1. Health Care, Education and Researchwww.billingsclinic.com Accountable Care Organizations: Perspectives from the Billings Clinic Experience Montana HealthCare Forum November 28, 2012 Helena F. Douglas Carr, MD, MMM Medical Director, Education & System Initiatives

2. Physician Group Practice Demonstration 2005-2010 The Alpha Medicare ACO Types of organizations: 2 MSGP 2 AMC 5 IDS 1 PHO Testing the concept that physician group practices can better coordinate care (Part A&B) than other delivery models to reduce rate of growth in per- capita expenditures while improving quality Rate of growth of PGP compared to same county comparison Individually risk adjusted (HCC) Attribution by plurality of office visits, All-Specialty Retrospective, blinded to both organization and beneficiary, changes yearly Minimum Savings Threshold: 2%, Cap: 5% Sharing is 80% only on savings >threshold but < cap Data feedback intended on quarterly basis 32 Quality measures (outpatient only, process + outcomes) create a gate for 50% of shared savings payment Shared Savings Model: FFS continues CMS shares % of calculated savings

3. Everett, WA – Everett Clinic Marshfield, WI – Marshfield Clinic Springfield, MO – St Johns Danville, PA-Geisinger Billings, MT-Billings Clinic St. Louis Park, MN – Park Nicollet Winston-Salem, NC-Novant- Forsyth Physician Group Practices Integrated Delivery Systems Academic Medical Center Ann Arbor, MI - University of Michigan Bedford, NH-Dartmouth Hitchcock 10 Organizations Physician-Hospital Organization Middletown, CT – Integrated Resources for Middlesex Area (IRMA)

4. Common Basis for Strategies among the PGP Groups 1. Focus: High Cost Areas Components of Medicare Expenditures For Billings Clinic (base year 2004) Inpatient40% Hospital OP24% Part B22% SNF 7% Home Health 3% DME 4% Reduce avoidable admissions, ER visits, etc. 2. Focus: Chronic Care & Prevention High prevalence and high cost conditions Provider based chronic care management Care transitions Palliative care Financial Savings are INPATIENT driven. Quality Measures are OUTPATIENT driven.

5. Diabetes Heart Failure Coronary Artery Disease HTN, Screening, Prevention Billings Clinic PGP Year 5 5

6. “A detailed analysis of the demonstration is currently available only for the first two years. That analysis showed that, for patients in the 10 group practices during the 2 nd year, average Medicare spending excluding the bonuses paid to physician groups was about 1 percent below projections…similar estimates are not yet available for other years…”

7. PY1PY2PY3PY4PY5Average Annual5 year Expenditures 1.21%2.00%2.56%3.63%2.37%2.39% 5 YearSavings$218,573,184$9,161,179,345 Summary Results

10. How The PGP (2005-2010) Influenced the Development of ACOs Accountable Care Act-2010: ACO provisions include Primary Care Attribution National comparison targets Target is absolute spending increase over base Retains risk adjustment Transition Demo (2011-12) Incorporated changes in ACA provisions Improved data reporting from CMS Quality Measures 32  45 Discussions/develop ment led to first ACO proposals that ignored some PGP recs The national consensus supported the PGP groups recommendations Final ACO Regs Quality Measures 65  33 Eliminate 25% withhold First Dollar sharing after minimum savings threshold Allows for 1 or 2- sided risk Preliminary prospective assignment 10

11. PGPTDACOPioneer Attribution retrospective All Specialty retrospective Primary Care BasePrior Year (2004) 3 -year wt. Averaging Term (before re- basing)3-->5 years233 Comparison Local Rate of growth National Absolute amount National 50% amount + 50% rate growth Threshold (MSR)2%1.47%-4.65% 2-3.9% or 2%1% Savings 80% above MSR 50% first dollar 50% above MSR or 60% first dollar 50% first dollar Quality Gate50%80%, 90%100% Quality Measures324533 Loss RiskNo No (1 sided) Yes (2 sided)Yes Risk Adjustment retrospective updated yearly prospective adjusted yearly prospective fixed for term Comparison of Shared Savings Models

12. Growth and Dispersion of Accountable Care Organizations November 2011 ACOs BY SPONSORING ENTITY “The range of entities that have sponsored ACOs, from small IPAs to national insurance companies indicates the wide range of business models that will ultimately provide accountable care.” Medicare SSP has lead to commercial adoption of ACOs Market specific clustering of activity Basic tenets of accountable care previously existed; title is new “It appears, for now, that defining oneself as an ACO represents an acceptance of the direction the industry has been headed rather than an adoption of a truly new form of care delivery.”

13. Growth and Dispersion of ACOs November 2012 30 SS-2 sided FFS Capitation Episode/DRG 36%34% 30%

14. 14 Projected Spending Target Spending Shared Savings Actual Spending ACO Launched Many ACOs are reimbursed on a Shared Savings model based on Spending Targets

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16. 16 Movement Towards ACO Raises Key Questions What is the COST impact of delivering accountable care? What is the REVENUE impact of delivering accountable care? What is the COST impact of building an ACO? How do you manage the hospital and physician relationship through transition to an ACO? How do you manage two parallel entities through the transition? How do you manage the pace of that transition? 16 Current FFS System Accountable Care Organization 16

17. 17 ACO Core Components People Centered Foundation Health Home High Value Network Population Health Data Management ACO Leadership Payer Partnerships Foundational Philosophy: Triple Aim ™ The Bridge from FFS to Accountable Care What are the underpinning building blocks? Current FFS System Accountable Care Measurement 17

18. The ACO Model 18 A group of providers willing and capable of accepting accountability for the total cost and quality of care for a defined population. Payer Partners  Insurers  Employers  States  CMS Core Components: People Centered Foundation Health Home High-Value Network Population Health Data Mgmt ACO Leadership Payor Partnerships

19. Why PCMH within ACO? Emphasizes prevention Encourages cognition/relationship over technology Less variation in utilization Allows for most efficient delivery methods: allied professionals, phone, e-mail, web-enabled Proven concept in other modern nations, staff- model HMOs Access closest to patients Promotes shared decision making Leverage point for post-hospital care

20. Montana Patient Centered Medical Home Initiative 10-2009 MT Medicaid received planning grant from NASHP to develop PCMH model; stakeholder discussion developed into planning for a multi-payer model 10-2010 Commissioner of Securities and Insurance assumed role of facilitating discussions among MT payers and providers 5-2011 Working group adopts NCQA Recognition as a definition standard of PCMH for Montana 9-2011 Creation of PCMH Advisory Council sponsored by office of Insurance Commisioner 2012 Adopted Framework for Payment as guideline for contract development Created Uniform Quality Measure Set Recommended the attributes of a state technology reporting platform; verified that designated HIE (Health Share Montana) meets them Developed proposed legislation to create commission with statutory authority to develop the market rules that encourages multi-payer PCMH www.csi.mt.gov/medicalhomes

21. BCBSMT PCMH Program Begun in 2009 with Western Montana Clinic (St. Patrick Hospital) and Billings Clinic. Added St. Patrick’s, CMC, Kalispell, Bozeman, and St. Vincent’s 2010-2011. Added Northern Montana Hospital and South Hills Medical Group in 2012. Planning to add St. Peters, Benefis, Holy Rosary. Limited to PCP providers with access to EMR. 2009/2010: Chronic disease only. 2011 and beyond: Chronic disease and preventative care. 21

22. PCMH-Physician Groups (*=active) Physician GroupNumber of Physicians Billings Clinic*77 MD (16 IM, 25 FP, 18 Peds, 18 OB), 23 Midlevel Western Montana Clinic*31 MD (8 IM, 14 FP, 5 Peds, 4 OB), 7 Midlevel St. Patrick’s Hospital*15 MD (6 IM, 9 FP), 5 Midlevel Benefis14 MD (7 IM, 3 FP, 4 OB), 5 Midlevel St. Peters Hospital14 MD (2 IM, 12 FP) Kalispell Regional MC*20 MD (3 IM, 6 IM-Peds, 11 FP), 11 Midlevel Comm. Medical Center*20 MD (5 IM, 11 FP, 4 Peds), 7 Midlevel Bozeman Deaconess*26 MD (9 IM, 6 FP, 6 Peds, 5 OB), 7 Midlevel Northern Montana Hosp*10 MD (3 IM, 5 FP, 2 OB) St. Vincents*9 MD (7 IM, 2 FP) Holy Rosary Healthcare4 MD (1 IM, 1 FP, 2 OB) South Hills Med. Group*2 MD (1 NP) Total Phys./Midlevels242 MD (67 IM, 99 FP, 6 IM-Peds, 33 Peds, 35 OB), 66 Midlevel. 22

23. 2012 BCBSMT PCMH Program Chronic Diseases Asthma Ischemic Vascular Disease Depression Diabetes Preventative Care Preventative exam Smoking statusBMIBP Breast cancer screening Cervical cancer screening Colon cancer screening Immunizations 23

24. BCBSMT-PCMH Early Trends PCMH ~ 16,000 LivesTotal Trend: 3.1% Stop-loss, excess risk adjusted Trend: 2.6% Evidence-Based Care Prevention Improved documentation and reporting on quality measures All other PCPs ~36,000 lives Total Trend 7.1% Stop-loss, excess risk adjusted Trend: 7.2% Status quo

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26. PCMH Perspectives Provider Team Model best able to Improve access Ensure EBM care Re-energize profession Requires Investment & Change IT FTEs Financial risk (reimbursement for non-RVU work, critical mass of pts.) “Rules of the Road” will help PCMH standards Framework for payment Quality metrics/reporting Payer Financial risk/commitmen t with need for eventual ROI Assurances that a practice is transforming Standards Quality reporting Improved Access Increased satisfaction Better outcomes Prevention EB Care Patients

28. 28 Questions?