Practice Managers Meeting March 19, 2015 2 Accountable Care - PowerPoint PPT Presentation

Practice Managers Meeting March 19, 2015

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Accountable Care Network 101 Aligning hospitals, their staffs, and community physicians into clinically integrated networks

Accountable Health Partners Vision To bring together community and faculty physicians, hospitals and other affiliated providers to develop a clinically integrated care network with aligned financial incentives, to improve population health, to provide patient-centered care and to promote efficient use of resources. 4

The Growing AHP Network PCP Adult PCPs Specialists CNMs Total Pediatricians Community 145 111 249 - 505 URMFG 174 16 993 13 1196 Total 319 127 1242 13 1701

Network: Ten-County Region

Network: Hospitals 7

Intro to AHP Gain Sharing Contracts • Sits on top of existing fee-for-service contracts • For 2014, upside only • Payer sets a budget and quality goals for the attributed population • Network performs under the budget and meets quality goals • The dollars saved (the “gain”) are shared between payer and network 8

MVP TAG Contract • Term: 2014-2016 • 30,000 attributed members • Upfront clinical integration payments to PCPs • HEDIS-based quality measures • Opportunities for gainsharing if quality goals are met 9

Excellus ACQA Contract • Term: 2014 (2015-2018 contract still being negotiated) • 128,000 attributed members • Commercial only (including self insured) • Upfront clinical integration payments to PCPs • Opportunities for gainsharing if quality goals are met • ARCADIA!! 10

2014-2015 Arcadia Analytics DRAFT Jan ’15 Connection & Validation Work plan Feb Wave #1 Wave #1 (1/30-3/27) Wave #9 (7/17-9/11) Wave #6 (5/15-7/10) • Breen and Assoc (HST) • UR Primary Care (EPIC) • Sheikh (CureMD) Mar • Sunrise Ped (Medent) • His Branches Health (Medent) Wave #1b (2/27-3/29) Wave #2 • Valley View Family (Medent) • Twelve Corners Ped(Medent) • Office of Dr. Kerper (EPIC) Wave #3 • Pinnacle Family (Vitera) • Office of Dr. Tinkelman (Medent) Apr Wave #2 (2/20-4/17) • Jones Memorial (LSS) • Office of Drs. Mahoney, Horohoe & Garneau (HST) • Victor Health (Medent) Wave #10 (8/7-10/2) Wave#4 Wave #7 (6/5-7/31) • Stonybrook Ped (eCW) • Family Medical Alfred May • Office of Dr. Qureshi (Chartmaker) Wave #3 (3/13-5/8) (Practice Fusion) Wave#5 • Bayoumi Medical (Chartmaker) • University Health Services • Office of Drs. Cahn-Hidalgo, Minnella, (Pyramed) • Abbasey Medical (Chartmaker) Plain, Tan, Yoon (Chartmaker) • Office of Dr.Akowuah (HST) June • Hope Internal (Amazing Charts) Wave#6 • UR Thompson (Medent) • Bloomfield Family • Northern Allegany (Amazing Charts) • Elmwood Ped (Medent) (Medent) • Lake Country Family (Amazing Wave#7 • Letchworth Family (Medent) Charts) Jul Wave #11 (8/28-10/23) • Alexander Medical (Medent) Wave #8 Wave #8 (6/26-8/21) • Blossom Rd Internal (Practice Wave #4 (4/3-5/29) Fusion) • Shifa Medical (eCW) Wave#9 • Finger Lakes Family(Amazing Charts) Wave #12 (9/18-11/13) • Noyes Health Aug • Honeoye Valley Family (HST) Employed(eCW) • Arnot Medical (eCW) • Tri-County Family (ECW) • Wayland Family(eCW) Wave#10 • Legacy Peds (TBD) • Lewis Ped (Medent) • James Three Seventeen • Brighton Peds (Soapware) • Keuka Family (Medent) Sept Medical (Practice Fusion) • Naples Valley (Medent) Wave#11 • Depner(Medent) Wave #5 (4/24-6/19) • Eastside Peds (Medent) Wave#12 Oct • Canandaigua Medical (Vitera) • Brighton Family(HST) • Zoneci Medical (HST) Nov • Jefferson Family (HST) • Goodman Peds(Medent) As of: • Pathway Peds (Medent) 2/6/15

UR Health Plan Contract • Term: 2015-2017 • 30,000 covered lives • Tier One Network • Employees pay lowest copay/deductible when obtaining services from AHP providers • Quality measures and integration measures TBD 12

Patient Population • Employees and their dependents covered under the University of Rochester Employee Benefit Plans • Excludes: • Affiliates • Medicare-eligible retirees • Members of 1199 SEIU • 30,000 individuals are covered by the UR employee benefit plan • Approximately 10,000 are seeing an out-of-network PCP 13

Benefits Basics • Two TPAs: Excellus BCBS and Aetna • Two plans: • PPO Plan • HSA-Eligible Plan • Both plans: • Three tiers of benefits • No PCP required • Preventive care covered at 100% whether AHP or Aetna/Excellus network 14

PPO Plan Deductibles: Single Aetna/ Excellus AHP OON Deductible $400 $800 $1600 Coinsurance 90% 80% 60% RC OOP Max $2000 $2500 $4000 $2500 $3000 $4000 Deductible applies to all health care expenses except office visits. 15

PPO Plan Deductibles: Family Aetna/ Excellus AHP OON Deductible $1000 $2000 $4800 Coinsurance 90% 80% 60% RC OOP Max $4000 $5000 $8000 $5000 $6000 $8000 Deductible applies to all health care expenses except office visits. 16

PPO Plan Coverage: Office Visits Aetna/ Excellus AHP OON PCP $15 $30 60% of RC Specialist $30 $60 60% of RC Preventive Care 100% (no copay) Not covered Chiropractor $30 60% of RC PT/ST/OT $30 60% of RC Optometrist $30 60% of RC 17

PPO Plan Coverage: Maternity Aetna/ Excellus AHP OON Prenatal 100% 100% 60% of RC Postnatal 100% 100% 60% of RC Hospital 90% 80% 60% of RC 18

PPO Plan Coverage: Hospital Aetna/ Excellus AHP OON Inpatient 90% 80% 60% of RC Outpatient 90% 80% 60% of RC 19

HSA Plan Deductibles: Single Aetna/ Excellus AHP OON Deductible $1300 $1800 $2500 Coinsurance 90% 80% 60% RC OOP Max $2500 $3500 $4750 $3000 $4000 $4750 University HSA contribution: $200 20

HSA Plan Deductibles: Family Aetna/ AHP OON Excellus Deductible $2600 $3600 $5000 Coinsurance 90% 80% 60% RC OOP Max $5000 $7000 $9500 $6000 $8000 $9500 University HSA contribution: $400 21

Deductibles Cross Apply Tier One-AHP Tier Two Non AHP Specialist 80% covered $1800 Non AHP Labs $350 Non AHP PCP visit $150 AHP Specialist Visit 90% covered $1300 $250 $250 Specialist Visit Specialist Visit $250 $250 $650 $650 Chest X-Ray PCP visit $150 $150

HSA Plan Coverage: Office Visits Aetna/ AHP OON Excellus PCP 90% 80% 60% of RC Specialist 90% 80% 60% of RC Preventive Care 100% (no copay or Not covered deductible ) Chiropractor 90% 60% of RC PT/ST/OT 90% 60% of RC Optometrist 90% 60% of RC 23

HSA Plan Coverage: Maternity Aetna/ AHP OON Excellus Prenatal 100% 100% 60% of RC Postnatal 100% 100% 60% of RC Hospital 90% 80% 60% of RC 24

HSA Plan Coverage: Hospital Aetna/ AHP OON Excellus Inpatient 90% 80% 60% of RC Outpatient 25

Two Tiered Services/Providers  AHP does not include all of the providers that deliver health care services (e.g., optometrists, podiatrists)  For these specialties, the UR employee claims will process at the highest benefit level (Tier One) if the provider is in the Aetna/Excellus networks.  If the provider is not in the Aetna/Excellus networks, the claim will process at the Tier Three benefit level. 26

Examples of Non-AHP Provider Services Covered at the Tier 1 Benefit Level  Acupuncture  Optometry (routine)/Eyewear  Ambulatory Surgery Center  Inpatient/outpatient Mental Health  Audiology  Inpatient/Outpatient Substance  Chest and respiratory Abuse therapy  Midwifery  Chiropractic  Podiatry  Dialysis  PT/OT/ST  DME  SNF  Dentistry  Speech Pathology  Infusion (facility and home)  Urgent Care  Oral Surgery/Endodontics (covered under medical) 27

Important!! Anesthesia in ASCs • ASCs are not tiered • UR health plan patients will have tier one benefits for their AHP surgeon and the ASC • Not all ASCs have AHP-par anesthesiologists • Example: Unity Linden Oaks Facility Surgeon Anesthesiologist Untiered AHP par not AHP Par Tier One Benefits Tier One Benefits Tier Two Benefits 28

Exclusive Benefits: BHP • Behavioral Health Partners • Comprehensive mental health services for UR employees and dependents (18+) enrolled in a UR benefit plan. • A team of therapists, NPs, psychiatrists and RNs. • Covered dx: depression, anxiety, stress • Services: diagnostic assessments, psychotherapy, medication management, consults with PCPs Referrals or consults: 585-276-6900 http://www.urmc.rochester.edu/behavioral-health-partners.aspx 29

Exclusive Benefits: BHP continued • PPO: no out-of-pocket costs • HSA: no out-of-pocket costs after deductible is met • Free parking • One week timeframe for initial consults • Day and evening appointments available Referrals or consults: 585-276-6900 30

Condition Management • No cost to employee or employee’s spouse/partner • Programs to help employees with a chronic disease manage the condition. • Programs include lifestyle modification and behavior change counseling • Referral by screening results or PCP • Seamless communications with PCPs to ensure effective, coordinated care 31

Condition Management Comprehensive Programs for: • Asthma • COPD • DM • CAD • A-fib • CHF • Hypertension • High cholesterol • Lower back pain • Stroke 32