Accountable Care Organizations: Health Care Delivery Redesign Thomas J. Biuso MD, MBA UnitedHealthcare Medical Director Clinical Assistant Professor of Medicine, University of Arizona

Presentation Goals Understand the reasons why we need new models of care and the implications of the ACA Answer the question: what is population health and what drives its costs? Define accountable care organization and its primary role Appreciate the difficulties for a network to integrate and coordinate care Understand the importance of community involvement

Why We Do What We Do – Achieving the “The Triple Aim”! Improve population health Improve individual experience Control inflation of per capita costs Triple Aim The Triple Aim: Care, Health, And Cost. Health Affairs, 27, no.3 (2008): Donald M. Berwick, Thomas W. Nolan and John Whittington

Population Health Williams Amy et al. Delivering accountable care to patients with complicated chornic illness. Am J Kidney Dis 2012;59(5):

Map or revascularization rates, by hospital referral region, from 2003 to Goodney P et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes 2012;5:94-102

What Accounts for Variation Patient-level differences Physician-level differences (volume, specialty, and use of endovascular procedures) Hospital-level differences (size, teaching status, financial status) Supply sensitive vs preference sensitive (shared decision making)

Alignment Drives Value High Quality Low Cost VALUE Care Management Programs Transparency and Premium Designation Program High Performing Preferred Networks Value-based Benefits Value-based Contracting

Delivery System Transformation Value-based Continuum Level of Financial Risk Degree of Provider Integration Fee-for-service Performance-based Contracts (PBC) Bundled/Episode Payments Shared Savings Shared Risk Capitation Capitation + PBC. Performance-based Programs Centers of Excellence Accountable Care Programs

What is an ACO? Primary care led, coordinated care organization that accepts a global budget for managing a defined population Facilitate the transformation of the current fee- for-service payment system into one that rewards greater quality and efficiency in care delivery and improved outcomes

Types Large primary care clinic Multispecialty group Integrated delivery system Physician Hospital Organization Independent Physician Association

Centers for Medicare and Medicaid Services Pioneer Shared Savings Program Advance Payment Model

Facts 114 provider groups in Medicare Shared Savings Program Shared Savings ACOs include 2 dozen smaller groups in CMS Advance Payment ACO Model Almost all Shared Savings ACOs chose the 3 year contract model with only 7 that opted for two-sided risk model 32 large provider groups launched Medicare Pioneer ACO 6 large integrated delivery systems in Physician Group Practice Transition Demonstration

Transformation Health information technology Care management Performance measurement Physician engagement Patient engagement Community involvement

Prioritizing Care Plan Management & Care Coordination 14 Multiple Chronic Conditions & Complex Patients

Rules for the Shared Savings Program Performance measures specified by CMS fall into four domains: - patient caregiver experience - care coordination and patient safety - preventive health - at risk population

Quality 33 quality measures in 4 domains that include patient experience, care coordination/patient safety, preventive care, and at-risk population first 18 months is for reporting must exceed 30 th percentile in 70% of the measures in all domains

Strategy Consider financial opportunity vs. strategic move Strategy means 3 year commitment with several questions that need to be answered: Will an ACO harm financial performance? Can ACO increase market share? Will an ACO allow better competition for commerical payer book of business?

Costs Network development and management Care coordination, quality improvement, and utilization management Clinical information systems Data analytics

Questions