The Alphabet Soup of Change SIM CPCI TCPI ENSW ACC/RCCO MU 1-2-3 MIPS APM

Forget the Acronyms Colorado Health Extension Service: One souce of information. Clarity about who, what, where, when and how. Ongoing and improving as it does.

HHS Announcement Better Care. Smarter Spending. Healthier People In three words, our vision for improving health delivery is about better, smarter, healthier. If we find better ways to pay providers, deliver care, and distribute information: We can receive better care. We can spend our health dollars more wisely. We can have healthier communities, a healthier economy, and a healthier country. Incentives Focus Areas Description Care Delivery Information Encourage the integration and coordination of clinical care services Improve population health Promote patient engagement through shared decision making Create transparency on cost and quality information Bring electronic health information to the point of care for meaningful use Promote value-based payment systems Test new alternative payment models Increase linkage of Medicaid, Medicare FFS, and other payments to value Bring proven payment models to scale In three words, our vision for improving health delivery is about better, smarter, healthier. If we find better ways to deliver care, pay providers, and distribute information, we can receive better care, spend our dollars more wisely, and have healthier communities, a healthier economy, and a healthier country. We understand that it’s our role and responsibility to lead … and we will. What we won’t do – and can’t do – is go it alone. Patients, physicians, government, and business all stand to benefit if we get this right, and this shared purpose calls out for deeper partnership. So we will continue to work across sectors and across the aisle for the goals we share: better care, smarter spending, and healthier people. Source: CMS

Target percentage of Medicare FFS payments linked to quality and alternative payment models All Medicare FFS (Categories 1-4) FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4) 2016 2018 85% 30% 50% 90% Source: CMS

CMS Payment Reform – 4 Categories   Category 1: Fee for Service— No Link to Quality Category 2: Fee for Service— Link to Quality Category 3: Alternative Payment Models Built on Fee-for-Service Architecture Category 4: Population-Based Payment Description Payments are based on volume of services and not linked to quality or efficiency At least a portion of payments vary based on the quality or efficiency of health care delivery Some payment is linked to the effective management of a population or an episode of care. Payments still triggered by delivery of services, but opportunities for shared savings or 2- sided risk Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (i.e., >1 year) Medicare FFS Limited in Medicare fee-for-service Majority of Medicare payments now are linked to quality Hospital value-based purchasing Physician Value-Based Modifier Readmissions/Hospital Acquired Condition Reduction Program Accountable care organizations Medical homes Bundled payments Comprehensive primary care initiative Comprehensive ESRD Medicare-Medicaid Financial Alignment Initiative Fee-For-Service Model Eligible Pioneer accountable care organizations in years 3-5 Source: CMS

Current Law and SGR reform timeline Sunset of existing quality value penalties under PQRS, VBM, EHR 12/31/2018 Permanent repeal of SGR APM participating providers exempt from MIPS; receive annual 5% bonus (2019-2024) Track 1 Current Law 2018 4% Physician Quality Reporting System Penalty 2015 -1.5% 2016 & beyond -2.0% Value-based Payment Modifier penalty (up to %) -1.0% 2016 2017 -4.0% Merit-Based Incentive Payment System (MIPS) adjustments 2019 +/-4% 2020 +/- 5% 2021 +/- 7% 2022 & beyond +/- 9% MIPS exceptional performance adjustment; Up to 10% annually (2019-2024) Updates in physician payments 0.5% (7/2015-2019) 0% (2020-2025) 0.25% (2026 ) Meaningful Use Penalty (up to %) -4.0%? 2019 & beyond -5.0%? -3.0% 2018 & beyond ???% Track 2 0.75% update (2026 ) 2022 2023 2024 2025 2026 SGR repeal & annual updates 0.5% increase in physician payments for 5 yrs (beginning June 2015); Freeze through 2025 Beyond 2025: physicians in advanced payment models (APMs) receive 1% annual updates, all others receive 0.5% (these out years not pictured in graph) Time to develop quality measures & clinical improvement activities Value-Based Performance (VBP) Payment Program 2017, payments adjusted for physicians’ performance in prior period 2018: Consolidate PQRS, VBM & EHR MU into VBP 4% tied to performance in 2019; 5% in 2020; 7% in 2021; 9% in 2022 & beyond. Secretary can increase funding pool in 2021 and beyond to no more than 12% Maximum upside and downside adjustment equal to funding pool % (e.g. +/- 4% in 2019) Professionals will be measured on: Quality Resource use Clinical practice improvement activities EHR MU Encouraging provider participation in APMs APM participating providers exempt from VBP; receive annual 5% (2019-2024) Significant share of revenues must be from APM with 2-sided risk and quality measurement Reimbursed according to payment arrangements of model ANTHEM PROPRIETARY AND CONFIDENTIAL Source: Premiere

“Change Concepts”: 10 Building Blocks "Change concepts" are general ideas/directions for transforming a practice to stimulate specific, actionable steps that lead to improvement. (Wagner et al, 2012; Commonwealth Fund) Insights from PCPCC Accredidation Work Group Demonstrating value & performance (continuous commitment to and skill at ongoing measurement of quality, costs, patient experience, organizational performance) Access (acute/urgent care appointments, non-traditional hours, telehealth, someone on the care team who has patient information 24/7, interoperable EHR) Process to include patients as partners (in quality improvement, care design, patient and family engagement, evaluation, peer support) Population health management (empanelment, risk stratification, data-driven technology, evidence-based care guidelines, social determinants, health literacy, shared care planning) Organized teams provide comprehensive care to include behavioral health support, health coaching, care coordination, shared decision making Organizational Culture Change (leadership commitment, leadership skill in change management, coaching and developing the team, satisfied patients and staff, operational efficiency) Bodenheimer et al (2014) http://www.annfammed.org/content/12/2/166.full

The Care Model

Medical Practice vs. Leadership Practice (Gordon Barnhart, O’Brien Group) Physician Leader Prescribe and expect compliance Immediate and short term focus and results Procedures and/or episodes Relatively well-defined problems Consistently effective solutions, protocols, best practices, processes Increasing focus on specialization Focus on patient’s interests Working with a person or family Being “the” expert Relating primarily to the physical being Relating to sick/injured people Working solo or with small teams Receiving lots of thanks Respect and trust of colleagues Lead, influence and collaborate Short, medium and long term focus and results Complex processes over time Ill-defined and messy problems Frequent environmental shifts requiring complementary changes in solutions, processes, best practices, style and approaches Increasing need for comprehensive and integrated approach Focus on patients’ interests Working with many diverse stakeholders Being one of many experts Relating to whole beings Relating to healthy people Working with larger teams and complex networks Encountering lots of resistance Suspicion of being “a suit”

Physician vs. Team Physician Self-sacrifice Physician-driven care Individual hero Ownership: “my patient” Full control Lone expert Team Building relationships Collaborative health workers Well-being of all team members Collaborative responsibility: “our care” Shared control Team expertise

Important Components Align stakeholders Workflows Team based Patient engagement Technology Physician engagement Effectiveness

Risk Stratification Process 1 2 3 Identification of Patients by Payor/ Program Stratification of Patients by Risk Allocation of Resources by Skill Set/Type of Intervention Rising Risk Moderate Risk Low Risk High Risk # Chronic Conditions Health Care Utilization Clinical Risk Social Risk Behavioral Risk Source: Mount Sinai Health System , Managing High Risk Populations - Adding Value While Aligning Care Coordinators, Patients and Physicians , slide 14

Value Based Payment vs. FFS Volume

Value Based Payment vs. FFS Volume

Isn’t the second pie bigger? No. Total Cost PMPM Advanced Practices $479.30 Behavioral Health Payments $4.35 Total $482.85 Conventional Network Average $505.83 Risk Normalized Difference -4.54%

“The best way to predict the future is to invent it.” ~ Peter Drucker