What You Need to Know About Medicare Advantage 2016 Annual AMGA Conference. Ken Cohen MD, FACP, CMO New West Physicians

Transcription

1 What You Need to Know About Medicare Advantage 2016 Annual AMGA Conference Ken Cohen MD, FACP, CMO New West Physicians

2 Who We Are Since our inception in 1994, New West Physicians has grown to become the largest physician-owned primary care group practice in Colorado Family practice, internal medicine, hospitalists, physician assistants, nurse practitioners, behavioral health, cardiology, neurology, endocrinology, and gastroenterology 95 providers 17 offices throughout the Denver Metro area Employees - $58M Revenue

3 Quality In 2011, the American Hospital Association commissioned a national study on Accountable Care and chose four delivery systems representing different models of care. New West Physicians was chosen as the primary care model for that study. In 2013, New West Physicians received the Colorado Best Practice of the Year Award by the Colorado Academy of Family Physicians Foundation. In 2015 the AMGA awarded NWP the Acclaim Award for the organization which most closely approaches the ideal health system as measured by the IOM Triple Aim

4 NWP and Medicare Advantage 12% of our total patient volume represents 40% of total revenue Average income in NWP is ~75% higher than Denver metro average MA bonus accounts for ~30% of average income

5 Population Health Management EHR with Data Timely Feedback to Physicians Care Mgmt Evidence- Based Guidelines at Point of Service Patient Centered Medical Home Access Patient Portal Team-Planned Visits Care Coordination ACO s Management of Full Continuum of Care Comparative Effectiveness Emphasis on Cost & Quality Remunerative Mechanisms

6 Essence of Population Health Management.. Achieving the simultaneous goals of: The delivery of high quality care The ability to provide high levels of patient service The elimination of wasted care

7 Population Health Management Primary Care ER and Urgent care SNF Care Specialty Care Post Hospital Care Transition Hospital Care Palliative and End-of-Life Care

8 Two Keys to MA Success Culture Supported by Infrastructure Attention to both revenue (premium) and expenditures

9 Revenue Side of the Equation Premium = RAF + CMS Star Rating

10 RAF Critical Importance Patient A healthy 65 year old annual premium from Medicare ~$6000 Patient B 78 year old with diabetes, congestive heart failure and peripheral arterial disease annual premium from Medicare ~$26,000

11 76-year-old Female Medicaid Eligible Diabetes Chronic Kidney Disease Stage 5 Ulcer Right Great Toe Health Status/DX Code HCC RAF Score 76 YO Female NA Medicaid Eligible NA E N L Total RAF 1.716

12 76-year-old Female Medicaid Eligible Type 2 Diabetes w/ Diabetic Chronic Kidney Disease Chronic Kidney Disease Stage 5 Dialysis Status Type 2 Diabetic Angiopathy w/ Gangrene Arteriosclerosis of Right Leg with Ulceration of Other Part of Foot Ulcer of Right Foot Great Toe with Necrosis of Muscle Amputation Status Left Great Toe Insulin Dependence Health Status/DX Code HCC RAF Score 76 YO Female NA Medicaid Eligible NA E N Z E I L Z Z Total RAF 3.848

13 Total yearly premium for first example = $14,300 Total yearly premium for this example = $31,500 Same patient/same diagnoses it s all in the coding! Health Status/DX Code HCC RAF Score 76 YO Female NA Medicaid Eligible NA E N Z E I L Z Z Total RAF 3.848

14 RAF Optimization 1 on 1 Provider Education RAF reference desk tool RAF Tips of the Week Quarterly reporting to all PCP s Yearly RAF sweep for missed codes Portion of individual bonus tied to RAF Coder feedback to providers

15 CMS Star Program Overview Plans rated at 1-5 stars no bonus if 4 star threshold not met Currently at 0-6% of premium $1.3 million per 10,000 lives if 4 star bonus achieved

16 Expenditure side of the equation There is no relationship between cost of care and quality of care More care does not equal better care

17 Wasted Care Wasted care is care that does not improve health outcomes or quality of life Estimated at 35% of all HC expenditures

18 Why Medicare Advantage? Largest pool of wasted care is in the Medicare population Elimination of wasted care and quality improvements translate directly into improved patient care and bonus revenue to the group

19 Wasted Care High Frequency Cardiology Asymptomatic CAD - Nuclear stress testing Preoperative evaluation Nuclear stress testing Mild to moderate valvular lesions echocardiogram Gastroenterology Colon polyp follow-up guideline Barrett s esophagus screening Pulmonary Low risk lung cancer screening Dermatology Mohs for small basal cell cancers

20 Wasted Care High Cost Urology prostate cancer screening > 70 yrs Orthopedics Lumbar fusion for osteoarthritis Arthroscopy in advanced knee DJD Neurology screening for asx carotid stenosis Oncology futile care for advanced cancers Lucentis/Eylea for macular denegeration

21 In Summary

22 Why Medicare Advantage Largest pool of wasted care is in the Medicare population Elimination of wasted care translates directly into bonus revenue to the group

23 Opportunities Improved patient quality and service Improved coordination of care Significant bonuses are achievable Autonomy from hospitals and health plans

24 Who Will Succeed? Culture is critical Shift from patient to population management Comprehensive care at all levels and locations, and across all specialties Accurate, timely and actionable data Focused case management Equal attention to both quality and utilization Aligned compensation model

25 Thank you and Opportunity for Questions The mission of New West Physicians is "to enhance the physical, mental and spiritual health of communities we serve through an integrated, primary-care owned and patient centered healthcare delivery system."