Value Based Contract Overview and Experience of an Independent Physician Practice Jamie Stevens, MSHS, MBA Administrator/Consultant Clay Platte Family Medicine Clinic, P.C. HQMS
Value Based Performance Objectives • Recognize necessary for practice transformation that is needed improve probability of success under value based contracts • Define the role of physician leadership to succeed under performance based contracts • Assess practices capacity to measure and act to improve risk adjustment in patient populations • Recognize data available within their practice that can be used to drive cost and quality improve • Identify strategic partners in the community that are essential to success under performance based contracts
Value Based Payment Models • Value-based programs reward health care providers with incentive payments for the quality of care they give to an attributed population of patients. These programs are part of a larger quality strategy to reform how health care is delivered and paid for. • Value-based programs support the three-part (Triple) aim: o Better care for individuals o Better health for populations o Lower cost
Triple Aim and Payment/Delivery Reform
Accountable Care Organizations • Accountable Care Organizations (ACOs): o Groups of physicians, hospitals, and other providers that agree to be financially responsible for the total cost and quality of care for a defined patient population. o Provider groups are entering into contractual agreements with both commercial (or private) payers and public payers, such as Medicare and Medicaid.
Recent ACO Trends In the first quarter of 2018, commercial ACO contracts accounted • for a little more than half of all ACO covered lives, while Medicare contracts accounted for 37 percent, and Medicaid contracts accounted for the remaining 10 percent. The next slide shows the number of ACO contracts over time • broken down by Medicare, Medicaid, and commercial arrangements. There are slightly more commercial ACO contracts than Medicare • with Medicaid contracts making up 5 percent. Medicare ACO contracts continued to grow, commercial contracts • saw very little net growth in 2017 and 2018, and Medicaid contracts saw a slight contraction as some state demonstration programs were not renewed.
Growth of Commercial and Medicare/Medicaid ACOs
Lives covered by ACOs by Over Time
Emergence of Other Alternative Payment Arrangements
Limitations of Alternative Payment Models One impediment keeping providers from making major delivery • system reforms is the limited business case for many of these organizations. Most provider organizations that have formed ACOs still have only a • some of their patients covered by alternative payment models and risk-based payments. Currently, ACOs see the need to experiment with risk-based payment • models because they want to prepare for a potential future when such models are more prevalent. Many are reluctant to undertake major delivery reforms that are not • sustainable under the predominant fee-for-service payment model that still determines their financial success. To encourage organizations to change how they deliver care, the • depth of risk is important, but perhaps more important is the breadth of risk—what share of revenue is under value-based payment arrangements.
Clay Platte Family Medicine Clinic • Independent primary care practice with 19 FTE providers practicing at locations in North Kansas City & Lee’s Summit • High intensity, average volume clinic with a focus on preventative care, chronic disease management and quality • High staffing model o 180 FTEs o 3 floor nurses per physician plus triage, referrals o Licensed therapist/care managers/diabetic educator/HEDIS o 20 business office staff o 5 of 11 coders are certified as risk adjustment coders
Value Based Payment Progression • Commitment to value based contract performance as a strategy in 2012 • Early focus on Medicare Advantage and progressed to PCMH based patients and Medicare due to MSSP ACO participation • Today most patients are in value based contracts (PCMH, CPC+, Medicare Advantage) • Increase in share of total revenue from value based payment over the past 5 years • Current standing as: o Among the highest ranked PMPM by population in the metro area for major MA plans o Second highest (out of 32 practices) risk adjusted practice for a large PCMH agreement o Significantly higher than average PMPM payment for CPC+ population
Percent of Revenue from Value Based Payments 2015-18 20.0% 17.7% 18.0% 16.0% 14.0% 12.8% 12.0% 10.0% 7.9% 8.0% 6.0% 4.0% 3.2% 2.0% 0.0% 2015 2016 2017 2018 13
Shared Effort by Entire Practice • Leadership o Financial commitment (staff, training, provider time) o Transparency o Alignment of incentives • Providers o Familiarity with value based contracts o Familiarity with risk adjustment and impactful codes o Quality measure management-use of preventative care • Staff o Increased responsivity of non-physician clinical staff o Focus on quality o Alignment of incentives o Addition of non-traditional primary care staff
System Approach • Monthly all provider meetings o Standing agenda items include practice revenue, quality performance, risk adjustment • Chart audit for gaps in care and code capture o Robust flag system for quality measure gaps o Coding staff with prospectively review charts to flag codes not yet captured in the calendar year o Providers review prior history for missing quality and risk adjustment opportunities o Use reports provided by health plans
System Approach • Quarterly team based trainings which include provider, nurses and administration and billing staff Review documentation trends that lack support for diagnosis o Review performance on a number of clinical quality measures o Evaluate patient population and opportunities for risk adjustment • All staff trainings and awareness o All new staff spend time with coders to learn about activities that contribute to improved cost and quality o New nurses and physicians receive more intensive and frequent training on quality and risk adjustment
Care Management and Primary Care • Patients with more complicated physical and/or mental illnesses are at increased risk of potentially serious, even fatal, exacerbations and complications. • They may benefit from more intensive follow-up and management than can be done through repeated office visits. • Implement risk stratification scores to all patients for easy identification of the highest need patients. • Evidence suggests that well-organized care management by a nurse or other health professional can reduce patients' risk of deterioration and readmission, and the associated health care costs. • One-half of patients readmitted to hospitals within 30 days of discharge have not seen a community provider.
Care Management Activities • Recently transitioned to Northland Health Care Access program for care management programs in an effort to increase patient satisfaction and improve outcomes, while reducing costs. • Examples of care management activities and services include: o Care plan development and tracking progress o Patient education o Social needs assessment o Transportation o Food o Language o Social support
Engaging the Care Team Primary clinical Primary clinical team + Care team Manager • Cares for healthy • High risk/acutely ill population patients • Provides routine care • Patients with increased psychosocial needs • Controls and stabilizes chronic disease • Patients requiring support that expands • Identifies need for outside the practice advanced care management 19
Six Steps To Risk Stratification 1. Identify criteria that define risk 2. Assign risk score & record in a discrete, searchable EMR field 3. Develop a strategy or approach for each risk level 4. Define team roles and responsibilities related to care management and coordination support 5. Engage community resources: Partner with sub-specialists, ER, hospital and other services o Maintain real time communications within the medical neighborhood o Make sure to actively engage family and caregivers o 6. Measure to monitor impact Internal/External quality measure reports o Claims based cost management data o Patient Experience o 20
High Cost Members-Data to Support Risk Stratification
IP and OP Utilization Practice Trends
RX and ER Utilization Reports to Support Care Management Efforts
Risk Adjustment Role in Value Based Payment Contracts • Medicare and other payers use risk adjusted factors (RAF) to determine the anticipated cost of care for beneficiaries based on their documented conditions. • The higher the RAF the greater the anticipated cost of care and the greater an opportunity to gain shared savings. • Health status must be re-determined each year o Must be assessed, treated and documented in the medical record annually o Based on diagnosis reported through claims/encounter data o Higher importance to document and code all conditions that are evaluated at each visit • Health status is the primary driver of shared savings
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