Join us for “LAN Learnings in August,” a LAN webinar on August 17 from 12:00-1:30 PM ET, where the featured promising payment practice will be presentations on innovative bundled payments for joint replacements. The Centers for Medicare & Medicaid Services (CMS) will highlight their experience with testing bundled payment and quality measurement for an episode of care associated with hip and knee replacements. You will also hear a perspective from a provider who has applied innovative bundled payments for joint replacements.
For the Guiding Committee update portion of the webinar, Guiding Committee cochair Mark Smith will share outcomes of the July 30 Guiding Committee call (also see below), results from the kick-off meeting of the APM Framework and Progress Tracking Work Group, and plans for the next LAN work group while providing an opportunity for LAN participants to ask questions and offer comments.
Register for the third webinar in the LAN monthly series.
The LAN Guiding Committee held a virtual meeting on July 30. Members heard an update on the APM Framework and Progress Work Group, the first to be launched. They then identified the focus for the next two work groups [see sidebar Work Group Corner].
Potential work group focus areas had been narrowed down to clinical episodes and population-based payment/ACO-like models at the Committee’s June 22 meeting. At that meeting, the members also agreed that for these and other work groups, it would be necessary to specify model components for alignment among payers, such as attribution and performance measurement.
The members decided that a population-based payment model work group would be launched next. A kick-off call will be scheduled in September. A clinical episodes bundle work group will be started in October, initially focusing on joint replacement.
The Committee also talked about opportunities to engage and inform LAN participants. Guiding Committee members are poised to be both dissemination channels and sounding boards to expand LAN awareness and input, especially as the work groups begin developing recommendations.
Slides and a longer summary for this meeting will be posted on the Guiding Committee.
The second LAN webinar on July 21 attracted nearly 1000 registrants. It featured presentations by two health plans on the use of innovative payment approaches for cancer care. LAN Guiding Committee Co-Chair Mark Smith began the webinar by summarizing outcomes from the June 22 Guiding Committee meeting. He also described plans for the first LAN work group, the APM Framework and Progress Tracking Work Group, chaired by Dr. Sam Nussbaum, which held its kick-off call on July 31. A description of the Work Group can be found here.
Dr. Lee N. Newcomer, Senior Vice President, Oncology, Genetics and Women’s Health presented UnitedHealthcare’s pilot that explores a head and neck cancer care payment model focused on quality patient care and outcomes. UnitedHealthcare launched a cancer episode payment pilot in 2009 that modified the current fee-for-service payment by adding feedback data and incentives that rewarded physicians for improved quality and lower total costs. The results were very positive: for 810 patients, there was a 34% reduction of total medical costs, with a savings of $33 million. These significant savings were achieved without any measurable effect on quality outcomes or toxicity, which challenges the assumption that any reduction of resources results in worse outcomes for cancer. An article about the pilot is available here.
Dr. Jennifer Malin, Staff Vice President, Clinical Strategy, presented A
nthem’s pathway-oriented model, which provides certain treatment options and provider payment arrangements. Oncologists participating in the Cancer Care Quality Program receive additional up-front payment for treatment planning and care coordination when they select a Pathway treatment regimen. Pathways are a subset of regimens supported by evidence and clinical guidelines, aligned with health plan medical policies, and reviewed by external advisors. The program is administered through a web-based platform with low burden for practices. Since the program rolled out in July 2014, Anthem found that the Pathway payment equalizes the difference between what oncology practices earn in Anthem’s program and what they would earn for higher cost, but not necessarily more effective, drug regimens.
Shelley Fuld Nasso, Chief Executive Officer of the National Coalition for Cancer Survivorship (NCCS), discussed the importance of patient engagement in cancer care planning through shared decision-making at diagnosis and at major transition points during treatment and survivorship. NCCS considers changing the conversation between doctor and patient as the essential foundation of delivery reform. Payment reforms must be aligned to improve communication, treatment decision-making, symptom management, and coordination of care. Ms. Nasso listed nine principles for patient-centered payment reform.
On Friday July 31, the APM Framework and Progress Tracking Work Group launched its effort to address two key objectives identified by the LAN Guiding Committee: 1) to provide recommendations on a framework for categorizing APMs, and 2) to provide a recommended measurement framework for tracking the progress of APM adoption across the U.S. health care system. Led by Dr. Sam Nussbaum, Executive V.P., Clinical Health Policy and Chief Medical Officer at Anthem, Inc., this 14-member group represents a diversity of LAN stakeholders. Its next meeting will be August 27 in McLean, Virginia.
Next Work Groups Identified
At its July 30 meeting, the Guiding Committee confirmed plans for future work groups.
The goal of the second work group is to determine the most effective way to align the nation’s payer and provider efforts around population-based payment models (PBPMs). The work group will focus on six “components” that comprise essential programmatic features of PBPMs (e.g., patient attribution and financial benchmarking). For each component, the work group will recommend national payment standards, allowing for variation between different types of PBPMs (e.g., physician- vs. hospital-led) and different levels of operational readiness.
The work group will tackle each component in a series of six sprints, incorporating input from the LAN. Once a set of recommendations has been finalized, members of the work group will implement them within their networks of influence, with the proximate goal of having 50% of PBPMs implementing the recommendations within two years of their finalization. The work group will be composed of diverse stakeholders, representing payers, providers, and consumers who have substantial experience implementing PBPMs in the public and private sectors.
The third work group, to launch in October, will determine the most effective way to align the nation’s payer and provider efforts around clinical episode-based payment by focusing on a series of episodes that when combined represent a spectrum of episode types. The first will be joint replacement. Cancer care, maternity care, and cardiac care are under consideration to follow. The group will work in a series of sprints to define key technical components, such as episode definition, quality measures, benchmarking, and data sharing. One preliminary proximate goal is for 5-10 large payers and 5-10 large provider systems to use the findings to begin to experiment with a wider variety of episode types within one year of finalization.
LAN participants may suggest individuals or organizations to be represented on these Work Groups. Stay tuned for the call for nominations.
The National Rural ACO pools knowledge, patients, and resources so that independent community health systems can participate in new population healthbased reimbursement models. Lynn Barr, MPH, Chief Transformation Officer, spoke with a member of the CAMH team on July 28th .
[CAMH]: What is the National Rural ACO’s goal, and what key approaches are you using?
Barr: We focus only on rural communities. Though 20% of Medicare beneficiaries get care in rural America, these health systems are far behind in population health management. Many have not done care coordination, performance measurement, etc. Our goal is to help them make improvements in quality and cost. For example, their aggregate quality scores in 2014 were 60%. We want to get to 70-75% in year two and 80-90% in year three. We also aim to reduce costs by 10% within the first three-yearcycle. For 2016, we’re putting in applications to CMS for 26 rural ACOs with 179 health systems in 32 states. Our biggest goal is getting people started on the journey of population health management. We are very excited about that.
Our first step is to set up care coordination in each community. Every member hires a care coordinator. This is great for the patients, and it helps lower costs and improve quality. Second, we add annual wellness visits. A provider can hit 11 quality scores in an annual visit. About 50% of our members haven’t been doing annual wellness visits. It’s a billing issue. In other feefor-service clinics, when a patient comes in for a regular visit, the provider can also do the wellness visit and bill for both. Rural providers and Federally Qualified Health Centers aren’t allowed to bill separately. That’s a huge disincentive. The third component is reducing Emergency Department (ED) utilization. Rural beneficiaries use the ED for primary care because rural providers aren’t available 24/7. Fifty percent of rural ED visits are for primary care. Total ED utilization per beneficiary is 20% higher than the national average. We want to bring that down significantly. Another component is analytics. We provide data to support the other three components. It makes a big difference. For example, we found that the cost of home health in one of our ACOs is $1000 per month, while the national average is just $300. There is a great opportunity to make a difference.
[CAMH]: Who can join? Is there a typical profile of a member?
Barr: All our members are “community health systems.” Typically there is one hospital with a group of affiliated physicians. Our goal is to take that delivery network and integrate it with others to improve performance and coordinate care.
[CAMH:] How much variety is there across your ACOs and why?
Barr: Rural providers are very diverse. Our hospitals range from 4 to 250 beds. Our communities have anywhere from 175 to 8,000 attributed patients, with the average being about 1,000 attributed lives.
[CAMH:] To what extent are rural health systems’ challenges unique?
Barr: One of the biggest differences is size. Almost all of these health systems don’t have the minimum 5000 attributed beneficiaries, which is why we need to combine them. They have extremely limited capital; lack of funding is a huge barrier. They also have very little IT infrastructure, so we have to provide it for them. Almost all have electronic health records. Rural providers are right up with rest of country for EHR adoption, but their EHRs are very simple. We use the Lightbeam Health population management system to pull all their claims data together with their clinical data. Data is critical. We get it to them quickly and show them how to use it. Their care coordination program is built around claims data.
[CAMH]: Are the components of your ACO approach different from what might work in urban ACOs?
Barr: Yes, they are very different from urban ACOs. The top rural health system concerns are building relationships with patients and building secondary and tertiary networks. They have few or no networks and highly fragmented care. For example, the 175 patients in our smallest community with were seen in 75 different Part A facilities in the last 2 years. Our focus is around engaging the community and, as a result, improving cost and quality. Urban ACO communities are huge. You can’t really understand the concept of community until you live and work in a rural hospital. Everyone shows up for a hospital board meeting and cares about their providers. In small communities, patients have deep relationships with their providers. We can succeed and thrive by serving their needs.
Urban ACOs don’t focus on community per se, because the ACO is just one of many players in town. Their patients change providers more often, so they focus on services they deliver and how to maximize cost and quality improvements. Our biggest advantage is that the patient population tends to be more stable. They may go other places for care, but they tend to come back home. For example, if we do a good job on colorectal screening, we can wipe out colorectal cancer in our town. That is very satisfying.
Also, our approach wouldn’t work so well in urban settings where there is competition. There isn’t competition among our rural health systems, so it is easier to build collaboration.
On the other hand, we are similar to urban ACOs, insofar as this is a lot of hard work for everyone.
[CAMH]: Do you have any results yet?
Barr: Our first ACO started in the 2014 performance year. By end of the first year, it had reduced utilization in every category except physician visits. It is too early to tell for the others. We only have 90 days of data so far, but there are some promising trends.
[CAMH]: What in your mind are the most important lessons you’ve learned so far about standing up and running ACOs in rural health systems?
Barr: We changed the program quite a bit after the first year. We initially thought start up would be simpler. It takes a lot more interaction than we had assumed. We had to increase staffing to work more closely with each partner.
It is more labor intensive, but rewarding. We really appreciate the support we are getting from the CMS Center for Medicare and Medicaid Innovation. We feel that they are committed to helping rural providers and to our success.
Be the first to visit and join the new LAN collaboration portal! This platform gives you the opportunity to connect with other LAN participants, have discussions on payment models, and share resources. LAN work groups will post questions and draft products to get your input. You’ll also receive updates on LAN activities, including Guiding Committee meetings, work group announcements, and webinar invitations and archives. Bookmark it so you can keep abreast of new updates.
Stay tuned for information and registration details for a fall stakeholder meeting we are planning for the Washington, D.C. metro area. This meeting will provide an opportunity to exchange ideas on new payment models with other participants and hear from success stories. There will be updates from LAN work groups as well as general and breakout sessions. We hope you will join us!
To achieve the goal of better care, smarter spending, and healthier people, the U.S. health care system must substantially reform its payment structure to incentivize quality, health outcomes, and value over volume. The Health Care Payment Learning and Action Network (LAN) was established as a collaborative network of public and private stakeholders, including health plans, providers, patients, employers, consumers, states, federal agencies, and other partners within the health care community.