Maximus, Inc. · NYSE:MMS
Maximus — MAXIMUS Webinar Series (October 2010)
36 slides from Maximus's conference presentation, Oct 29, 2010
Slide 1: Accountable Care Organizations and Patient Centered Medical Homes
Accountable Care Organizations and Patient Centered Medical Homes October 29, 2010 Joshua Lipsman, MD, JD, MPH Medical Consultant, MAXIMUS MAXIMUS Webinar Series 1
Slide 2: Goals of the Presentation
Goals of the Presentation • Explain ACOs and PCMHs in the context of health reform • Lay out the statutory and structural foundations of ACOs and PCMHs • Show the relationship between ACOs and PCMHs • Offer some policy considerations around ACOs and PCMHs MAXIMUS Webinar Series 2
Slide 3: Topics to Be Covered
Topics to Be Covered 1. Health Reform Legislation 2. Accountable Care Organizations 3. Patient Centered Medical Homes 4. Health Homes MAXIMUS Webinar Series 3
Slide 4: Health Care in the U.S.
Health Care in the U.S. • Ever changing field • Always searching for the “holy trinity”: cost, access, quality • Historical examples: health insurance, Medicare, Medicaid, HMOs, CQI, MCOs, P4P • Among the latest: Electronic Health Records (EHRs), Accountable Care Organizations (ACOs) and Patient Cen
Slide 5: ARRA and PPACA on EHRs and ACOs
ARRA and PPACA on EHRs and ACOs • ARRA HITECH push for EHRs • PPACA (H.R. 3590) amends §1899 of SSA, ACO incentives under Medicare by 1/1/12 • PPACA includes Pediatric ACO Demonstration Project: authorizes States to offer incentives through Medicaid and CHIP, 1/1/12 – 12/31/16 • HHS Secretary to iss
Slide 6: Accountable Care Organization
Accountable Care Organization • Term attributed to Dr. Elliott Fisher (Dartmouth Atlas Project), 2006 • Shifts locus of accountability from individual provider to collective entity, from per unit payment to outcomes • Network of physicians and other providers working together to improve quality and
Slide 7: ACO Implications for Cost and Quality
ACO Implications for Cost and Quality • Public and private payers hold system accountable for high-quality care while reducing unnecessary cost • ACO that improves performance financially rewarded • Virtuous cycle of improved care management, further rewards, steady evolution toward fully coordinate
Slide 8: ACO Statutory Entities
ACO Statutory Entities • Physicians and other professionals in group practices • Physicians and other professionals in networks of practices • Partnerships or joint venture arrangements between hospitals and physicians/professionals • Hospitals employing physicians/professionals • Other forms the Se
Slide 9: Shortell and Casalino, 2007
Shortell and Casalino, 2007 9
Slide 10: Health Policy Brief: Update - Accountable Care Organizations
“Health Policy Brief: Update - Accountable Care Organizations. Health Affairs, August 13, 2010 http://www.healthaffairs.org/healthpolicybriefs/ 10
Slide 11: Health Policy Brief: Update - Accountable Care Organizations
“Health Policy Brief: Update - Accountable Care Organizations. Health Affairs, August 13, 2010 http://www.healthaffairs.org/healthpolicybriefs/ 11
Slide 12: ACO Statutory Requirements
ACO Statutory Requirements • Shared governance • Legal structure to receive/distribute shared savings • Leadership and management structure includes clinical and administrative systems • Adequate patient/provider ratio • Minimum 5000 patients (Medicare fee-for-service parts A and B) • ACO agrees to
Slide 13: ACO Statutory Requirements (cont'd)
ACO Statutory Requirements (cont’d) • Promote evidenced-based medicine • Patient engagement and patient-centeredness (e.g., patient/caregiver assessments, individual care plans) • Coordinate care, especially through health IT • Cannot also be under “independence at home” or 1115A pilot • Other less
Slide 14: ACO Quality Requirements
ACO Quality Requirements • Likely will measure: – Clinical processes and outcomes – Patient and, where possible, caregiver experience – Utilization • CMS may raise standards over time, introduce new measures • Must be met to receive payment • Consider tie to CMS QIOs, other like organizations MAXIMU
Slide 15: ACO Reporting Requirements
ACO Reporting Requirements May include: • Care transitions across settings – Hospital discharge planning – Post-hospital discharge follow-up • PQRI-related – E-prescribing – EHRs – Eligible for additional incentive payments MAXIMUS Webinar Series 15
Slide 16: Payments to ACOs
Payments to ACOs • Continue to receive routine payments, plus • If estimated average per capita expenditure is at least x percent below adjustable benchmark, as determined by • Most recent available three years of comparable expenditures, then • A percent of that percent up to a specified limit, but
Slide 17: Spending Before and During an ACO
Spending Before and During an ACO ACO launch Shared savings Projected Spending Spending Benchmark Actual Spending MAXIMUS Webinar Series 17
Slide 18: Other ACO considerations
Other ACO considerations • Secretary to determine how to assign patients to ACO • Assignment invisible to beneficiary and will not affect benefits or choice of doctor • Patients free to come and go at will • If avoid high-risk patients, sanctions (including termination as an ACO) • Is a new concept
Slide 19: Pediatric ACO Demonstration Project
Pediatric ACO Demonstration Project • States apply to DHHS for authorization to allow pediatric ACOs similar to §1899 ACOs • Five year window (1/1/12 – 12/31/16), ACO must participate minimum three years • Care guidelines developed by Secretary in consultation with States and providers • ACO enters
Slide 20: Challenges for ACOs
Challenges for ACOs • Current fee-for-service model entrenched; volume maximizers reluctant to change • Smaller practices lack IT and administrative infrastructure • Antitrust and other legal hurdles • Monopolies could cause failure to realize savings • Up front incentives needed for some MAXIMUS We
Slide 21: Challenges for ACOs
Challenges for ACOs • Determining benchmark thresholds • Determining savings distribution methodology among providers • Not a closed system: efficiency leaks out, cost leaks in • Maintaining or improving quality while cutting costs • Measuring quality MAXIMUS Webinar Series 21
Slide 22: PCMHs
PCMHs • An ACO is built on physician practices that may be organized as PCMHs • The ACO is the medical neighborhood for the PCMH • ACO and PCMH models are complementary • >20% of US population (~65MM) live in officially designated primary care shortage areas MAXIMUS Webinar Series 22
Slide 23: Accountable Care Organization and Patient Centered Medical Home
Patient Accountable Centered Care Medical Organization Home MAXIMUS Webinar Series 23
Slide 24: PCMH
PCMH • NCQA standards – Reflects principles developed by • American College of Physicians (ACP) • American Academy of Family Physicians (AAFP) • American Academy of Pediatrics (AAP) • American Osteopathic Association (AOA) – New standards expected 1/11 • Joint Commission to begin accrediting Primary
Slide 25: PCMH
PCMH • >100 demonstration projects have already tested effectiveness of PCMHs • Thirty-one states planning or implementing PCMH pilots within Medicaid or CHIP • Twelve states have developed PCMH initiatives involving multiple payers • CMS developing Medicare-specific demonstration (2010) • Medicare
Slide 26: PCMH
PCMH • Private payers supporting PCMH include – Aetna – CIGNA – Empire BlueCross BlueShield – Group Health Cooperative – Independent Health – Geisinger Health Plan • Payment model – Ongoing fee-for-service payments – Fixed (typically monthly) case management fee – P4P bonus payments MAXIMUS Webinar
Slide 27: PCMH defined (§3502)
PCMH defined (§3502) A model of care that includes • Personal physicians • Whole person orientation • Coordinated and integrated care • Safe and high-quality care through evidence informed medicine, appropriate use of health information technology, and continuous quality improvements • Expanded acce
Slide 28: PPACA on PCMHs (1)
PPACA on PCMHs (1) • Secretary, through AHRQ, to establish Primary Care Extension Program (PCEP) employing Health Extension Agents to assist primary care providers (PCPs) to implement PCMHs • Competitive grants to States for PCEP State Hubs to assist PCPs to implement PCMHs – Hubs to include state h
Slide 29: PPACA on PCMHs (2)
PPACA on PCMHs (2) • Secretary to implement grants or contracts to establish community-based interdisciplinary, inter-professional teams (“health teams’’) to support PCMHs • Secretary, with quality experts and stakeholders, to develop guidelines for health plans to report to Health Benefit Exchanges
Slide 30: PPACA on Health Homes
PPACA on Health Homes • State option to provide Health Homes (HHs) to Medicaid enrollees with chronic conditions begins 1/1/11 • Extra payments for providing HHs • $25MM for planning grants to States (with required match) also available beginning 1/1/11 MAXIMUS Webinar Series 30
Slide 31: Health Home definitions
Health Home definitions • Chronic conditions include – Mental health condition – Substance use disorder – Asthma – Diabetes – Heart disease – Being overweight • Health Home means individual or team providing – comprehensive care management – care coordination and health promotion – comprehensive tra
Slide 32: Challenges for PCMHs
Challenges for PCMHs • Healthcare system and medical culture inertia or opposition • Structure/definition • Upfront costs; involvement of facilitators • Concomitant payment model change (ACO?) • Patient expectations • Name? HHS: Advanced Primary Care Practice MAXIMUS Webinar Series 32
Slide 33: Resources
Resources • "Health Policy Brief: Accountable Care Organizations," Health Affairs, July 27, 2010 • Shortell, Casalino and Fisher, “How The Center For Medicare And Medicaid Innovation Should Test Accountable Care Organizations,” 29, no. 7 (2010): 1293- 1298 • Cohen, “A Guide to Accountable Care Organ
Slide 34: Resources
Resources • “Health Policy Brief: Patient-Centered Medical Homes,” Health Affairs, September 14, 2010 • NCQA, Physician Practice Connections® - Patient-Centered Medical HomeTM • CMS, Details for Medicare Medical Home Demonstration • PCPCC, Patient Centered Medical Home MAXIMUS Webinar Series 34
Slide 35: Questions??
Questions Questions?? MAXIMUS Webinar Series 35
Slide 36: Thank you!
Thank you! For more information, please email us at: webinars@maximus.com @MAXIMUS_news MAXIMUS Webinar Series 36