How To Make Value-Based Care

“Work” in Cardiology

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Speakers

Jasen Gundersen, MD Jim Chiakulas Joseph Sasson, PhD

Chief Executive Officer & Value-Based Care Advisor Chief Commercial Officer &
Co-Founder @ CardioOne @ CardioOne EVP @ MedAxiom
Speaker Speaker Moderator

Formerly @ TeamHealth, Navvis Formerly @ eviCore healthcare,

Healthcare & Practicing Physician Fresenius Health Partners, VillageMD

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 On average, someone in the
US dies from cardiovascular
disease every 34 seconds

And it’s only going to get worst…

recent projections estimate a
~30% increase in heart disease.

Projected Increase in CVD Through 2060

2025 2060
+31%

29M

22M +30%
+34%
+33%
16M
15M
13M 12M
10M 11M

Heart Failure Ischemic Myocardial Infarction Stroke

Heart Disease

CONFIDENTIAL Source: Heart Disease Facts. Center for Disease Control. 2023; Cardiovascular Disease Projections
3
in the United States Based on the 2020 Census Estimates. National Institute of Health. Aug 9 2022.
Agenda 01
02
Defining Value-Based Care
Specialty Care & VBC
03 VBC Mechanics in Cardiology
3a Technology & Data
3b Care Team & Management
3c Contracting
04 Present & Future of VBC

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Defining Value-Based Care: It’s A Continuum

Value-based care is a continuum.

Moving from payment for volume

to payment for delivering outcomes.

As the risk increases, the rewards also increases…

but the need for scale becomes necessary.

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 Many Types of Contracts Across The Value Continuum

Value-based care Global payment or

contracting is broken capitation

up into various

Degree of Risk Managed by Provider

Shared risk

components. Shared savings

Providers migrating Bundled payments

(single bearer)
to the right and Bundled payments
taking on more risk, (single bearer)

will to scale their Pay for

performance
resources to match Pay for coordination
the needs of the
contract. Fee-for-service Reach
measured Manage event or
Payment for volume targets specific condition Manage a population

Level of Provider Sophistication & Required Scale

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Source: Value-Based Care Framework. The Actuary Magazine. April 2020. .
Why Does It Matter? Why Now?
CVD Costs Compared To Other
Disease Groupings, 2015 Current CVD Costs vs. Projected CVS Costs, 2035

350 Current 2035

250 +142%
300
+125%
250 200
+126%
200 150
+154%
150
100
+129%
100 +150%
50
50

0 0
CVD Alzheimers Diabetes High Blood CHD CHF Stroke Afib Other
Pressure

Source: Heart Disease & Stroke Statistics 2023. American Heart Association; Cardiovascular
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Disease, A Costly Burden: Projections through 2035. American Heart Association. 7
Diverse Risk Sharing Models Growing Beyond Primary Care

High Current Adoption Low Current Adoption

Primary Care Nephrology Oncology Orthopedics Cardiovascular Behavioral health

Source: Investing in the new era of value-based care. McKinsey & Compandy. Dec 16, 2022.
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Value-Based Care Payment Models On The Rise
2008 2010 2012 2014 2016 2018 2020+

VALUE-BASED PROGRAM DEVELOPMENT SINCE PASSAGE OF ACA

ACA: Shared Savings; MACRA; Next MIPS: Merit- Making Primary

Affordable Comprehensive Gen ACO Based Care (MCP): VBC
MIPPA: Medicare Care Act Primary Care Incentives for small groups
Improvements for Pioneer ACO: PAMA: Protecting SNF Direct
Patients & Providers Act Accountable Access to Value-Based Contracting;
Care Orgs. Medicare Act Purchasing ACO REACH

SPECIALTY PARTICIPATION IN VALUE-BASED PRODUCTS ON THE RISE

IHA Bundled Hoag bundles: Comprehensive Joint Kidney Care

Payment: Total joint Replacement Payment Choices (KCC)
Provider Payment Total hip and arthroplasty Model: total hip, or knee
Refort total knee Minnesota Birth BPCI: 48 or lower extremity
BPCI Advanced: 29 inpatient
(PROMETHEUS): replacement Centers Bundle: conditions (ie. clinical episodes and 3
21 defined clinical Maternity care acute MI, CABG) outpatient clinical episodes
episodes, such as
hip replacements Humana Oncology
and diabetes Case Rate: 12 common
oncology conditions
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Source: Bundled-Payment Models Around the World: How They Work and What Their Impact Has 9
Been. Commonwealth Fund. April 6, 2020.
 Estimated Number of Lives in All Value-Based Care Model,
in Millions & Percentage Growth Over Time
Annual
140 Growth:

VBC Models
10 3%
10 15%

Expected to
Grow Across Medicare FFS
85
10 75 10-15%

All Lines of Affordable Care Act 5

Business Commercial 40

20 2-5%

Medicaid 20
25 15-20%
Medicare Advantage 10
2022 2027
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Source: Investing in the new era of value-based care. McKinsey & Compandy. Dec 16, 2022.
 Who Does Value-Based Care Benefit?

Patients Clinicians Payers Industry Society

Increase patient
Reduced burnout, Improved alignment Improved health
satisfaction, better Reduced
better care with services, and outcomes, reduced
outcomes and unnecessary costs,
efficiencies and competitive healthcare
quality of life, and and reduced risks
increased pay advantage spending
lower costs

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Making a Value-Based Care
“Work” In Cardiology

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What Does VBC Actually Mean For Cardiology Practices?

Fundamentals of Value-Based Care Adoption How Do We Get There?

1
Solve for Today
Optimized Practice Operations
• Appointment Availability
• Patient Engagement

2
• Patient/Caregiver Education
• Accurate Coding and Documentation
Patient Identification & Analytics • TCM/CCM Programs

3
Build for Tomorrow
Interventions & Care Management • Remote Patient Monitoring
• Care Team Development

4
• High Performing Networks
• Data & Analytics
Reporting & Contracting • Payor/Provider Contracting

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TECHNOLOGY

Mechanics of a Value-Based Care Program in Cardiology

The digital components
necessary to identify and
provider care coordination

Technology

The infrastructure needed to The team required to deliver

Patient
track, analyze and most care across the entire care
Data &
importantly, report out on Care Teams continuum, not just during an
quality measures. Analytics office visit

Contracting

The vehicle necessary to get

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versus services rendered.
TECHNOLOGY

The “Why” Behind Building a Value-Based Infrastructure

Building A Technology Infrastructure Requires Deep Involvement Across A
Patients Journey of Care, Even When They’re Not In Your Office

IDENTIFY SUPPORT REPORT

Clinical Decision Population Patient

Reporting &
Support Tools To Health Activation and
Tools to Identify Ability to Risk Tracking Tools
Provide Management Outreach Tools
Patient Cohorts Stratify Patient To Understand
Preventative Tools To Really to Keep Open
& Potential Risks Cohorts Outcomes &
Care & Steer “Know” Your Line of
Follow Ups
Patients Patients Communication

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TECHNOLOGY

One Unified Platform With Core Required Capabilities

We leverage a best-in-class EMR, but decided it didn’t go far enough

Utilization Contract Billing,

Management Management Claims & ERA

Care Coordination

Patient
Existing
Identification
Integrated Value-Based Practice
Remote Patient Technology Platform Management
Monitoring
Platform
Risk Adjustment
Capability

Social Det. of Data & Measures Care Mgmt.

Health Reporting Interface

Payers,
PCPs,
Health Systems
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CARE TEAMS

The Importance of Care Teams

A robust and empowered care team improves coordination of necessary healthcare,
improves health outcomes, increases patient engagement and satisfaction, and reduces
redundant medical services and associated costs

Care Team Members Care Team Responsibilities Tips for a Successful Care Team
● Advocacy
● MA/LPN/RN ● Building relationships with patients and caregivers
● Patient Activation/Participation
● MD/DO/PA/NP ● Advocating for patients
● Care Team Participation
● Social Worker ● Administering assessments and developing individualized care plans
● Data Analysis
● Receptionist ● Connecting patients and caregivers to community support services
● Communication
● Case Managers ● Establishing relationships with patients’ providers
● Understanding
● Patient Advocates ● Facilitating administrative communication between providers
● Support
● Monitoring care gaps and ensuring appointments are scheduled
● Community
Comparing current care with proposed services
● Communicating with hospital staffs, family doctors, specialists, etc.
● Assessing various risks in the patient’s home and environment

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 A Value-Based Technology Platform In Action A Patient Perspective
Visit Summary
Patients get sent an automated visit
summary, so they know exactly what to do
Practice Management Tool

An Efficient Visit With My Provider Paying My Bill Online

With our pre-built cardiology care clinical With online-bill pay, not only is it
templates, workflows, and macros… visits run much easier to pay their bills—they
much more smoothly for both you, and the patient are also much more likely to!

Cardiology-Purposed EMR Patient Portal

Eligibility & Auth Determination

Telehealth Visit
Saving patient’s time & money upfront by
determining eligibility, co-pay, deductible met/not Patient’s condition suddenly gets worst and
met and patient payments immediately can schedule an online visit next-day.

Practice Management Tool Telemedicine / Patient Portal

CARE POST-VISIT
Scheduling An Appointment, Hassle-free Remote Patient Monitoring
Due to an easy-to-use online scheduling system, Physician produces a treatment plan and puts
patients or care advice line nurses can schedule their them on remote patient monitoring.
own visit according to their specific care needs.
Remote Patient Monitoring
Integrated Scheduling

Patient Calls After-Hours Care Advice Line

MONITOR Abnormal Trigger & Triage
Patient tries calling office, but gets redirected to a Patient has an abnormal reading that triggers an
24/7 nurse advice line. After triaging, nurse sends alert, triaged by our care team and escalated to
treatment plan and makes next-day appointment for the physician for review
patient, diverting from emergency room
Care Advice Line Patient Identification
HIGH TOUCH,
ENGAGED PATEINT
HF Patient Has Mild Chest Pain
Patients easily can find you online or ACCESS CARE My Physician Sees Me First Thing Monday

get in touch with your practice to Physiican determines its not emergent and sees patient first
thing Monday morning, resulting in another ED diversion.
Symptom Onset
Care Coordination
CONTRACTING

VBC Contracting Focuses On Quality of Care Making Data &

Reporting of Those Measures Critical
Some examples of quality measures might include things like:
• total cost reduction
• timeliness
• plan all-cause readmissions
• emergency department utilization
• hospitalization for potentially preventable complication

There are national benchmarks that may be used:

MIPS – Merit-based Incentive Payment System
• Measured across 4 areas: cost, quality, improvement activities, and promoting interoperability.

eCQMs – Electronic clinical quality measures

• Measures many aspects of patient care, including patient safety, care coordination, and more.

HEDIS – The Healthcare Effectiveness Data and Information Set

• Tracks the clinical quality of health plans
• Not specifically used to track provider performance, but plans still leverage providers to improve scores

HCAHPS – The Hospital Consumer Assessment of Healthcare Providers and Systems Survey
• Survey of patients’ perspectives of hospital care used to measure patient experience

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CONTRACTING

Designing A Value-Based Care Contract: Key Elements

The elements of a value-based care contract are fairly standard across the board;
understanding key components is critical to designing and negotiating risk contracts

Attribution Defines the population to be measured against a measurement period

Quality Defines quality measures that are typically tied to full or partial savings or care management fees
Reporting Types of data that need to be furnished, and when, deadlines for submitting quality data
Requirements
Minimal Panel Size Defines the minimal number of attributed members for the risk provisions to apply
Value-Based Product Defines the products that will be included under the population; most common are fully insured
commercial, self-insured employee health plans and Medicare Advantage
Benefits Defines the benefit options and cost-sharing for current and potential members
Network Defines the provider network that will be used to market the products that are included in the
agreement
Payment Terms Including financial risk levels, timetable for bonus and risk-sharing payments and whether payments
are retrospective or prospective
Covered Services Codes included and excluded from payments, what type of providers may submit claims, and what
triggers payments for episodic care

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CONTRACTING

Knowing What (And How) To Measure From The Beginning

Understanding What To Measure Common Metrics in VBC Contracts

Utilization Metric Size of Impact
Focus on what matters to payers
Inpatient Per 1,000 patients $$$$

Hospital Admit per 1,000 patients $$$$

Define Success Early & Specifically % of Caths Not Preceding
$$$$
Cardiac Intervention
Hospital Readmissions $$$$

Use established metrics when possible Generic Drug Utilization $$$

Interventions Per Cath $$

Identify upstream metrics to know your model is working and Multiple Imaging Stress Tests $$
avoid delays
Unnecessary rate testing $$

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The Present & Future of
Cardiology Value-Based Care

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Critical Success Factors in VBC & Population Health
Providers must…
... engage in making cultural shift from volume-based mindset to
value-based mindset
Managing Patient Cohorts
… standardize and scale to create consistent, high-quality
treatment plans
High risk Goal: Trade high-cost services for
… educate themselves in the basic concepts of risk-contracts patients low-cost care management

… invest in care management infrastructure, activities, and

information technology to manage populations Rising risk Goal: Avoid unnecessary
patients spending and risk escalation
… align their objectives with the right payer partner

… assess their risk tolerance

… have a clear plan to manage various patient cohorts

Low risk patients Goal: Keep patients healthy
and loyal to system

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 Case In Point: Real World Cost Saving Examples in VBC Contracts
Admission Avoidance Cost Savings
OPPORTUNITY MECHANICS BENEFITS
TECHNOLOGY INCREASE IN QUALITY OF CARE
Potential to reduce ED & IP • Real-time encounter notifications via
• ED avoidance
utilization and generate an admission, discharge, triage (ADT) • Improved patient experience
significant savings by engaging feed. • Decreased patient out of pocket due to
• ADT feed integration with EMR
and diverting these patients • Smart triaging for alerts (ED vs. non-
ED visit diversion
appropriately to a lower-cost ED)
setting (office setting). DECREASE IN COST OF CARE
CARE TEAMS
• Average cost of heart failure admission =
• More thoughtful and intensive • Dedicated team to accept alerts $11,800
• Provider integration into workflow to
follow up office visits assess patent disposition at ED
• Savings generated from avoiding
readmission = $11,800
• Refer them to monitoring • Influence over treatment plan
programs
• Highly engaged post- DATA & REPORTING INCREASE IN COMPENESATION
discharge • Measure key KPIs (i.e. readmits)
• Location view: track where patients go Depending on contract, can
• Diagnosis view: cardiology vs. non- receive up to 50% of savings:
cardiology related admits ~$5,900 per admission avoided

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Case In Point: Real World Cost Saving Examples in VBC Contracts
Cardiac Cath Cost Savings
OPPORTUNITY MECHANICS BENEFITS

INCREASE IN QUALITY OF CARE

• Reduces unnecessary procedures
Potential to reduce utilization of • Improves overall patient experience
CARE TEAMS • Similar outcomes with less disruption
high-cost diagnostic testing,
• Patient/candidate identification
such as cardiac caths, in • Provider willingness and education on
patients with stable chest pain. lower-cost CCTA option DECREASE IN COST OF CARE
• Clinical decision support to steer • Average cost of cardiac cath $8,600
• For low and intermediate qualified patients • Average cost of coronary CTA: -$500
pretest probability patients, a • Savings generated to CCTA steerage:
DATA & REPORTING $8,100
CCTA is clinically appropriate
• CCTA can help identify patients who
• Similar outcomes may benefit from further invasive
procedures such as cardiac catheterization. INCREASE IN COMPENESATION
Depending on contract, can
receive up to 50% of savings:
~$4,050 per cath avoided

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Partnering with PCP’s: The 5C’s
Our success in value-based care will continue to partner heavily with primary care
providers—a critical component is assuring we’re being thoughtful partners for PCPs

Non-
Communicate Collaborate Cooperate Contract
Compete

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Fostering Communication With PCPs: A Care Compact
What Is A Care Compact? Four Steps To A Care Compact
● Agreement between PCPs and specialists that defines:
○ referral protocols
Audit
○ care transition expectations changes
Educate and
○ care management responsibilities train staff

Articulate
Benefits measurable care
compact goals
● Improved transitions of care
● Coordinated patient access between providers Identify
communication gaps
● Defined collaborative care management activities
● Enhanced patient and provider satisfaction
● Avoid unnecessary or duplicative testing

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Major Takeaways For Providers Today

Begin building out and testing the capabilities today, so you’re prepared for tomorrow

Stabilize and optimize current operations; value-based care is a non-starter in a financially unstable practice

Assemble the technology, care teams and contracts to succeed in executing and reporting on key quality measures

Ease into value-based care by obtaining performance-based contracts instead of diving straight into risk

Start being thoughtful partners to primary care providers; understand their needs and succeed together

You need scale and leverage to succeed in value-based care arrangements

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Questions?
Or want to discuss VBC in more detail?
Give me a call or send me an e-mail directly:

774-696-9422 (cell)
[email protected]

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