PRESCRIPTIONS FOR EXCELLENCE IN HEALTH CARE A COLLABORATION BETWEEN JEFFERSON SCHOOL OF POPULATION HEALTH AND LILLY USA, LLC ISSUE 23 | WINTER 2015 EDITORIAL TABLE OF CONTENTS ACOs Due for Their Annual Checkup David B. Nash, MD, MBA A Message from Lilly: Opportunities, Uncertainty Loom in 2015 for the Editor-in-Chief Health Exchange Marketplace Ryan Urgo, MPP ....................................................2 As 2013 drew to a close, Premier with more than 190,000 physicians Healthcare Alliance predicted and other health care professionals Biography of a New ACO Joel Port, FACHE .............................................4 that participation in accountable participating.2 Although the care organizations (ACOs) would number of Medicare ACOs has Evolving Health Care Models and double in 2014 as a result of more grown more rapidly than the the Impact on Value and Quality providers developing core ACO number of non-Medicare ACOs, Bruce Perkins ...................................................6 capabilities.1 Premier’s forecast 46-52 million Americans (15%- Employers and Accountable Care was made on the basis of its 18% of the total population) are Organizations: A Good Marriage? survey of 115 senior executives patients in organizations with ACO Laurel Pickering, MPH .....................................9 that revealed a growing trend in arrangements with at least 1 payer.2 high-risk population management, coupled with reductions in cost The next question is, are ACOs and increases in health care quality doing what they are designed to do and patient satisfaction. Of those (ie, improving quality and lowering who responded: costs)? Although it is far too early to draw conclusions, the Centers • More than 75% reported for Medicare & Medicaid Services Prescriptions for Excellence in Health that they were integrating (CMS) has begun to release Care is brought to Population Health clinical and claims data to financial and quality outcomes. Matters readers by Jefferson School better manage population Matthew Petersen and David of Population Health in partnership with Lilly USA, LLC to provide essential health respondents. Muhlestein provide a good synopsis information from the quality improve- in their article, ACO Results: What ment and patient safety arenas. • 50% reported using predictive We Know So Far. For example: analytics to forecast individual Editor-in-Chief patient and population needs. • The Pioneer ACO program David B. Nash, MD, MBA reported mixed results; of the Managing Editor • 46.3% reported using $147 million in total savings, Janice L. Clarke, RN, BBA integrated data to bring about a $76 million of which was Editorial Staff reduction in silos. returned to the program, only Deborah C. Meiris 12 of the 32 original ACOs Alexis Skoufalos, EdD So, as we barrel toward 2015, is the shared in the savings. All This newsletter was jointly developed and subject to ACO movement gaining traction? Pioneer ACOs were successful editorial review by Jefferson School of Population By mid-2014, a leading health in reporting quality metrics Health and Lilly USA, LLC, and is supported through funding by Lilly USA, LLC. The content and viewpoints care data and research resource (related to patient experience, expressed are those of the individual authors, and identified 537 ACOs nationwide are not necessarily those of Lilly USA, LLC or the Jefferson School of Population Health. (up from 320 the previous year), CONTINUED PRESCRIPTIONS FOR EXCELLENCE IN HEALTH CARE care coordination, patient I couldn’t agree more with solutions for enhancing quality safety, preventive health, Petersen and Muhlestein – these health outcomes at a lower cost. and at-risk populations) and early results have real value that With the aid of a clever analogy, demonstrated improvement goes beyond answering the “Employers and Accountable Care where comparable data question of how we’re doing. Organizations: A Good Marriage?” were available.3 They can be enormously useful sheds light on the pros and cons of in helping ACOs develop this interesting “relationship.” • The broader ranging, and winning strategies and avoid less stringent, Medicare potential pitfalls. As always, I welcome feedback Shared Savings ACO program from our readers at 2 released preliminary results on In this issue, we wrap up our [email protected]. 114 ACOs that were started in series on Creating a Framework 2012. Of the 54 that held costs for Accountable Care with REFERENCES below established budget articles from 3 different but 1. Leventhal R. Premier Report: ACO participation rates projected to double in 2014. Healthcare benchmarks, 29 received a complementary perspectives. The Informatics, December 18, 2013. http://info. portion of the $126 million in first article relates the “Biography of healthdirections.com/blog/bid/331272/Report- Hospital-ACO-Participation-Projected-to-Double- shared savings – in addition a New ACO,” an ongoing exercise in-2014. Accessed October 22, 2014. to generating $128 million in in transforming health care 2. Perna G. Report: number of ACOs ticks above total CMS trust fund savings. delivery and adjusting to payment 500. April 25, 2014. http://www.healthcare- informatics.com/news-item/report-number- Importantly, all but 5 of the reforms in a large urban/suburban acos-ticks-above-500/. Accessed ACOs successfully reported health system. “Evolving Health September 29, 2014. 3. Petersen M, Muhlestein D. ACO results: what the required set of 33 ACO Care Models and the Impact we know so far. Health Affairs Blog, May 30, quality metrics.3 on Value and Quality,” offers a 2014. http://healthaffairs.org/blog/2014/05/30/ aco-results-what-we-know-so-far/. Accessed glimpse into innovative payer September 29, 2014. initiatives; specifically, Humana’s A MESSAGE FROM LILLY Opportunities, Uncertainty Loom in 2015 for the Health Exchange Marketplace Ryan Urgo, MPP With open enrollment for the 2015 Health Exchange a 25% increase in the number of issuers offering Marketplace now under way, insurers are preparing Marketplace coverage for 2015 compared to 2014.2 for what they hope will be a promising start to Recently, HHS has tamped down expectations the new plan year. After turning the corner on a for total enrollment in 2015, predicting a range challenging launch in 2014, state-run and federally- somewhere between 9 and 10 million.3 However, facilitated exchanges have enrolled just under 7 staffing decisions made by many national plans million beneficiaries, meeting the estimate set by suggest a decidedly more bullish position. According the Congressional Budget Office in May 2013.1 to a recent survey by Reuters, most large national These enrollment numbers were reassuring to managed care organizations expect a minimum 20% plans, leading many national and regional insurers to increase in their 2015 Exchange membership, and expand their presence in 2015. many have doubled or tripled their support staff in advance of open enrollment in a display A Health and Human Services (HHS) report released of confidence.4 on September 23, 2014 stated that there will be MH92294 | This newsletter was jointly developed and subject to editorial review by Jefferson School of Population Health and Lilly USA, LLC, and is supported through funding by Lilly USA, LLC. PRESCRIPTIONS FOR EXCELLENCE IN HEALTH CARE In general, state-run and federally-facilitated Supreme Court rules to invalidate subsidies for Exchanges contain sufficiently balanced risk pools the millions of beneficiaries enrolled in coverage to avert extreme cases of adverse selection, wherein through a federally-facilitated exchange (37 states), a disproportionately sicker membership leads to it would significantly disrupt the Marketplace. premiums increases that would be unaffordable Barring a regulatory or legislative solution, premiums to many enrollees. Recent studies show that 2015 would become unaffordable for most enrollees, Exchange premiums increases will average 8% leading them to drop coverage and increasing the – growth that is considered manageable by the likelihood of what the insurance industry would historical standards of US health care inflation.5 term a marketplace “death spiral.” There is growing concern about this case among proponents of the Though all of this can be viewed positively by ACA because of the potentially devastating financial 3 consumers and proponents of the Affordable impact. In addition to the very real effects that would Care Act (ACA), the devil continues to lurk in the be felt by consumers, insurers, and other health care details. A New York Times analysis revealed that providers, the case poses a major threat to a key many insurers with the largest market share in 2014 component of the ACA itself. Until a final decision is intend to raise premiums much higher than the rendered, subsidies will continue to be available to “average.”6 Additionally, HHS will permit beneficiaries all beneficiaries – and at the moment it is business as to autoenroll in their current plans – a decision that usual – with 2015 open enrollment under way. could reduce complexity, but also make it more likely that consumers will forgo a search for a more Taken together, early signs suggest the Exchange cost-effective plan in 2015. Moreover, beneficiaries Marketplaces are poised for success in 2015, though who do not revisit healthcare.gov to update their uncertainty also looms large. Like much of health annual income will receive the same subsidy reform thus far, another chapter is yet to be written, awarded