Dan Nye Central Florida Kidney Centers

1. Dan Nye Central Florida Kidney Centers Challenges of ACO’s & Integrated Care

2. Challenges of ACO’s & Integrated Care Growth trends in the ACO arena and the expanding Market of Integrated Healthcare At least one ACO in is present in 75% of all the major markets in the US. ACOs choose one of the two “risk” tracks proposed by CMS for garnering shared savings (or even shared losses) Most ACOs are very likely to also contract with Private Payers in a similar fashion. There are already several Payers and Providers who have entered into aligned incentive contracts aiming to reduce redundant or unnecessary utilization and increase performance against evidence based quality measures. Standardization and clinical protocols of care designed to: reduce variance, coordinate care improve performance Specific quality measures will be the low hanging fruit for easy savings. “ACOs are like the elusive unicorn, everyone knows what one looks like but no one has actually seen one”. Well, ACOs are not unicorns anymore. CMS has implemented and is refining rules The ACO movement will be much more of an evolution than a revolution.

3. Suppliers perspective • Selling products to ACO providers is a great time to evaluate value propositions • Ensure alignment with ACO goals of improved quality and reduced costs. • Need to ensure that quantifiable metrics are known to decision makers • choosing “premium” or “standard” product lines. • Do the ancillary or downstream costs of choosing a lesser expense device or drug outweigh the immediate savings? • Premium product suppliers will have to prove it with greater rigor and validity. . • Can suppliers add value to products by aligning with ACO needs to: • use lower cost sites of service • meet specific performance measures, • activate patients to make greater contributions to their own health outcomes? Challenges of ACO’s & Integrated Care

4. Specialty ACOs: The Next Step in Integrated Accountable Care • The concept of accountable care organizations has mainly been focused on primary care since the idea was formalized by the Patient Protection and Affordable Care Act in 2010. • Lately, however, the focus of ACOs has shifted slightly from primary care to specific chronic diseases, such as cancer, chronic kidney disease and end stage renal disease. There are major cost savings to be had in chronic disease management. • 1.3 percent of Medicare patients have end stage renal disease, but they account for 7.5 percent of annual Medicare spending, per the USRDS 2012 report. • In 2010 cancer care cost the nation $124.6 billion, according to the National Cancer Institute. • That number is expected to continue to grow • The National Institutes of Health has projected national cancer costs will reach $158 billion by 2020. • Because of the scale of the cost, small changes can really move the odometer. • Small percentage points of savings in a specialty role can provide significant return. • This is important to us in ESRD, as we are on a similar high aggregate cost per patient healthcare expenditures. Challenges of ACO’s & Integrated Care

5. Providing low-cost, high-quality specialty care can be hard on a traditional ACO's budget • One or two high-cost episodes can blow an ACO’s budget. • That’s why ACOs are currently managing high-risk patient populations by contracting treatment out to specialty practices in the area. • For example, Phoenix-based Southwest Kidney Institute works that way with Banner Health's ACO. • When Banner became an ACO, they decided to reach out, and collaborate • Based on the close relationship between Banner & SWKI they can work together and help each other achieve the goals of an ACO • Enhancement of the relationship and sharing of the philosophies • Under the agreement with Banner, SWKI, a nephrology group with 35 physicians, is a part of Banner's risk-baring Pioneer ACO agreement. • This type of arrangement is becoming more and more common as organizations are getting their beneficiary list and have patients with a high propensity to those diseases, • This works because large specialty groups typically do a better job managing the cost of patient care. Challenges of ACO’s & Integrated Care

6. Taking it a step further: Contracting with Payors • Many specialty groups are providing care for patients by working with primary care ACOs in their area. • Some groups are going a step further and signing contracts with payors to form their own, disease-specific ACOs. • For example, insurer Florida Blue formed two oncology ACOs in 2012: • One with Tampa, Fla.-based Moffitt Cancer Center • Another with Coral Gables, Fla.-based Baptist Health South Florida and an oncology group. • "Oncology costs are the biggest cost driver in Florida," says Jon Gavras, MD, CMO of Florida Blue, of why the insurer sought out the new model. • Going after the hard one first! Was the mindset of Florida Blue • CMS is also getting into the disease-specific ACO space. With our new ESCO (Comprehensive ESRD Care initiative specific to end stage renal disease) • How the model works • Specialty ACOs, like the organizations Florida Blue has put together, are set up in a similar fashion to the nation's primary care ACOs. • If providers succeed in improving on several quality metrics, such as reducing readmissions and overall drug costs, they can share in the financial gain Challenges of ACO’s & Integrated Care

7. ESRD & the ESCO Model of Integrated Care • The ESRD ACO program set up by CMS also has a similar format to primary care ACOs. • The provider groups will be evaluated on their performance on quality measures and can then share in Medicare savings with CMS if they meet those metrics. • There are some differences between the two styles of ACOs. • There will be a large focus on providing evidence-based care in the ESCO • Need to design clinical pathways…that reflect how we deliver care. • They are specific steps to take with each dialysis patient. • Size • When it comes to the success of a disease-specific ACO, the size of the practice involved and its patient base matters. • Many chronic diseases typically have low patient volume, the patient base for some practices may be too small to work in an ACO model. • If you are too small the population doesn't have enough members to bare the risk out. • Hence the 350 patient minimum for the Renal ESCO • Looking back at the Moffitt center that serves thousands of patients each year and is well established in its market. • But not every practice has a well-established patient base. Challenges of ACO’s & Integrated Care

8. ESRD & the ESCO Model of Integrated Care • Collaborate • Collaboration avails the opportunity for specialty providers to come together to form a larger patient base • Creates the opportunity to gather the data necessary to succeed in an ACO. • Example…. Southwest Kidney Institute • success tools in the ESCO initiative model. • Nephrology group is working with others in its market and Athenahealth • Pooling of data in one warehouse for better future leverage with payors. • Pooling all of the groups' data into one warehouse and working together, the groups achieve a larger patient base. • Necessary for success, and also become more attractive to payors. Challenges of ACO’s & Integrated Care

9. ESRD & the ESCO Model of Integrated Care • Example 2…. FPG Pioneer ACO • Primary Care Managed Care Group in Orlando w/ over 54,000 covered patients • Collaborates with Multiple specialties in Greater Orlando • Gastro, Cardiology, & ESRD (Central Florida Kidney Centers, Inc) • Enhanced existing Patient Data Repository • Continual enhancements to Data Analytics • Development of Patient trends for holistic disease management • Integrating and sharing patient ESRD data in Data Repository • Coordination of care for patients from Stage 3 thru 5 of Kidney Disease • Aggressive management of stage 3 & 4 • Lower level of acuity for patients as they transition to stage 5 • Utilization of Coordinated Care Case Manager Challenges of ACO’s & Integrated Care

10. Challenges of ACO’s & Integrated Care • Collaboration • After the specialty ACO format is nailed down start to organize • New organization will have to somehow work with existing primary care ACO’s to provide care to chronically ill patients. • The big debate to overcome • Who is going to be accountable for a patient. • Need to be made clear who the primary [physician] is and who is secondary. • The primary physician [for a patient] could be the specialist. • The Devil is in the details as the ESCO model is still evolving. • Keep current on the Regulations and how they impact your model. • Need to determine how this collaboration will work between primary care ACOs and disease-specific ACO’s. • The groups must work together to keep patients healthy, which could prove to be a power struggle.

11. The Future • Many payors are still primarily developing relationships with providers to form primary care ACOs and groups that have already entered the specialty ACO field. • Focus on total cost of care ACO’s. • Ultimately, disease-specific ACOs hold great promise of cost savings and improved care. • Especially in oncology and ESRD. • CMS will look to the successes & failures of thr ESCO model to develop future disease specific ACO’s Challenges of ACO’s & Integrated Care

12. What’s Happening with the Pioneer ACO’s over the first 18 months • As the deadline nears for Medicare's first accountable care organizations to decide whether they will continue with the initiative; • Possible changes to the program's design that would address how geographic variation in healthcare costs and use could affect potential bonus payouts. • The Pioneers were the first to test the payment model under the Patient Protection and Affordable Care Act and were followed by Medicare's less-ambitious Shared Savings Program, which has 220 ACO’sand continues to expand. • Pioneer ACOs lack some of the advantages of Medicare managed-care plans to help hospitals and doctors control costs and improve quality. • Patients “can go where they want” under accountable care, despite the fact that hospitals and doctors within the ACO are held responsible for the quality and cost of patients' care. • Under managed care, patients have a limited choice of hospitals and doctors. • Information about the use and cost of healthcare for patients included in the ACO has been slow in coming from CMS. • Billing data from Medicare managed-care patients would be more timely. Challenges of ACO’s & Integrated Care

13. Why one Medicare Pioneer ACO succeeded in saving money. “HOW WE CAN LEARN FROM THEM” • Beth Israel Deaconess Care Organization, a Boston-based ACO, came in 4.2% below it’s budget target. • produced more than $15 million in shared savings, which it split with Medicare • Utilization of a sophisticated computer algorithm to see who's at risk for hospitalization. • Data is shared with the primary-care doctors and the ACO collaboratively develops care-management resources as appropriate. • refined data analytics were essential tools that helped them achieve the savings. • Utilize data to target high-risk patients for tailored services. • Treating patients in the most cost effective triaged environment • Sickest homebound patients benefited from the organization's nurse practitioner home visit program, versus being treated in the ER. • Nurse Practitioners visited these patients at least monthly. • Similarly, registered nurses serving as care managers helped the next-lower tier of sick patients through both telephonic and personal visits. Challenges of ACO’s & Integrated Care

14. Why one Medicare Pioneer ACO succeeded in saving money. “HOW WE CAN LEARN FROM THEM” • Primary Care Leadership Structure • Establish primary-care pods, or groups of physicians. • Each pod has a primary-care physician leader who thoroughly understands how to manage patient health on fixed payments. • Each Leader communicates with colleagues about care management and utilization of services. • Primary-care structure facilitates communicate with all primary-care physicians what the programs are and how to avail access. • Enhanced development and understanding how to continually improve quality and decrease unnecessary utilization. • Gather data and allow providers to see where they stand on respective benchmarks Challenges of ACO’s & Integrated Care

15. Tackling Reporting Challenges • Accountable care organizations need to be successful at reporting. • Medicare Shared Savings Program and Pioneer ACO participants must report to CMS on patient health outcomes to track quality and outcome performance. • Case Sample • Cumberland Center for Healthcare Innovation, a physician-driven ACO based in Cookeville, Tenn. • The ACO is made up of 29 independent physician practices spread through 14 counties in rural Tennessee. • There are 12 different electronic medical record systems in the ACO. • ACO’stend to tie together physicians from different practices and even multiple hospitals that all bring their own style of data entry and EMR use to the table. • Used analytics to overcome the hurdle of disparate and varying EMR systems& successfully reported necessary data to CMS • Utilizing outside help availed CCHI the ability to take a number of EMRs and the same data from different fields and consolidate it. • This fixed the ACO's two main reporting concerns in one fell swoop. • The fix was so effective, CCHI was able to report on 100 percent of the patients CMS asks for in the first year. Challenges of ACO’s & Integrated Care

16. 3 Organizational Tips for structuring your ACO &/or Integrated Care Group • Remember the End Goal • “Provide patient-centered, high-quality, low-cost care” • How is your organization is doing in terms of: • evidence-based medicine • providing patient-centered care. • 1. Take a Group approach to finding solutions • Get the leaders together and talk about the mission and ongoing activities of the organization. • You may realize you are already integrating care more then you think. • Look within your own community for hospitals, health systems or physician groups who are recognized PCMH organizations • If groups are already a PCMH, a lot of competencies that CMS is looking for are already displayed by achieving PCMH recognition Challenges of ACO’s & Integrated Care

17. 3 Organizational Tips for structuring your ACO &/or Integrated Care Group • 2. Define your governance. • A large chunk of the ACO application covers structure and governance • It is important to define what the governance structure and the leadership of the ACO is going to be. • Align your governance and the back-office to reach maximum capabilities • Develop a comprehensive plan to address all aspects of governance • Ex. How to address the requirement of having a Medicare fee-for-service beneficiary on the governing board, • Creative solution.. Develop a patient advisory panel with multiple patient members to incorporate a broad patient spectrum. •  3. Decide if the ACO will receive beneficiary-identifiable claims. • MSSP applicants have the choice of requesting beneficiary-identifiable claims data from CMS for Medicare beneficiaries who would be attributed to the ACO. • Take advantage of this • This is the data which will aid you in deciding/determine which patients have the highest opportunity for improved quality and reduced costs • Remember to detail how you plan to use the information and keep it safe. Challenges of ACO’s & Integrated Care

18. Managing ESRD Patients: The Strategy employed by One ACO • Heritage Provider Network, which runs the Heritage California ACO (Northridge, CA) • Partnered Fresenius Medical Care to provide integrated care management of the ACO's ESRD patients. • Fresenius nephrologists have signed up to be part of Heritage's ACO, • ESRD patients going to area Fresenius nephrologists are attributed in the ACO model to Heritage. • The two groups work together to coordinate the care of the ESRD patients. • Both when the care is provided in a Heritage ACO facility or a Fresenius facility. • Heritage is good at managing inpatient hospital care, getting excellent results and quality outcomes. • Fresenius is good at managing dialysis of ESRD patients. • Collaboration of both partners strengths leads to lower cost, higher quality care to ESRD patients in the ACO • Coordination of care with one another • Heritage ACO gave Fresenius access to its enclosed, self-contained ACO management electronic medical records system • Key access to patient data, care management plans and patient communication tools. • You can take a high cost, difficult to manage population and give them better care through coordination…. Challenges of ACO’s & Integrated Care

19. Four Key Parting Words • Collaborate • Facilitate • Analyze • Share Challenges of ACO’s & Integrated Care

20. Questions ???? Challenges of ACO’s & Integrated Care