Medicine to move to value:
Value-based
Financial stability
payment is not
Ability to treat patients in ways that are not typically
just about risk. reimbursed under a payer’s fee schedule
• Care for patients in preferred method
It’s also about (e.g., telehealth)
• Coordinating with other providers
flexibility. • Covering the cost of care managers
• Addressing patients’ social determinants of health
Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use CareAllies 8
and distribution limited solely to authorized personnel. © 2021 CareAllies.Which risk-based contracts are right for your
practice?
• Volume-based model • Improved coordination • Improved coordination • Improved coordination
where a pre-determined and population health and better population • Better population health
fee is paid for each management health management management
service or procedure • Gaps in care • Management of • Management of potential
• Care management potential upside and upside and downside
• Registries downside risk risk
- Claims and costs • Multi-year risk sharing
- Contract across a group
Management • Full risk arrangements
• Multi-year risk sharing requiring mature
across a group capabilities
- Utilization
- SDOH
- Provider metrics
- Risk scoring
FFS Pay for Shared Risk/ Capitation/
Reimbursement Performance Bundled Payments Global Payments
Provider accountability for quality and cost
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesConsiderations when entering these arrangements
Your Value-based Forward-thinking Reporting Goal Ability to Make
Goals Partners Efficiency Alignment Decisions
What mix of Which payers have Which payers have Does their approach to Does the arrangement
government and progressive policies similar requirements utilization management give you the flexibility
private contracts around the treatment of for quality reporting empower your practice to care for your
makes the most sense chronic conditions and that could make it to manage and control patients without
for your organization? actively invest in easier to test and scale service and treatment financial fears guiding
services that combat risk-based offerings for patients? your decisions?
Does the payer’s set of social determinants of arrangements?
quality reporting cover health challenges
holistic, person- within your
centered care, community?
including behavioral
health needs of the
patient?
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesValue-based care relies on effective collaboration
and data sharing
Health Coverage
Patient Provider Availability of Care
Collaboration Population Health Quality Metrics
Provider &
Data Sharing Health Outcomes
Payer Utilization Data
Social Determinants
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesThe role of nontraditional data
Consumer
Claims Data EHR
Data Data
More likely to drive More likely to inform
actionable results SDOH gaps/risk for gaps
Community-
HIE based Census
Data Org. Data
Data
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesSocial determinants of health
Factors other than clinical care can
account for over 80% of health outcomes.
Reference: https://www.ncbi.nlm.nih.gov/pubmed/26526164
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesSocial determinants of health play a vital role in
clinical outcomes and health care expenditures
Food Access Housing Financial assistance Social Support
Health Education Psychosocial Needs Transportation
If a patient has social, economic or physical barriers, what do they do?
They often wait until it is too late for preventive care, and go to the emergency room.
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAllies.Addressing challenges around social determinants
of health
Improve the ability to identify and prioritize patients whose health may be
impacted by SDOH present in their lives or community.
Improve patient health and affordability by creating and enhancing solutions and
benefits.
Empower providers to assess their patients for SDOH and provide
appropriate resources to impact patient health.
Collaborate with clients and community partners to address SDOH at the
local market level
Influence policies and regulations that impede or advance a provider’s or
payer’s ability to address SDOH
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAllies.Improving quality outcomes at IKP Family Medicine
Three-prong approach to improve quality outcomes
1 Patient Physicals 1st 90 Days 2 Follow Ups 3 Social Determinants
Experienced and well-trained Follow-up visits are used along When difficult social determinants
physician extenders that focus on with up-to-date gaps in care occur, IKP leverages case
Process
seeing all patients for physicals reports to close any management programs, vendors
during the first quarter of the year. outstanding gaps. and will at times arrange for an
In the patient’s mind, this is a true internal medical provider to meet
physical. It lasts an hour and all and care for the patient in their
necessary metrics for the year are home.
covered at that time.
Interdisciplinary Team
• Physician • Pharmacist
Staffing
• NP • LPN • Embedded Care Coordinator
• RN • SW
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesValue-based arrangements provide an opportunity to
improve outcomes
• 6% patient panel growth since 20161
• Met 100% of quality measures
• 5-Star rating for 20212
1 Based on Cigna MA attribution between 2016 and 2020
2 Based on preliminary 2019 Cigna Medicare data for Part C and Part D
Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use CareAllies 18
and distribution limited solely to authorized personnel. © 2021 CareAllies.Questions and discussion
Stop by our ACO Exhibit Hall virtual booth
www.acoexhibithall.com/vendor-booth/careallies/aco-development-operations/138/
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Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesThank you
Joseph Nicholson, DO Timothy Irvine, MD
Chief Medical Officer, CareAllies President, IKP Family Medicine
Joe.Nicholson@CareAllies.com timothyirvinemd@gmail.com
www.careallies.com www.IKPFM.com
www.ACOExhibitHall.com
CareAllies 21
Confidential, unpublished property of CareAllies. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2021 CareAlliesAll CareAllies products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including CareAllies, Inc. The CareAllies name, logo, and other CareAllies marks are owned by Cigna Intellectual Property, Inc. © 2021 CareAllies
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