Preliminary Recommendations on Patient Attribution and Financial Benchmarking

1. Preliminary Recommendations on Patient Attribution and Financial Benchmarking • for Providers • March 1, 2016 • 1:00-2:00pm EST

2. Welcome • Anne Gauthier • LAN Project Leader, • CMS Alliance to Modernize Healthcare (CAMH)

3. Session Objectives • Learn: • Understand the PBP Work Group recommendations on Patient Attribution and Financial Benchmarking • Identify barriers to payer and provider alignment on patient attribution and financial benchmarking methodologies • Engage: • Ask your questions • Provide your comments on the recommendations in the draft White Papers • Prepare to submit written comments on the papers

4. Agenda

5. KEY Discussion topics • What questions do you have about Patient Attribution & Financial Benchmarking recommendations? • What changes or additions to these recommendations would you suggest that would help you implement PBPs in your market? • What do you see as the most significant barriers to adopting these recommendations? • What are the barriers to private and public payers to adopting the same methodologies? Use the chat window in your webinar dashboard to provide comments, feedback, or presenter questions.

6. Poll • Who is in the audience? • Academic Health Center • Single-Hospital Network • Multi-Hospital Network • Community Health Center • Private Practice • Primary Care Physician or OBGYN • Specialty Care Physician • Medical Laboratory or Imaging Service • Mental Health Provider Organization • Post-Acute Care Provider—Rehabilitation • Post-Acute Care Provider—Skilled Nursing Facility • Post-Acute Care Provider—Nursing Home • Post-Acute Care Provider—Home Health • Other

7. Guiding Committee Welcome • Angelo Sinopoli. MD • Member, • LAN Guiding Committee • Vice President of Clinical Integration and Chief Medical Officer, • Greenville Health System

8. OUR GOAL Goals for U.S. Health Care Adoption of Alternative Payment Models (APMs) 2016 30% In 2016, at least 30% of U.S. health care payments are linked to quality and value through APMs. 2018 50% In 2018, at least 50% of U.S. health care payments are so linked. These payment reforms are expected to demonstrate better outcomes and lower costs for patients. Better Care, Smarter Spending, Healthier People

9. LEADERSHIP GROUPS • LAN has established seven groups with varying purposes. Guiding Committee Work Groups PBP Population-Based Payment APM FPT APM Framework & Progress Tracking CEP Clinical EpisodePayment Payer Collaborative Affinity Groups States State Engagement PAG Purchaser CPAG Consumer & Patient

10. ENGAGE, LEARN, AND ACT The LAN will only succeed with robust stakeholder engagement across the field Visit the Website Join the Discussion Follow Us Attend Webinars Access Resources Submit Comments Attend LAN-wide Meetings

11. LAN SUMMIT • https://www.lansummit.org • Spring LAN Summit • April 25-26, 2016 • Sheraton Hotel • 8661 Leesburg PikeTysons, VA 22182 • Save the Date • Presentations Planned from Work Groups on Work Products • Call for Sessions Coming Soon!

12. Q & A • What questions do you have about the Guiding Committee report? • Use the chat window in your webinar dashboard

13. Poll • What are the biggest barriers to adopting PBP models? Check all that apply • Patient understanding of PBP model • Various patient attribution tactics • Various benchmarking tactics • Variations in performance measures • Operational issues in sharing data • Capacity to make necessary changes • Legal and regulatory concerns • Other: write in biggest barriers

14. Moderator • Patient Attribution & Financial Benchmarking • Dana Gelb Safran • Chief Performance Measurement & Improvement Officer • Senior Vice President, Enterprise Analytics, • Blue Cross Blue Shield Massachusetts

15. PBP Work Group Population-Based Payment (PBP) 16 Members Chairs Dana G. Safran Chief Performance Measurement & Improvement Officer; Senior Vice President, Enterprise Analytics Blue Cross Blue Shield of Massachusetts Glenn Steele, Jr. Chairman, xG Health System • Key Activities • Establishing patient attribution and financial benchmarking standards • Developing performance measurement guidelines • Identifying data sharing requirements This group is identifying the most important elements of population-based payment models for which alignment across public and private payers could accelerate their adoption nationally, with a focus on data sharing, financial benchmarking, quality measurements, and patient attribution.

16. APM FRAMEWORK Population-Based Payment • At-a-Glance The framework is a critical first step toward the goal of better care, smarter spending, and healthier people. • Serves as the foundation • Provides a road map • Acts as a "gauge" for measuring progress • Establishes a common nomenclature and set of conventions Within the APM framework, population-based-payment models fall into categories some of 3 and 4. The framework situates existing and potential APMs into a series of categories.

17. Priority Areas • Population-Based Payment Work Group Draft February 8, 2016 Draft Summer 2016 Draft February 8, 2016 Draft Summer 2016 • Patient attribution identifies the patient-provider relationship and forms the basis for performance measurement reporting and payment in a PBP model. • Financial benchmarks are set to help providers and payers to manage resources, plan investments in delivery support infrastructure, and identify inefficiencies. PBP models require a measurement system through which providers and payers monitor performance, and performance is rewarded. Data sharing refers to the exchange of information between payers and providers to successfully manage total cost of care, quality, and outcomes for a patient population. Financial Benchmarking Patient Attribution Data Sharing Performance Measurement for PBP models for PBP models for PBP models for PBP models

18. Panelist • Patient Attribution • Amy Nguyen Howell, MD • Chief Medical Officer, • CAPG

19. Why Attribution?

20. Assumptions • For Patient Attribution • Patient attribution is a foundational component of population-based payment, as it identifies the patient-provider relationship and forms the basis for performance measurement, reporting, and payment. • Even though methods begin by identifying a patient-clinician dyad, recommendations use this information to attribute patient to the appropriate provider group/system for purposes of PBP models. • The consensus guidelines are intended for use in payment models that involve provider accountability for care across the full continuum. Different attribution methods are required for episode-based models. • The PBP work group suggests that the consensus guidelines should be generalizable for use across all commercial insurers and should be evaluated for applicability to government programs.

21. Key Steps • in Patient Attribution

22. Recommendations (PART 1) • Patient Attribution • Encourage patient choice of a primary care provider • Use a claims/encounter-based approach when patient attestation is not available • Define eligible providers at the beginning of the performance period • Provide transparent information to patients about their attribution • Prioritize primary care providers in claims/encounter-based attribution

23. Recommendations (PART 2) • Patient Attribution • Consider subspecialty providers if no primary care is evident • Use a single approach for attribution for performance measurement and financial accountability • Use the patient attribution guideline nationally for commercial products. • Alignment among commercial, Medicare, and Medicaid populations may be possible with adjustments. • Regardless of whether prospective or concurrent attribution is used, providers should receive clear, actionable information about patients attributed to them.

24. COMPARISON TABLE Comparison of the PBP Work Group recommendations with CMS program approaches to attribution 1 1 1 2 1 2 2 1 3 4 3 2 3 2 5

25. Panelist • Financial Benchmarking • Hoangmai H. Pham, MD, MPH • Chief Innovation Officer, • Center for Medicare & Medicaid Innovation

26. Principles • Financial Benchmarking • The purpose of financial benchmarks in PBP models is to enable accountability, compare performance across sites and over time, and to establish a target that fairly rewards high performers. • Payers should transparently communicate to providers the risk-sharing parameters involved in participating in a PBP model. • Unexpected events will require collaborative responses from purchasers, payers and providers. In such cases, trust between payers and providers must already exist to update methodologies in a way that is financially responsible and fair for providers.

27. Why Financial Benchmarking?

28. Assumptions • Financial Benchmarking • Participation in PBP models will likely be voluntary in the vast majority of circumstances, but participation in PBP models should be driven in part by decreasing demand for FFS-based alternatives. • Successful approaches to financial benchmarking must simultaneously encourage participation while meeting financial and quality objectives. • The goal of financial benchmarks is to enable 1) efficient provider organizations to succeed; 2) struggling organizations to improve; and 3) failing organizations to fail.

29. Recommendations (PART 1) • Financial Benchmarking • Approaches to financial benchmarking should encourage participation in the early years of the model’s progression, while driving convergence across providers at different starting points towards efficiency in the latter years. • The initial baseline should be based on provider-specific spending, taking into account the provider organization’s history and local market forces. • Updates to the initial baseline should quickly drive convergence around local spending rates, with an eventual movement to regional and national rates in the medium to long term. • That is, the initial baseline should be tied to organization-specific historic spending levels, but move towards regional spending levels and perhaps converge with national spending levels over time. Once convergence is achieved, the growth rates should inherently be the same. • There are multiple pathways to convergence, but the end point is what matters.

30. Recommendations (PART 2) • Financial Benchmarking • Risk adjustment must strike a fine balance, such that providers who serve disadvantaged populations are not unduly penalized, and disadvantaged populations do not receive substandard care. • The state of the art of risk adjustment is likely to change over time, and it will be important to keep up with recent developments that improve the precision of risk-adjustment approaches. • Risk adjustment models should minimize the connection between utilization and risk, in part by increasing the time lag between when variables are coded and when adjustments are applied. • Successful risk-adjustment models should accurately predict spending at the population and subpopulation, but it is not important for models to accurately predict spending at the individual level. • PBP models should not disrupt care for high-need populations, and risk adjusting for socioeconomic status (SES) may be one way to accomplish this. Nevertheless, SES adjustments should not be a mechanism for forgiving lower care for needy populations.

31. Discussion • What comments or questions do you have on the draft recommendations? • Use the chat window in your webinar dashboard

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