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- 1. Is ACO-Led Payment Reform Working? Conference of Consulting Actuaries April 13, 2016 www.archwayhealth.com dterry@archwayha.com
- 2. www.archwayhealth.com Contents • About Archway Health • Bundled Payment Overview • Searching for the Best - Bundled Payment Analytics • Payment Reform Market Evolution 2
- 3. www.archwayhealth.com Archway Health – Making Bundled Payment Simple 3 Unique team of healthcare operators, big data analysts, tech developers We are a Convener in the CMS BPCI program & we support other BPCI Conveners Currently working with over 50 providers of all types (Hospital, Physicians Groups, SNFs, HHAs) to manage their bundled payments programs. Built a comprehensive bundled payment platform including: Patient Tracking, Web-based Claims Data Analytics, Advisory Services, Preferred Provider Networks & Risk Sharing Focus To Partner with providers & payors to execute bundle payment programs Mission To fix healthcare through payment reform
- 4. www.archwayhealth.com Bundle Payment Initiatives Market Size Key Participants* Bundled Payment for Care Improvement (BPCI) - CMS • 6,700 applicants • 1,520 participants • $8-10B of healthcare spend* • 720 Skilled Nursing facilities • 410 Hospitals • 180 Hospitalists groups • 100 Orthopedic groups • 100 Home Health Agencies Oncology Care Model (OCM) - CMS • 125 applicants • $2B in HC spend* • Oncology groups • Hospital systems w/Cancer services Comprehensive Care for Joint Replacement (CCJR) - CMS • 800 Hospitals • $3B in HC spend* • All Hospitals in 67 MSAs State Programs • Hundreds of Millions • States: OH, TN, AK • Specialties: Ortho, OB, Geriatrics Commercial Market • Billions • Self-Insured Employers • Health Plans • ACOs • Unions * Estimated based on publicly available information Bundled Payment Overview CMS Better, Smarter, Healthier Initiative • $300B of Medicare spend in alternative payment models by 2018 • Also encouraging commercial plans to participate Medicare is pushing aggressively toward new payment models, with bundled payment playing a key role. 4
- 5. www.archwayhealth.com Bundled Payment Overview 5 Bundled payment programs create unique new opportunities for key specialists and acute care providers to benefit from improved care transition and coordination efforts. • Providers responsible for the full episode of care • Episode prices established up front • Meet episode specific quality metrics • Coordinate care along the continuum • Track patient progress • Respond to “red alerts” when patient has complications • Opportunity to access new revenue sources Provider as Healthcare “General Contractor”
- 6. www.archwayhealth.com 6 Major Joint Replacement (DRG470) Bundle Price Benchmarking 90 Day Episode $9,400 We often see significant variation in the cost of a bundle across providers, clinical conditions and regions. $8,400 $7,800 $- $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 DME LTCH IRF SNF HHA Readmission Out-patient Part B Index Hospital Searching for the Best - Select Analytics
- 7. www.archwayhealth.com Searching for the Best - Select Analytics 7 Skilled Nursing Facility Mean Episode Costs 90 Day Episodes We have also seen dramatic differences in historical performance of Skilled Nursing Facilities.
- 8. www.archwayhealth.com Searching for the Best - Select Analytics 8 OCM Opportunity Analysis by Cancer Type 6 Month Episodes There is also broad variability in the cost of cancer care
- 9. www.archwayhealth.com Sources of Savings Pricing variability • High priced hospitals vs. lower priced hospitals • Inpatient vs. outpatient care • Hospital outpatient vs. freestanding outpatient services • Resource utilization • Post-acute services • Diagnostics • Coordinated care Bundle Cost Variation – Hip Replacement Searching for the Best - Select Analytics 9 $- $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 Min Max The BCBS Association has also highlighted significant variation in the commercial market. Commercial Market Variability
- 10. www.archwayhealth.com • Patient reported health status • Patient goals • Physical function • Quality of life • Clinical measures • Complications • Readmissions • Key clinical stats • Patient satisfaction • Provider communication • Overall experience • Employer measures • Back to work • Physical function 10 Source: International Consortium for Health Outcomes Measurement (ICHOM) ICHOM Standard Metrics Bundled payment enables focused, condition specific quality and outcomes measures. Condition Specific Quality Metrics Searching for the Best – Quality Metrics
- 11. www.archwayhealth.com Payment Reform Market Evolution 11 Fee-for-Service Pay-for-Performance Select Bundles Global Cap Global Cap + Bundles Payment Reform Value Progression Provider Driven Demand Consumer Driven Demand Specialist engagement & accountability, driven by bundled payment initiatives, have the potential to reduce trend even further within traditional global cap programs. Shared Savings Bundle-Driven PPO
- 12. www.archwayhealth.com Payment Reform Market Evolution – Bundled PPO 12 Orthopedics Hip & Knee Replacement Spine Procedures Sports Procedures Urology TURPs Bladder Surgery UTI Obstetrics Normal Deliveries High Risk Deliveries Neonates Gastroenterology Endoscopy Bowel Obstruction Cholecystectomy Cardiology AMI CABG/PTCA CHF Cancer Breast Lung Colorectal Chronic Care Diabetes COPD CHF • Traditional PCPs • Urgent Care Centers • Convenience Care • Remote Care – (Web, Telehealth) Primary Care Services Bundled Specialty Services • Un-Bundled Specialty Care • Out of Network Services • Emergency Care • Sub-Specialty Services Other Services PPO Product Elements • No PCP gatekeeper • Bundled Payment Value Engine • Bundle specific quality metrics • Bundle pricing w/ warranties • Outlier protections • May need to start with shared savings model • Patient incentives • Shared patient savings if bundled specialists are chosen • Out of network options at higher cost • Aligns well with high deductible and Tiered Co-Pay plans The long term goal is to create a comprehensive PPO product that drives value across many conditions through the bundled payment model.