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Pioneer ACO Program Proposal Strategy
CPM Board Meeting Discussion July 27, 2011
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Discussion Objectives
Communicate MaineHealth and PHO activities regarding the Pioneer ACO Program Engage CPM in a discussion of what this means for CPM Discuss how to move forward given tight timeframes and complexity of situation
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We must be prepared to respond to the health reform imperative
National Conversation on Economy and Health Reform Commitment to Payment Reform: CMS MaineCare Commercial MaineHealth Must Respond System alignment with Triple Aim Changes for long term sustainability
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The Pioneer Program presents a strong opportunity to advance our preparation for health reform
Best current (not perfect!) option for CMS payment reform participation Our process is as important as the outcome: We will re-affirm capabilities for accountable care We will discover limitations we must address MaineHealth must respond. System alignment with Triple Aim Changes for long term sustainability
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The Pioneer Program contains several attractive design features and poses a number of challenges
Our Strategy Submit a proposal for an Alternative Payment Model in coordination with the Northern New England Accountable Care Collaborative Recognize our structure and approach may depart from what CMS is seeking but emphasize the value our proposal presents to them Plan to avail ourselves of the option to withdraw if necessary
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Points for Coordination
We will coordinate our responses to the Pioneer ACO Program with our NNEACC partners Points for Coordination Common format Joint proposal for an Alternative Payment Model Internal finances and risk pools are separate Cross reference content on technical, analytic, and quality improvement capabilities Propose common strategies for achieving the Triple Aim
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MaineHealth Pioneer AC Workgroup Members ~Physicians are in bold~
Quality Care Model Finance Steering Blumenfeld, Barry Cawley, Jacquelyn Cutler, Josh Fay-LeBlanc, Renee Fourre, Mark Powers, James Salvador, Doug Wennberg, David Wilson, Nathan Moore, Jennifer Nemec, Kimberly Patstone, Andrea Smith, Janet Albaum, Michael Wight, Joe Landry, Daniel Roy, Michael Belair, Norm Cox, John Kirby, Jeffrey McCue, Bob McGinty, Francis Moore, Jennifer Moynihan, Daniel Patstone, Andrea Swallow, Al Aalberg, Jeffrey Brewster, Tom Brown, Vance Clark, Mike Goldsmith, Dana Johnson, Betsy Stevenson, James Wennberg, David Arsenault, Maryanna Cowan, Tim Deatrick, Deb Haynes, Margaret Osgood, Julie Patstone, Andrea Bates, Peter Hawkins, Robert Herlihy, Kate Johnson, Betsy Lafleur, Joel Lavoie, Frank Loiselle, Daniel Brown, Vance Mette, Stephen Biscone, Mark Caron, William Churchill, Tim Frank, Robert McGinty, Francis Petersen, Richard Quigley, Donald Skillings, Lois White, Skip Wood, Peter Patstone, Andrea
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Subcommittee Reports Care Model: Jeff Aalberg Quality: Josh Cutler Steering: Stephen Mette Finance: Dan Landy
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System Approach to PCMH Three Critical Infrastructure Elements
HIT* Disease management platform Access to care Team building Culture modification Office system design promotes EHR Registry Secure messaging Monitoring outcomes Coordinating care Access to information supports *health information technology
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Care Model Work Group The Triple Aim* Helps Us Focus
*In The Triple Aim* Helps Us Focus Return to emphasis on health Improve care for the patient Watch the cost Macro integrator (Neighborhood) Resources & providers to support a population Micro integrator (PCMH) Providers delivering care with patient & family at the center Needs: infrastructure, integration and execution
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Quality Work Group Section E: ACO Motivation and Capabilities
27. … why the Applicant organization wishes to participate in the Pioneer Model 28. … description of the strength of the Applicant organization's primary care infrastructure 29. … narrative description of the Applicant organization's ability to accomplish Promotion of evidence based medicine Process to ensure pt engagement and SDM processes Care coordination Beneficiaries’ access to medical records Ensuring individualized care Routine assessment of experience of care Integration of care with community resources 30. Percent of providers that will attest to meaningful use by end of 2012 31. EHR functionality 32. 3rd party assessments of performance (NCQA, regional multipayer collaboratives, etc) 33. Experience in teaching or training in care improvement
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Quality Work Group Question 34
34. Please attach a narrative description and quantitative documentation of at least one illustrative instance in which the Applicant organization has designed, implemented, and assessed the effectiveness of specific care improvement interventions. Include information on how the problem(s) was identified, why and how the intervention(s) was selected and designed, how progress (or lack thereof) was measured, and any corrective action or adjustments made (maximum 5 pages, single spaced).
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Quality Work Group Question 34
System Capacity for QI Initiatives CPM/PHO, CIR MH Center for Quality and Safety MH Clinical Integration How we choose initiatives (Health status/health needs assessment) AMI (STEMI) Program Target Diabetes Rationale for choice Data reflecting improvement Program expansion/evolution Extension/translation into other management/improvement initiatives Chronic diseases; depression; hand hygiene
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Steering Work Group MaineHealth Pioneer ACO Definitions
Member. An entity that infuses capital into the ACO, assumes responsibility for financial operations, and is entitled and required to share in gains and losses sustained by the ACO. Participant. An entity connected by ownership or by contract to the ACO that is entitled to gains and assumes responsibility for losses sustained by the ACO. Network Provider / Supplier. An entity affiliated by a contract to the ACO that may be eligible for certain incentive payments based on either the performance of the ACO as a whole or the entity’s established costs and quality but is otherwise not entitled or required to share in and gains or losses.
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Board of Directors Decisions
Steering Work Group MaineHealth Pioneer ACO Proposed Governance Structure Board of Directors Decisions Election and annual evaluation/re-election of CEO Adoption of annual operating and capital budget Adoption of strategic, business, and financial plan Development of changes in programs and services Approval of contracts except as delegated to CEO Operations, management, and financial oversight and approvals
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Steering Work Group MaineHealth Pioneer ACO Proposed Governance Structure
Member Decisions Initial capitalization Future capital calls including reserve requirements ACO debt or capital expenditure exceeding $1,000,000 Mergers, Consolidations, Dissolution, Bankruptcy/insolvency Joint Ventures Amendment of Articles and Bylaws Addition of new members Election of Directors Weighted by capital investment, super majority, or majority
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Board of Directors – 12 Directors
Steering Work Group MaineHealth Pioneer ACO Proposed Governance Structure Board of Directors – 12 Directors MaineHealth 1 Management Maine Medical Center 2 Management 1 Physician 1 Hospital Trustee Other Members 2 Management Physicians 4 Physicians
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Finance Work Group Disclaimer: These are my interpretations of very complex material (i.e. over my head at times). ACO: New LLC ACO Contracts with MMC PHO to serve as care delivery system All Maine Health hospital and Mid Coast become members of PHO ACO Owners (Hospitals – limited to not-for-profit Entities) capitalize the entity with $10 Million 3 Proposed Models In all models: After achieve a 2% marginal savings, all savings are split 60% to ACO, 40% to CMS\ 1st million, and 25% of 2nd Million saved retained by ACO for any year to cover subsequent loss. After year 2, ACO responsible for 1st $million loss, and smaller portion of 2nd million. PHO responsible for remainder of loss
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Finance Work Group Model 1
%% Distribution of Gain %% Share of Loss ACO MH PHO ACO Participants Hospitals +45% -47.4% Primary Care +25% -26.3% Specialists +25% -26.3% Contracted Network Providers +5% -0%
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Finance Work Group Model 2 : Specialists may be eligible for incentive payments (model=12.5%) if goals achieved %% Distribution of Gain %% Share of Loss ACO MH PHO ACO Participants Network Provider Hospitals +57.5% -75% Primary Care +25% -25% Specialists +12.5% -0% Contracted Network Providers +5% -0%
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Finance Work Group Model 3: this model established to accommodate a Primary Care group not affiliated with PHO %% Distribution of Gain %% Share of Loss ACO **The Primary care groups share in the 25% gain / loss based on the individual performance of each MH PHO Unaffiliated Practice +25%* -25%* ACO Participants Network Provider Hospitals +57.5% -75% Primary Care +25%* -25%* Specialists +12.5% -0% Contracted Network Providers +5% -0%
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Finance Work Group Recommendation to CPM
Workgroup felt Model 3 most favorable: How do CPM Primary care feel about inclusion of Unaffiliated practice? Does inclusion of unaffiliated practice offer competitive disadvantage? Savings must flow to CPM for distribution to practice level Will assure Physicians remain in control of dollar flow Docs (rather than hospitals) must receive payments to incent savings. Money will not be equally distributed to practices but rather distributed based on pre-determined performance standards (Quality / Cost).
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Discussion
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