Tricia neuman. I wanted to let everybody know that you can tweet with us live with this event. You can tweet your questions. You may tweet your comments. For both the people in the room and also those who are joining us live on cspan. The hash tag is medicare demos. If you would like to access our speaker presentations and you are not in the room with us, you can find them on our website at w www. Allhealth. Org. Im going to turn this over now to our partner Tricia Neuman who will tell us more about why were here today. Thank you, marilyn. Its great to be here. Before we get started, i just want to congratulate you, marilyn, and sarah dash, wherever you may be, for taking over the helm of the alliance. We miss ed, but its great to see you both new coceos. So welcome. Of course, you have been here for a while. I want to thank all of you for coming here today on behalf of the Kaiser Family foundation. Im excited to be here. I think were going to all learn quite a bit. As we focus on the progress of medicare payment and Delivery System reforms. It wasnt long ago people talked about medicare as a static program. But things are changing pretty rapidly in traditional medicare. The longstanding concern that the main problem with medicare is that it only encouraged more and more care has really been changing, and changing at a fairly rapid clip as medicare is instilling more incentives for providers to do more, provide better care, to manage care and even potentially at a lower cost. So im here as you are all here to learn more about the progress of these demonstrations. I think its fair to say that we all have a lot to learn, not just about how they are today but how they will progress. Sometimes these things do take time. But its exciting to see so much change happening and so much Energy Behind the ongoing effort to improve medicare for the program but more importantly for the people who had covers. So thank you. Great. Okay. So im going to introduce our speakers. To my far right we have cristina bow cu bocutte. Shes associate director on the medicare policy at Kaiser Family. She has had a number of positions. Next to her is marilyn moon. Shes Institute Fellow at the american institutes for research. Marilyn is an economist. Shes analyzed the Medicare Program in various capacity, including for the congressional budget office. Shes also served as a Public Trustee for the Social Security and Medicare Trust funds in the 1990s. To my immediate right is patrick conway. He is acting Principal Deputy administrator at the centers for medicare and medicaid services. And he is also the director of its center for medicare and medicaid innovation, cmmi, you will hear that a lot today. Cmmi is overseeing the payment approaches that were going to be talking about today. Eric de jonge. Next to me is Tricia Neuman and eric de jonge, director of geriatrics and cofounder of the medical House Call Program at Washington Hospital center. Eric will give us a glimpse of the independence at home program that is getting so much attention and that med star is planning to expand to other facilities. To my far left is jim garnham, director of contract and Payment Innovation at the university of Rochester Medical Center. He leads rochesters bundle payment program. And he also has a hand in its aco and riskbased models. Were going to start off with cristina bocutte who will talk about the recent work that kaiser has done and what evidence we have on hand. Thank you. Lets see. Okay. Good. So im going to start with just a little context for Delivery System reform in medicare and then im going to go over very brief summary of three of the models and conclude with a few thoughts onion going challen on thoughts and context. Also cms had already been running some new models on Delivery System reform, the Affordable Care act really brought in a large multipronged effort for Delivery System reform. It created some permanent changes to the way hospitals are paid, for example, the hospital readmission reduction program. It created the office that called the Medicare MedicaidCoordination Office which is looking at ways to align payments for people who are duly eligible for medicare and medicaid. And the aca also established a cos through whats called the medicare shared savings program, which we will get into in a little bit. And the aca created the Innovation Center, which, of course, we call cmmi, because we love acronyms here in d. C. But cmmi was really marking a significant investment in testing new payment models. And the aca gave it Unprecedented Authority to expand models that achieved certain specified performance on quality and spending. I would also mention that underlying Delivery System reform in medicare was the passage of macra, the law that repealed the sgr, which was, of course, many former alliance briefing topics. But macra has within it financial incentives for physicians to be paid a bit more if they are participanttnts in alternative payment models. This will come in future years. Cms is planning to release some regulations in the near future, some proposed rules on what exactly will be define will be used to define the alternative payment models. That should be coming out soon. And then a final piece of context is, of course, hhss overarching goals to shift more of traditional medicare payments towards value instead of volumebased reimbursement. Perhaps dr. Conway would be talking about that. So im not going to. But i will move on quickly to this slide which shows on lefthand side three models of Delivery System reforms that we cover in the primer that is in your handouts. And im going to talk about some of the individual models that are there on the righthand side. So starting with medical homes. To distill it down, medical homes are really based on the concept that investing a bit more main comprehensive primary care could lead to lower overall spending due to Better Health outcomes when you invest earlier in primary care. All three of the models on this slide here involve Care Management fees to the medical homes. And the first two specifically have a focus on coordinating medicare Care Management fees with other insurers like private insurance and medicaid. And you can see on the map you can see on the map that theyre clustered a bit for this reason. The lighter blue is the mapcp model. That has more involvement with states. You can see the whole state is colored in. And then the orange dots represent the cpc participants. And in those models, cmmi is playing a greater convening role with those insurers. The evaluation reports for the medical homes are starting to come in. I think at this time net savings are not very high. But more results are coming. And the cpc model is showing some grains in quality. But, again, the others are awaiting more results. I will move on just for a moment to the independence at home model, which is also a primary care model. But, of course, we have an expert with direct experience. So i will just give you a couple teasers that show whats unique about this model. And one is that it focuses on home visits to address the care needs of frail patients. A second unique feature of this primary care model is that it does not involve Care Management fees. In fact, has within it the opportunity for the independence at home practices to share in savings if they have lowered spending. And then well say that early results from independence at home are showing some promising savings. So then moving on to the acos, these are entities that have agreed to be held accountable for both spending and quality for the beneficiaries that have been assigned to them. They can contract with hospitals, physician groups, healthcare facilities. The model that accounts for the most beneficiaries by and large is the mmsp models. They account for 7 million beneficiaries across over 400 acos. The one that the mssp model with the most beneficiaries is the one that are called track one. In that model, the providers dont take on financial risk with medicare. But they can share in savings. There are new tracks that are coming up, but perhaps dr. Conway would mention them. So i wont. Then theres also nine pioneer models which are required to take on financial risk. I would say that about well, about a quarter of the msmps i mentioned shared in savings as results came out for 2014. Half of the pioneers achieved were able to share in savings. That model did get certified to be expanded. Then the last little model i want to note is the bundled payment model. Bundle payments, of course, were lucky enough to have someone here who can talk about direct experience. So i would just characterize this model as one that focuses on a whole episode of care rather than payments that are made to individual providers for the individual services that they themselves provide. The bpci demo has four different payment models. Theyre triggered by a hospitalization. But there are many details. So im not really going to get into them. But to say that the results are very preliminary. So finally, i will just close with a few comments oni ongoing challenges and opportunities. We see here that actually, i have to put my glasses on. Cms launched a lot to be fair, a large number of payment models in a very short period of time and in a changing healthcare environment. We can note that while were all sitting here wanting results, congress, providers, cms for sure, it takes time. And so theres certainly attention between what we want and letting these models be fully implemented as theyre being tested. I would say that the ability for cms to change these models while theyre ongoing based on early results and based on unforeseen circumstances presents great opportunities and great challenges. For the evaluators certainly. Finally, i would note that a key consideration that cms and congress will be considering as results come in for these models is how Medicare Beneficiaries are really faring in these models. Particularly, those with high healthcare needs. Theyre the ones that we think some of these models were designed to help. So lets learn about them in particular. Thank you. Thank you, cristina. Thats actually a great transition. Marilyn moon is now going to talk to us about how consumers are faring under these models. Marilyn . Thank you. Im going to be relatively brief because i may be talking about a one horse pony here idea. And that is that consumers matter, and you really need to take them into accounts in these kinds of models. Some of the earliest innovations that occurred and some of the earliest thoughts about innovations really were often done without thinking very much about consumers. Imagine an aco thats getting organized, an Accountable Care organization that is thinking about steering patients into different other providers and a slightly different model and approaches, but the beneficiary often has no idea that theyre in an aco. They may or may not have gotten a letter. They may or may not have known they have gotten a letter. And in many cases, theyre not quite sure why the physician is doing that. If it is for good purposes for both improved quality of care and lower prices, thats all for the better. But you are going to get a lot better cooperation, a lot better engagement and involvement if the beneficiary actually is engaged and knowledgeable about that. I remember when people were talking at an early event i went to about medical homes, which would you thi you would think would be particularly consumer sensitive. And after mentioning pisht s ii centered care, the term patient never arose, including when someone was asked about it. They said, the physicians have the patients best interests at heart. They can take care of that problem. I think we need to change everyones minds and attitudes in the health care world. You are not going to change the heal Health Care System if you have people resistant to the change. None of us like to change things that we become familiar with and comfortable with, especially when its something as complicated and uncomfortable and important as health care. So its very important to get people on the same page. Air where i work did a study a number of years s ago that i wasnt involved with but i thought was fascinating where they interviewed patients and then they interviewed doctors and gave them the same exact specific scenarios about health care trying to get people interested in quality. What they found was the reaction of the patients and the physicians were totally different. The patients reactikreactions they were encouraged to look at quality measures to decide where to go to deliver a baby, reaction was, why would i want do that . I would ask my neighbor. And in the case of the physician, the reaction was, why would i do that . Why would i even want to take this patient, because he or she is going to be la tinlous itigiy are trying to steer me to a particular hospital. They were not only resistant to quality, but they were on a different page. So theres a lot of education and activity that needs to go on. No now, i will note that as mentioned in the primer, the new generations of models coming out are getting much better at that. Theyre trying to think of ways to encourage and involve patients. So i think that its important to keep in mind that this may be a little bit of a dated comment but its something to keep in mind because its easy when people get focused on the tough technical things to do to leave the consumer out of it. One of the important pieces that needs to be part of all of this is to ask the question, what do patients really want to achieve . And when designing goals for example for complex care, lets say postacute care, its very important to know what the patient wants to achieve. I can give you a personal example. When my husband was first out of the hospital and on home health after a stroke where he couldnt read numbers and he was very confused about a lot of things, he had a therapist who insisted that he needed to learn how to dial a telephone. And i kept telling her, no, he doesnt really need do that. All he needs to do is push this button because we have technological advance that allows him to just push this button. Nonetheless, she was bound and determined that he was going to deal the telephone. After about five sessions, we told her she didnt need to come back. She never asked him what he wanted to achieve. There were plenty of things that he could have achieved that she could have helped with him in that period of time rather than the frustrations that he went through. So whether it be to climb a set of stairs to sleep in your own bed after if you have health problems, whatever it is, the patient often has a goal. Getting them involved very early on is really important. And finally, its important that its an opportunity to build in consumer issues from the very start to make sure that that gets baked into a new Healthcare System rather than added on at the last minute. I think this is part of the reason why it takes time to achieve savings, because everybody is adjusting to a new environment. And before we either give up on new technology on new innovations or before we say that they arent working, we have to make sure that everybody who is involved, physicians, other providers and patients, are all on board before we really judge whether or not it has been successful. Thank you. Patrick . Thanks for having me here today. Really appreciate it. Thanks for allowing me to be two minutes late. I apologize. I was coming from another speaking engagement. So its actually a great segue. I think the reason we do this work is the people and the patients and families we serve. Will hit on some highlights, but at its core, we think we can have a system that achieves Better Health, smarter spending and healthier people. To get there, i do think patients and families have to be at the center of care. We have policy principals we use at cms. One of them is around patients and families first. So these are the goals that were alluded to just briefly. The president and the secretary announced in early 2015 that we wanted to move at least 30 of payments by the end of 2016 in alternative payment models. By the end of 2016. Then in march, we actually announced we reached that a year ahead of schedule. I will that really is a dramatic shift in the Delivery System. Lots more to learn. On what works and why and what is scaleable and expandible. But a major shift in how we think about paying for care. Goal number two included value based purchasing. Includes things like hospital value based purchasing and other programs that tie payment to quality and or cost. And the goal there was 85 of payments with link to quality and cost. We reached that ahead of schedule. This is not just a medicare issue. Its medicaid. Its state. Its commercial payers. So we launched a Healthcare Program and learning and Action Network to collaborate to not only achieve these goals but achieve better care on behalf of patients. We have now got eight of the ten largest payers engaged. We have over 1,000 providers. We have consumer and patient organizati organizations. The focus of the work is how do we agree on goals which we have, agree on payment definitions which we have, agree on how to report on those, which were starting to do now. And then maybe most importantly, work on alignment in many of the models. If were talking about an aco, can we agree on basic construct around risk adjustment or quality measures or attribution models. This is a longterm journey. We set up the structure for effective public and private partnership. I was at the guiding committee. A numbe