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Successful Switch Hitting in a Combined Volume and Value Environment

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Successful Switch Hitting in a Combined Volume and Value Environment J. Churchill Hindes PhD (Iowa 1977) Chief Operating Officer, OneCare Vermont ACO – PowerPoint PPT presentation

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Title: Successful Switch Hitting in a Combined Volume and Value Environment


1
Successful Switch Hitting in a Combined Volume
and Value Environment
  • J. Churchill Hindes PhD (Iowa 1977)
  • Chief Operating Officer, OneCare Vermont ACO
  • Vice President for Accountable Care, Fletcher
    Allen Health Care
  • Clinical Associate Professor of Medicine,
    University of Vermont

2
HEALTH CARE IN VERMONT
  • Vermont superlatives Small, pretty, rural
    healthy
  • First or second Healthiest State in the USA
  • 625,000 population (equals Denver or Milwaukee)
  • Low number of uninsured6.8 (before exchange)
  • Low to average health care spend per person
  • Health care is nearly 20 of state economy

3
HEALTH CARE IN VERMONT
  • 2 academic health systems
    (University of Vermont and nearby Dartmouth)
  • 14 hospitals (8 are Critical Access)
  • 1,900 physicians (65 are hospital employed)
  • Two commercial health insurers dominate market
  • All major players are non-profits
  • Largely non-competitive provider model

4
HEALTH CARE IN VERMONT
  • Aggressive state reform agenda
  • Committed to Single Payer by 2017
  • Fueled by SIM fundingMost per capita in USA
  • Exchange required for individuals and business
    lt100
  • One dominant, liberal political party
  • Closely regulated health care system
  • Providers and public sector closely engaged

5
HEALTH CARE IN VERMONT
  • University of Vermont (UVM, in Burlington) is
  • 90 minutes south of Montreal Canada
  • 6 hours north of New York
  • 4 hours north of Boston
  • Dartmouth and UVM on opposite state borders
  • VT NH among smallest states with Med Schools

6
Top 10 University Hospital
  • University HealthSystem Consortium (UHC) ranked
    University of Vermont / Fletcher Allen Health
    Care
  • 1st in the nation for patient safety for 2014
  • 7th for overall quality of care

7
Vermonts Reform Legacy
  • Northern New England Medical Compact (1958)
  • Cooperative Health Information Center of Vermont
    (1970)
  • John Wennbergs small area variations (1970)
  • CON controls (since 1979) Hospital budget
    reviews (since 1983)
  • State public controls after Reagan era relaxation
    (1987)
  • Vermont Program for Quality in Health Care (1988)
  • Medicaid expansion (1987)
  • Health insurance reforms (1991)
  • Creation of statewide Health Care Authority
    (1992)
  • Howard Deans unsuccessful universal access
    attempt (1992-94)

8
Vermonts Reform Legacy
  • Blueprint for HealthChronic disease and PCMHs
    (2003)
  • Choices for Care long term care reforms (2004)
  • Statewide HIE mandate (2005)
  • Catamount Health Plan (2007)
  • Contribution to and capitalization on PPACA (2010
    to present)
  • William Hsiao Report on 3 Single Payer
    opportunities (2011)
  • Single Payer mandate (2011)
  • Green Mountain Care Board (2011)
  • OneCare Vermont first statewide Medicare ACO
    (2013)
  • Medicaid and Commercial ACO programs (2014)
  • Physician Assisted Dying legislation (2014)

9
Health Care Reform Path 2011-2017
2010-2011 Legislative Action National
PPACA Vermont Act 48
2012-2014 Becoming Real National ACA benefit
plans, exchanges, Medicaid expansion Vermont SIM
Grant, VT Health Connect, Multi-Payer ACOs
population-based SSP on top of FFS
2017 Future Model National Refined national
model and/or state innovation Medicare/Medicaid
funding challenges Vermont GMC as right of
citizenship new funding and provider revenue
model(s)
2014-2016 Redesign and Results National MSSP ACO
risk stabilize ACA and national
exchange Vermont ACO Multi-Payer GMC Funding
design continued provider consolidation Start
move to non-FFS
2011-2012 Early Implementation National MSSP
ACO Program Age 26 Exchange Planning Vermont
GMCB seated VT exchange legislation Hospital NR
growth limits, payment reform pilots
10
Vermont Public Reforms
  • Primary public agenda elements
  • Act 48
  • Commitment to Single Payer reforms
  • Public financing of system (taxes replace
    premiums)
  • State Innovation Model grant program (SIM)
  • Payment reforms away from fee-for-service
  • Vermont Health Connect (PPACA insurance exchange)
  • To become single payer enrollment tool
  • To access to federal exchange premium subsidies
  • Insurance market changes
  • Individuals, most employers must purchase via
    exchange

11
Key Public Priorities
12
Vermonts Private Reforms
  • Primary private elements include
  • Capitalize on federal and state legislative
    opportunities
  • Explore payment reform alternatives to fee for
    service
  • shared savings gt bundled payments
  • global budgets gt pay for performance
  • Explore Accountable Care Organizations and
  • ACO programs (Medicare, Medicaid, Commercial)
  • Integrate Vermont Blueprint for Health PCMH
    initiative
  • Structural changes (UVM Network, OneCare Vermont
    ACO)
  • Eliminate cost shift
  • Eliminate premium hikes at multiples of GDP rates

13
Key Provider Priorities
14
Vermonts Reform Landscape
15
Who Should Focus on What?
16
Both Pulling Together
17
Filling the Funnel
18
Filling the Funnel (detail)
19
Flowing to Providers
20
Flowing to Providers (detail)
21
(No Transcript)
22
Enter the OneCare Vermont ACO
  • OneCare Vermont ACO
  • Began in 2012 as joint venture between Dartmouth
    and University of Vermonts Academic Health
    System to
  • Explore potential for further collaboration
  • Attempt a broad statewide population health
    strategy
  • Present a unified front in politics of Vermont
    reforms
  • Structured as a Medicare SSP track one ACO

23
Enter the OneCare Vermont ACO
  • OneCare Vermont ACO
  • Discovered by Vermont public reform authority
  • Adopted as a SIM program payment reform pilot
  • Asked to co-design Medicaid and Commercial ACO
    deals
  • Agnostic to revenue sources including tax funding
  • Now providers lead vehicle in Vermont reform
    efforts
  • Commissioned to design flow from bottom of the
    funnel
  • Goal is a design that is
  • Collaborative, cohesive and consistent
  • Sustainable with reasonable growth rates

24
Center Place in the Landscape
25
Vermont is a bit different
  • Across the nation, ACOs are typically business
    arrangements between groups of providers and one
    or more payers. Providers see ACO as a way to
    maybe make a little extra money.
  • In Vermont, ACOs are business arrangements
    between groups of providers and multiple payers.
    Providers see ACO as a way to maybe make a little
    extra money
  • AND, the ACOs (particularly the OneCare ACO) are
    high profile leaders for statewide health care
    reformprivate provider led efforts that
    complement the public sector led initiatives

26
ACOs as a platform for reform
  • ACOs as a Health Care Reform Trifecta
  • Structure a broad network of linked providers
  • Contract voluntarily to mutual performance
    agreements
  • Commit to better understand community status
    needs
  • Commit to test and add new ideas into daily
    practice
  • Strive to achieve slower cost growth
  • (While improving clinical quality and patient
    satisfaction)
  • Collaborate with insurers (Medicare, Medicaid,
    Blues)
  • Willing to be paid differently
  • Willing to assume more financial risk

27
OneCare Vermont Roles
Legislators
  • Provider-Led, Population-Based Coordination,
    Alignment, and Support
  • Forum for Delivery System Design/Optimization
  • Payment Reform Leadership
  • Revenue Model Design
  • Incentive Programs
  • Care Management Design and Support
  • Primary Care/PCMH Alignment
  • HIE Facilitation
  • Population-Based Clinical and Analytic Systems
  • Quality Measurement

Regulator(s)
Payer(s)
ACO
Physicians
Hospitals
Other Providers
28
OneCare Vermont
  • Multi-payer, private/public collaboration
  • Credentialed by Vermont reform authority as a
    SIM payment reform program
  • 100,000 attributed beneficiaries
  • (16 of statewide population)
  • 750,000,000 accountable spend
  • (17 of statewide health care spending)
  • MSSP began January 2013
  • Medicaid (VMSSP) began January 2014
  • Commercial (XSSP) began January 2014
  • Quality measures CMS-33 plus others for
    Medicaid and Commercial ACO programs
  • Preparing for two-sided risk starting in 2016

29
OneCare Vermont
  • Statewide ACO Provider Network
  • Two Academic Medical Centers
  • (University of Vermont and Dartmouth)
  • Every hospital in the state
  • 550 Primary Care clinicians
  • 90 are NCQA medical home practices
  • 1,400 Specialist physicians
  • 4 Federally Qualified Health Centers
  • 5 Rural Health Clinics
  • Broad network model
  • Nearly every VNA, Hospice, SNF and
    Community Mental Health and Substance Abuse
    agency statewide
  • Links to other large ACOs in upstate New York,
    New Hampshire and Maine

Hospitals with Employed Attributing Physicians
Significant Attribution from Community Physicians
30
Some OneCare Notable Notes
  • Central role in Vermont statewide health care
    system reform 
  • Credentialed by state regulators as payment
    reform program
  • One of very few statewide ACOs in nation
  • One of few ACOs sponsored by two academic health
    centers
  • One of largest rural ACOsnow at over100,000
    attributed lives
  • Now accountable for 750,000,000 in health care
    costs and growing
  • One of relatively few multi-payer ACOs
  • Unusually broad-spectrum provider network
    strategy
  • Linked to ACOs from St Lawrence valley in New
    York to coastal Maine
  • Close collaboration with Vermont s statewide
    medical home model
  • Designed to be compatible with Vermonts plans
    for Single Payer

31
The Future of Vermont Reforms
  • Opportunities
  • Providers are engaged and collaborative
  • Population-based approach is being widely
    embraced
  • Broad physician alignment
  • 65 of MDs work for hospitals or FQHCs
  • All hospitals and FQHCs are in multipayer ACOs
  • Data infrastructure is approaching maturity
  • Statewide HIE
  • All-payer claims databases
  • Northern New England Accountable Care
    Collaborative
  • OneCare provides statewide framework for real
    change

32
The Future of Vermont Reforms
  • Challenges
  • How do you improve on our high-performing system?
  • Ongoing tension about who should lead reform
  • Best public-private balance?
  • Best locus for public leadershippolitical or
    policy centric
  • Best roles for providers / payers / ACOs / state
    agencies?
  • Providers concerns about their future
    sustainability
  • Wariness about Vermont state intensions
  • Wariness about Dartmouth and UVM intensions
  • The heaviest lifting has yet to come

33
Some Key Unknowns
  • Will Vermont receive its required federal
    waivers?
  • Will the Vermont legislature approve public
    financing? The largest tax increase in state
    history Substituting payroll taxes
    for private insurer premiums
  • Where will Single Payer risk be held?
  • Will state or providers control key reform
    infrastructure?
  • What role will commercial payers continue to
    play?
  • Will ERISA plan employers successfully sue
    Vermont?

34
Some Key Unknowns
  • How will Vermont reforms impact out of state
    providers?
  • (Dartmouth Hitchcock, Boston Childrens)
  • Will the reforms adversely impact the state
    economy?
  • Will Vermonts high performing system be
    maintained?
  • What will the changes mean for Vermont providers?
  • Will changes result from the Nov 4 Vermont
    elections?
  • Will changes result from the Nov 4 federal
    elections?

35
A Closing noteThenand now!
  • Then C. Rufus Rorem
  • visited us at Iowa and spoke
  • about his work on the CCMC
  • 1969 -1925 It was 44 years ago!
  • None of us were born then!
  • What an old codger!
  • Now J. Churchill Hindes came to
  • Iowa in 1969, back speaking today
  • 2014 -1969 Its been 45 years!
  • None of us were born then!
  • OMG! Who? Me? Old?!

36
Questions and Discussion
churchill.hindes_at_onecarevt.org802-847-6249
37
(No Transcript)
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